Introduction
- E. Lyle Cain, MD
Epidemiology
- •
Most common in young amateur or professional athletes, ages 15 to 40 years
- •
Most common in males, with 9 : 1 ratio male : female
- •
Most common in baseball, with occasional occurrence in other overhead sports (football, javelin throwing, softball, tennis, wrestling, soccer, gymnastics, cheerleading, and pole vaulting)
- •
Baseball pitchers make up 89%, followed by catchers
- •
Incidence evenly distributed among high school, collegiate, and professional levels
- •
Incidence of UCL injury requiring surgery in high school and adolescent athletes has risen dramatically in the past 5 years.
Pathophysiology
Intrinsic, Extrinsic, and Traumatic Factors
- •
Injury generally occurs during the acceleration phase of the throwing motion ( Figure 11-1 ).
FIGURE 11-1
Phases of the overhead throwing motion.
- •
Biomechanical factors resulting in poor power transfer from the trunk to the arm may predispose the athlete to UCL injury.
- •
Based on cadaveric testing, UCL tensile failure is approached with every throw, especially in high-velocity throwers.
- •
Overuse-type throwing habits result in repeated microtrauma to the static restraints of the throwing elbow, without adequate time for healing.
- •
Accumulation of elbow microtrauma causes the UCL to become weakened and prone to catastrophic failure.
- •
The failure process is exacerbated by high pitch velocity, the throwing of breaking pitches, and inadequate warm-ups.
Classic Pathological Findings
- •
Anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow during functional range of motion between 20° and 120° of flexion.
- •
Dr. Frank Jobe pioneered surgical reconstruction of the UCL in 1974, often referred to as “Tommy John Surgery” in reference to the first recipient of the reconstruction procedure.
Clinical Presentation and Examination
- •
All patients report elbow pain while athletically active (throwing, tennis).
- •
Baseball players primarily (96%) complained of pain during the late cocking and acceleration phase of throwing.
- •
Half report an acute onset of pain at the medial elbow, whereas half cannot identify a single inciting event.
- •
For those athletes who can identify the onset of symptoms, three out of four report that the onset occurred during a game, 10% during practice, 10% during the preseason, 4% during the off-season, and 1% while playing recreationally.
- •
Decreased velocity and/or loss of control is a common complaint.
Abnormal Findings
- •
The primary exam finding is tenderness to palpation of the anterior band of the UCL.
- •
Pain with valgus stress (milking maneuver) and active valgus stress are common.
- •
Preoperatively one in four athletes has neurological symptoms, most commonly intermittent paresthesias in the ulnar nerve distribution (ring and small fingers) during throwing.
Pertinent Normal Findings
- •
Elbow range of motion is generally full, although many overhead athletes have a flexion contracture of about 5°.
- •
Only one in four patients demonstrates valgus instability to manual testing at 30° elbow flexion.
Imaging Studies
- •
Radiographic examination is normal in half, whereas half have assorted radiographic abnormalities, most commonly olecranon osteophyte formation and ectopic calcification within the UCL substance.
- •
Magnetic resonance arthrography (MRA) with intraarticular contrast is the gold standard diagnostic test.
- •
MRA may show complete tearing or a partial undersurface tear of the anterior band of the UCL.
- •
CT arthrogram is useful in patients who cannot undergo MRA
- •
Ultrasound may be useful in diagnosis and may be helpful to allow some level of reparative process of the ligament with nonsurgical treatment.
Differential Diagnosis
- •
Flexor pronator tendinitis: tenderness anterior to the UCL along the medial epicondyle, pain with resisted wrist pronation
- •
Ulnar neuritis: sensory disturbance to the ring and small fingers, positive Tinel’s at the cubital tunnel, normal imaging
- •
Olecranon osteophyte/valgus extension overload: posterior medial pain along the olecranon tip with extension, pain during ball release or follow-through, osteophyte on radiographs
Treatment
Nonsurgical Options
- •
Rest: cessation from throwing or any valgus producing stress to the elbow
- •
NSAIDs
- •
Physical therapy to maintain elbow motion, decrease pain, strengthen both the shoulder and elbow musculature
- •
Injection of corticosteroids or platelet rich plasma: controversial
Guidelines for Choosing among the Nonsurgical Treatment Options
- •
Level of play: Higher level of play (major league) is more likely to have successful outcomes than lower level (high school, recreational).
