The medial elbow is exposed to tensile forces, and the lateral elbow is forcefully compressed during the throwing motion, therefore both ligament complexes are at risk for injury.
The Thrower’s Ten Program consists of an upper limb-strengthening program and plyometric exercises that are slowly initiated and commonly used in nonoperative management of elbow instability.
Postsurgically, therapists need to receive detailed information about ligament reconstruction to initiate an appropriate early motion program.
Postoperative management requires a balance between stability to avoid stress on ligamentous repair and mobility to minimize loss of elbow motion.
Management of elbow instability requires rehabilitation for the entire kinetic chain, including the scapula, upper limb, trunk and pelvis (core), and lower extremities to ensure the athletes’ return to high-level sports participation.
Athletes employing overhead movements often experience injuries to the elbow. The repetitive overhead motion involved in throwing is responsible for unique and sport-specific patterns of injuries to the elbow. These are caused by chronic stress overload or repetitive microtraumatic stress observed during the overhead pitching motion as the elbow extends at over 2300 degrees/sec, producing a medial shear force of 300 N and lateral compressive force of 900 N. In addition, the valgus stress applied to the elbow during the acceleration phase of throwing is 64 N•m, which exceeds the ultimate tensile strength of the ulnar collateral ligament. Thus, the medial aspect of the elbow undergoes tremendous tensile (distraction) forces, and the lateral aspect of the elbow is forcefully compressed during the throwing motion. The posterior compartment is subject to tensile, compressive, and torsional forces during acceleration and deceleration phases. This may result in valgus extension overload with the posterior compartment leading to osteophyte formation, stress fractures of the olecranon, or physeal injury.
The purpose of this chapter is to provide an overview of general rehabilitation principles for elbow instability. Furthermore, specific nonoperative and postoperative treatment guidelines for the thrower’s elbow are also discussed.
Ulnar Collateral Ligament Injury
Injuries to the ulnar collateral ligament (UCL) of the elbow are becoming increasingly more common in overhead-throwing athletes, although the higher incidence of injury may be due to our increased ability to diagnose these injuries. The elbow experiences a tremendous amount of valgus stress during overhead throwing. These stresses approach the ultimate failure load of the ligament with each throw. The repetitive nature of overhead-throwing activities such as baseball pitching, javelin throwing, and football passing further increase the susceptibility of UCL injury by exposing the ligament to repetitive microtraumatic forces. The stresses on the UCL are greater with specific types of pitches, such as the slider and split-fingered pitch.
Nonoperative treatment is attempted with partial tears and sprains of the UCL, although surgical reconstruction may be warranted for complete tears or if nonoperative treatment is unsuccessful. Our nonoperative rehabilitation program is outlined in Box 87-1 . Range of motion (ROM) is initially permitted in a nonpainful arc of motion, usually from 10 to 100 degrees, to allow for a decrease in inflammation and the alignment of collagen tissue. A brace may be used to restrict motion as well as prevent valgus loading. Furthermore, it may be beneficial to rest the UCL immediately following the initial painful episode of throwing. This is done to prevent additional deleterious stresses on the injured UCL. Isometric exercises are performed for the shoulder, elbow, and wrist to prevent muscle atrophy. Ice and anti-inflammatory medications are prescribed to control pain and inflammation.
