Rehabilitation after UCLR: 12 Week Post-Op to Return to Play

During this phase of rehabilitation after Tommy John surgery, isokinetic exercise can be initiated if available and interval throwing program (ITP) can be initiated. In most protocols, isokinetic shoulder internal and external rotation, wrist flexion and extension, and forearm pronation and supination exercises can be initiated after 12 weeks after surgery. Shoulder internal and external rotation exercise may be initiated even earlier. However, these exercises should be done pain free or any ulnar nerve symptoms. Shoulder and wrist plyometric exercises after 12 weeks. Strengthening exercises should be advanced including shoulder exercises with shoulder in 90 degrees of abduction (closer to throwing motion). The athlete will start swinging a bat and start a batting program. Fielding the ball can also the initiated without throwing.  

 ITP is usually initiated after 16 weeks post-operatively. There are several ITP's available, each of which starts with short distance and gradually increases in distance and the number of throws (an example of ITP is listed below). Again, ITP must be done symptom free throughout. If any symptoms exist, it should be stopped until it resolves. After completion of ITP, the athlete will gradually return to play. For baseball pitchers, it usually takes about 10-12 months before they will start pitching in a game.

The goals of this phase are 1) to maintain full ROM, 2) to advance in strengthening program, 3) to initiate plyometric exercise for shoulder and wrist, 4) to start sport specific training such as ITP, swinging a bat, and fielding, and 5) to gradually return to play. 

Interval Throwing Program (ITP) (Phase 1: Soft Toss) 

Distance (ft)                   Warm-Up                  # of Throws

30                                                                      20 - 20
45                                    30                              20 - 20
60                                  30 - 45                         20 - 20
75                                  30-45-60                      20 - 20
90                                  45-60-75                      20 - 20
120                                45-60-90                      20 - 20
150                                45-60-90-120               20 - 20
180                                45-60-90-120-150        20 - 20

This is an example of ITP. The athlete will soft-toss 2-3 times at each distance before advancing to next and may throw 10-15 times at each distance for warm-ups. And ITP should be done every other day. The distance can go farther than 180 feet if athletes want to. 

Interval Throwing Program (ITP) Phase 2

In this phase of ITP, the athlete will start throwing with intensity gradually increasing. They will start at a shorter distance (around 60 feet) and less intensity (50%) and gradually increase in intensity and distance as needed.

Rehabilitation after UCLR: 6-12 Week Post-Op

After 6 weeks post-operatively, strengthening exercises of forearm, wrist, and shoulder should be advanced while maintaining/regaining full ROM of the elbow. Isometric and isotonic exercises can be used for forearm, wrist, and shoulder muscles. The goals of this phase is 1) to maintain or regain full ROM, 2) to control pain/inflammation, and 3) to progress in strengthening program. Some examples of shoulder (posterior cuff and scapular) exercises can be seen in our website (Please note that NOT ALL of these exercises are appropriate for this phase of rehabilitation after UCLR). Wrist curls using free weights and tubing, radial and ulnar deviations, pronation and supination, grip exercises are some of examples.

If full ROM is not achieved by this phase, it is critical to regain full ROM, especially in extension. ROM (active and passive) exercise to regain full ROM should be emphasized. Exericises that cause any pain on the surgical site or any ulnar nerve symptoms should be avoided. Note that ulnar nerve may or may not be transpositioned.

Use of elbow brace is usually discontinued at week 6 (may vary depending on the surgeon's protocol).

Rehabilitation after UCLR: 2-6 Weeks Post-Op

During this phase of rehabilitation after UCLR, elbow range of motion (ROM) is increased gradually (i.e.5 degrees/week). The goal of this phase is to regain full ROM by the week 6, especially extension, control pain/inflammation, and retard muscle atrophy. Shoulder and scapula strengthening exercises can be initiated in this phase as well as some forearm exercises such as grip exercises and wrist exercises. It is more common to use the muscle splitting technique than cutting the forearm muscles to reconstruct UCL, however, aggressive forearm strengthening targeting the wrist flexors/forearm pronators using heavy weights should be avoided in this phase. If the forearm muscles are cut, any forearm flexor strengthening should be avoided at least 6 weeks after surgery. Some of the shoulder and scapular exercises can be found on our website (Note that some of these exercises may not be allowed in some protocols). Also note that any strengthening exercise should be done pain-free. All of the rehabilitation exercises (ROM and strengthening) are to be progressed based on tissue healing and athletes' tolerance.    