- •
Degree of injury (partial vs. complete): Complete tears are more likely to lead to chronic symptoms.
- •
Timing of season: Return to play generally takes approximately 1 year.
- •
Position (pitcher vs. fielder): Pitcher and catcher require more elbow endurance, and may take longer to return after surgery.
- •
Acute versus chronic injury: Chronic ligament insufficiency is less likely to respond favorably to nonsurgical treatment.
- •
Symptom magnitude: Some athletes can participate at various levels (i.e., fielding but not pitching) despite ligament damage.
Surgical Indications
- •
Absolute: complete tear in pitcher who has failed nonoperative treatment and is unable to participate at the desired level of play
- •
Relative: any degree of tear in any sport or position that is unable to return to the desired level of competition after appropriate nonsurgical treatment, and is willing to participate in a minimum 1 year rehabilitation period
- •
Most UCL injuries in nonoverhead athletes (e.g., football, gymnastics, soccer) do not require surgery for continued participation.
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
Age
- •
Level of play
- •
Degree of injury (partial vs. complete)
- •
Timing of season
- •
Position (pitcher vs. fielder)
- •
Acute versus chronic injury
- •
Symptom magnitude
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Graft choice: palmaris longus versus gracilis tendon (autografts)
- •
Additional procedures as indicated: ulnar nerve transposition, olecranon osteophyte excision, loose body removal
- •
Muscle-splitting versus modified Jobe (muscle elevation)
- •
Graft fixation: suture fixation versus interference screw versus docking
Evidence
Multiple Choice Questions
- QUESTION 1.
During which phase of the throwing motion do symptoms most commonly occur with UCL injury?
- A.
Wind-up
- B.
Acceleration
- C.
Ball release
- D.
Follow-through
- A.
- QUESTION 2.
What position in baseball most commonly injures the UCL?
- A.
Catcher
- B.
Infield
- C.
Outfield
- D.
Pitcher
- A.
- QUESTION 3.
What is the most common physical exam finding with UCL injury?
- A.
Pain with resisted pronation
- B.
Positive Tinel’s at the cubital tunnel
- C.
Pain with valgus stress
- D.
Loss of motion
- A.
- QUESTION 4.
What percentage of athletes is expected to return to the same level or higher competition after UCL reconstruction?
- A.
Less than 25%
- B.
25% to 50%
- C.
50% to 75%
- D.
Greater than 75%
- A.
- QUESTION 5.
What is the gold standard diagnostic test for UCL injury?
- A.
Plain radiographs
- B.
CT scan
- C.
Ultrasound
- D.
Arthrogram MRI
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Clinical Presentation)
- QUESTION 2.
Correct answer: D (see Epidemiology )
- QUESTION 3.
Correct answer: C (see Clinical Presentation)
- QUESTION 4.
Correct answer: D (see Evidence )
- QUESTION 5.
Correct answer: D (see Imaging Studies )
Nonoperative Rehabilitation of Ulnar Collateral Ligament Injuries
- E. Lyle Cain, MD
- Kevin E. Wilk, PT, DPT
- Todd R. Hooks, PT, OCS, SCS, ATC, MOMT, MTC, CSCS, FAAOMPT
- Kevin E. Wilk, PT, DPT
- •
Restrict elbow range of motion and valgus forces during the early phases of treatment to minimize stresses upon healing structures.
- •
Conduct a proper assessment and institute a proper rehabilitation of the entire kinetic chain to reduce the valgus stresses imparted upon the elbow during overhead athletics.
- •
Ensure an appropriate functional interval return to play program is implemented to allow for a controlled progression into sporting activities.
- •
Proper communication between coach, player, physician, and clinician to determine appropriate return to play guidelines based upon sport of the athlete.
Phase I (Immediately following injury through week 2)
Protection
- •
A hinged elbow brace is used to restrict motion and prevent valgus strain.