Immediate Motion Phase (Week 0–2)
Goals: Increase ROM
Promote healing of ulnar collateral ligament
Retard muscle atrophy
Decrease pain and inflammation
Brace (optional) nonpainful ROM [20–90 degrees]
AAROM, PROM of elbow and wrist (nonpainful range)
Isometrics—wrist and elbow musculature
Shoulder strengthening (no external rotation strengthening)
Ice and compression
Intermediate Phase (Week 3–6)
Goals: Increase ROM
Improve strength and endurance
Decrease pain and inflammation
Gradually increase motion 0–135 degrees (increase 10 degrees/week)
Initiate isotonic exercises wrist curls, wrist extensions, pronation–supination, biceps–triceps dumbbells: external rotation, deltoid, supraspinatus, rhomboids, internal rotation
Ice and compression
Advanced Phase (Week 6–12)
Criteria to Progress
No pain or tenderness
No increase in laxity
Strength 4/5 of elbow flexors and extensors
Goals: Increase strength, power, and endurance
Improve neuromuscular control
Initiate high-speed exercise drills
Initiate exercise tubing, shoulder program: Thrower’s Ten Program, biceps–triceps program, supination–pronation, wrist extension–flexion, plyometrics throwing drills
Return to Activity Phase (Week 12 –14 )
Criteria to Progress to Return to Throwing:
Full nonpainful ROM
No increase in laxity
Isokinetic test fulfills criteria
Satisfactory clinical exam
Initiate interval throwing
Continue Thrower’s Ten Program
AAROM, active assisted range of motion; ROM, range of motion; PROM, passive range of motion.
ROM of both flexion and extension is gradually increased by 5 to 10 degrees per week during the second phase of treatment or as tolerated. Full ROM should be achieved by at least 3 to 4 weeks. Elbow flexion–extension motion is encouraged to promote collagen alignment. We attempt to control valgus loading onto the elbow joint to control stress on the UCL. Rhythmic stabilization exercises are initiated to develop dynamic stabilization and neuromuscular control of the upper extremity. As dynamic stability is advanced, isotonic exercises are incorporated for the entire upper extremity.
The advanced strengthening phase is usually initiated at 6 to 7 weeks after injury. During this phase, rehabilitation is progressed to the Thrower’s Ten Program, which consists of an isotonic strengthening program and plyometric exercises that are slowly initiated (see Appendix A , online). An interval return-to-throwing program, described in a later section, is initiated once the athlete regains full motion, adequate strength, and dynamic stability of the elbow. The athlete is allowed to return to competition following the asymptomatic completion of the interval sport program. The recurrence of symptoms during the interval throwing program is often observed as the athlete throws from longer distances, with greater intensities, or with off-the-mound throwing. If symptoms persist, the athlete is reassessed and possible surgical intervention is considered.
Lateral Collateral Ligament Injury
Stability of the elbow occurs mainly through the osseous configuration but secondarily through the medial and lateral collateral ligaments (LCLs). In particular, the lateral ligament complex prevents rotational instability between the distal humerus and the proximal radius and ulna. However, disrupting the soft tissue constraints through a traumatic onset often results in subluxation or dislocation. The elbow is the second most commonly dislocated large joint after the shoulder. In children younger than age 10 years, elbow dislocations are the most commonly dislocated joint.
In general, two main mechanisms of dislocation have been suggested. Elbow dislocations are thought to result from hyperextension, in which the olecranon process is forced into the olecranon fossa, and the trochlea is then levered over the coronoid process. Most elbow dislocations occur in a directly posterior or posterolateral direction. Very rarely will an anterior dislocation occur (~1%–2%). Another proposed mechanism of injury is posterolateral rotation, in which combined forces of axial compression, elbow flexion, valgus stress, and forearm supination create a rotational displacement of the ulna on the distal humerus.
Recurrent lateral instability of the elbow is a phenomenon that rarely occurs in the orthopedic patient population. Nestor and colleagues describe this recurrent posterolateral instability as a result of injury to the ulnar aspect of the LCL. This laxity allows transient rotator subluxation at the ulnohumeral joint along with secondary subluxation or dislocation of the radiohumeral joint. Generally, the annular ligament remains intact; therefore, the proximal radius and ulna continue to function as a single entity.
Nonoperative rehabilitation should commence immediately following the traumatic event. The focus of the rehabilitation is to restore ROM within the limits of elbow stability while slowly applying progressive stresses to the healing structures. Methods for controlling pain and swelling, such as cryotherapy and a compressive sleeve, may be utilized. Additionally, a hinged elbow brace with the forearm in a neutral or slightly pronated position is utilized to protect against excessive valgus and varus forces. The brace should restrict ROM to approximately 30 to 90 degrees initially, then is progressively increased by 5 degrees of extension and 10 degrees of flexion. A slow ROM progression for forearm supination and elbow extension protects the healing LCL structures. Wolff and Hotchkiss provide guidelines for early motion, as early as 2 days after injury, during the initial healing phase.
