Phase I: Acute Phase

This first phase is designed to reduce pain and inflammation, normalize range of motion (ROM) and muscle balance, correct postural adaptations, and reestablish baseline dynamic joint stability. The athlete may be prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) and/or local injections and local therapeutic modalities, such as ice, laser, iontophoresis, and electrical stimulation, to reduce pain and inflammation. The athlete is also educated about activity avoidance and modification during exercise and strenuous activities.

ROM activities are initiated to normalize elbow motion. It is common for athletes to exhibit a loss of elbow extension after injury or surgery, particularly throwers. ^, The elbow is predisposed to flexion contractures because of the intimate congruency of the joint articulations, the tightness of the joint capsule, and the tendency of the anterior capsule and brachialis to develop adhesions and scar following injury. ROM activities should be performed for all planes of elbow and wrist motions to prevent the formation of scar tissue and adhesions by providing nourishment to the articular cartilage and assisting in the synthesis, alignment, and organization of collagen tissue. ^{, ,} Restoring full elbow extension is the primary goal of early ROM activities.

Joint mobilizations are performed to minimize the occurrence of joint contractures and improve joint mobility. Grade I and II mobilization techniques are used to neuromodulate pain by stimulating type I and type II articular receptors. Posterior glides of the humeroulnar joint are performed at end range of available joint mobility to assist in regaining full elbow extension ( Fig. 1 ), along with mobilizations of the radiocapitellar and radioulnar joints.

Posterior mobilization of the ulna on the humerus to improve elbow extension.

The aggressiveness of the stretching and mobilization techniques is determined by the healing constraints of the involved tissues, the specific pathologic condition or surgery, and the amount of available motion and end feel. If the athlete presents with a reduction in motion and a hard end feel without pain, aggressive stretching and mobilization techniques may be used. Conversely, an athlete who exhibits pain before resistance or an empty end feel should be progressed slowly with gentle stretching.

At times it can be difficult to regain full elbow extension, and low-load, long duration (LLLD) stretch is needed to produce deformation or creep of the collagen tissue. This stretch can be performed by having the athlete lie supine with a towel roll placed under the distal humerus to act as a cushion and fulcrum. Light resistance exercise tubing is applied to the athlete’s wrist and secured to the table or to a dumbbell on the ground ( Fig. 2 ) as the athlete is instructed to relax for the duration of 10 to 15 minutes of LLLD treatment. The amount of resistance applied should be of low magnitude to enable the athlete to perform the stretch for the entire duration of the treatment without pain or muscle spasm. Athletes are instructed to perform the LLLD stretches several times per day, equaling at least 60 minutes of total end range time to improve extension and reduce joint stiffness.

LLLD stretch to increase elbow extension. The stretch is performed using light resistance while the shoulder is placed in internal rotation, with the forearm pronated to minimize compensation and best isolate the stretch on the elbow joint.

During this phase, the voluntary activation of muscle and the retardation of muscular atrophy are also addressed via pain-free submaximal isometrics for the elbow flexors and extensors, wrist flexors and extensors, as well as the forearm pronators and supinators. Shoulder isometrics also may be performed during this phase, with caution against internal rotation and external rotation exercises if they are painful. Rhythmic stabilization drills are also incorporated for the elbow and shoulder to begin reestablishing proprioception and neuromuscular control of the upper extremity.

Phase II: Intermediate Phase

This phase is initiated when the athlete has achieved full ROM, experiences minimal pain and tenderness, and has a good (4/5) manual muscle strength of the elbow flexor and extensor musculature. The goals of this phase are to progress the strengthening program, maintain normal physiologic flexibility, mobility, and ROM of the elbow, and enhance neuromuscular control of the upper quarter.

A combination of stretching and ROM exercises as well as grade III/IV joint mobilizations of the elbow, shoulder, and trunk is incorporated throughout this phase of rehabilitation to stretch the joint capsule and improve mobility. Flexibility exercises are continued for the wrist flexors, extensors, pronators, and supinators, with increased emphasis on improving elbow extension and forearm pronation flexibility.

