Rehabilitation
Following surgical intervention, a 90-degree posterior splint is used for one week. This is to protect the medial aspect of the elbow from possible valgus forces and to limit tension placed on newly constructed UCL from elbow flexion and extension. Excessive pronation and supination should also be avoided as this adds tension to the UCL as well. The elbow splint may be teamed with a sling for comfort and reduced chances for damage to the surgical site.
Assessments need to be made before every rehabilitation session and check-up to determine progress in the rehabilitation program as well as to identify any problems or special considerations that need to be added to the program. These assessment areas include injury status, surgical results, joint mobility, flexibility, neurological status, muscular strength/endurance, muscular atrophy, postural evaluation, general physical fitness, and psychological status.
Pain and swelling can be reduced by the continuation of NSAID or prescription use, as well as: ice, compression dressing under brace, massage, and protection. Common prescriptions following a UCL reconstruction include Vicodin and Percocet. These should be used periodically throughout the first week as need, especially during the 2-3 days following surgery. Special consideration needs to be applied with icing if an ulnar nerve transposition was combined with the surgery.
Submaximal isometrics can be completed for wrist flexion, extension, pronation, supination, ulnar deviation, radial deviation, and grip. Submaximal contractions are key, as they do not put a lot of stress on the healing tissues. Grip exercises can be completed with putty, sand bucket, or a finger web. Hand intrinsic musculature and wrist range of motion and musculature can be worked on through baseball pitch fingerings. This will not only be a good exercise for strength and range of motion, it also provides a sport-specific exercise for psychological purposes for a pitcher. Isometrics can be done on the shoulder musculature and biceps. All shoulder external rotation and valgus stresses should be completely eliminated due to the added stress to the healing site. The 90-degree posterior splint should be worn during shoulder and wrist isometrics.
Surgical complications also need to be watched for. This includes any tingling sensations to the extremity, specifically the pinky finger and ulnar side of the hand, as well as abnormal inflammation. These may indicate complications with blood vessels and nerves, particularly the ulnar nerve. Psychological conditions need to be taken into consideration throughout the rehabilitation progression. Depression and irrational thoughts should be monitored for. Abdominal breathing exercises as well as relaxation techniques may be used to calm patients prior to advances in the rehabilitation progression.
After 5-7 days, the 90-degree posterior splint may be removed if sufficient healing has occurred. A functional hinged brace should be placed on the elbow after the posterior splint. This functional hinged brace should be initially limited between 30-100° elbow flexion. It should be locked at 90° for protection unless range of motion exercises are being completed. This range should be kept for another 5-7 days and increased progressively with a rate of about 10° of flexion and 5° of extension per week.
Range of motion exercises for this 30-100° range should gently begin passively with the functional hinged brace being a guide for this range. Joint mobilizations may also be used to increase range of motion while decreasing the pain. Other devices may also be used to create a passive range of motion such as the CPM (Continuous Passive Motion) machine. This machine allows the elbow to be moved continuously through a specific and accurate range with a specific speed. These initial motions should be progressed to gentle active elbow flexion and extension. Range of motion progression should be progressed according to pain.
Below is a sample rehabilitation plan throughout the entire progression:
Week 1 (Day 1 to 5-7):
· Submaximal isometrics: 2 sets, 20 seconds
-Wrist flexion and extension (0°, 20° flex, and 20° ext)
-Supination and pronation (neutral)
-Ulnar and radial deviation (0°, 20° uln, and 10° rad)
-Grip (varying thickness of objects)
-Baseball fingerings (4-seam, 2-seam, curve, knuckle, splitter, change, circle change, etc.)
· Isometrics: 2 sets, 20 seconds
-Shoulder: elevation, flexion, extension, internal rotation, adduction, and abduction.
Week 2 (Days 5-7 to 10-14):
· Continue and increase submaximal wrist and hand isometrics: 4 sets, 30 seconds
· Add elbow flexion and extension submaximal isometrics
-Keep within allowed range of motion
· Continue and increase shoulder isometrics
-4 sets, 20 seconds
· Continue cardiovascular exercises
· Replace posterior splint with a functional hinged brace set from 30-100°
· Begin elbow ROM exercises
-Passive and active flexion and extension from 30-100°
Week 3 (Days 10-14 to 17-21):
· Continue submaximal wrist, hand, and elbow isometrics
· Continue and progress shoulder isometrics and cardiovascular exercises
· Increase elbow ROM
-Passive and active flexion and extension from 25-110°
Week 4 (Days 17-21 to 24-28):
· Increase ROM on functional brace from 20-120°
-Active assisted and passive flexion and extension, include stretching
· Begin elbow isotonics: 2 sets, 15 reps
-Exercises: curls, triceps extensions, weighted supination, and weighted pronation.
