Journal of Orthopaedic Surgery ���������������
2010;18(1):76-9
Static progressive stretching using a turnbuckle
orthosis for elbow stiffness: a prospective
study
Anil K Bhat, Kumar Bhaskaranand, Surej Gopinathan Nair
Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka, India
ABSTRACT
Purpose. To assess the effectiveness of a turnbuckle
orthosis as a means of improving the range of motion
in patients with elbow stiffness.
Methods. 17 males and 11 females aged 8 to 68 (mean,
32) years underwent static progressive stretching using
a turnbuckle orthosis for elbow stiffness secondary to
trauma or surgery. Patients were instructed to wear the
orthosis during the daytime for a mean of 15 hours and
remove it during sleep as well as at breakfast, lunch,
and dinner. One hour of range-of-motion exercise was
performed during each break. Patients were followed
up every month and the range of motion was recorded
with a standard goniometer. The use of orthosis was
discontinued when there was no further improvement.
Range-of-motion exercise was encouraged thereafter to
maintain the results. The extent of flexion contracture
and range of motion before and after the treatment
were compared.
Results. The mean duration of orthosis use was 5
(range, 3–8) months. The mean flexion contracture
reduced from 59º to 27º and the range of motion
improved from 57º to 102º. 19 of the patients achieved
Address correspondence and reprint requests to: Dr Anil K Bhat, Department of Orthopaedics, Kasturba Medical College,
Manipal, 576104, Karnataka, India. E-mail: anilkbhat@yahoo.com
a functional range of motion. Improvement in the
range of motion was excellent in 6 patients, good in
11, satisfactory in 7; at the end of follow-up (mean,
29 months), the results were maintained or improved
further in 20 patients (even in those with long-
standing contractures).
Conclusion. Static progressive stretching using a
turnbuckle orthosis is reliable and cost-effective for
treating elbow stiffness.
Key words: contracture; elbow joint; muscle stretching
exercises; orthotic devices; range of motion, articular; splints
INTRODUCTION
A stiff elbow restricts the function of the entire upper
limb.1 The extent of elbow stiffness is determined by
the force of injury, the extent of periosteal stripping,
the degree of articular involvement, and the duration
of immobilisation. Re-establishment of the range of
motion can be difficult because of the proximity of
joint musculature, a high degree of articular congruity,
and the vulnerability of soft tissues; all are major
limiting factors in elbow rehabilitation.2
Non-operative management for elbow stiffness
Vol. 18 No. 1, April 2010 Turnbuckle orthosis for elbow stiffness 77
includes passive- and active-assisted mobilisation,
continuous passive motion,2 manipulation under
anaesthesia,3 serial casting,4 and static splinting.2,5,6 All
these are time consuming and therapist dependent,
with moderate-to-low ability to improve the range of
movement.7
A turnbuckle orthosis works on the principle
of static progressive stretching followed by load
relaxation of the stretched tissues to gradually
improve the range of motion by plastic deformation.1,8
The dense contracted tissues undergo a biological
response that modifies the length or cross-linking of
collagen.9,10 By contrast, dynamic splinting2,5,6 (based
on the principle of creep) places a contracted tissue
under a constant load causing soft-tissue damage and
inflammation, which leads to a loss of range of motion
in the opposite direction. We therefore assessed the
