Radial Head Replacement - Recovery is possible!
Hi MTBR forums,
I wanted to post here and talk about my experiences over the past few months with radial head replacement after a riding injury. Specifically, because it's a reasonably uncommon injury amongst the general populace and when I was trying to get some personal stories about it, the only first-hand accounts that exist on the internet are amongst the mountain biking community. Some of those accounts are years old at this point and I think a fresh voice may help other riders going through this sort of injury.
So here is my story for everyone, I hope it helps:
For the record, I'm nearing 30 and in Colorado.
At the end of August I was out on a local trail around my neighborhood, I was very familiar with the area, having ridden it countless times. But halfway through a turn I lost my rear wheel on some gravel and when I recovered it, deathwobble started up and I couldn't recover. I went down fast and hard.
The result was a severe elbow dislocation combined with my proximal (elbow-end) radial head being smashed into pieces and beyond any hope of repair.
Due to some healthcare issues, I had to change hospitals/surgeons. Both of the orthopedic surgeons I saw ended up giving me the same outlook: months of recovery, probably a permanent loss of motion, and that's with surgery. I ended up having surgery around 3 weeks after the accident(<7 days is highly recommended) so I was cautioned that may hurt the final outcome slightly.
The surgery itself went well and three days later I was removed from my immobilization splint and put into a hinged brace and given some basic movement to start working on. At that point, I couldn't straighten my fingers out by themselves, rocking my wrist forward and back was a strain, and bending my arm even slightly was the most difficult physical task I've ever handled.
I was to do these exercises 4-6 times a day, and I settled on a rhythm of 5 times a day, 6 on weekends. Around two weeks later I had recovered all my hand motion but all the elbow motion was still very tight.
They sent me to a physical therapist(OT, specifically) who gave me a 5-times-a-day regimen of just stretching the arm out with about a pound of weight; stretch it straight for 5 minutes, stretch it flexing for 5 minutes, stretch it rotating in both directions for 5 minutes. I only saw them at the hospital once a week.
Last week, 8 weeks out from surgery, and I've got >97% of my range-of-motion back after doing this regimen and never, ever taking a day off or going easy on myself. The surgeon says it's basically a perfect example of why you stick to your physical therapy routine.
I have only just started worrying about things like strength build-up, since the arm as atrophied quite a bit since the accident, and the surgeon says I still have a month or two before the arm is stable enough internally to really try riding again, but as far as the possibility of posture - nothing exists to prevent me from riding normally.
The takeaway lesson from all of this, to any readers who have just gotten the news that they're going to need surgery to fix up the elbow, is that you NEED TO DO YOUR PHYSICAL THERAPY. It's _that simple_. You don't need to over do it - more often or with more weight than recommended - you just need to do it and never give yourself a break. During recovery one of my milestones was based on a post somewhere here in these forums where someone mentions no longer being able to touch his shoulder while flexing. I kept flexing and stretching and pulling the arm until I could touch the shoulder, and then touch it with my bent thumb, and then just being able to do this without intentional stretching at all.
Recovery sucks and isn't fun, but if you stick with it you will heal. Just do what the doctors and physical therapists ask of you and you'll be in working order again soon.
Last edited by docendo; 09-26-2014 at 02:37 PM.
Thanks for the inspiring Story.
I had a similar accident in Mid September this year and the exact same surgery.
Today I'm 3.5 month after and have around, 99% rotating, 95% Straight, 80% Flex (can touch the shoulder when stretching).
I was wondering if if you can share how exactly did you stretch your arm with the weight (Staright, Flex, Rotating), what kind of positions?
I'm happy to talk about it!
Sympathies for the injury, radial-head-buddy, this is all pretty overwhelming!
It sounds to me like you're doing really well and i'd be curious how you're saying you only have 80% of flexion back if you can touch your shoulder. Do you mean that to 'touch' your shoulder you have to rotate your hand and lay it flat? Because by my therapy numbers, being able to keep my fingers 'straight forward' and touch my shoulder with a stretched thumb was like ~130 degrees of flexion, and being able to touch my shoulder with the middle knuckle of my thumb was like ~140, which is basically >95%.
In any case, the weights stretching I did came after the 'under my own muscle power' stretching and after the 'use a surface to lean against' stretching.
I started at 1 pound and moved up to 2 pounds after a few weeks. I just want to be very clear: This is for PROXIMAL radial head injuries(at the elbow) - doing some of this for DISTAL radial head injuries(at the wrist) is a bad idea. This also supposes you have been advised by your surgeon/physical therapist to use weights. PLEASE DISCUSS THESE EXERCISES WITH A MEDICAL PROFESSIONAL TO ENSURE THAT THEY BELIEVE YOUR INJURY HAS HEALED ENOUGH THAT THESE EXERCISES ARE SAFE. Doing these stretches too soon into your recovery could cause further injury!