-Motions: flexion, extension, pronation, supination
-1-2 lbs. initially
· Begin wrist isotonics: 2 sets, 15 reps
-Exercises: wrist curls, wrist extensions, ball squeezes, rice bucket, and ulnar deviation and radial deviation with weight.
-Motions: flexion, extension, ulnar deviation, radial deviation, grip
-1-2 lbs. initially
· Begin shoulder isotonics: 3 sets, 12 reps
-Exercises: side lying abductions, modified ‘save the can,’ modified lying reverse raises, and modified face down final goal.
Week 5 (Days 24-28 to 31-35):
· Increase ROM to 15-130°
-Continue and progress ROM improvement activities
· Continue and progress elbow isotonic
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Continue and progress shoulder isotonic
Week 6 (Days 31-35 to 38-42):
· Increase ROM to 15-130°
-Continue and progress ROM improvement activities
· Continue and progress elbow isotonic
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Add external rotation to shoulder isotonics
-Progress movement through submaximal efforts
· Continue and progress shoulder isotonics
-Exercises added: external rotation with theratube, hitchhikers, and 6 count field goals
Week 7 (Days 38-42 to 45-49):
· Increase ROM to allow full range of motion
-Remove everyday use of functional elbow brace
-Use functional brace during sleep and unsafe activities
· Continue and progress elbow isotonics with a full range of motion
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Continue and progress shoulder isotonic
-Exercises added: beach curl tubing, shoulder blade touches, and standing 4-way shoulder. Un-modify face down final goals, lying 3-way reverse raise, ‘save the can,’ and side-lying abduction
Week 8 (Days 45-49 to 52-56):
· Continue and progress elbow isotonics
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Continue and progress shoulder isotonics
· Initiate aquatic therapy
-Exercises: elbow flexion with paddles, elbow flexion with hand webbings, elbow extension with dumbbells, elbow extension with kickboard, shoulder adduction with dumbbells, supination with paddle, pronation with paddle, and bat swings.
Week 9 (Days 52-56 to 59-63):
· Initiate PNF exercises
-Progression: passive PNF pattern to active PNF pattern to PNF pattern in pool to manually resisted PNF pattern to PNF pattern with paddle in pool to PNF pattern with Bodyblade
· Initiate plyometric exercises
· Phase 1
-Exercises: two-arm chest press, supine toss, soccer throw, two-arm toss with rotation, push-up with a clap, one-arm chest pass with rotation, plyoback standing single-arm toss, and single-arm ball throw.
· Initiate CKC exercises
-Exercises: weight shifts, push-ups, step-ups, and slide board.
· Initiate functional exercises
· Phase 1
-Exercises: towel whips, throwing progressions, PNF pattern with Bodyblade on Airex pad and reactive catching drills.
· Add eccentrics to elbow isotonics
-Exercises added: eccentric elbow flexion and elbow extension
· Continue and progress shoulder isotonics
-Exercises added: push-up plus and thumb screws
· Continue and progress aquatic therapy
-Increase intensity accordingly
Week 10-13 (Days 59-63 to 87-91):
· Continue and progress PNF exercises
· Continue and progress plyometric exercises
· Continue and progress CKC exercises
· Continue and progress basic functional exercises
· Continue and progress aquatic therapy
· Initiate large upper body isotonic machine work
-Exercises added: bench press, seated row, and lat pulldown
Week 14-16 to 22-24:
· Initiate Phase 1 of Return to Throwing Program
· Initiate Thrower’s Ten Exercise Program
- Exercises: PNF tubing D2 extension and flexion, tubing external rotation at 0° abduction, tubing internal rotation at 0° abduction, shoulder abduction to 90°, scaption (external rotation), side-lying external rotation, prone horizontal abduction, prone rowing, prone rowing into external rotation, press-ups, push-ups, elbow flexion, elbow extension, wrist flexion, wrist extension, supination, and pronation.