- •
The athlete is allowed to perform personal care ADLs while wearing brace.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 3 to 10) | PHASE III (weeks 10 to 14) | PHASE IV (weeks 14 to 18) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
- •
Analgesic and antiinflammatory medications may be used as needed to decrease pain and swelling.
- •
The athlete is instructed to perform cryotherapy for 20 minutes every hour throughout the acute phase or until swelling subsides.
- •
Therapeutic modalities (IFC, Hi-Volt, TENS, and low level laser therapy [cold laser]) can be used to decrease pain and inflammation and augment the healing process.
- •
A compression wrap can be worn to decrease swelling.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
The rehabilitation specialist can perform manual PROM of the elbow within 20° to 90° to neuromodulate pain and aid in collagen alignment of the healing ligamentous tissue.
Soft Tissue Techniques
- •
The clinician may begin edema massage from distal to proximal to assist in swelling reduction.
- •
Soft tissue mobilizations to decrease muscle guarding and tone can be performed by the clinician.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Light pain-free stretching activities can be prescribed for the wrist and forearm musculature within the prescribed elbow range of motion limitations.
- •
Shoulder PROM can be conducted to maintain capsular and shoulder mobility.
Other Therapeutic Exercises
- •
The athlete can perform stationary biking activities while wearing a hinged elbow brace to maintain cardiovascular fitness.
- •
Core strengthening exercises that do not task the upper extremity, such as crunches, can be implemented.
- •
Lower extremity strengthening and stretching exercises may be initiated to retard muscle atrophy and maintain flexibility.
Activation of Primary Muscles Involved
- •
Week 1: gripping exercises, wrist, elbow, and shoulder isometrics
- •
Week 2: rotator cuff (ER/IR tubing at 0° abduction, full can, and abduction) and scapular (prone row, prone horizontal abduction) exercises can be performed.
Sensorimotor Exercises (Balance Proprioception, Kinesthesia)
Rhythmic stabilization drills for the scapula ( Figure 11-2 ), shoulder, and elbow joint can be performed as well as passive/active joint repositioning for sensorimotor stimulus ( Figure 11-3 ).
Open and Closed Kinetic Chain Exercises
- •
Week 1: OKC exercises for the throwing arm are performed to minimize any undue stresses at the elbow.
- •
Week 2: CKC exercises can be initiated such as wall wipes ( Figure 11-4 ) and table slides.
FIGURE 11-4
Closed kinetic chain exercises can be initiated with exercises such as wall wipes. The athlete can emphasize the rotator cuff by performing circular movements and target the scapular musculature with horizontal abduction/adduction motions.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
The patient will perform low resistance, high repetition exercises for the involved upper extremity to improve vascularity, endurance, and diminish atrophy.
Neuromuscular Dynamic Stability Exercises
- •
The athlete may perform sitting or side-lying scapular PNF ( Figure 11-5 ) and neuromuscular drills.
FIGURE 11-5
Side-lying scapula PNF. The clinician will give tactile input to the superior, medial, inferior border of the scapula, and at the elbow to provide resistance as the athlete performs scapula elevation, retraction, depression, and protraction.
- •
The clinician can give tactile and verbal cueing to the patient to assist in proper muscle recruitment and correct movement patterns during the exercises.
Milestones for Progression to the Next Phase
- •
Minimal joint effusion
- •
Elbow ROM 20° to 90°
- •
Pain free special tests and minimum to no increased laxity with valgus stress testing
- •
No pain to palpation at medial elbow
Phase II (weeks 2 to 10)
Protection
A hinged elbow brace should continue to be used and will be gradually opened 10° per week.
Management of Pain and Swelling
- •
The patient can continue with NSAID treatment as prescribed by MD.
- •
The clinician can initiate rehabilitation with moist hot pack to increase local blood flow and prepare tissues for treatment by increasing tissue extensibility.
- •
Laser treatment can also be performed to assist in soft tissue healing.
- •
Following the rehabilitation treatment, the clinician can mitigate any exercise induced inflammation and/or soreness with the use of ice, compression, and electrical stimulation treatment.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
The clinician can progress with passive range of motion to the elbow to allow full elbow range of motion by week 4.