There are two rules of thumb for all of these stretches:
A. If it *hurts*, stop immediately. I mean physical pain, not stiffness, achiness, or discomfort. Some of this sucks and kind of feels uncomfortable because you're stretching stuff out, but it shouldn't be a sharp pain.
B. SLOWLY end the stretching. When you're done stretching, don't immediately move the opposite directions. Slooooooooooooooooowly reverse the motion.
For rotation, I just manually rotated the forearm:
1. Keep your upper arm/elbow at your side.
2. Bend your elbow 90 degrees so that your arm sticks straight out in front of you.
3. Grip with your other hand at the wrist. You should be able to feel the heads of the radius and ulna and use those as leverage points to rotate the forearm.
4. Rotate the forearm as much as possible without assistance, and then manually force it to rotate *SLIGHTLY* more. Emphasis on SLIGHTLY. You aren't trying to manually force it to rotate all the way, just *slightly* more than you can do under your own power.
5. Hold for 2-3 minutes.
6. Release and slowly bring your forearm back to neutral(hand vertical).
7. Under your own muscle power, softly rotate back and forth in both directions a couple of times.
For Extension(straightening), I rigged up a 1-2 pound(increased as motion came back) weight with some shoelaces to make a loop. I sat down and had a surface in front of me. I stacked a number of books(anything solid and flat will do) such that when I rested my upper arm on the stack, it was parallel to the floor and my lower arm was unsupported.
1. Once your arm is in position, straighten it as much as you can on your own.
2. Slowly lower the weight onto the end of the arm. When your motion isn't great, use your hand between your thumb and fingers. When you get more extension, you can move to hanging weight off your wrist below the thumb.
3. Passively just let the weight hang there for 5 minutes.
4. Slowly remove the weight while keeping the arm stretched out.
5. Slowly ratchet the arm back up to flexion. So flex it a few degrees, then extend it back out, then flex it a bit further, then extend it back out. This shouldn't hurt and should probably feel better than just trying to go immediately back to flexing!
For Flexion, I used that same 1-2 pound weight and support system.
1. With your upper arm rested and supported, flex your arm as much as you can on your own.
2. With the weight over your shoulder(probably resting on your back) slowly add that weight to the arm. Either by gripping the strings with your hand to start, or by hanging the weight from the wrist.
3. Passively let the weight hang for 5 minutes.
4. Slowly remove the weight, keeping the arm flexed.
5. Slowly ratchet the arm back to extension.
Once I had done both my extension and flexion stretches with weight, I did a quick 'windmill' to functionally re-teach my brain to trust the arm to move on its own:
1. Stand up and clear of all obstacles.
2. Start with your upper arm at your side.
3. Flex your elbow as much as you can on your own.
4. Straighten the arm and 'reach' for your feet.
5. Flex your elbow as much as you can on your own.
6. Straighten the arm and 'reach' for the ground in front of your feet.
7. Keep repeating the flex/reach, reaching a little higher each time, until you're reaching for the ceiling. Then rotate back down and do a few 'behind you' reaches.
Also SERIOUSLY IMPORTANT: After I did all these stretches I had a wrap-around coldpack that I wrapped the elbow in for around 20-30 minutes afterwards.
All of these exercises were done 5 times a day, they took maybe 30-45 minutes in total.
I hope this helps with your recovery!
Wow, thanks you so much for your very fast reply, I am more than impressed!
The injury I have is exactly like users, I dislocated my elbow, shattered my Radial head that was replaced and had my ligaments sewn back.
I also read some posts here and decided to to take my recovery very seriously since I'm looking to have an almost normal arm in 8-10 months from surgery.
In the first two months I did three excersise sets everyday togethwer with a 40 minute walk every morning to straighten the hand with the natural use of gravity (at the begining without weight and 1.5 months post surgery with 2 pound weights).
In the last month I've started to work at the gym with my Physitherapist with almost no weight just to start moving all the muscels in the arm and those that are attached it (Shoulder, chest, etc).
My surgen and physiotherapist have been very happy with my recovery so far but I feel that I've been slacking a bit in the last month, I find myself only doing a morning walk and excersie set in the morning.
After reading your story I decided i should go back to do stretches at least three times a day.
The 80% felxion I menntioned is just a number I throwed out there, its nothing scientific, just a general feeling, I can touch my shoulder only after I do flex stretches in the morning with a 2 pound weight lying on the floor.