effectiveness of a turnbuckle orthosis as a means of
improving the range of motion in patients with elbow
stiffness.
MATERIALS AND METHODS
Between February 2004 and March 2008, 34 patients
underwent static progressive stretching using a
turnbuckle orthosis to treat elbow stiffness secondary
to trauma or surgery. Their functional range of motion
was restricted (<100º elbow flexion [from 30º to 130º]
and <100º forearm rotation [50º pronation and 50º
supination]),11 and whatever the improvement there
was had plateaued after a mean of 11 (range, 6–26)
weeks of supervised physiotherapy. Patients with
heterotopic ossification and bony blocks around the
elbow were excluded, as were those with burns,
paralytic causes, infection, and systemic arthritis. 17
males and 11 females aged 8 to 68 (mean, 32) years
who were followed up for at least 12 (mean, 29; range,
12–49) months were included in the analysis. All
had undergone open reduction and internal fixation
(n=18), anterior transposition of the ulnar nerve (n=1),
or conservative treatment (n=9); 16 involved the right
side, 12 the left side, and in 19 it was the dominant
side. The aetiology of stiffness included fractures
around elbow (n=23), posterior dislocation (n=2), and
immobilisation not involving the elbow joint for >4
weeks (n=3).
The turnbuckle orthosis consisted of an arm
component and a forearm component (made of
alkathane), double hinges at the elbow (in line with
the medial and lateral epicondyles), and a turnbuckle
(placed in the midline to provide greater mechanical
strength) [Fig. 1]. The length of the turnbuckle was
adjusted by turning; one full revolution translated to
Figure The turnbuckle orthosis consists of the arm and
forearm components, the turnbuckle at the midline, and the
elbow hinges.
a distance of 2 mm. Patients were taught to actively
stretch the elbow to the point of discomfort but not
pain, as pain suggests soft-tissue tears that induce
inflammation and further scarring and stiffness. The
turnbuckle was tightened further when the feeling
of discomfort subsided. This gradual application of
load maximises the viscoelastic nature of soft tissues
and enables them to respond in a more compliant and
ductile manner to achieve plastic deformation.12
Patients were instructed to wear the orthosis
during the daytime for a mean of 15 hours and
remove it during sleep as well as at breakfast, lunch,
and dinner. One hour of range-of-motion exercise
was performed during each break to ensure that the
gain in range of motion in one direction was not at the
expense of the opposite direction. The time spent on
exercise was reduced when sleep exceeded 6 hours.
Patients were followed up every month and the
range of motion recorded with a standard goniometer.
Any symptoms of neurovascular compromise or
pressure sores were recorded. Use of the orthosis
was discontinued gradually over a one-month period
when there was no further improvement in the range
of motion over at least one month. Thereafter, range-
of-motion exercises were encouraged to maintain
the gains. The extent of flexion contracture and the
range of motion before and after the treatment were
compared using the paired-t test.
RESULTS
The mean time from injury/surgery to orthosis use
was 7 (range, 4–24) months; in 7 of these patients
it was 16 months. The mean duration of orthosis
use was 5 (range, 3–8) months. The mean flexion
contracture reduced from 59º to 27º and the range of
motion improved from 57º to 102º (Table 1). 19 of the
patients achieved a functional range of motion.11
78 AK Bhat et al. Journal of Orthopaedic Surgery