Rehabilitation after UCLR: Immediate Post-Op

Ulnar collateral ligament injuries are very common in baseball pitchers and some other over head athletes such as javelin throwers. When athletes tear their UCL, surgical reconstruction of the injured ligament is often needed to restore stability of the medial elbow. There are several approaches to surgical methods including fixation method. Also, post-surgical rehabilitation protocol may vary depending on the surgeon. We will discuss general rehabilitation process for UCLR, however, please note that protocols may vary depending on who the surgeon is.

Immediate Post-Op (Week 1-2)

The goals of this phase are to protect reconstructed graft and graft site, to decrease inflammation, and to retard muscle atrophy. The athlete's elbow will be put in a splint right after surgery for about a week. Then, he/she will be fitted to an elbow brace with range of motion (ROM) usually limited from 30 degrees of extension to 100 degrees of flexion. The athlete may start doing wrist flexion/extension active range of motion (AROM) exercises and grip exercise.

Schematic view of reconstructed graft using end button

Tommy John Surgery

Tommy John surgery is a commonly used name for ulnar collateral ligament (UCL) reconstruction. There are several different methods to reconstruct torn UCL, such as Jobe procedure, docking technique, modified docking technique, DANE procedure, etc. There are different fixation methods, different graft donating sites, different approach to the ligament, etc. Originally, the procedure was done detaching the forearm muscle group to access the reconstruction site. However, it is more common now to split the muscle instead of detaching it. Usually, the muscle in the forearm called palmaris longus is used as a graft, however, it can be taken from the knee muscle. Also, originally, ulnar nerve transposition (relocating the 'funny bone' nerve) was done at the same time the Tommy John surgery was done. However, it may not be done unless the athlete is having ulnar nerve symptoms. There are several variations to this procedure, but, the goal of the surgery is to regain stability to the elbow by reconstructing a torn UCL which provides static constraint to the medial side of the elbow in throwing motion. 

       Rehabilitation after UCLR is a long process. It usually takes about 10-12 months to return to full pitching activities. Even after returning to full pitching, a pitch count and innings pitched may be limited. Studies show about 85% success rate after the procedure. However, it may take longer than 12 months to return to pre-injury performance level. Recently, Stephen Strasburg of Washington Nationals came back from Tommy John surgery and seems to be pitching well. Joe Nathan (Texas Rangers) is in his 2nd year coming back, I believe. Fransisco Lariano (Minnesota Twins) seems to be struggling. Adan Wainright (St.Louis Cardinals) is pitching his first season after the surgery.

       We will discuss rehabilitation after UCLR later.     

UCL Injury in Baseball Pitchers

It's only a few weeks into Major League Baseball season and there have already been a few pitchers  that are out of UCL tear requiring surgery. But what is UCL? Why is this so common? The ulnar collateral ligament of the elbow (UCL) is located in the medial side (inside) of the elbow connecting two bones (humerus and ulna) and plays a primary role in stabilizing the joint during pitching motion, especially during cocking phase. It is also under considerable amount of stress close to its maximal capacity before it fails according to the literature. The muscles around the ligament and joint also play a role as a dynamic constraint to protect the joint and the ligament from an injury. However, over time and from repetitive stress from pitching may put enough stress to injure the ligament. A tear can happen in one pitching motion, however, the most of the times, it is from overuse. Can we prevent this?! Sure, we can! It is important that pitchers especially in younger age limit their pitch count. One study shows that younger pitchers who pitch more than 100 innings per year are 3.5 times more likely to injure their shoulder or elbow. It is also important that they learn a good pitching mechanics. We know that poor throwing mechanics will put more stress in the shoulder and the elbow. We also need to address the whole body as kinetic chain because the majority of the strength to throw baseball is created in the lower extremities not in the throwing arm. Any break in the kinetic chain will result in more stress placed on some other parts of it. Imagine throwing baseball on the firm ground, then, in the mud.....it would be more difficult to throw hard in the mud, right?! That's how important the legs are in order to be able to throw or pitch.