It is common for the overhead athlete to lose internal rotation, horizontal adduction, and at times external rotation. The loss of internal rotation is commonly described as a glenohumeral internal rotation deficit. An 18° loss of internal rotation in the throwing shoulder has been implicated in elbow injuries and shoulder pathologic conditions. External rotation should be assessed, because a loss of motion here can result in increased strain on the medial aspect of the elbow during the throwing motion. Because of these potential issues, shoulder flexibility exercises in all planes of movement should be performed in this phase.

Isotonic strengthening exercises begin concentrically and then are advanced to eccentric movements. Emphasis is placed on the elbow and forearm musculature, but exercises for the glenohumeral and scapulothoracic musculature must also be incorporated. The Thrower’s Ten Program, which is based on electromyographic (EMG) data to ensure the restoration of muscle balance in the treatment process, can be used as a base comprehensive program for every athlete. ^, Also, because the external rotators are commonly weak, particular focus should be placed on this muscle group via the inclusion of side-lying shoulder external rotation and prone rowing into shoulder external rotation exercises, because these movements have been shown to have high EMG activity of the posterior rotator cuff.

The proximal stability needed for effective distal arm mobility is provided via the scapulothoracic musculature. ^, Specific exercises for these muscles have been developed to enhance proprioceptive and kinesthetic awareness facilitating improved neuromuscular control of the scapulothoracic joint. Closed kinetic chain exercises, such as table pushups on a tilt board or ball, are incorporated to strengthen the upper and middle trapezius and serratus anterior ( Fig. 3 ). Rhythmic stabilization drills can be performed by having the athlete place a hand on a small ball against a wall as the clinician performs perturbation drills to the athlete’s arm ( Fig. 4 ) in combination with neuromuscular control exercises, including proprioceptive neuromuscular facilitation exercises with rhythmic stabilizations and manual resistance drills ( Fig. 5 ).

Pushup on an unstable surface with manual rhythmic stabilizations to facilitate dynamic stability for the shoulder and core musculature.

Dynamic stability training with the patient’s hand placed onto a ball against a wall. The arm is in the scapular plane to provide compressive forces into the glenohumeral joint as the clinician provides rhythmic stabilizations.

Manual proprioceptive neuromuscular facilitation using concentric and eccentric resistance with rhythmic stabilizations.

Phase III: Advanced Strengthening Phase

This phase initiates aggressive strengthening exercises, progressing functional drills to enhance power and endurance, and improve neuromuscular control to prepare for a gradual return to sport. Before advancing to this phase, the athlete should exhibit full nonpainful ROM, have no pain or tenderness, and demonstrate strength that is 70% of the contralateral side.

Athletes are progressed to the Advanced Thrower’s Ten Exercise Program, which incorporates high-level endurance and alternating movement patterns to further challenge neuromuscular control and restore muscle balance and symmetry. Because muscle fatigue has been shown to decrease neuromuscular control and diminish proprioceptive sense, the program uses sustained holds and challenges the athlete to maintain a set position while the opposite extremity performs superimposed isotonic exercises. Manual resistance drills can be added to increase muscle excitation and promote endurance, including manual resistance, while seated on a stability ball to augment muscle excitation and improve upper quarter core endurance ( Fig. 6 ).

Manual resistance external rotation using tubing performed on a stability ball to incorporate proximal and core stabilization.

Elbow flexion and extension exercises are progressed to emphasize eccentric control because the biceps is a critical stabilizer in many overhead activities controlling the deceleration of the elbow and preventing pathologic abutment of the olecranon within the fossa. Elbow flexion can be performed manually or with elastic tubing to emphasize slow- and fast-speed concentric and eccentric contractions. Manual external rotation exercises with rhythmic stabilization for enhanced neuromuscular control are incorporated, including side-lying external rotation and standing external rotation with exercise tubing at 0° and finally at 90° ( Fig. 7 ).