Soft Tissue Techniques
- •
The clinician should assess for any increase muscle guarding, tone, and/or trigger points.
- •
The clinician can perform soft tissue mobilization techniques to restore normal muscle extensibility and hemodynamics to the forearm musculature.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
The athlete can continue to progress with a flexibility program for the forearm and glenohumeral musculature.
- •
The clinician should assure full mobility and flexibility of the scapula, trunk, and lower extremity to allow for the transfer and absorption of kinetic chain energy to optimize performance and decrease potential strains incurred during overhead athletics.
Other Therapeutic Exercises
- •
Lower extremity exercises can be progressed including elliptical and machine-based LE strengthening exercises.
- •
The athlete can perform well-armed strengthening exercises such as lateral raises, shoulder rows, and shoulder press to maintain strength and promote the neuromuscular crossover effect for the involved upper extremity.
- •
Core strengthening and stabilization exercises can be performed including planks, and stabilization exercises on unstable surface (physio ball) ( Figure 11-6 ).
FIGURE 11-6
Trunk and scapula stabilizations performed on a BOSU ball as the clinician incorporates perturbations upon the athlete’s trunk and upper extremity.
Activation of Primary Muscles Involved
- •
Wrist strengthening exercises are progressed, with emphasis upon wrist flexion and pronation strengthening.
- •
Biceps and triceps exercises can be implemented as tolerated.
- •
Scaption, abduction, side-lying ER, prone row, prone extension, prone horizontal abduction, prone scaption, and prone row into ER are progressed as tolerated.
Sensorimotor Exercises (Balance Proprioception, Kinesthesia)
- •
Lower extremity proprioception and coordination drills can be performed for hip/core stabilization, including: tilt board squats, single leg activities, and perturbation training drills.
Open and Closed Kinetic Chain Exercises
- •
CKC exercises can be integrated into rehabilitation program, including stabilization exercises on a ball ( Figure 11-7 ), push-up plus, and upper extremity machine-based weight training. The athlete is instructed to perform these exercises in a pain-free range and perform the exercise with the elbows maintained close to the trunk to minimize strain upon the UCL.
FIGURE 11-7
Ball on wall stabilization drills. The athlete places an open palm onto a ball and maintains a static position while keeping the elbow extended as the clinician performs rhythmic stabilizations. These stabilization can begin proximally upon the upper arm and progress distally upon the wrist.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
The athlete can be progressed with strengthening exercises by decreasing repetitions and increasing weight to allow for progression training of the forearm, glenohumeral, and scapulothoracic musculature.
Neuromuscular Dynamic Stability Exercises
- •
Manual PNF resistance exercises for the distal arm can by performed by alternating resistance of the elbow, wrist, and finger flexion and forearm supination followed by elbow, wrist, and finger extension and forearm pronation ( Figure 11-8 ).
FIGURE 11-8
Manual PNF resistance of the elbow/wrist performed as the clinician concomitantly resists elbow, wrist, and finger flexion and supination followed by elbow, wrist, and finger extension and pronation.
- •
Manual resistance exercises can also be performed for external rotation. Because of the high EMG activity in the follow-through phase of throwing, eccentric manual resistance exercises can be implemented for the scapula, rotator cuff, and forearm musculature.
Functional Exercises
- •
The athlete should perform total body strengthening exercises to allow for synchronization of hips/core/shoulder movement patterns. This can also include performing single leg and split stance exercises, as well as PNF patterns involving the trunk and lower extremities.
- •
Agility exercises for the lower extremity such as cone and agility ladder exercises can be incorporated into the athlete’s program.
Sport-Specific Exercises
- •
Athletes involved in contact sports and those suffering from injury on the nondominant extremity may be released to return to competitive sports following clearance from MD.
- •
In addition, quarterbacks have been shown to return to competition sooner than baseball pitchers. reported a mean return to play following nonoperative management of an acute UCL injury to be 26.4 days; therefore proper communication is needed to determine appropriate return to play expectations.
Milestones for Progression to the Next Phase
- •
Full, pain-free elbow range of motion
- •
MMT 5/5 for involved upper extremity
- •
Satisfactory clinical examination with negative valgus laxity and provocation testing.
