UCL reconstructions are indicated in patients with persistent medial elbow pain with throwing/overhead activities despite nonoperative treatments who are willing to participate in a postoperative rehabilitation program. Seasonal timing, competitive level, personal expectation, and concomitant pathology of the elbow can influence the indications for the surgery.

Although there is limited literature documenting the efficacy of nonoperative management of UCL tears in overhead throwing athletes, conservative management is the initial approach in most cases. There is uniform consensus that initial strategies for recovery include a 6- to 8-week period of cessation from sport that also incorporates principles of restoration of elbow and shoulder motion, shoulder rotator cuff endurance, scapular stability, and eventual introduction of a modified throwing program. Platelet-rich plasma (PRP) injections to the medial elbow have been advocated by some to enhance healing of the injured ligament before and/or during rehabilitation, but current supporting outcomes research is lacking to provide universal agreement regarding the efficacy of PRP treatments.

A successful rehabilitation program will address specific areas of the kinetic chain (lower extremity/core) with particular attention to restoration of shoulder motion/strength. Principles of total range of motion (TROM) and strength ratios of the rotator cuff are evaluated and treated to significantly decrease potential injury risk upon return to competitive sport. Once motion is restored, adequate shoulder strength ratios are achieved, and total glenohumeral ROM is within acceptable parameters, an athlete may begin a modified two-phase throwing program. This program encompasses flat ground throwing followed by mound throwing progressions designed to safely expose the elbow/shoulder to progressive stresses with gradual return to full competition.

UCL reconstruction is contraindicated if the tear is asymptomatic (no associated symptoms with throwing), the patient is unwilling or not able to participate in a postoperative rehabilitation program, or the patient has inappropriate expectations following surgical procedure despite counseling.

The ipsilateral palmaris longus or gracilis tendon is harvested. A curved 8-cm to 10-cm skin incision is centered over the medial epicondyle. The dissection protects the medial antebrachial cutaneous nerve branches. A muscle-splitting approach is then used, which incises the raphe of the flexor carpi ulnaris (FCU). The muscle fibers are bluntly separated from the UCL. The ulnar nerve traverses posterior to the border of the MCL and is retracted for its protection. Eventual transposition of the ulnar nerve is carried out following completion of the MCL reconstruction if indicated based on significant ulnar nerve symptoms or ulnar nerve subluxation. A longitudinal incision is made in the UCL (Figure 15.1). Gapping of the ulnohumeral articulation indicates UCL insufficiency. Pathology, such as ulnar or humeral detachment and midsubstance damage, is observed. Two converging tunnels are made with a drill in the ulna, one anterior and one posterior to the sublime tubercle. Tunnels are created on the inferior medial epicondyle at the anatomic origin of the anterior bundle without penetrating the posterior cortex. One 3.2-mm drill tunnel is placed just anterior to the attachment of the medial intermuscular septum and directed to communicate with the central drill hole. A second 3.2-mm drill tunnel is made, leaving at least a 1-cm bone bridge. The graft is passed through the ulna bone tunnels and through the medial epicondyle, creating a figure-eight configuration (Figure 15.2). Tension is applied to the graft and the ulnar side of the graft is sutured to the remnants of the UCL adjacent to the sublime tubercle. The proximal limb of the graft is sutured to the medial intermuscular septum. If possible, the native ligament is repaired over the graft. The muscle fascia and skin are closed.

The docking technique is a modification to the Jobe method to ease graft passage, decrease epicondylar tunnel diameters, and improve graft tensioning. The docking technique uses the muscle-splitting approach with similar ulna tunnels as described for the modified Jobe technique. A central distal humeral tunnel is located in the medial epicondyle at the anatomic insertion of the native UCL. The upper border of the epicondyle is exposed, incising the overlying muscular fascia. Two 2-mm exit tunnels with a 5-mm to 1-cm bone bridge are drilled from superior to inferior, communicating with the central tunnel at its proximal apex. The graft is passed through the ulnar tunnels; then, the posterior limb of the graft is passed into the central humeral tunnel and tensioned on the far cortex by pulling its associated sutures through the posterior exit tunnel. The anterior limb of the graft is then estimated for proper length; sutures are placed in it and docked into the humeral tunnel (Figure 15.3). The sutures controlling the graft are then tied over the bony bridge on the humeral epicondyle with the elbow in 40 to 60 degrees of flexion, forearm supination, and varus stress. The fascia overlying the flexor pronator mass is repaired, and the skin is closed in standard fashion.

