Rehabilitation following UCL Reconstruction/Repair in Athletes

Wilk - Rehabilitation Following UCL Surgery

2017 Injuries in Football Course 2017

1

Rehabilitation following UCL Rehabilitation following UCL Reconstruction/Repair in

AthletesKevin E. Wilk, PT, DPT,FAPTA

Kevin E Wilk, PT, DPT,FAPTA2017 Injuries in Football

Faculty Disclosure:• Theralase Laser – Medical Advisory Board

• LiteCure Laser – Consultant

• AlterG – Medical Advisory Board

• Intelliskin USA – Medical Advisory Board

• Zetroz Medical – Medical Advisory Brd

• Throw Like A Pro – Co-Owner

• Dr PRP – Rehab Advisor

• Educational Grants:

» Empi Medical

» Joint Active System

» ERMI

» Bauerfeind Brace

• Book Royalties:

» CV Mosby, Lippincott, Human Kinetics



2

American Sports Medicine InstituteBirmingham, Alabama

asmi.org

Elbow Injuries in SportsIntroduction

• Number of elbow injuries

appear to be increasing

• Repetitive high forces –

overhead athlete

�22% of all baseball injuries

• Macrotraumatic forces –dislocation / fractures / tears

• Thrower’s “not all or none”

Rehabilitation Program Must Be Specific For Each Type of Athlete

Elbow Dislocation



3

J Sports Health ‘12 J Sports Health ‘12

UCL Rehabilitation Rehab Plan



4

Beckett et al: AJSM ‘14

• Assessment of scapular & hip joint

in preadolescent (7-12 yrs) &

adolescent (13-18 yrs) in baseball

players

�High rate of scapular dyskinesis in

adolescent players compared to

pre-adolescent

�Also poor single leg squat test

�Higher coracoid process distance

– correlated to dyskinesis

UCL RECONSTRUCTION REHABLower Extremity Strengthening

UCL RECONSTRUCTION REHABLower Extremity Strengthening Linking UE & LE



5

11%

18% 18% 18%21%

29%28%

32% 31%

38% 38%

44%

40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

UCL Surgeries on Pitchers at ASMOC

Adolescent

Adult• 1281 UCL procedures, 1265 reconstructions

• Follow-up on 79% (743 patients)

• 95% baseball players ( 89% pitchers)

• Average follow-up: 49.1 months

� 83% returned to same level (recon)

• 63% of repairs returned to same level competition

• Return to competition: 11.6 months

• ITP initiated – 4.4 months

AJSM 2010

RTP – “when they’re ready”

• 179 UCL reconstructions included in study

� 148 returned to play 83% returned to same level

�Only 5 pitchers were not able to return to play

�Return to competition: 20 months

�Length of career 3.9 months

� Pitchers performance improved after surgery

AJSM 2014

• 80 active minor league pitchers

• 40 UCLr compared to 40 normal

• PROM, radar gun ball velocity, & biomechanics

were analyzed

�Conclusions: no sign stat diff in any area tested

AJSM 2015

Oshbar, Cain, Dugas et al: AJSM ‘13

• UCL reconstruction in throwing athletes – a

minimal 10 year follow-up

• 256 of 313 (82%) available for F/U

• Average follow up 12.6 yrs + 4.5 yrs

• 90% were pitchers

�83.5% of overhead throwers RTP

• Longevity of career after UCLr 3.6 yrs for all

levels

• 86% retired due to something else than UCL

• 98% still throwing

• Utilizing MLB player performance statistics

�Overall 78% (14/18) pitchers returned to MLB play

within 2 full seasons

�Relief pitchers were able to resume 50% workload &

starters reached 35% workload

�Relievers demonstrated better pitching stats

compared to the starters

JSES 2013



6

Fleisig, Bolt, Fortenbaugh, Wilk: JOSPT ‘11

• 17 healthy college pitchers

• Biomechanical analysis of long & short throwing

• Threw 18.4m , 37m, 55m & maximal distance on a

line

• Shoulder line was horizontal for mound distance but

gradually went uphill as distance increased

�Maximal throwing distance resulted in more ER,

more Elb Flexion, more shoulder IR torque & more

varus elbow torque

• Trunk tilt gradually increased with distance

Biomechanics change with increase distance

Interval Throwing Programs

�Go slow

�Don’t be in a big hurry

�Stay at reasonable distances

�Crow Hop – use your legs

�Watch mechanics

�Watch mechanics

�Slow to go off mound

�Don’t throw high velocity or distance –until ready

UCL ReconstructionReturn to Play & PerformanceVitale & Ahmad: AJSM ‘08

• Systematic review of UCLr in overhead athletes

� 83% excellent result

• 10% complication rate

• Muscle splitting,decr handling UN, & docking improved outcomes

• 41 MLB pitchers underwent UCL reconstruction – pair

matched group

• 8 did not return to MLB play

• No sign change in velocity following UCL

• No sign diff in innings pitched, ERA, walks, SO etc

• No sign diff in UCL group

Jiang & Leland: AJSM ‘14

Elbow Injuries in BaseballUCL Surgeries – Conte, Wilk: AJSM ‘15

�Surveyed all Minor League Baseball Players

�4,052 respondents (2,145 pitchers)