Strengthening activities may be initiated early on to prevent atrophy due to immobilization. Multiangle isometrics may begin during the initial phase (1–10 days after injury). Progressive resistance exercises for the elbow are introduced during the intermediate phase (days 10–14). During the advanced phase (weeks 2–8), functional progressions and sport-specific activities are initiated. The athlete may be allowed to return to sports participation once sufficient strength, power, and endurance are at least 85% of the uninvolved limb. A brace may be utilized during competition to prevent hyperextension and varus–valgus stresses.
General Rehabilitation Guidelines
Rehabilitation following elbow injury or surgery follows a sequential and progressive multiphased approach. The ultimate goal is to return the patient to the previous functional level as quickly and safely as possible. The next section provides an overview of the rehabilitation process after elbow injury or surgery, followed by rehabilitation protocols for specific pathologies.
Phase I: Immediate Motion
The first phase of elbow rehabilitation is the immediate motion phase. The goals of this phase are to minimize the ill effects of immobilization, reestablish nonpainful ROM, decrease pain and inflammation, and to retard muscle atrophy.
Early ROM activities are performed to nourish the articular cartilage and assist in the synthesis, alignment, and organization of collagen tissue. ROM activities are performed for all planes of elbow and wrist motions to minimize scar tissue adhesions. Active-assisted (AAROM) and passive range of motion (PROM) exercises are performed for the ulnohumeral joint to restore flexion–extension as well as supination–pronation for the radiohumeral and proximal radioulnar joints. Reestablishing full elbow motion, or preinjury motion, is the primary goal of early ROM activities to minimize the occurrence of elbow flexion contractures, which are common with elbow injuries. The preoperative elbow motion must be carefully assessed and recorded. Postoperatively, if the patient was not seen prior to injury or surgery, the therapist should ask the patient whether or not full elbow motion, especially extension, has occurred in the past 2 to 3 years. Wright and coworkers reported on 33 throwing athletes prior to the competitive season. The average loss of elbow extension was 7 degrees, and the average loss of flexion was 5.5 degrees. Postoperative ROM is often related to preoperative motion, especially in the case of UCL reconstruction. This can be a deleterious side effect for the overhead-throwing athlete. The elbow is predisposed to flexion contractures due to the intimate congruency of the joint articulations, the tightness of the joint capsule, and the tendency of the anterior capsule to develop adhesions following injury. The brachialis muscle also attaches to the capsule and crosses the elbow joint before becoming a tendinous structure. Injury to the elbow may cause excessive scar tissue formation of the brachialis muscle, resulting in adherence to the anterior capsule of the elbow.
In addition to ROM exercises, joint mobilizations may be performed as tolerated and indicated to decrease loss of motion. Initially grade I and II mobilizations may be used for pain modulation, progressing to grades III and IV at end ROM during later stages of rehabilitation when symptoms have subsided and joint motion needs to be restored. Joint mobilization techniques must include glides for all three articulations of the elbow: ulnohumeral, radiohumeral, and proximal radioulnar joints.
If the patient continues to have difficulty achieving full extension using therapeutic exercises and mobilization techniques, a low-load, long-duration (LLLD) stretch may be performed to produce a deformation (creep) of the collagen tissue, resulting in tissue elongation. We have found this technique to be extremely beneficial for regaining full elbow extension. The patient lies supine with a towel roll or foam placed under the distal brachium to act as a cushion and fulcrum. A light resistance exercise band is applied to the wrist of the patient and secured to the table or a dumbbell on the ground ( Fig. 87-1 ). The patient is instructed to relax as much as possible for 10 to 15 minutes per treatment. The amount of resistance applied should be of low magnitude to enable the patient to perform the stretch for the entire duration without pain or muscle spasm. This technique should impart a low load but a long-duration stretch. Patients are instructed to perform this stretch technique several times per day, equaling 60 minutes of total end-range time. Patients may perform a 15-minute stretch, four times per day. This type of program has been referred to as the TERT program (total end-range time). This program has been extremely beneficial for patients with a stiff elbow. Therapists with experience in orthotic fabrication may consider the use of various long arm orthoses that can provide a low-load, prolonged stretch to restore either elbow extension or flexion. Chapters 79 and 80 provide several examples of the use of long arm orthoses to restore elbow motion.
