Rehabilitation Variability After Elbow Ulnar Collateral Ligament Reconstruction

Abstract

Background: Investigations specifically delineating the safest and most efficacious components of physical therapy after ulnar collateral ligament (UCL) reconstruction of the elbow are lacking. As such, while a number of recommendations regarding postoperative therapy have been published, no validated rehabilitation guidelines currently exist.

Purpose: To assess the variability of rehabilitation protocols utilized by orthopaedic residency programs in the United States (US) and those described in the scientific literature.

Study design: Cross-sectional study.

Methods: Online UCL reconstruction rehabilitation protocols from US orthopaedic programs and from the scientific literature were reviewed. A comprehensive scoring rubric was developed to assess each protocol for the presence of various rehabilitation components as well as the timing of their introduction.

Results: Overall, 22 protocols (14%) from 155 US Electronic Residency Application Service (ERAS) orthopaedic programs and 8 protocols published in the scientific literature detailing UCL reconstruction postoperative rehabilitation were identified and reviewed. After reconstruction, the majority of ERAS and review article protocols (77% and 88%, respectively) advised immediate splinting at 90° of elbow flexion. The mean time to splint discontinuation across all protocols was 2.0 weeks (range, 1-3 weeks). There was considerable variability in elbow range of motion recommendations; however, most protocols detailed goals for full extension and full flexion (>130°) at a mean 5.3 weeks (range, 4-6 weeks) and 5.5 weeks (range, 4-6 weeks), respectively. Significant diversity in the inclusion and timing of strengthening, proprioceptive, and throwing exercises was also apparent. Thirteen ERAS (59%) and 7 review article (88%) protocols specifically mentioned return to competition as an endpoint. ERAS protocols permitted return to competition significantly earlier than review article protocols (29.6 vs 39.0 weeks, respectively; P = .042).

Conclusion: There is notable variability in both the composition and timing of rehabilitation components across a small number of protocols available online. While our understanding of postoperative rehabilitation for UCL reconstruction evolves, outcome-based studies focused on identifying clinically beneficial modalities and metrics are necessary to enable meaningful standardization.

Keywords: physical therapy; reconstruction; rehabilitation; ulnar collateral ligament.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: E.C.M. has received educational support from Pinnacle and Smith & Nephew, consulting fees from Smith & Nephew, and hospitality payments from Smith & Nephew and Stryker. C.S.A. has received consulting fees from Arthrex, speaking fees from Arthrex, royalties from Arthrex, and hospitality payments from DePuy. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.

Variability in postoperative adjunctive therapies between rehabilitation protocols. While the majority of all protocols recommended immediate postoperative splinting, followed by functional bracing, scar mobilization was only recommended by ERAS protocols. ERAS, Electronic Residency Application Service; NMES, neuromuscular electrical stimulation.

Figure 2.

(A) Strengthening and proprioceptive exercises. A significant variation was found between protocols from orthopaedic programs versus the published literature with regard to the types of exercises included in rehabilitation protocols. (B) A significant variation was also found with regard to recommended start times for strengthening exercises. The numbered circle within each range represents the mean of the data set. -ER, without external rotation; PNF, proprioceptive neuromuscular facilitation; RC, rotator cuff.

Figure 3.

(A, B) Plyometric exercises. A significant variation was found between protocols from orthopaedic programs versus the published literature in the inclusion of exercises as well as recommended start times for exercises. The numbered circle within each range in (B) represents the mean of the data set.

Figure 4.

(A) Return to athletic activity/throwing and (B) start dates. The numbered circle within each range in (B) represents the mean of the data set.