�29/30 teams responded

�100% responses in 29 teams

�331 players had UCLr (8%)

�Pitchers: 300/2145 (14%)

�Position players: 31/1907 (2%)

�Avg age at time of surgery 21



7

Elbow Injuries in BaseballUCL Surgeries: Conte, Wilk: AJSM ‘15

�Surveyed all Major League Baseball Players

�1,036 respondents

�30/30 teams responded

�100% responses in 30 teams

�166 players had UCLr (16%)

�Pitchers: 25%

�Position players: 5%

�49% UCLr received concomitant surgery

Thrower’s ShoulderKey Points

� Pitchers sustain injuries at the highest rate

� 61% of all team injuries pitchers compared position players

� 72% of all pitchers injuries are to their shoulder/elbow

� Specific risk factors increases injuries

�Pitching when fatigued, or pitch too much (volume), improper

throwing mechanics, or max effort - all increase injury risk

�GIRD & GERI is predominantly due to boney

adaptations

� ~83% boney & ~17% due to soft tissue

�Maintaining motion in throwing shoulder when healthy

isn’t difficult

� Specific exercises & stretches are important

Injuries in Baseball PlayersIncidence of Injury

�Major League Baseball Injuries 1998-2012

�DL Days:

�72% of all DL days are due to shoulder &/or

elbow injuries

� 1998-2007: 2:1 shoulder to elbow DL days

� 2007 to now: 1.9:1 elbow to shoulder DL days

�61% of all DL days are pitchers

� relievers account for 31.5 % of DL days

� starters account for 29.7% of DL days

AJSM ‘16

• UCLr in the State of NY from 2002 to 2011

�UCLr increased by 193%

• UCLr mean age 17-18 & 19-20 yrs of age

• Private insurance patients were 25% more likely to

undergo a UCLr than those with Medicaid

• The number of institutions performing UCLr doubled

AJSM 2016Risk Factors for Injuries

Overview

Youth Baseball Pitchers Pro Baseball Pitchers



8

�Pitching when fatigued

�Pitching too many innings/year

�Not enough rest from throwing at end season

�Too many pitches in game, week, year

�Pitching consecutive days

�Poor pitching or throwing mechanics

�Playing on multiple teams, leagues

Youth Baseball PlayerRisk Factors

Don’t Throw When Fatigued !�Excessive throwing when not pitching

�Throwing curveballs or sliders

�Too much Pitching

� Improper conditioning

� Not following proper conditioning guidelines

� Not following safe practice guidelines at

showcases

� Too much throwing with not enough rest !

Youth Baseball PlayerRisk Factors

Don’t Rush Through the Interval Throwing Program

� Pitching at maximum effort

“ too many pitches at 100% effort”

�Excessive retrotorsion

“excessive ER – increases velocity”

� Pitching too many innings

“over utilization”

� Pitching when fatigued

“alteration in normal throwing mechanics”

� Pitching beyond the player’s capabilities

“types of pitches, velocity, innings, reliever vs”

Elite Baseball PitcherRisk Factors for Injury



9

Glenohumeral Passive Range of Motion & the Correlation to Elbow Injuries in

Professional Baseball Players: An 8 year Prospective Study (AJSM 2014)

Kevin E. Wilk, DPT

Leonard C. Macrina, MSPT

Glenn S. Fleisig, PhD

Kyle Aune, MPH

Ronald Porterfield, ATC

Paul Harker, ATC

James Andrews, MD

1

Methods & Materials• 505 pitcher-seasons were included in this study

• 6,060 total PROM measurements taken

• 296 individual pitchers were included

• 46 pitchers were assessed in three or more consecutive

seasons

• 80 were assessed in two seasons

• 170 were assessed only once

• 220 pitched right-handed & 76 left-handed

• All subjects were asymptomatic when tested and had no

surgeries within two years prior to testing

• Same two examiners performed PROM assessment

each year

6

Results

• Subject demographics:

• 296 subjects: 505 pitcher-seasons

� 38 players sustained 50 elbow injuries

� Accounting for 2,581 days on the DL (avg days on DL 51 days/injury)

or 68 avg DL days per player

� Shoulder injuries accounted for 5,606 days on the DL during same

time period

10

Overall

Mean ± SD

Elbow

Injury

Mean ± SD

No Elbow

Injury

Mean ± SD p-Value

Age 24.7 ± 4.1 25.2 ± 0.6 24.6 ± 0.3 0.45

Height (cm) 188.6 ± 5.6 187.9 ± 5.9 188.7 ± 5.5 0.39

Weight (kg) 90.8 ± 10.1 91 ± 1.5 90.8 ± 0.7 0.87

Follow-Up Time (mo.) 49.1 ± 28.9 60.1 ± 3.9 46.7 ± 1.8 0.0009

Single Injury Duration (days) 51.6 ± 53.6

Results

Specific Type of Injuries:

Injury # of Injuries Days on DL % Days on DL

• Elbow Strains: 15 566 22.4%

• UCL 12 781 30.5%

• Inflammation 9 298 11.8%

• Surgery 6 352 14.0%

• Stress Reaction 4 309 12.2%

• Neuritis 3 203 8.3%

• Contusion 1 19 0.7%

50 252812

Conclusions & Clinical Relevance

�Based on the results of this study:

�Pitchers with a throwing shoulder deficit in TRM

had a 2.3x risk of sustaining an elbow injury

�Pitchers with a dominant shoulder loss of Flexion

exhibited a greater risk (2.8x) risk of an elbow inj

�GIRD did not correlate with elbow injuries

� Strong trend for increase ER incr risk UCL inj

�Clinicians need to be aware of this and plan a

preventative & rehabilitation program that addresses

these findings – this to prevent &/or treat elbow

injuries in the overhead pitcher 17

Noonan, Thigpen, Bailey, et al: AJSM ‘16

• Humeral torsion risk factor for shoulder/elbow

injuries in professional baseball pitchers

• Protective or Harmful

• 255 pitchers prospective study ROM, Retro US

�60 injuries were recorded (24%) 30 shldr 30 elb

�Players who sustained shoulder injuries

exhibited less retrotorsion compared uninj (4°)

�Players who sustained elbow injuries exhibited

an increase in humeral retrotorsion by 5°



10

Chalmers, Erickson, Romeo: AJSM ‘16

• Fast ball pitch velocity helps predict UCLr in MLB

pitchers

• Data base study design using Pitch Fx

• MLB pitchers from 4/2/07 – 4/14/15

• 1327 pitchers included

�309 (26.8%) underwent UCLr (145 had pre injury

velocity recorded

�Peak pitch velocity independent predictor (p<.001)

�Mean velocity, body mass & age 2nd predictors

UCL Pathomechanics

40

Maximum External

Rotation

Elbow Varus Torque =

64 Nm (40#)

Fleisig GS: AJSM ‘07



11

Noonan, Thigpen, Bailey, et al: AJSM ‘16

• Humeral torsion risk factor for shoulder/elbow

injuries in professional baseball pitchers

• Protective or Harmful

• 255 pitchers prospective study ROM, Retro US

�60 injuries were recorded (24%) 30 shldr 30 elb

�Players who sustained shoulder injuries

exhibited less retrotorsion compared uninj (4°)

�Players who sustained elbow injuries exhibited

an increase in humeral retrotorsion by 5°

Sports Illustrated

• How many MLB stars came from warm-

weather and cold-weather states?

MLB Hitters > 300 Home Runs

MLB Pitchers > 200 WinsOJSM ‘14



12

Elbow Injuries in SportsUCL Injuries

Traumatic UCL Injuries Repetitive Overhead

Stresses



13

Elbow Dislocation

Flexor/Pronator AvulsionUCL Avulsion (10 yr old)



14

10 wks post-op



15

Elbow Injuries – Overhead Thrower

• Tremendous forces & stress

�Acceleration phase:

64 NM valgus stress

• Increase stress with specific

• pitches (slider, split-finger)

• Pitchers are bigger & stronger

& able to generate

• Tremendous torques generated

Better recognition of injuries

Pathomechanics

Two critical instants

Max. ER Ball Release

UCL Pathomechanics

40

Maximum External

Rotation

Elbow Varus Torque =

64 Nm (40#)

Fleisig GS: AJSM ‘07



16





line





varus elbow torque


UCL Reconstructions in Youth Baseball Players (JRA)

Fleisig et al: Curr Spts Med Reports ‘09

Youth & High School Total % Youth & HS

• 1994 0 6 0%

• 1995 2 21 10%

• 1998 5 43 12%

• 2000 17 93 18%

• 2004 35 174 20%

• 2006 36 140 26%

• 2007 38 125 30%

• 2008 33 103 32%

• 2009 34 121 28%

Total 333 1476 23%

Prevention Programs for the Throwing Athlete

Prevention Programs for the Throwing Athlete

www.asmi.org

www.aossm.org



17

“Throw Like A Pro” App The Overhead ThrowerIntroduction

• Why the increase in injuries at all levels of baseball???