I'm definitely going to try your routine and see how it works out for me, hopefully it will its charm for the last bit that is left to get to full range of motion.
How are you doind 4.5 months post operation? did you change the stretches you are doing?
Thanks again, this is much appreciated!
I'm actually only about 3.5 months post-op and 4 months post-accident!
I have 'mostly' discontinued regular daily stretching since about a month ago. I wrote this post actually right after I got an 'all-clear' in terms of range-of-motion from my surgeon. At the time the only real measurable thing I was 'missing' was 5 degrees of extension. Even at that point, he told me to stop trying to force any more range-of-motion with weighted stretching. His justification is that all considered, this is a pretty serious injury and *some* lasting effects are to be expected; Trying to force any additional range-of-motion could end up damaging something, and since I was so close to 100% there just wasn't any reason to risk that.
Even without doing it daily, those last few degrees have mostly come back, so no harm in backing off.
Since then I've just been on some light weight stuff to rebuild strength(sitting around not doing anything with the arm for a few months made it pretty weak!) - just a bunch of shoulder/bicep/tricep exercises with a 2 pound weight, as well as some resistance-putty that I'm using to regain grip strength.
What I'm going to recommend, from my experiences, is to get some *real measurements* done by your physiotherapist. They should have some sort of tool to measure your range-of-motion, and can do a comparison from your 'good arm' to your 'recovering arm' to let you know *exactly* how much you've recovered.
I do want to say right out there that all things considered I think it's worth noting that we've been through a pretty serious injury. My surgeon is unbelievably happy with my recovery and progress - but says it's expected that I still feel a bit stiff at times. These arms probably aren't going to go back to 100% pre-injury normal, but we can get *close*!
I still repeatedly through the day just instinctively kind of reach and straighten out my arm just to stretch all the connective tissues and stuff. Because it feels a bit stiff after a while, and it feels good to keep it stretched out. Towards the end of the day especially I tend to feel some aches - but my surgeon also says that's pretty normal and not to worry about it.
Before worrying about really pushing towards more range-of-motion, I'd just get them to measure you and see how much you're really 'missing' - in lieu of that you can always just consider one arm to the other. In my case while my other arm can whip right to full extension/flexion without even thinking about it, I do have to kind of pull and work the recovering arm to get the same amount of motion. It doesn't come as naturally anymore, and I can see how that could make me think that it wasn't actually doing as well as it was - but it might get better over time!
I don't naturally just wake up in the morning and have full range-of-motion, either. Generally the 'after I've stretched' limits show what your body is *capable* of - months ago neither of us could come anywhere near straightening our arm out no matter what we did, recall. So every morning I kind of slowly work my arm to extend and flex and rotate and then go about my day - maybe every hour just taking a quick minute to do a full extend/flex a few times before getting back to work. Don't worry if you don't *always* have full motion, if you can do it while pulling on it with weights, then the tissues support it and it's just a matter of getting the muscles and stuff back into shape.
My latest follow-up was with my surgeon last week, actually. We did the usual stuff: X-rays, him manipulating the elbow manually to feel for articulation, etc. He pretty much said that I'm completely healed from an injury standpoint. Yep, I still get stiff and achy, but hey I've got metal in my arm and it needs time to figure out that out! His exact phrasing was that if I were to manage to injure the arm at this point, it'd have to be doing something that would have injured it *anyway* regardless of the previous accident. I'm not seeing him for 3 months, and he says that my goal for that appointment is to be able to report back that I treat the arm normally again; Right now I'm still kind of aware of it - I protect it a little bit and sometimes do things like move my shoulder rather than extending it completely when reaching for things. In 3 months he just wants to see that I'm using it 'normally' in day-to-day, so that's what I'm working towards.
My therapist gave me some more broad exercises to do to get the muscles built up more and more and a few more just 'idle' stretches - things like locking my fingers, rotating my palms away from me, and then stretching my arms out.
It's all looking positive, I have to admit. I still don't think I can ride quite yet - impacts and sudden shock forces hurt so riding over bumps in the ground sounds terrifying. But maybe in the Spring - we will see.
Quick addendum, I'm curious - do you happen to know what type of implant they used for you?
I've got one of Acumed's Anatomic Radial Head Replacements in my elbow, for instance. It's one of the impact-fused monoblocks(single piece) - but some surgeons prefer a bipolar(2-piece) system, so I'm just curious. it's a bit late for either of us to do anything about them, but I'd be curious!
If you feel like sharing, I'd also be curious if you remember how you crashed. I remember the moments before I came off the bike, and I remember coming to a stop on the ground, but I have no memory of *how* I hurt myself. The surgeon says I must have come off the bike and straightened my arm out to try and break my fall and that's what caused all the damage, but I just have no memory of it.