The rehabilitation specialist must consider the surgical technique utilized to properly design safe and progressive isotonic strengthening exercises for the patient. The modified Jobe technique will allow the rehabilitation specialist to perform ROM and resistive exercise earlier in the rehabilitation course secondary to a muscle-splitting/sparing visualization to the medial elbow when compared to previous techniques that utilized a complete detachment of the flexor/pronator complex. The modified Jobe technique will allow for earlier flexibility to the wrist and forearm. Scar tissue mobilization is utilized at the proximal wrist to limit a dimple effect (indentation resulting from palmaris longus graft harvesting). Palmar aponeurosis extensibility will also be promoted with early mobilization of the wrist and hand, which allows greater extensibility for wrist/hand motion and dexterity (Figure 15.4).

The rate of progression toward achieving full passive range of motion (PROM) and transitioning to the intermediate strengthening phase will be based on the surgical procedure performed, physiologic healing response of the patient (end feel), and patient subjective reports. The elbow is initially immobilized in a posterior splint in 90 degrees of elbow flexion and neutral forearm rotation for 5 to 7 days to protect the graft, flexor/pronator musculature, and skin incision. The elbow is then placed in a hinged brace to allow ROM while continuing to protect the reconstruction.

Postoperative complications can present in the early rehabilitation phase regarding elbow extension. Pain associated with arthroscopy/osteophytic débridement, elbow edema, and resultant spasmodic activity of the forearm flexors and extenders can cause limitation in elbow ROM. Prolonged pain and muscle spasm may produce elbow flexion soft-tissue contractures and elbow joint capsular stiffness secondary to anterior capsular adhesions. The rehabilitation specialist can minimize the propensity for elbow stiffness by consistently evaluating the end feel when performing ROM exercise during the early rehabilitation course. If the patient exhibits a loss of motion and a firm elbow capsular end feel with no pain, more
aggressive PROM techniques, such as grade 3 or grade 4 joint mobilization and static progressive stretching (Figure 15.5), can be employed. If pain is present with a loss of motion prior to an end feel being established, a more conservative approach utilizing soft-tissue massage, heat modalities, grade 1 or grade 2 ulnohumeral joint distraction, and low-amplitude stretching may be warranted.

The transition from the immediate postoperative phase to the intermediate strengthening phase begins at week 4 and progresses to week 8. There are specific clinical markers pertaining to motion and strength that must be addressed during this time interval. Full elbow motion should be achieved by week 6. Upper extremity strengthening is progressed with particular attention placed on glenohumeral rotator cuff strengthening, scapular stabilization, and core endurance. Upper extremity strengthening progresses with elbow forearm flexors/extensors achieving grade 4 on manual muscle testing.

Isotonic strengthening of the shoulder and elbow complex is initiated during this phase to promote rotator cuff co-contraction for glenohumeral stability, elbow proximal stability, and periscapular neuromuscular control. The principles of the “throwers 10 program” are utilized during postoperative weeks 5 to 6, which include shoulder internal and external rotation (limited external ROM to neutral to decrease valgus stress to elbow) using resistance bands. Standing shoulder abduction and standing scaption are incorporated initially using arm weight and then slowly progressed with weighted dumbbells. Side-lying external rotation, prone extension, prone scaption, and prone abduction with external rotation are performed to enhance proximal shoulder girdle strength. Isotonic elbow strengthening includes wrist flexion, extension, and forearm pronation/supination with progression based on patient symptoms and endurance. Resistance exercises are progressed from 3 sets of 10.

Neuromuscular control drills for the scapula are performed in a side-lying position (Figure 15.6) and progressed to a seated position to challenge core musculature. A stability ball is introduced during postoperative weeks 8 to 10 for higher-level neuromuscular control of the upper and lower extremities. The patient performs shoulder isotonic exercise in a seated and prone position on the stability ball to promote higher levels of glenohumeral/scapulothoracic stabilization while performing isotonic shoulder strengthening (Figure 15.7). Lower extremity and core stability exercises are incorporated for enhanced kinetic chain recruitment. Resistance exercise is generally alternated between stability ball shoulder isotonic strengthening and plinth exercises, with higher repetitions and lower resistance utilized for stability ball exercises for the promotion of muscular endurance. Arm ergometry (arm cycle) further promotes muscular endurance and upper extremity (shoulder and elbow) mobility; thus, it should be incorporated and continued throughout the remainder of the rehabilitation program. Manual resistance exercises of the elbow flexors are also introduced and have an important role in medial elbow stabilization during throwing (Figure 15.8). Two sets of 10 repetitions are prescribed for these exercises to enhance muscular strength and endurance development. Shoulder manual side-lying external rotation (Figure 15.9A) and manual prone rowing are promoted for posterior rotator cuff strengthening (Figure 15.9B).

Neuromuscular control drills emphasizing proprioceptive facilitation such as rhythmic stabilizations with medicine ball perturbations (Figure 15.10) aid in co-contraction of musculature at the elbow and shoulder joint necessary for stabilization and controlled motion during sport-related activity. The exercises are initiated with proximal perturbations close to the glenohumeral joint and progressed to the distal extremity for higher-level neuromuscular control.