• Factors that influence injury rates:�Arm fatigue

�Technique & Skill level

�Size of players

�Number of pitches per game

�Number of games per year

�Number of years throwing

�Type of pitches

Lyman, Fleisig, et al: AJSM ’02

Lyman, Fleisig, et al: Med Sci Spts Ex ’01

Olsen, Fleisig, et al: AJSM ‘06

» Pitches allowed per game

• 17-18 yrs 105 pitches



• 9-10 75 pitches

• 7-8 50 pitches

Injury Prevention

� Little League Pitch Count Rule (since 2007)

• Days rest after pitching (14 and under)

•66 or more pitches 4 days

•51-65 pitches 3 days

•36-50 pitches 2 days

•21-35 pitches 1 day

Olsen, Fleisig, Dun, Loftice, Andrews: Am J Sports Med ‘06

• Risk factors for developing shoulder & elbow injuries in adolescent baseball pitchers

• Compared 95 pitchers who had surgery to 45 pitchers who never had a significant injury

• Risk factors:» Pitched more months per year

» Games per year

» Innings per game

» Pitches per game

» More starting pitchers

» Participated in showcases

» Pitched at higher velocity

» Pitched more often & when fatigued

» Used NSAIDs & ice

» Injured group was taller & heavier

Biomechanics of the Elbow

Throwing

Biomechanics of the Elbow Joint Complex During

Throwing



18

Physical Characteristicsof the

Thrower’s Elbow

The Elbow Joint in ThrowersRange of Motion

• Wilk, Macrina, Reinold, Porterfield Unpublished: ’15

• Extension: 7 ± 70

• Flexion: 147 ± 40

• Pronation: 98 ± 40

• Supination: 93 ±40

n = 732


Wright,O’Neal,Paletta:AJSM ’05

• Tested 33 pitchers

• Bilateral difference in ROM

• Elbow extension 7 degrees

• Elbow flexion 5.5 degrees

• Total ROM difference 13 deg.


• ROM during throwing

Fleisig: JOSPT ‘93

» 19 to 990

» elbow ext : 50

» wrist ext: 50

» shoulder IR: 70

» shoulder ER: 60

Wilk, Reinold : AJSM ‘08

LOM following throwing

Elbow Injuries in SportsOverview

Common elbow injuries in

the overhead athletes

�Vaglus extension overload

�Flexor/pronator tendonitis

�Extensor tendonitis

�Ulnar collateral ligament sprains

�Degeneration of elbow joint

�Ulnar neuritis



19

Elbow Injuries in SportsOverview

Common elbow injuries in

the overhead athletes

�Vaglus extension overload

�Flexor/pronator tendonitis

�Extensor tendonitis

�Ulnar collateral ligament sprains

�Degeneration of elbow joint

�Ulnar neuritis

Treatment of UCL Sprains in the Throwing Athlete

Medial Elbow PathologiesUCL Sprains

• UCL is the main medial

stabilizer of the elbow

• Anterior bundle is the

primary structure

involved in throwing

Pathomechanics

Two critical instants

Max. ER Ball Release

UCL Pathomechanics

40

Maximum External Rotation

Elbow Varus Torque = 64 Nm

UCL tensile strength-32 N

UCL Pathomechanics

• Contribution to Varus Torque:Morrey, An, 1983 (in vitro)

(Without muscle contribution)

» UCL: 54%

» Osseous: 33%

» Soft tissue / capsule: 13%

• Muscle Contribution to Varus Torque:Buchanan, Delp, Solbeck, 1998 (simulation)

» Pronator Teres: 15%

» FCR + FCU: 7%



20

Ulnar collateral ligament injury

MRI Studies – T SignTimmerman,Andrews:AJSM’94



21

UCL -Valgus Stress Testing

Valgus Stress Testing - Seated

Valgus Stress Testing - Supine Valgus Stress Testing - Prone

UCL TestingMilking Maneuver - O’Brien

UCL Testing –Moving Valgus Test - O’Driscoll



22

Bruce, Joyner, Andrews: JSES’15

• Stress radiograghs performed on

273 baseball players pre-operative

prior to surgery

• How much joint opening present in

UCL insufficient throwing elbows

• Elbow tested at 20 to 30 with 15

daN force

�UCL injured elbow: 0.4mm

�UCL complete tears: 0.7 mm

Elbow Laxity in Professional Baseball Players/Pitchers

Ellenbecker, Mattalino:

AJSM ’98

• 40 uninjured professional

pitchers

• Stress radiograghs 15daN

• D: 1.20mm ND: 0.88

�Bilateral Diff: 0.32 mm

Ciccotti et al: AJSM ’14

• 368 asymptomatic

professional baseball

pitchers (10 yrs)