External rotation at 90° of abduction using exercise tubing. The clinician provides manual resistance and rhythmic stabilizations.

Resistance exercises with weight machines are incorporated at this time, including bench press, seated rowing, and front latissimus dorsi pull-downs, along with plyometric exercises to further enhance dynamic stability and proprioception, gradually increasing functional stresses on the upper quarter. Enhanced joint position sense, kinesthesia, and power have been demonstrated following 6 to 8 weeks of plyometrics. ^, A plyometric program has been described that systematically introduces stresses on the healing tissues, beginning with 2-hand drills, such as the chest pass, side-to-side throws, side throws, and overhead soccer throws, progressing to 1-hand drills, including standing 1-hand throws, wall dribbles, and plyometric step-and-throw exercises ( Figs.8–10 ). Specific plyometric drills for the forearm musculature include wrist flexion ( Fig. 11 ) and extension flips, which specifically emphasize the forearm and hand musculature.

Plyometric 2-handed chest pass.

Plyometric 1-handed Baseball throw.

Endurance wall dribble with medicine ball.

Plyometric wrist flip using a 2-lb medicine ball to strengthen the wrist flexors.

Endurance training, such as wall dribbles with a medicine ball, prone ball drops ( Fig. 12 ), wall arm circles, the upper-body cycle, and the Advanced Thrower’s Ten Program, is critical because studies have shown that muscle fatigue decreases proprioception, alters biomechanics, decreases performance, and can contribute to elbow injuries. ^,

Athlete performing a prone ball drop and catch, with the shoulder in horizontal abduction for local muscular endurance.

Phase IV: Return-to-Activity Phase

The last phase of the rehabilitation process focuses on a return to unrestricted full competition and includes implementation of sport-specific interval program. The criteria to enter this phase include full ROM, the absence of pain or tenderness, a satisfactory isokinetic test result, and a satisfactory clinical examination. Isokinetic testing goals for bilateral comparison at 180°/s for elbow flexion of the involved arm are 10% to 20% stronger and the involved extensors typically 5% to 15% stronger than the uninvolved arm.

Interval programs have been developed for a wide variety of sports and activities to gradually introduce the quantity, distance, intensity, and types of activities needed to facilitate the restoration of normal function. The most commonly used upper-extremity interval program is for throwing. An interval throwing program (ITP) is divided into 2 phases: phase I is a long-toss program that is initiated at 45 feet (15 m) and is progressed by increasing distance and volume of throws until phase II, throwing from the mound for pitchers is appropriate. During the long-toss program, as intensity and distance increase, the stresses also increase on the athlete’s medial elbow and anterior shoulder. The long-toss program is designed to gradually introduce loads and strains and should be completed successfully before throwing from the mound is allowed.

The athlete is instructed to continue with all previously described exercises and drills to maintain and improve upper-extremity, core, and lower-extremity strength, power, and endurance during this phase of rehabilitation. It is also important to teach the athlete a year-round conditioning program, including sport-specific periodization strength-training activities, to help prevent overtraining. Investigators have shown that the incorporation of a dynamic variable resistance exercise program can significantly improve athletic performance, particularly in throwing athletes. ^,

Ulnar Collateral Ligament Injury

Nonsurgical treatment is generally attempted for partial UCL tears. A brace can be used to restrict motion and minimize valgus stress in a nonpainful arc of motion generally from 10° to 100°, progressing gradually by 5° to 10° per week expecting full ROM in 3 to 4 weeks. Because the flexor carpi ulnaris and flexor digitorum superficialis overlay the UCL, strengthening exercises for these muscles can assist the UCL in resisting valgus stresses at the elbow. In addition, posterior rotator cuff and scapular strengthening exercises are performed to restore proximal stabilization. The advanced strengthening phase usually is initiated at 6 to 7 weeks after injury, with valgus loading monitored throughout the rehabilitation program. An interval return-to-throwing program is initiated after the athlete regains full motion, adequate strength, and dynamic stability of the elbow. The athlete can return to competition following the asymptomatic completion of the interval sport program. If symptoms recur during the ITP, they typically present when throwing at longer distances, with greater intensity, or during throwing from the mound. If symptoms persist, the athlete is reassessed, and surgical intervention is considered.