Phase III (weeks 10 to 14)
Protection
- •
The hinged elbow brace can be discharged during this phase.
Management of Pain and Swelling
- •
Cryotherapy can be used following treatment as needed to avoid post-rehabilitation soreness and inflammation.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Ensure the athlete maintains full elbow and shoulder range of motion throughout treatment and avoiding the potential loss of motion with the addition of plyometric and the integration of sporting activities.
Soft Tissue Techniques
- •
The clinician should continue to evaluate the entire upper extremity and scapular musculature to assess for pliability of the soft tissue. Soft tissue restrictions, trigger points, and decreased flexibility could cause movement impairments for the athlete.
- •
The clinician can perform soft tissue mobilization treatments and in addition instruct the athlete in soft mobilization techniques as part of the activity warm-up and cool down program.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
The clinician should continue to monitor the flexibility and pliability of the soft tissue of the entire upper extremity to ensure the athlete does not develop any diminished flexibility as the result of delayed onset muscle soreness (DOMS).
Other Therapeutic Exercises
- •
Lower extremity strength training should continue to be progressed for quadriceps, hamstrings, and hip musculature. These exercises can be progressed to include functional exercises such as multidirectional lunges, and step up drills.
- •
Core stabilization and strengthening exercises should be progressed to include stable and unstable surfaces and resistive core training.
- •
Upper extremity weight training can be progressed with rows, lat pull downs, shoulder presses, and bench press as tolerated.
Activation of Primary Muscles Involved
- •
The athlete should continue with Thrower’s Ten exercise progression (see Figure 11-3 ).
Sensorimotor Exercises (Balance Proprioception, Kinesthesia)
- •
The athlete can perform PNF training exercises on unstable surface in both seated and standing position to allow integration of core and lower extremity stabilization.
Open and Closed Kinetic Chain Exercises
- •
The athlete can progress with upper extremity CKC exercises including front and side planks, push ups, and weight bearing stabilization drills on unstable surfaces as deemed necessary based upon sporting participation.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Lower extremity and core strengthening and stabilization exercises can be performed in a kneeling, double and single leg stance to allow for functional training of the athlete.
- •
Upper extremity strengthening exercises are progressed with machine and free weight training with bench press, rows, latissimus dorsi pull downs, and triceps extension exercises are incorporated.
Neuromuscular Dynamic Stability Exercises
- •
Dynamic rhythmic stabilization and upper extremity strengthening exercises can be performed with the arm in an overhead position to increase strength and stability with the arm in a functional position ( Figure 11-9 ).
FIGURE 11-9
Stabilization drills performed at 90/90 position as the athlete performs external plyometric wall dribbles.
Plyometrics
- •
Two-hand plyometric exercises are initiated at week 10. The athlete will begin with hands close to the trunk with chest and side throws, and progress to side-to-side throws and soccer style throw.
- •
The athlete will perform two hand plyometric exercises for approximately 2 weeks and upon successful completion will progress to one-hand plyometric drills.
Functional Exercises
- •
A swimming program can be implemented to include an aquatic shoulder therapeutic program that can be performed as an adjunct to the rehabilitation program.
Sport-Specific Exercises
- •
Stabilization exercises and manual resistance training drills are performed in an overhead position. The athlete can perform plyometric exercises and drills that incorporate the trunk and lower extremity with weighted medicine balls ( Figure 11-10 ).
FIGURE 11-10
Forward lunge with overhead plyometric toss to incorporate trunk synchronization with upper extremity movement patterns.
Milestones for Progression to the Next Phase
- •
Full pain-free elbow ROM
- •
Satisfactory clinical examination, including valgus and provocation testing
- •
Satisfactory completion of two-hand plyometric drills
- •
MMT 5/5 strength all muscle groups
Phase IV (weeks 14 to 18)
Protection
- •
Functional elbow brace if prescribed by MD if athlete is involved in a contact sport
Management of Pain and Swelling
- •
Cryotherapy as needed to mitigate postexercise-induced soreness.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
PROM to maintain full wrist, elbow, and shoulder ROM
Soft Tissue Techniques
- •
The clinician can continue with soft tissue mobilization techniques to address facial or musculature restrictions as well and any tone or trigger points that may occur as part of an increase in workload activities.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Flexibility exercises for the wrist, elbow, and shoulder musculature are encouraged throughout the rehabilitation program pre- and posttreatment to minimize postexercise soreness.