Thanks again for sharing all of this, it really helps reading everything you are going through as I'm on an almost parallal path.
I'me going to schedule a meeting with another physiotherapist so I can get proper measurments.
Its only been two day but your advice is already helping, I've been doing the flex stretches and I can already touch my shoulder with my thumb after finishing the stretches. I'm hoping this will only get better in the coming 1-2 weeks of doing it.
I can also get my arm staright but only of I press it with my other hand when lying on the floor, there is still work to be done there.
I'm almost sure I got the exact same Acumed implant as you, the surgeon also decided to do an "anchor" in my case because is had a small fracture in the Coronoid.
Funny enough my injurry happend while playing soccer. I was ruuning in full spead when a stupid player decided to tack me from the right and I fell forward on the left side. In order to prevemt me from falling on my shoulder/head I had to stop my self with my left hand when my arm was in a 90 degree angle.
When the hand his the ground I heard two small knacks and felt something bad happend, after standing up I could feel my entire arm stretched and saw that my elbow was completely dislocated. I wasn't too stressed because I could move my fingers normally so there was no nerval damage.
I'm going on a checkup in the next two weeks and see what the doctor will say then, last time I wen he was super happy with my progress and even filmed me to show the other surgens.
No thanks necessary! I can't explain how happy it makes me that I'm able to help someone else going through this just by sharing my experiences!
It's pretty easy to identify the Acumed implant if you have copies of your xrays - it's signature trait on imaging is that the stem that goes down into the radius is tapered halfway down one side, not like a nail(that tapers on both sides) but like a door-stop, where one side is tapered and the other is straight.
If you have injuries to the Coronoid, that could be part of the differential in movement between us; I somehow got lucky in that my dislocation at most maybe chipped the Coronoid, but not badly enough that it required any surgical intervention. So I got away with only 3 pieces of metal: My radial head prosthesis, and then 2 suture anchors to re-position my LCL, which I tore clean off the humerus when my elbow dislocated. If you also had to have something to repair the Coronoid, that would be totally expected in this type of injury, but could also explain some of the motion loss.
Also oof, having read your story now I'm wondering if I don't feel luckier not to remember feeling/hearing the actual break! I had the same thing where I could move my fingers but not my arm, and so nobody seemed too concerned about it until the xrays came back and then it was all "bad news, you're going to need to talk to an orthopedics specialist."
Good luck with your checkup! I had almost the exact same experience you described at my last one - after all the usual stuff, my doctor asked to take a bunch of pictures for the classes/seminars he teaches. Of course I obliged him, not only because he took some pictures of my surgery for me(they wouldn't let me KEEP my broken radial head pieces so at least I have a picture of them!) but also because he saved my arm.
I just wanted to follow-up one more time, as I recently got my one-year surgical follow-up:
Imaging looks good, implant is still solidly in place, so I've been fully cut loose indefinitely. Keep on the lookout for major forearm pain, but that without some major event(another fall, etc) I shouldn't even expect any trouble for decades if not longer.
Nothing has really changed on the recovery front since the last information. Nothing has been gained/lost in range-of-motion, I still have full rotation and flexion, and am only lacking a little bit of extension - hardly noticeable except in direct comparison to the other arm.
I haven't gotten the bike back out on the trails - unfortunately I really can't afford to risk any accident, however minor, since it'll be a while before I finish paying off this one. But I do have it up on a trainer and have been putting in some time with it. Riding itself doesn't seem too bad, but there's definitely some stiffness when I keep my arm riding position for an extended period of time; this also means a little discomfort when bringing it off the handlebars and flexing it.
I'm a little nervous getting it out where there will be actual shocks and bumps, but that's a ways off yet so there's a chance that as everything settles down and the arm gets more and more accustomed to the position and load, it'll be fine.
In general it's back to life as usual and I don't really compensate at all for it anymore. I notice it - its hard not to - but in general it's pretty much a solid recovery.
To anybody reading this in the future after googling about the injury and the surgery and the outcomes. Please don't lose heart. It isn't all doom and gloom. This isn't a story about a friend of a friend. This is just me, average dude, with a very bad prognosis who can tell you that recovery is possible. After surgery you just need to follow directions from your surgeon and your therapist. Don't overdo it, don't underdo it, just do it. If they say 5 times a day, make the time, force yourself to do it. It'll be boring most of the time, it'll be painful some of the time, but it's temporary and a few months of discomfort buys you relief from the permanent discomfort of not being able to bend or stretch your arm!
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