• Stress US assessment

�UCL thicker on D elbow

� Joint opening:

D 4.5mm

ND: 3.72mm

Diff: 0.8mm

Treatment of UCL Injuries in The Overhead Throwing Athlete

Non-Operative Rx Operative Rx

Stop Pitching



Stop Pitching Rehab

Successful Outcome



Stop Pitching Rehab Reconstruction Repair

Successful Outcome

Non-Operative Rehab Partial Thickness UCL Tears in Throwers

Rehab ProgramJobe: Clin Spts Med ’86

Yocum: Clin Spts Med ’89

Jobe: Instr Course Lect ’91

Wilk & Andrews: Spts Med Arth Rev ’95

Azar & Wilk Op Tech Spts Med ’96

Wilk & Andrews: JOSPT ‘93

Rettig: AJSM ’01*

Podesta et al: AJSM ‘13

Effective Treatment Plan – What % of Patients



23

Non-Operative Rehab UCL SprainsTypical Program - Literature

• No throwing for 8 weeks to 4 months (severity)

• Restricted motion; caution with valgus stress

• Progressive strengthening

» Esp. of wrist flexors/pronators

» Emphasize shoulder program

• Initiate throwing program at timeframe: 6-8

weeks to 3-4 months from time of initial injury ?

Mixed clinical results – how many return to play

Rettig, Sherill, et al: AJSM ‘01

• 31 overhead athletes suspected UCL sprains

» (20 pitchers, 2 javelin throwers)

• Some had MRI or stress views

• Treated non-operatively

» No throwing 2-3 months

» ROM exercise & ice

» Strengthening program

» Begin throwing at 2-3 months

� 42% were able to return to play

�*Average time to return 24.5 weeks (13-54 weeks)

UCL Sprains in Contact Sports

• Clam down tissue

• Immediate PROM AAROM @ 2-7

days

• Posterior splint at 90 deg.

• Consider bracing to limit motion –

control valgus stress

• Strengthen flexor/pronator muscles

• Control forces for 4-6 wks

• Symptoms reduce -

• Return to play ??

UCL Sprains InjuriesDislocated Elbow

• Hyperextended elbow- often UCL injury & capsular tear

• Immobilize in posterior splint

• Begin easy ROM program

• Control elbow extension

• Gradual restore ROM

• Strengthening program

• Functional brace



24

Podesta, Best, Yocum: AJSM ‘13

• 34 overhead athletes with confirmed (MRI)

partial thickness UCL tear

• All players failed non-op Rx previously

• All Rx with 1 injection IA PRP injection

& specific rehabilitation program

�30/34 (88%) returned to same level of play

without any complications (1 had UCLr)

�Average return to play 12 weeks

�Joint opening reduced from 7 to 2.5 mm

PRP – Platelet-rich Plasma

Platelet Rich PlasmaOverview - PRP

• Autologous blood therapy

• Uses patient’s own blood components to

stimulate healing response

• PRP – enhance body’s own healing

response

• Uses platelets which have growth

factors

• Used to treat “injured tissues”

Platelet Rich PlasmaOverview - PRP

• Withdraw autologous blood sample

• Add anticoagulant

• Centrifugation twice

» 1st remove RBC’s

» 2nd separate platelet poor plasma from platelet rich plasma

• Extract PRP

» 4-8x whole blood concentration

• Add calcuim & thrombin to activate platelets

• Relatively quick & easy

Rehab UCL Sprains in Throwers

� Immediate restricted motionNon-painful ROM*

Usually almost full ROM*

Gradually establish full ROM

�Consider ROM brace ??Control valgus stress

Brace for 3-4 weeks

�Muscle trainingIsometric for UE/ shoulder

Emphasize flexor/pronators

�Control applied forcesNo throwing 2-3 months

� Throwing mound (12-16 wks)



25

UCL SPRAINS REHABMuscular Strength Training

• Wrist & hand isometrics day 1

• Isometrics UE week 1-2

• Isotonics program week 3-4

• Thrower’s Ten program week 4

• Advanced Thrower’s Ten wk 6-8

• Weight lifting week 8

• Sports (golf) week 8-12

• Plyometrics

» Two hand drills week 6-8

» One hand drills week 8-12

Manual Resistance Techniques

Elbow Rehabilitation in Athletes

Dynamic Stabilization

Davidson et al: AJSM ‘95


Advanced phase:

�Gradually increase applied

stresses & forces

» Thrower’s ten program

» Plyometrics

�Initiate Throwing Program

(criteria-based)

�Mild sprain 6-8 wks

�Moderate sprain 3-4 mos



26


Advanced phase:

�Gradually increase applied

stresses & forces

» Thrower’s ten program

» Plyometrics

�Initiate Throwing Program

(criteria-based)

�Mild sprain 6-8 wks

�Moderate sprain 3-4 mos

UCL Sprains in Contact Sports

• Immediate following injury

• Posterior splint at 90 deg.