Table 1
Flexion contracture and range of motion before and after the orthosis use

Study Mean±SD (range) flexion Mean±SD (range) maximum Mean±SD (range) range of
contracture flexion motion
Green and McCoy8
Before orthosis use 60º±15º (40º–90º) 118º±20º (85º–150º) 58º±29º (10º–110º)
After orthosis use 23º±19º (0º–70º) 124º±17º (90º–150º) 101º±29º (45º–135º)
Gelinas et al.13
Before orthosis use 32º±10º (10º–55º) 108º±19º (80º–150º) 76º±17º (35º–110º)
After orthosis use 27º±10º (5º–45º) 127º±12º (105º–145º) 100º±18º (65º–135º)
Present study
Before orthosis use 59º±16º (12º–90º) 118º±18º (77º–145º) 57º±24º (12º–101º)
After orthosis use 27º±13º (0º–52º) 126º±17º (80º–145º) 102º±24º (45º–131º)
Improvement 32º±9º (12º–46º) 8º±11º (-5º–38º) 45º±16º (20º–67º)
t 16.64 3.18 12.90
p Value <0.001 0.004 <0.001
End of follow-up 28º±13º (0º–54º) 129º±29º (13º–145º) 100º±30º (13º–129º)
(mean, 29 months)

In 4 patients the orthosis was used to improve Table 2

flexion alone, but there was also a mean of 12º gain
in extension. In 19 patients the orthosis was used to
improve extension alone, 4 lost a mean of 5º (range,
4º–8º) of flexion, 5 maintained their maximum flexion,
and 10 gained a mean of 9º (range, 3º–19º) of flexion.
In 5 patients the orthosis was used to improve both
flexion and extension, their mean gains in flexion and
extension were 30º and 35º, respectively. The orthosis
did not have any effect on forearm pronation and
supination.
After the treatment, improvement in the range
of motion was excellent in 6 patients, good in 11,
satisfactory in 7, and poor in 4 (Table 2). All 4 patients
with poor outcome had undergone more than 2
surgeries entailing variable periods of immobilisation.
Of the 6 patients with excellent outcomes, one had a
lateral condylar fracture, 3 had post-immobilisation
stiffness following a forearm injury, and 2 had
post-traumatic stiffness following an intercondylar
humeral fracture.
Two patients had mild cutaneous allergic
reactions to the ethaflex lining, which resolved
after a cloth fabric was used. A 36-year-old woman
(who had posterior dislocation) developed an ulnar
neuropathy. She underwent anterior transposition of
the ulnar nerve and then resumed using the orthosis.
At the end of follow-up (mean, 29 months), 5
patients maintained their range of motion, 8 lost a
mean of 4º (range, 2º–13º), and 15 gained a mean of
further 4º (range, 2º–7º).
DISCUSSION
Orthotic devices based on the principle of static
Improvement in range of motion after orthosis use
Improvement in range Grading No. of
of motion patients
>55º Excellent 6
40º–55º Good 11
25º–39º Satisfactory 7
<25º Poor 4
progressive stretching are effective in treating elbow
contractures,8,13,14 although not all parties agree.15
Unsatisfactory results are probably due to poor patient
compliance in wearing the orthosis during sleep and
activities of daily living.13,14 The compliance of all our
patients was good; they wore the orthosis during the
daytime for a minimum of 15 hours. Nonetheless,
a randomised study is needed to determine which
regimen of orthosis use, and what intensity and
frequency of intervention are the most effective. All
our patients had undergone a course of supervised
physiotherapy before using the orthosis. They acted
as their own controls for the purpose of determining
improvement in the range of motion.
Stress relaxation leads to a reduction in applied
forces over time, in a material that is stretched and
held at a constant length. This results in realignment
of fibres and elongation of the material.16 In contrast
to dynamic splinting that exerts a force that does not
stop when the tissues reach their elastic limit and thus
causes microtrauma, appropriately set tension of the
orthosis does not continue to stress tissues beyond
elastic limit.17
At the initial assessment, most of our patients
had a hard-end feeling at the extremes of movements,
Vol. 18 No. 1, April 2010 Turnbuckle orthosis for elbow stiffness 79

suggestive of mature scar tissue with advanced cross-
linking with a probable ‘check-rein’. These joints
required more torque to achieve a maximum range
of movement and thus a static progressive splint was
used.17 Soft-end feeling or springiness is indicative of
younger scar tissue or transient physiologic changes
(such as swelling or poor-quality cartilage). These
joints require less torque to achieve a maximum
range of movement and thus a dynamic splint should
suffice.
Some studies regard the turnbuckle orthosis as
ineffective in long-standing contractures.8,13 However,
in 7 of our patients, the interval was 9 to 24 months
post injury/surgery and yet a mean improvement
in the range of motion was 44º. This compares
favourably to a patient who applied the orthosis 22
months after injury and achieved a 20º gain in the
range of motion.8
Placing the turnbuckle in the midline rather
than on the lateral side is biomechanically
more efficient. This avoids the rotational effect
on the forearm and may contribute to greater
improvement in the range of motion, thus ensuring
greater transference of the force imparted by
the turnbuckle in stretching the tissues. 18 The
turnbuckle orthosis is also easy to fabricate,
amenable to alterations, and cost-effective (US$35),
all of which should increase patient compliance and
successful outcome.
ACKNOWLEDGEMENTS
We thank Mr William Frederic, Mr Balasubramaniam,
and Mr Prabhakar Acharya for designing and fitting
of the turnbuckle orthosis.

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