Week 22-24 to 30-32:
· Initiate Phase 2 of Return to Throwing Program
· Continue and progress Thrower’s Ten Exercise Program
Following surgical intervention, a 90-degree posterior splint is used for one week. This is to protect the medial aspect of the elbow from possible valgus forces and to limit tension placed on newly constructed UCL from elbow flexion and extension. Excessive pronation and supination should also be avoided as this adds tension to the UCL as well. The elbow splint may be teamed with a sling for comfort and reduced chances for damage to the surgical site.
Assessments need to be made before every rehabilitation session and check-up to determine progress in the rehabilitation program as well as to identify any problems or special considerations that need to be added to the program. These assessment areas include injury status, surgical results, joint mobility, flexibility, neurological status, muscular strength/endurance, muscular atrophy, postural evaluation, general physical fitness, and psychological status.
Pain and swelling can be reduced by the continuation of NSAID or prescription use, as well as: ice, compression dressing under brace, massage, and protection. Common prescriptions following a UCL reconstruction include Vicodin and Percocet. These should be used periodically throughout the first week as need, especially during the 2-3 days following surgery. Special consideration needs to be applied with icing if an ulnar nerve transposition was combined with the surgery.
Submaximal isometrics can be completed for wrist flexion, extension, pronation, supination, ulnar deviation, radial deviation, and grip. Submaximal contractions are key, as they do not put a lot of stress on the healing tissues. Grip exercises can be completed with putty, sand bucket, or a finger web. Hand intrinsic musculature and wrist range of motion and musculature can be worked on through baseball pitch fingerings. This will not only be a good exercise for strength and range of motion, it also provides a sport-specific exercise for psychological purposes for a pitcher. Isometrics can be done on the shoulder musculature and biceps. All shoulder external rotation and valgus stresses should be completely eliminated due to the added stress to the healing site. The 90-degree posterior splint should be worn during shoulder and wrist isometrics.
Surgical complications also need to be watched for. This includes any tingling sensations to the extremity, specifically the pinky finger and ulnar side of the hand, as well as abnormal inflammation. These may indicate complications with blood vessels and nerves, particularly the ulnar nerve. Psychological conditions need to be taken into consideration throughout the rehabilitation progression. Depression and irrational thoughts should be monitored for. Abdominal breathing exercises as well as relaxation techniques may be used to calm patients prior to advances in the rehabilitation progression.
After 5-7 days, the 90-degree posterior splint may be removed if sufficient healing has occurred. A functional hinged brace should be placed on the elbow after the posterior splint. This functional hinged brace should be initially limited between 30-100° elbow flexion. It should be locked at 90° for protection unless range of motion exercises are being completed. This range should be kept for another 5-7 days and increased progressively with a rate of about 10° of flexion and 5° of extension per week.
Range of motion exercises for this 30-100° range should gently begin passively with the functional hinged brace being a guide for this range. Joint mobilizations may also be used to increase range of motion while decreasing the pain. Other devices may also be used to create a passive range of motion such as the CPM (Continuous Passive Motion) machine. This machine allows the elbow to be moved continuously through a specific and accurate range with a specific speed. These initial motions should be progressed to gentle active elbow flexion and extension. Range of motion progression should be progressed according to pain.
Below is a sample rehabilitation plan throughout the entire progression:
Week 1 (Day 1 to 5-7):
· Submaximal isometrics: 2 sets, 20 seconds
-Wrist flexion and extension (0°, 20° flex, and 20° ext)
-Supination and pronation (neutral)
-Ulnar and radial deviation (0°, 20° uln, and 10° rad)
-Grip (varying thickness of objects)
-Baseball fingerings (4-seam, 2-seam, curve, knuckle, splitter, change, circle change, etc.)
· Isometrics: 2 sets, 20 seconds
-Shoulder: elevation, flexion, extension, internal rotation, adduction, and abduction.
Week 2 (Days 5-7 to 10-14):
· Continue and increase submaximal wrist and hand isometrics: 4 sets, 30 seconds
· Add elbow flexion and extension submaximal isometrics
-Keep within allowed range of motion
· Continue and increase shoulder isometrics
-4 sets, 20 seconds
· Continue cardiovascular exercises
· Replace posterior splint with a functional hinged brace set from 30-100°
· Begin elbow ROM exercises
-Passive and active flexion and extension from 30-100°
Week 3 (Days 10-14 to 17-21):
· Continue submaximal wrist, hand, and elbow isometrics
· Continue and progress shoulder isometrics and cardiovascular exercises
· Increase elbow ROM
-Passive and active flexion and extension from 25-110°
Week 4 (Days 17-21 to 24-28):
· Increase ROM on functional brace from 20-120°
-Active assisted and passive flexion and extension, include stretching
· Begin elbow isotonics: 2 sets, 15 reps
-Exercises: curls, triceps extensions, weighted supination, and weighted pronation.