Ulnar Colleteral Ligament of the Elbow

   

Core Stabilization Exercise III

In our past post, we discussed basic core strengthening exercises such as pelvic tilt or draw-in exercise. This is the fundamental of core exercises because that position has to be maintained during any core exercises. Click here to read the post. There are numerous things you can do to make it harder once draw-in exercise can be achieved easily. One way to do it is to add arm and leg movements. From that draw-in position, you can slide one led down straightening the leg and  slide it back up and alternate legs. Once again, the draw-in position must be maintained during leg movement. Dead-bug exercise is more advanced core exercise. Plank is also a good core stability and endurance exercise. It can also be made more difficult by using an unstable surface (see picture).  Burdock, lower trunk rotation, multifidus walk, etc. also are a good core exercises. However, theses exercises only mean a little if the fundamental of core exercise is not established.

What We Don't Know about ACLR: Grafts' Health

Athletes can return to sports successfully after ACLR even though there are chances of re-injury. Rehabilitation process has been shortened and they may return as soon as 4 months post-operatively. However, it is unclear that what is healthy and what is unhealthy to do in a rehabilitation process. We do know what puts stress on the graft and mechanisms of injury. So, we need to avoid things that stress it. For example, during the last 30 degrees of open kinetic knee extension, ACL is under stress from quadriceps muscle contraction force. But we can only assume that things such as walking, weight-bearing, not using a knee brace or crutches are safe to do. But we do not know for sure that it is safe in a long run. We just know that athletes do well either way and it does not appear to affect rehabilitation process or re-injury rate. It is difficult to know how safe and what is safe without knowing graft maturation process and when they are ready to do what. To our knowledge, there are no studies that show when it is too early to do what in terms of graft safety and re-injury rate. We just know the most athletes do well with current ACLR rehabilitation protocols. We feel like there are a lot more studies to be done on this topic especially some studies suggest that ACL grafts elongate after surgery as much as 3mm compared to graft length at the time of reconstruction. Some studies show that re-injury rate after ACLR in active people may be up to 18%. There are many things we know about ACL compared to 10 years ago, but, at the same time, there are many things we do not know yet.   

Soft Tissue/Bony Adaptation in Throwing Elbow

It is known that our body has an ability to adapt in response to stress placed on it. Muscles get bigger and stronger after weight lifting. Endurance improves after prolonged exercise. In similar way, properties of joints and soft tissues changes as a result of stress placed on them. For example, in overhead athletes, they will lose the amount of internal rotation range of motion (ROM) and gain external rotation ROM, commonly known as GIRD (glenohumeral internal rotation deficits). In throwing elbow, as a result of repetitive throwing motion, soft tissue and bony adaptation about the elbow joint occurs. During throwing motion, distractive force is placed on the medial side (inside) of the elbow, where ulnar collateral ligament is. Compressive force exists on the lateral side (outside) of the joint. Also, stress is placed between trochlea and olecranon on the back of the elbow joint. After repetitive stress placed on the joint, it is shown that properties of UCL may change without any symptoms. In a study conducted on non-injured high school-aged baseball pitchers, MRI's were taken on their throwing elbows and non-throwing elbows and those images were compared. They found out that more than 60% of pitchers had thickening of the ligament in throwing elbow. Also, they found sclerosis in ulnar-throchlea joint without symptoms. Sclerosis means hardening of a bone mainly as a result of repetitive direct contact between two bones. We do not know it this will be a risk factor for future injuries or this may indicate anything significant. However, even in healthy pitchers, these changes do occur. When evaluating throwing athletes, it is important to know that these changes in MRI may not indicate an actual injuries if it is not consistent with objective and subjective evaluation. Other findings in the study was edema around UCL attachment, bone spur, etc. Further studies will be needed to investigate whether this soft tissue and bony adaptation may indicate risks of future injuries.  

MRI image of UCL tear