Stretching and mobilization techniques are based on healing constraints of the involved tissues, the specific pathology or surgery, and the amount of motion and end-feel. If the patient presents with a decrease in motion and hard end-feel without pain, a vigorous stretching and mobilization technique may be used. Conversely, a patient exhibiting pain before resistance or an empty end-feel progresses slowly with gentle stretching.
Another goal of this phase is to decrease the patient’s pain and inflammation. Grade I and II mobilization techniques may also be utilized to neuromodulate pain by stimulating type I and type II articular receptors. Cryotherapy and electrotherapy such as high-volt pulsed current may be performed as required to further assist in reducing pain and inflammation. Once the acute inflammatory response has subsided, thermotherapy agents such as hot packs and ultrasound may be used at the onset of treatment to prepare the tissue for stretching by enhancing extensibility of the capsule and musculotendinous structures. Increased tissue extensibility is likely to improve the motion achieved by therapeutic exercise and joint mobilizations.
The early phase of rehabilitation also focuses on voluntary muscle activation and preventing muscle atrophy. Nonpainful and submaximal isometrics are performed initially for the elbow flexors and extensors, as well as the wrist flexor, extensor, pronator, and supinator muscle groups. Shoulder isometrics may also be performed during this phase with caution against internal and external rotation exercises, if painful. Alternating rhythmic stabilization drills, a proprioceptive neuromuscular facilitation technique, for shoulder flexion, extension, horizontal abduction, adduction, internal and external rotation, along with the elbow flexors, extensors, supinators, and pronators are performed to begin reestablishing proprioception and neuromuscular control of the upper extremity.
Phase II: Intermediate
Phase II, the intermediate phase, is initiated when the patient exhibits full ROM, minimal pain and tenderness, and a grade equal to “good” (4/5) manual muscle test of the elbow flexor and extensor musculature. The emphasis of this phase is on enhancing elbow and upper extremity mobility, improving muscle performance (strength and endurance), and reestablishing neuromuscular control of the elbow complex.
Stretching exercises are used to maintain full elbow and wrist ROM. Mobilization techniques may be progressed to more aggressive grade III level as needed to apply a stretch to the capsular tissue at end-range. Flexibility is progressed during this phase to focus on wrist flexion, extension, pronation, and supination. Elbow extension and forearm pronation flexibility is of particular importance for throwing athletes to enable efficient throwing. Shoulder flexibility is also maintained in athletes, with emphasis on external and internal rotation at 90 degrees of abduction, flexion, and horizontal adduction. In particular, shoulder external rotation at 90 degrees of abduction is emphasized; loss of external rotation may result in increased strain on the medial elbow structures during the overhead throwing motion. Additionally, internal rotation stretching is also diligently performed.
Strengthening exercises are progressed during this phase to include isotonic contractions, beginning with concentric and progressing to include eccentric contractions. Emphasis is placed on elbow flexion and extension, wrist flexion and extension, and forearm pronation and supination. The glenohumeral and scapulothoracic muscles are also placed on a progressive resistance program during the latter stages of this phase. Emphasis is placed on strengthening the shoulder external rotators and scapular muscles, particularly the middle and lower trapezius muscles. A complete upper extremity strengthening program, such as the Thrower’s Ten Program may be performed (see Appendix A , online).
Neuromuscular control exercises are initiated in this phase to enhance the muscles’ ability to control the elbow joint during athletic activities. These exercises include proprioceptive neuromuscular facilitation exercises with rhythmic stabilizations ( Fig. 87-2 ) and slow reversal, manual resistance elbow–wrist flexion drills ( Fig. 87-3 ).