Ulnar Collateral Ligament Reconstruction Surgery

Surgical reconstruction of the UCL attempts to restore the stabilizing functions of the anterior bundle of the UCL using one of several procedures. ^, The modified Jobe procedure can be used with either a palmaris longus or gracilis graft passed in a figure-of-8 pattern through drill holes in the sublime tubercle of the ulna and the medial epicondyle. A subcutaneous ulnar nerve transposition is also frequently performed at the time of a UCL reconstruction. The rehabilitation program in current use following UCL reconstruction is outlined in Box 2 . The athlete’s arm is placed in a posterior splint with the elbow immobilized at 90° of flexion for the first 7 days postoperatively to allow early healing of the UCL graft and fascial slings involved in the nerve transposition progressing to a hinged elbow ROM brace to protect the healing tissues from valgus stresses until the beginning of week 5.

Box 2

Postoperative rehabilitation protocol following ulnar collateral ligament reconstruction using autogenous palmaris longus graft (accelerated range of motion)

Data from Wilk KE, Arrigo CA, Andrews JR, Azar FM: Rehabilitation following elbow surgery in the throwing athlete. Oper Tech Sports Med 1996;4(2):114-132.

• 
  

  Immediate postoperative phase (0–3 weeks)

  
  
  
  
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    Goals: To protect healing tissue, reduce pain and inflammation, retard muscular atrophy, protect graft site to allow healing

    
    
    
    
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      Week 1

      
      
      
      
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        Brace: Posterior splint at 90° elbow flexion

        
        
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        ROM: Wrist AROM extension/flexion immediately after surgery

        
        
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        Elbow: Postoperative compression dressing 5 to 7 days

        
        
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        Wrist (graft site) compression dressing 7 to 10 days as needed

        
        
      • 
        

        Exercises: Gripping exercises, wrist ROM, shoulder isometrics (no shoulder ER), biceps isometrics

        
        
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        Cryotherapy to elbow joint and to graft site at wrist

      
      
      
      
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      Week 2

      
      
      
      
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        Brace: Elbow ROM 15°–105° or as tolerated

        
        
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        Motion to tolerance

        
        
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        Exercises: Continue all exercises listed above

        
        
      • 
        

        Elbow ROM in brace 30°–105°

        
        
      • 
        

        Initiate elbow extension isometrics

        
        
      • 
        

        Continue wrist ROM exercises

        
        
      • 
        

        Initiate light scar mobilization over distal incision (graft)

        
        
      • 
        

        Cryotherapy: Continue ice to elbow and graft site

      
      
      
      
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      Week 3

      
      
      
      
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        Brace: Elbow ROM 5°/10°, 115°/120°, motion to tolerance

        
        
      • 
        

        Exercises: Continue all exercises listed above

        
        
      • 
        

        Elbow ROM in brace

        
        
      • 
        

        Initiate AROM wrist and elbow (no resistance)

        
        
      • 
        

        Initiate light wrist flexion stretching

        
        
      • 
        

        Initiate AROM shoulder

        
        
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        Full can

        
        
      • 
        

        Lateral raises

        
        
      • 
        

        ER/IR tubing

        
        
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        Elbow flexion/extension

        
        
      • 
        

        Initiate light scapular strengthening exercises

        
        
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        May incorporate bicycle for lower-extremity strength, endurance

      
      

    
    

  
  
  
  
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  Intermediate phase (weeks 4–7)

  
  
  
  
