Ulnar Collateral Ligament (UCL) Reconstruction Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy program following ulnar collateral ligament (UCL) reconstruction of the elbow. It is designed to guide progression through various phases of recovery, focusing on pain management, range of motion restoration, strength and endurance development, and return to sport-specific activities. This protocol serves as a guideline; individual progress may vary depending on factors such as graft type, surgical technique, patient compliance, and pre-operative condition. Frequent communication between the physical therapist, surgeon, and patient is essential for optimal outcomes.

Pathophysiology

The UCL is the primary stabilizer of the elbow against valgus stress, particularly during overhead throwing motions. Repetitive valgus stress, common in baseball pitchers, softball players, and other overhead athletes, can lead to microtrauma and eventual UCL failure. Reconstruction involves replacing the damaged UCL with a tendon graft, typically harvested from the palmaris longus, hamstring, or toe extensor. The graft is secured to the humerus and ulna using sutures, screws, or interference fit techniques.

Phase I: Protection (Weeks 0-4)

Goals: Protect the healing graft, control pain and edema, initiate gentle range of motion, and restore basic muscle activation.

• Immobilization: Elbow splinted in approximately 90 degrees of flexion.
• Pain and Edema Management:
  • Cryotherapy: Apply ice packs for 15-20 minutes several times daily.
  • Elevation: Keep the elbow elevated above the heart to minimize swelling.
  • Gentle massage: Light massage to the forearm and upper arm to reduce edema.
• Range of Motion (ROM):
  • Wrist and hand ROM exercises: Initiate immediately and perform multiple times daily.
  • Shoulder ROM exercises: Initiate immediately and perform multiple times daily, focusing on pain-free movement.
  • Gentle elbow AROM within protected range (usually 30-90 degrees) starting at week 1-2, as tolerated.
  • Elbow PROM (0-30 degrees) initiated around week 2-3, as tolerated, performed by therapist only.
• Muscle Activation:
  • Grip strengthening exercises (soft ball squeezes).
  • Shoulder isometrics: Flexion, extension, abduction, adduction, internal and external rotation.
  • Biceps and triceps isometrics (in splint).
• Precautions:
  • Avoid active elbow extension against resistance.
  • Avoid valgus stress to the elbow.
  • No lifting greater than 1 pound.

Phase II: Loading (Weeks 4-12)

Goals: Gradually increase ROM, improve strength and endurance, and normalize elbow mechanics.

• ROM Progression:
  • Gradually increase elbow ROM, working towards full extension by week 6-8.
  • Continue with PROM and AAROM exercises.
  • Initiate elbow joint mobilization techniques as needed to address stiffness.
• Strengthening:
  • Light resistance exercises with dumbbells and resistance bands, focusing on biceps, triceps, and forearm muscles.
  • Prone Rows and Scapular Squeezes to enhance shoulder blade stability.
  • Progress to isotonic exercises, increasing resistance gradually.
  • Begin wrist and forearm pronation/supination exercises.
  • Consider wrist weights to enhance strengthening of forearm muscles.
• Proprioception:
  • Balance board exercises for upper extremity.
  • Perturbation exercises.
• Functional Activities:
  • Simulate throwing motion without ball (shadow throwing) starting around week 8-10.
  • Light plyometric exercises (e.g., medicine ball chest passes) may be initiated.
• Precautions:
  • Avoid activities that provoke pain or swelling.
  • Continue to avoid excessive valgus stress.
  • No throwing until cleared by the surgeon and physical therapist.

Phase III: Return to Function (Weeks 12+)

Goals: Restore full strength, power, and endurance, and gradually return to sport-specific activities.

• Strength and Endurance Training:
  • Continue progressive resistance exercises.
  • Incorporate sport-specific exercises to simulate throwing demands.
  • Plyometric exercises with increasing intensity and velocity.
  • Consider isokinetic testing to assess strength and power.
• Throwing Program:
  • Initiate a structured throwing program under the guidance of a qualified coach or trainer.
  • Gradually increase throwing distance, velocity, and frequency.
  • Monitor for pain, swelling, and fatigue.
  • Focus on proper throwing mechanics to minimize stress on the UCL.
• Functional Progression:
  • Gradually increase participation in sport-specific drills and activities.
  • Monitor for pain, swelling, and fatigue.
• Criteria for Return to Sport:
  • Full, pain-free ROM.
  • Symmetrical strength and endurance compared to the non-operative arm.
  • Successful completion of a throwing program without pain or complications.
  • Surgeon and physical therapist clearance.

Common Special Tests for UCL Injuries

• Moving Valgus Stress Test: Patient supine or seated. Examiner abducts the patient's arm to 90 degrees, maximally externally rotates the shoulder, and then quickly extends the elbow from maximal flexion to approximately 30 degrees of flexion while applying a valgus stress. A positive test is indicated by pain reproduced between 70 and 120 degrees of elbow flexion.
• Valgus Stress Test (at 0 and 30 degrees of elbow flexion): With the patient supine or seated, the examiner applies a valgus force to the elbow while stabilizing the humerus. The test is performed at both 0 degrees (full extension) and 30 degrees of flexion. Increased laxity or pain compared to the uninvolved side indicates a positive test. Laxity at 0 degrees may indicate injury to the posterior capsule, olecranon, or other ligaments in addition to the UCL.
• Milking Maneuver: Patient seated or standing. Patient's elbow is flexed to 90 degrees with the forearm supinated. The examiner grasps the patient's thumb, pulling it inferiorly, applying a valgus stress to the elbow. Pain reproduction is a positive test.

Disclaimer: This protocol is intended as a guideline and should not be substituted for professional medical advice. Consult with your physician and physical therapist to develop a personalized rehabilitation plan.