• Consider bracing to limit motion

– control valgus stress

• Strengthen flexor/pronator

muscles

• Control forces for 4-6 wks

• Symptoms reduce -

• Return to play ??

UCL Sprains InjuriesDislocated Elbow

• Hyperextended elbow- often UCL injury & capsular tear

• Immobilize in posterior splint for 1-2 weeks

• Begin easy ROM program

• Control elbow extension

• Gradual restore ROM

• Strengthening program

• Functional brace

Rehabilitation FollowingUCL Reconstruction

Our Current Program (2017)

UCL RECONSTRUCTION REHABRecent Adaptations in Our Program

�Earlier restoration of motion

• Previous: 7-8 wks FROM

• Present: 4-6 wks FROM

• More present: Full ext ASAP *

Acute Injury Chronic Injury

• Emphasis on wrist flexors, shoulder strength

• Preparation phase of throwing –plyometrics longer

� Throwing programs – long toss (more time)…

delay hard throwing for longer –return to games delayed

• Phase I: Acute Post-Op Phase:

• Phase II: Subacute Phase:

• Phase III: Advanced Phase:

• Phase IV: Return to Activity Phase:

Rehabilitation Following UCLrin Throwers

Rehabilitation – 4 Phases Program



27

• Phase I: Post-Op Phase (weeks 0-8):

�Protect the healing tissue (UCL)

�Gradually restore motion

�Decrease inflammation & pain

�Prevent muscular atrophy

� Scapular, GH joint, leg, core program

• Phase II: Subacute Phase (weeks 9-12

�Continue ROM & stretching

� Isotonic strengthening program (Throw 10�Scapular & Glenohumeral joint

�Fine tune muscular ratios

�Core & Leg program

Rehabilitation UCLr ThrowersRehabilitation – 4 Phases Program

• Phase III: Advanced Phase(weeks 13-16

�Advanced isotonic program�Strength, power, & endurance

�Advanced thrower’s ten program

�Plyometrics

�Continue stretching & ROM program

• Phase IV: Return to Activity Phase: 4 mos

�Thrower’s ten program

�Plyometrics

� Interval throwing program (ITP)

�Light stretching program

Rehabilitation UCLr ThrowersRehabilitation – 4 Phases Program

Reconstruction of the UCL Surgical Overview

�Modification of Jobe procedure

Jobe: JBJS ’86

Andrews: Op Tech Spts Med ’96

Andrews et al: Am J Sports Med ‘10

• Subcutaneous ulnar nerve transposition

• fascial sling

• Graft source

• Palmaris longus

• Gracilis

Reconstruction of the UCL Surgical Technique Update

Graft location:

• UCL reconstruction - 2386

�Palmaris longus 62%

ipsilateral:(78%) contralateral: (22%)

�Gracilis 38%

Reconstruction of the UCL Surgical Technique

• Graft location: (from 1989 – present)

» Palmaris longus 81%

ipsilateral (84%) contralateral (16%)

» Plantaris 10%

» Gracilis 6%

» Toe extensors 3%

» Patellar tendon n=1



28

Reconstruction of the UCL Surgical Technique Update*

• Graft location:

• UCL reconstruction -

» Palmaris longus 65%

ipsilateral:(78%) contralateral: (22%)

» Gracilis 33%

» Anterior tibialis n=1



29



30

Reconstruction of the UCL Surgical Technique

• Docking Procedure

Altchek DW: HSS

• Muscle split

• Single huneral tunnel

• Smaller tunnels (?)