Phase III: Advanced Strengthening
The third phase involves a progression of activities to prepare the athlete for sport participation. The goals of this phase are to gradually increase strength, power, endurance, and neuromuscular control to prepare for a gradual return to sport. Specific criteria that must be met before entering this phase include full nonpainful ROM, no pain or tenderness, and strength that is at least 70% of the contralateral extremity.
Advanced strengthening activities during this phase include aggressive strengthening exercises that emphasize higher resistance, functional movements, eccentric contraction, and plyometric activities. Elbow flexion exercises are progressed to emphasize eccentric control. The biceps muscle is an important stabilizer during the follow-through phase of overhead throwing by eccentrically controlling the deceleration of the elbow and preventing pathologic abutting of the olecranon within the fossa. Elbow flexion can be performed with resistive tubing or bands to emphasize slow and fast concentric and eccentric contractions. Furthermore, manual resistance may be applied for concentric and eccentric contractions of the elbow flexors. Strengthening exercises with weight machines are also incorporated during this phase. These most commonly begin with bench pressing, seated rowing, and front latissimus dorsi pull-downs. The triceps are primarily exercised with a concentric contraction because of the acceleration (muscle shortening) activity of the muscle during the acceleration phase of throwing.
Neuromuscular control exercises are progressed to include side-lying external rotation with manual resistance. Concentric and eccentric external rotation is performed against the clinician’s resistance with the addition of rhythmic stabilizations. This manual resistance exercise may be progressed to standing external rotation with exercise tubing at 0 degrees and finally at 90 degrees of abduction ( Fig. 87-4 ).
Plyometric drills can be an extremely beneficial form of functional exercise for training the elbow in overhead athletes. Plyometric exercises are performed using a weighted medicine ball during the latter stages of this phase to train the shoulder and elbow to develop and withstand high levels of stress. Plyometric exercises are initially performed with two hands performing a chest pass, side-to-side throw, and overhead soccer throw. These may be progressed to include one-hand activities such as 90/90 throws ( Fig. 87-5 ), external and internal rotation throws at 0 degrees of abduction ( Fig. 87-6 ), and wall dribbles. Specific plyometric drills for the forearm musculature include wrist flexion flips ( Fig. 87-7 ) and extension grips. The latter two plyometric drills are an important component to an elbow rehabilitation program, emphasizing the forearm and hand musculature.
Phase IV: Return to Activity
The final phase of elbow rehabilitation, the return to activity, allows the athlete to progressively return to full competition using an interval return to throwing program. Other interval programs are used for the tennis player or golfer.
Before an athlete is allowed to begin the return to activity phase of rehabilitation, he or she must exhibit full ROM, no pain or tenderness, a satisfactory isokinetic test, and a satisfactory clinical examination. Isokinetic testing is commonly utilized to determine the readiness of the athlete to begin an interval sport program. Athletes are routinely tested at 180 and 300 degrees/sec. The bilateral comparison at 180 degrees/sec indicates the throwing arm’s elbow flexion to be 10% to 20% stronger and the dominant extensors 5% to 15% stronger than the nondominant arm.
Upon achieving the previously mentioned goals for returning to sport, we start the patient on a formal interval sport program as described by Reinold and associates. Patients returning to sports that involve the upper extremity, such as golf, tennis, javelin, baseball, and softball, are placed on an interval sport program. For the overhead thrower, we initiate a long-toss interval throwing program beginning at 45 feet and gradually progressing to 120 or 180 feet (player- and position-dependent) ( Table 87-1 , online). Throwing should be performed without pain or significant increase in symptoms. We believe it is important for the overhead-throwing athlete to perform a stretching and an abbreviated strengthening program prior to and after performing the interval sport program. Typically, our overhead throwers warm up, stretch, and perform one set of their exercise program before throwing, followed by two additional sets of exercises preceding throwing. This provides an adequate warm-up but also ensures maintenance of the necessary ROM and flexibility of the shoulder joint. The following day, the thrower exercises the scapular muscles and external rotators and performs a core stabilization program.