Other Therapeutic Exercises
- •
Lower extremity strengthening exercises are progressed with free and machine-based strengthening exercises.
- •
The athlete can progress with dynamic movement drills to replicate throwing motion. Core stabilization exercises drills can be performed in quadruped, kneeling, and standing position to progress with core training.
Activation of Primary Muscles Involved
- •
Advanced Thrower’s Ten exercise program is continued and can be performed on stability ball to integrate core stabilization with upper extremity exercises.
Sensorimotor Exercises (Balance Proprioception, Kinesthesia)
- •
PNF patterns to include the trunk and upper extremity using medicine balls, cables, or kettle bells ( Figure 11-11 ).
FIGURE 11-11
Cable chops performed in a split stance position.
Open and Closed Kinetic Chain Exercises
- •
Upper extremity CKC exercises on both stable and unstable support to facilitate proprioception input. These exercises and drills can be performed with and without manual stabilizations.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
The athlete can perform high-speed coordination and neuromuscular training exercises for the involved upper extremity including the rotator cuff and biceps musculature. Training at high speeds prepares the athlete for sporting activity to eccentrically control and dissipate the forces that are imparted upon the elbow during overhead activities such as throwing.
Neuromuscular Dynamic Stability Exercises
- •
Dynamic training exercises on unstable surfaces, trunk perturbations, and single leg activities are performed to mimic the throwing motion.
Plyometrics
- •
One-hand plyometric drills are initiated at week 12. These exercises are begun with internal and external rotation throws at 0° of abduction and wall dribbles. These exercises can be progressed to 90/90 throws and simulated throwing motion.
Functional Exercises
- •
Lower extremity agility and sport-specific running program to increase overall cardiovascular function and preparation for athletic competition.
Sport-Specific Exercises
- •
Initiate interval throwing program (Phase I) can be implemented during this phase and progressed to throwing off the mound (Phase II) upon successful completion.
Milestones for Progression to the Next Phase
- •
Pain that limits athlete at sporting activity
- •
Inability to complete sport specific program
- •
Unsatisfactory clinical examination including valgus testing
- •
Inability to return to competition following 3+ months of conservative management
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Full elbow ROM
- •
Completion of sport-specific training program
- •
Isokinetic testing of bilateral elbow flexion and extension reveals: elbow flexion 10% to 20% stronger and 5% to 15% stronger in extensors as compared with the noninvolved arm
- •
Satisfactory isokinetic testing ( Table 11-1 ).
Table 11-1
Isokinetic Testing of Elbow Flexion/Extension
Bilateral Comparison
Velocity
Elbow (Flex)
Elbow (Ext)
180°/sec
110% to 120%
105% to 115%
300°/sec
0.5% to 115%
100% to 110%
Unilateral Muscle Ratios
Velocity
Elbow (Flex/Ext)
180°/sec
70% to 80%
300°/sec
63% to 69%
Tips and Guidelines for Transitioning to Performance Enhancement
- •
The clinician should make certain the athlete maintains full shoulder and elbow ROM throughout the rehabilitation and return to sports program in order to minimize any stresses imparted upon the elbow with throwing activity.
- •
Total arm including scapular muscle strength should be emphasized during treatment to increase performance and minimize injury potential.
- •
The clinician should ensure a systematic program is used, including strength training, proprioception drills, flexibility, and proprioception, performed before the initiation of a throwing program.
