Acute Phase
Rehabilitation Program
Physical Therapy
Generally, 3-6 months of conservative therapy with rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and local physical therapy for ROM are necessary for recovery.
Recreational Therapy
When pain and swelling completely resolve and the athlete has returned to a premorbid ROM (usually not before 3 months of treatment), progressive return to activity with increasing velocity and duration of training may be attempted.
Medical Issues/Complications
Surgery may be considered in several situations. Surgical repair is generally indicated for acute tears in competitive athletes, when chronic instability exists, and when the patient has recurring pain and laxity after 2 or more attempts at conservative therapy.
Surgical Intervention
Direct repair of the ligament is generally not indicated. Reconstruction of the UCL (eg, repair of the anterior bundle) is the more common approach to surgical treatment, with use of a palmaris longus tendon autograft. The graft is pulled through bone tunnels in the medial epicondyle of the humerus and the sublime tubercle of the ulna in a figure-8 pattern. Ulnar nerve transposition may be undertaken at the time of surgery, if indicated.
Consultations
Consultation with an orthopedic surgeon, preferably a sports or upper-extremity specialist, is indicated when surgical intervention is contemplated.
Other Treatment
Steroid injection is not recommended for UCL injuries.
Platelet-rich plasma has shown promise in a case series of throwing athletes with partial UCL tears who had failed conservative treatment. Of these athletes, 88% were able to return to throwing activities an average of 12 weeks after a single injection of platelet-rich plasma. [14]
Recovery Phase
Rehabilitation Program
Physical Therapy
After surgery, the elbow is immobilized in a posterior splint for 10 days in 90° of flexion. The wrist is maintained free, and a soft rubber ball is given to the patient for squeezing to maintain grip strength. Active ROM is initiated after removal of the posterior splint. A hinged brace that prevents valgus stress should be used.
At approximately 1 month after surgery, isometric strengthening exercises should be initiated. Limited progressive strengthening can be initiated at 8 weeks and plyometrics at 12 weeks. Shoulder and elbow exercises should be instituted as soon as feasible, but valgus stress of the elbow should be avoided for at least 4-6 months until the graft has had sufficient time to incorporate.
Recreational Therapy
After 4-6 months, throwing may be resumed with a training program that is designed to return the patient to competitive throwing by 9-12 months after surgery.
Medical Issues/Complications
Both transient and permanent ulnar neuropathy may occur after reconstruction, occasionally requiring ulnar nerve transposition or revision of transposition. Flexion contracture (generally < 5°) may also occur in 25-30% of patients.
Surgical Intervention
Ulnar nerve transposition (or revision of transposition) may be required for persistent postoperative ulnar neuropathy.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Flexibility and strength training of the elbow are useful in the maintenance phase to prevent recurrent injury.
Recreational Therapy
During the maintenance phase, particular attention to the patient's throwing technique is essential to prevent recurrence of injury.
Medical Issues/Complications
Long-term complications may include chronic pain with throwing and chronic instability of the elbow.