• No ulnar nerve transposition

Rohrbough & Altchek: AJSM ’02

Dodson: AJSM ‘06

UCL RECONSTRUCTION REHAB

Range of Motion Progression

�Week one: splint at 90 degrees

�Week two: brace 30-100 degrees

�Week three: brace 15-115

degrees

�Progress program 5 degrees

of extension and 10 degrees

of flexion per week

�Full ROM at week 5-6

More Aggressive with ROM


UCL Strain with PROM

Bernas: AJSM ‘09



31

Wrist & hand ROM / gripping

Rehab of Graft Site

• Palmaris tendon graft:» Ice & compression first 5-7 days

» Immediate wrist motion, no aggressive stretching 2 weeks

» Immediate hand gripping exercises

» Soft tissue (scar) mobilization at 2 wks

» If scars: US, stretch, tissue tissue

» Begin strengthening program for wrist flexors

• Isometrics immediate

• Isotonics at 3 weeks

» Progress to stretch with open hand & digits extended

• Gracilis tendon graft

» Ice & compression first 5-7 days

» No stretching of hamstrings for 2-3 weeks

» Soft tissue (scar) mobilization on day 15

» No isolated hamstrings for 3-4 wks

» May bicycle at 2-4 weeks

» Begin strengthening program for hamstrings & calf

• Isometrics at 4 weeks

• Isotonics at 6 weeks

Rehab of Graft SiteUCL RECONSTRUCTION

REHABMuscular Strength Training

• Wrist & hand isometrics day 1

• Isometrics UE week 1-2

• Active ROM week 2-3

• Isotonics program week 3-4

• Thrower’s Ten program week 4/5

• Weight lifting week 10-12

• Sports (golf) week 11

• Plyometrics

» Two hand drills week 12

» One hand drills week 14

Thrower’s Ten Program



32

Bilateral Extremity Exercises

UCL RECONSTRUCTION REHABUCL RECONSTRUCTION REHAB

Rotator Cuff Strengthening

UCL RECONSTRUCTION REHABRotator Cuff Strengthening UCL RECONSTRUCTION REHAB

Advanced Strengthening Phase: Week 12-16

�Progress strengthening program

�Initiate isotonic strengthening program

• Bench press (seated)

• Pull-downs

• Seated Rows

• Biceps/Triceps

�Advanced Throwers’ 10



33

Manual Resistance Techniques

UCL RECONSTRUCTION REHABStrengthening Drills – Elbow/Wrist Flex/Pron

UCL RECONSTRUCTION REHABStrengthening Drills- MR Elbow/Wrist Flex C/E

UCL RECONSTRUCTION REHABStrengthening Drills-MR Elbow/Wrist Flex

Elbow Rehabilitation in Athletes

Dynamic Stabilization

Davidson et al: AJSM ‘95

UCL RECONSTRUCTION REHABStrengthening Drills



34

UCL RECONSTRUCTION REHABStrengthening Drills- RS Shoulder/Elbow





Advanced Thrower’s Ten Program



35


www.asmi.orgTubing ER/IR

Standing Full Can

Lateral Raises

D2 PNF Flexion


Sidelying ER

Prone Horz Abduct

Prone Full Can

Prone Row into ER


Prone rowing

Push-Ups

Elbow Flex/Ext

Sup/Pron & Wrist Flex/Ext

www.asmi.org

UCL RECONSTRUCTION REHABAdvanced Thrower’s Ten

UCL RECONSTRUCTION REHABAdvanced Thrower’s Ten Dynamic Stabilization Exercises



36

Dynamic Stabilization Exercises



37

Scapular NM Control DrillsDynamic Stabilization Exercises

Dynamic Stabilization ExercisesUCL RECONSTRUCTION REHAB

Strengthening Drills



38



UCL RECONSTRUCTION REHABAdvanced Strengthening Phase (Week 12-16)

• Plyometric Progression:

» Week 12: 2 hand drills

» Week 14: 1 hand drills

» Week 15: plyoball throws

» Wk: 15-16 wt ball

Gradual

Progression !!!

Kevinwilk.com/blog



39

Escamilla, Ionno, Wilk, et al: MMSE• Compared 3 baseball specific training programs on

maximum throwing velocity

• 68 high school players (aged 14-17)

• Randomly assigned to 1 of 4 groups:» Thrower’s Ten Program

» Kaiser cable system

» Plyometrics

» Control group

» 3 x week for 6 weeks

• Throwing velocity assessed pre & post training

�Compared to pre-test throwing sign increase in throwing velocity (p<0.05)�Throwers ten (1.7%)

�Plyometrics (2.0%)

�Kaiser (1.2 %)

CRITERIA TO RETURN TO THROWING

�Full non-painful ROM

�Elbow stability

�Satisfactory isokinetic test

�Satisfactory clinical exam

� moving valgus stress test (-)

�Adequate healing time

How long is that? 6, 9 or 12 mos.



40

CRITERIA TO RETURN TO

COMPETITIVE THROWING

� ER strength > opposite side

� Full can strength > opposite side

� Ball drops at 90° prone with 1 Ib ball

� 20 throws against wall with RS at

every 5 reps – w/o pain or difficulty

� 30 throws into plyoback with #1.5

ball without pain & proper mechanics

�Completed ITP w/o difficulty

�Intra-squad game w/o problems

UCL RECONSTRUCTION REHABReturn to Activity

�ITP (I): long toss – week 16

�ITP (II): mound - week 26-30

�Competitive throwing –

9 mos > (simulated game)

�RTP: 12-16 mos

�“Thrower’s Ten” program

» Strengthening & Stretching

UCL RECONSTRUCTION REHABReturn to Activity

�Interval Throwing Program:

� Caution with high intensity

throwing !