Performance Enhancement and Beyond Rehab: Training/Trainer, and Optimization of Athletic Performance
- •
Continued maintenance program for the throwing athlete during the season that is usually performed every other day
- •
Endurance and cardiovascular fitness to decrease injuries related to fatigue
- •
Core strengthening and stabilization exercises to allow for efficient transfer and dissipation of energy throughout the kinetic chain.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Satisfactory clinical examination
- •
Clearance by MD
- •
Successful completion of an interval sporting program
- •
Pain and symptom free with sports participation
- •
MMT 5/5 strength for all muscle groups
- •
Satisfactory isokinetic testing (see Table 11-1 )
Evidence
Multiple Choice Questions
- QUESTION 1.
Once adequate strength, range of motion, and tissue healing has occurred, when is it safe to begin a plyometric program?
- A.
Week 2
- B.
Week 6
- C.
Week 10
- D.
Week 16
- A.
- QUESTION 2.
Based upon anatomical approximation to the UCL, these muscle groups are emphasized during rehabilitation to provide dynamic stability to the medial aspect of the elbow with overhead athletics.
- A.
Wrist extensors and forearm pronators
- B.
Wrist extensors and forearm supinators
- C.
Wrist flexors and forearm pronators
- D.
Wrist flexors and forearm supinators
- A.
- QUESTION 3.
A hinged elbow brace is frequently prescribed during the acute phase to minimize stress upon the UCL and diminish inflammation. What range of motion guidelines are generally used for elbow motion?
- A.
0° to 90° for 1 week, full elbow motion by week 2
- B.
20° to 90° for 2 weeks, full elbow motion by week 4
- C.
40° to 100° for 4 weeks, full elbow motion by week 6
- D.
Full elbow ROM allowed immediately within brace
- A.
- QUESTION 4.
Which statement is NOT true in regard to Phase II (weeks 3 to 10)?
- A.
An interval throwing program can be initiated during this phase.
- B.
Elbow range of motion is gradually restored to full range.
- C.
Thrower’s Ten Program is progressed for elbow, glenohumeral, and scapulothoracic strengthening.
- D.
Hinged elbow brace may be discharged during this phase.
- A.
- QUESTION 5.
Which of the following criteria would warrant failure of nonoperative treatment and consideration of surgical repair of UCL?
- A.
Unable to complete sport-specific program
- B.
Failure to return to competition following 3+ months of conservative management
- C.
Pain that limits sporting activity
- D.
All of the above
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Phase III )
- QUESTION 2.
Correct answer: C (see Phase II )
- QUESTION 3.
Correct answer: B (see Phases I and II )
- QUESTION 4.
Correct answer: A (see Phase II )
- QUESTION 5.
Correct answer: D (see Phase IV )
Postoperative Rehabilitation after Ulnar Collateral Ligament Reconstruction
- E. Lyle Cain, MD
- Kevin E. Wilk, PT, DPT
- Todd R. Hooks, PT, OCS, SCS, ATC, MOMT, MTC, CSCS, FAAOMPT
- Kevin E. Wilk, PT, DPT
Indications for Surgical Treatment
- •
Physical examination demonstrating excessive valgus instability
- •
Imaging studies (i.e., MRI) confirming UCL injury ( Figure 11-12 )
FIGURE 11-12
MRI of a full-thickness UCL tear.
- •
Persistent pain with inability to perform at desired level of sports/activities
- •
Failure of nonoperative rehabilitation program
- •
Surgery may be recommended without undergoing nonoperative rehabilitation in the overhead athlete depending on history and seasonal timing issues.
Brief Summary of Surgical Treatment
Major Surgical Steps
- •
Our current surgical approach is a modification of the original technique described by Jobe et al.
- •
The modifications include elevation of the flexor-pronator muscle mass without detachment and subcutaneous rather than submuscular ulnar nerve transposition.
- •
An anterolateral arthroscopic portal is established for evaluation of the anterior compartment articular surfaces and synovium and to perform the arthroscopic valgus stress test at 70° of flexion with the arm pronated.
- •
A medial opening of greater than 1 to 2 mm suggests ulnar collateral ligament insufficiency.
- •
The open procedure begins with a medial incision centered over the medial epicondyle.
- •
The medial antebrachial cutaneous nerve is initially identified and protected.
- •
The ulnar nerve is carefully dissected free from the cubital tunnel and protected with a vessel loop. Ulnar nerve release must continue proximally to the arcade of Struthers and distally into the flexor carpi ulnaris muscle mass.