-Motions: flexion, extension, pronation, supination
-1-2 lbs. initially
· Begin wrist isotonics: 2 sets, 15 reps
-Exercises: wrist curls, wrist extensions, ball squeezes, rice bucket, and ulnar deviation and radial deviation with weight.
-Motions: flexion, extension, ulnar deviation, radial deviation, grip
-1-2 lbs. initially
· Begin shoulder isotonics: 3 sets, 12 reps
-Exercises: side lying abductions, modified ‘save the can,’ modified lying reverse raises, and modified face down final goal.
Week 5 (Days 24-28 to 31-35):
· Increase ROM to 15-130°
-Continue and progress ROM improvement activities
· Continue and progress elbow isotonic
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Continue and progress shoulder isotonic
Week 6 (Days 31-35 to 38-42):
· Increase ROM to 15-130°
-Continue and progress ROM improvement activities
· Continue and progress elbow isotonic
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Add external rotation to shoulder isotonics
-Progress movement through submaximal efforts
· Continue and progress shoulder isotonics
-Exercises added: external rotation with theratube, hitchhikers, and 6 count field goals
Week 7 (Days 38-42 to 45-49):
· Increase ROM to allow full range of motion
-Remove everyday use of functional elbow brace
-Use functional brace during sleep and unsafe activities
· Continue and progress elbow isotonics with a full range of motion
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Continue and progress shoulder isotonic
-Exercises added: beach curl tubing, shoulder blade touches, and standing 4-way shoulder. Un-modify face down final goals, lying 3-way reverse raise, ‘save the can,’ and side-lying abduction
Week 8 (Days 45-49 to 52-56):
· Continue and progress elbow isotonics
-Increase weight accordingly
· Continue and progress wrist isotonics
-Increase weight accordingly
· Continue and progress shoulder isotonics
· Initiate aquatic therapy
-Exercises: elbow flexion with paddles, elbow flexion with hand webbings, elbow extension with dumbbells, elbow extension with kickboard, shoulder adduction with dumbbells, supination with paddle, pronation with paddle, and bat swings.
Week 9 (Days 52-56 to 59-63):
· Initiate PNF exercises
-Progression: passive PNF pattern to active PNF pattern to PNF pattern in pool to manually resisted PNF pattern to PNF pattern with paddle in pool to PNF pattern with Bodyblade
· Initiate plyometric exercises
· Phase 1
-Exercises: two-arm chest press, supine toss, soccer throw, two-arm toss with rotation, push-up with a clap, one-arm chest pass with rotation, plyoback standing single-arm toss, and single-arm ball throw.
· Initiate CKC exercises
-Exercises: weight shifts, push-ups, step-ups, and slide board.
· Initiate functional exercises
· Phase 1
-Exercises: towel whips, throwing progressions, PNF pattern with Bodyblade on Airex pad and reactive catching drills.
· Add eccentrics to elbow isotonics
-Exercises added: eccentric elbow flexion and elbow extension
· Continue and progress shoulder isotonics
-Exercises added: push-up plus and thumb screws
· Continue and progress aquatic therapy
-Increase intensity accordingly
Week 10-13 (Days 59-63 to 87-91):
· Continue and progress PNF exercises
· Continue and progress plyometric exercises
· Continue and progress CKC exercises
· Continue and progress basic functional exercises
· Continue and progress aquatic therapy
· Initiate large upper body isotonic machine work
-Exercises added: bench press, seated row, and lat pulldown
Week 14-16 to 22-24:
· Initiate Phase 1 of Return to Throwing Program
· Initiate Thrower’s Ten Exercise Program
- Exercises: PNF tubing D2 extension and flexion, tubing external rotation at 0° abduction, tubing internal rotation at 0° abduction, shoulder abduction to 90°, scaption (external rotation), side-lying external rotation, prone horizontal abduction, prone rowing, prone rowing into external rotation, press-ups, push-ups, elbow flexion, elbow extension, wrist flexion, wrist extension, supination, and pronation.
Week 22-24 to 30-32:
· Initiate Phase 2 of Return to Throwing Program
· Continue and progress Thrower’s Ten Exercise Program