� When is it safe to throw hard

UCL RECONSTRUCTION REHABFunctional Drills

• Thrower’s ten program

• Plyometric drills

• Stretching

• Core & leg program

• Interval throwing program:

» long toss

» interval mound throwing

» Gradual return to competition





line





varus elbow torque


Azar, Andrews, Wilk: AJSM ‘00

• 91 UCL reconstructions, 17 primary repairs

• 41% professional baseball, 45% collegiate

• Average follow-up 35.4 months

• 79% return to previous level

• Return to competitive throwing 9.8 months



41

• 1281 UCL procedures, 1265 reconstructions

• Follow-up on 79% (743 patients)

• 95% baseball players ( 89% pitchers)

• Average follow-up: 49.1 months

• 83% returned to same level (recon)

• 63% of repairs returned to same level competition

• Return to competition: 11.6 months

• ITP initiated – 4.4 months

AJSM 2010 UCL RECONSTRUCTION Complications

UCL RECONSTRUCTION Complications

Assess for contracture, loss of motion and joint stiffness

The Elbow Joint is an Unforgiving Joint!!The Elbow Joint is an Unforgiving Joint!!

Man, if I don’t get this elbow straight

I’m goin’ to go nuts !



42

FLEXION CONTRACTURETreatment

�Active - passive warm-up

� Joint mobilization – posterior glides of humerus & radius

�Low load long duration stretch – (with heat)

�Modalities (ultrasound)

�CR, HR, passive stretching

� Progress program, repeat process

�Evaluate for splint, home program LLLD 3-4X

TERT Treatment

Total End Range Time Concept

• Load applied to create tensile

stress

• Resulting in remodeling

• Apply stress – “dosage”

» Intensity – low intensity

» Frequency – multiple

» Duration – 60 min/ day

Flowers & Michlovitz: APTA ‘88

McClure: Phys Ther ‘94

Goal: Tissue Remodeling

Stiff Elbow Treatment

Low Load Long Duration Stretch



43


Low Load Long Duration Stretch


Joint Mobilization


Joint Mobilization with LLLD



44

�Early Motion –

no immobilization – short term immob.

�Early functional activities

� Joint mobilization

� Stretch frequently

�Overpressure into ext LLLD

�Home program

UCL RECONSTRUCTION REHABFlexion Contracture

Prevention is the key !!!


Conclusions

�Elbow injuries common in the overhead

thrower

�UCL injuries occur in several situations

(throwers, macrotraumtic)

� Surgery often indicated for UCL injuries

�Rehab must match the surgery

�Gradual restoration through rehab

�Adequate tissue healing

� Stiffness occurs in less than 3%

Predictable & Reproducible Results

Rehabilitation Following UCL Repair with Augmentation AJSM 2016



45

UCL Surgery Repair

• 2 x 3.5 mm corkscrew PEEK anchors

• Collagen-coated Fiber Tape

• Size 0 supersuture (Ticron)• One limb of FiberTape and suture placed through the

eyelet of the first anchor

• First anchor placed at the site of avulsion

• Suture used to repair avulsed ligament

• Both limbs of tape placed through eyelet of the second anchor

• Second anchor placed at other insertion UCL• Caution on tension of tape

Novel Construct UCL Repair Augmentation Rehab

• Week 1: Posterior splint 5-7 days

» Shoulder isometric exercises

» Scapular exercises

• Week 2: ROM Brace (30-110°)

» Continue shoulder exercises isotonics

» Initiate elbow & wrist exercises

• Week 3-4:

» Thrower’s Ten Program

» Week 4-5 full PROM

• Week 5-6:

» Advanced Thrower’s Ten Program

UCL Repair Augmentation Rehab

• Week 6:

» Advanced Thrower’s Ten Program

» Plyometrics 2 hand drills

• Week 8:

» Plyo 1 hand drills

» hitting week 10

• Week 11-16:

» ITP Phase I (week 10-11

» ITP Phase II (wk 14-15

• Week 16-21

» Return to play

Dugas, Walters,Franz et al: ‘17

• 170 UCL repairs with internal brace

performed by JRD

• First 40 F/U 1 yr

• 75% baseball players, 3 softball players, 1

football, 1 gymnast, etc…

• 39/40 returned to pre-injury level

• KJOC score in throwers: 93.5



46


Conclusions

�Elbow injuries common in the overhead

thrower

�UCL injuries occur in several situations

(throwers, macrotraumtic)

� Surgery often indicated for UCL injuries

�Rehab must match the surgery

�Gradual restoration through rehab

�Excellent outcomes: 85% > return sport

� Stiffness occurs in less than 2%

Predictable & Reproducible Results

Documents

Rehabilitation following UCL Reconstruction/Repair in Athletes