- •
A portion of the medial intermuscular septum is removed to prevent tenting of the ulnar nerve after transposition.
- •
The anterior band of the ulnar collateral ligament is exposed by elevation of the flexor muscles from the ulnar collateral ligament distal attachment at the sublime tubercle of the ulna.
- •
The ligament is inspected for attenuation or tearing and is incised longitudinally to permit visualization of the deep portion of the ligament if a complete tear is not present.
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If concomitant valgus extension overload with olecranon osteophytes is suspected, a vertical posterior capsulotomy is placed proximal to the fibers of the posterior band of the ulnar collateral ligament to expose the olecranon tip. Posteromedial olecranon osteophytes are removed with a small osteotome and high-speed burr.
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Graft harvest is then performed. Ipsilateral palmaris longus tendon is our current graft choice, followed by contralateral palmaris longus or contralateral gracilis (autografts).
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The median nerve lies deep to the palmaris longus tendon and should be protected during harvest by avoiding deep dissection.
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Tunnels are then placed in the ulna and medial epicondyle with a 3.2-mm drill bit. A single ulnar tunnel is made by placing two ulnar drill holes 3 to 4 mm distal to the articular surface of the coronoid process, separated by approximately 1 cm at the native attachment site of the ulnar collateral ligament.
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Two medial epicondylar tunnels are placed along the proximal portion of the epicondyle and converge at the origin of the native ulnar collateral ligament.
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The graft is then passed in a figure-eight fashion.
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The elbow is placed at 30° of flexion and varus stress is applied while the graft is secured side-to-side with multiple nonabsorbable sutures.
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The ulnar nerve is then transposed subcutaneously and held in place with a single fascial sling from the flexor pronator muscle fascia. The sling is tensioned loosely to prevent any compression of the ulnar nerve.
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The skin is closed with subcuticular suture and the elbow is splinted at 90° of flexion for the first week after surgery to allow soft tissue healing.
Factors That May Affect Rehabilitation
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Graft choice, graft fixation, additional procedures (osteophyte excision, ulnar nerve transposition)
Other Surgical Techniques and Options
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Other techniques use a flexor muscle splitting approach, often without ulnar nerve transposition.
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Graft fixation using interference screws or a “docking technique” may also alter the rehab program.
Before Surgery: Overview of Goals and Guidelines 1
1 The pre-habilitation outline is included in the nonoperative treatment section of this chapter .
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Educate patient about postoperative rehabilitation and expectations.
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Normalize elbow range of motion and document preoperative elbow motion.
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Diminish pain and swelling.
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Perform wrist, elbow, glenohumeral, and scapula strengthening exercises.
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Normalize shoulder ROM and scapular posture.
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Understand the surgical technique, including graft selection and whether a concomitant ulnar nerve transposition was performed.
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Appreciate the biomechanical stresses that occur with exercises and activities during the rehabilitation program.
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Utilization of elbow hinged brace for 4 to 6 weeks to minimize stress.
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Respect ROM progression and proper end feel assessment to determine the appropriate manual therapy and exercise techniques to restore motion.
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Proper rehabilitation progression to allow for return to sports for the overhead athlete, including plyometric exercises and completion of an interval throwing program.
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Protection of the repair during postoperative therapy.
Phase I (first days 14): Immediate Postoperative Period
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Decrease pain and swelling through cryotherapy, compression, PROM, and electrotherapeutic modalities.
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Minimize the effects of immobilization.
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Protect the reconstructed UCL and associated surgeries.
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Elbow PROM 25° to 100°.
During this phase the clinician should assess for any postoperative complications involving the ulnar nerve. The patient should perform isometric and ROM exercises to diminish the effects of inactivity. The patient should avoid exercises on the involved leg for 1 week if a gracilis graft was used. Initiate wrist and hand ROM, gripping exercises to prevent Complex regional pain syndrome (CRPS).
| PHASE I (weeks 0 to 3) | PHASE II (weeks 4 to 7) | PHASE III (weeks 8 to 14) | PHASE IV (weeks 14 to 32) |
|---|---|---|---|
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