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    Goals: Gradual increase to full ROM, promote healing of repaired tissue, regain and improve muscular strength, restore full function of graft site

    
    
    
    
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      Week 4

      
      
      
      
      • 
        

        Brace: Elbow ROM 0°–135°, motion to tolerance

        
        
      • 
        

        Exercises: Begin light resistance exercises for arm (1 lb); wrist curls, extension, pronation, supination; elbow extension/flexion

        
        
      • 
        

        Progress shoulder program emphasizing rotator cuff and scapular strengthening

        
        
      • 
        

        Initiate shoulder strengthening with light dumbbells

      
      
      
      
    • 
      

      Week 5

      
      
      
      
      • 
        

        ROM: Elbow ROM 0°–135°

        
        
      • 
        

        Discontinue brace

        
        
      • 
        

        Maintain full ROM

        
        
      • 
        

        Continue all exercises; progress all shoulder and upper-extremity exercises (progress weight 1 lb)

      
      
      
      
    • 
      

      Week 6

      
      
      
      
      • 
        

        AROM: 0°–145° without brace or full ROM

        
        
      • 
        

        Exercises: Initiate Thrower’s Ten Program, progress elbow strengthening exercises, initiate shoulder ER strengthening, progress shoulder program

      
      
      
      
    • 
      

      Week 7

      
      
      
      
      • 
        

        Progress Thrower’s Ten Program (progress weights)

        
        
      • 
        

        Initiate PNF diagonal patterns (light)

      
      

    
    

  
  
  
  
• 
  

  Advanced strengthening phase (weeks 8–14)

  
  
  
  
  • 
    

    Goals: To increase strength, power, endurance; maintain full elbow ROM; gradually initiate sporting activities

    
    
    
    
    • 
      

      Week 8

      
      
      
      
      • 
        

        Exercises: Initiate eccentric elbow flexion/extension, continue isotonic program: forearm and wrist, continue shoulder program (Thrower’s Ten Program), manual resistance diagonal patterns, initiate plyometric exercise program (2-hand plyometrics close to body only), chest pass, side throw close to body, continue stretching calf and hamstrings

      
      
      
      
    • 
      

      Week 10

      
      
      
      
      • 
        

        Exercises: Continue all exercises listed above; program plyometrics to 2-hand drills away from body: side-to-side throws, soccer throws, side throws

      
      
      
      
    • 
      

      Weeks 12 to 14

      
      
      
      
      • 
        

        Continue all exercises; initiate isotonic machines strengthening exercises (if desired): bench press (seated), lateral pull down; initiate golf, swimming; initiate interval hitting program

      
      

    
    

  
  
  
  
• 
  

  Return-to-activity phase (weeks 14–32)

  
  
  
  
  • 
    

    Goals: Continue to increase strength, power, endurance of upper-extremity musculature; gradually return to sport activities

    
    
    
    
    • 
      

      Week 14

      
      
      
      
      • 
        

        Exercises: Continue strengthening program; emphasize elbow and wrist strengthening and flexibility exercises; maintain full elbow ROM; initiate 1-hand plyometric throwing (stationary throws); initiate 1-hand wall dribble; initiate 1-hand baseball throws into wall

      
      
      
      
    • 
      

      Week 16

      
      
      
      
      • 
        

        Exercises: Initiate ITP (phase I, long-toss program); continue Thrower’s Ten Program and plyometrics; continue stretching before and after throwing

      
      
      
      
    • 
      

      Weeks 22 to 24

      
      
      
      
      • 
        

        Exercises: Progress to phase II throwing (after phase I successfully completed)

      
      
      
      
    • 
      

      Weeks 30 to 32

      
      
      
      
      • 
        

        Exercises: Gradually progress to competitive throwing/sports

      
      

    
    

  
  

Abbreviations: AROM, active range of motion; ER, external rotation; IR, internal rotation; PNF, proprioceptive neuromuscular facilitation.

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