Rehabilitation Following UCL Repair with Internal Brace

Elbow injuries in the overhead athlete, particularly baseball pitchers, continue to increase in frequency because of extreme repetitive valgus stress.


Introduction
Elbow injuries in the overhead athlete, particularly baseball pitchers, continue to increase in frequency because of extreme repetitive valgus stress [1][2][3][4]. This repetitive stress results in ulnar collateral ligament (UCL) insufficiency which produces elbow pain, medial joint laxity, and an inability to throw. 16 Pitchers are the most injured players in Major League Baseball and elbow injuries account for 22-26% of pitching injuries [1,5,6]. The risk factors related to sustaining a pitching related UCL injury are pitching when fatigued, a high pitch volume, improper mechanics, and repetitive throwing at maximal effort in the youth player and throwing a high number of pitches at peak velocity in the professional athlete [7]. The current preferred surgical treatment for most UCL tears that fail conservative management is a reconstruction using one of several autogenous grafts. [8] Extensive follow-up data on UCL reconstructions with a minimum 2-year follow-up shows that just 83% of the athletes undergoing reconstruction were able to return to the same level of play or higher and that on average return to competition took 11.6 months [9].
However, recent technological advances have sparked renewed interest in repair of the UCL augmented by an internal brace (Internal Brace; Arthrex Inc) in a search for a surgical option that would allow a faster recovery than what is typical following UCL reconstruction. Repair of the UCL with internal brace is a direct repair of the native ligament with a spanning tape dipped in collagen (Internal Brace) anchored on each end of the UCL [10]. (Figure 1) Two 3.5mm Swive Locks spanned with a 2mm piece of Fiber Tape (Arthrex, Inc. 1370 Creekside Blvd., Naples, FL, 34108) and size 0 nonabsorbable sutures are used to repair the native ligament back to its anatomic origin and insertion ensuring that tension of the Fiber Tape matches that of the native UCL during range of motion (ROM). A UCL repair with internal brace is reserved for use in cases of partial or complete tears at the origin or insertion of the UCL with good ligament tissue and low-grade mid-substance partial

Rehabilitation Guidelines
Rehabilitation after UCL repair with internal brace surgery is accomplished via a sequential and progressive 5 phased approach, designed to return the athlete to their previous level or higher as quickly and safely as possible [13][14][15] (Table 1). Initially rehabilitation interventions are designed to minimize the effects of immobilization, facilitate early healing of the UCL, re-establishing pain-free ROM, reduce pain and inflammation, and retard muscular atrophy. Early limited passive elbow/forearm ROM exercises and grade I/II joint mobilizations are incorporated in conjunction to neuromodulate pain, promote articular cartilage nutrition and aide in the synthesis, alignment, and organization of collagen tissue [16][17][18][19], [20][21][22][23][24][25]. Local modalites, including Cryotherapy, electrical stimulation and Class IV deep tissue laser are used to control pain, inflammation, speed healing of the incision and increase nitrous oxide in the healing tissue [26]. Pain free, submaximal isometrics are used to initiate muscle activation and retard atrophy for all planes of elbow, forearm, wrist and shoulder movements. Shoulder external rotation (ER) and internal rotation (IR) isometrics are performed with caution and must be completely pain free. Rhythmic stabilization and neuromuscular control drills for shoulder, elbow and wrist along with seated scapular and postural exercises are also introduced early in the rehabilitation process.

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Week 20+: Initiate gradual return to competitive throwing

Perform dynamic warm-ups and stretches
Continue thrower's ten program

Return to competition when athlete is ready (physician decision)
Note: ** Each athlete may progress through ITP at different rates/pace Should complete 0-90 ft within 3 weeks of starting ITP and complete 120 ft within 8 weeks The controlled mobility phase runs for a total of 3 weeks starting at the second week after surgery and focuses on a stepped restoration in elbow ROM (outlined in Table 1), improved muscular strength/endurance, and normalizing joint arthrokinematics.
Active-assisted, active, and passive ROM exercises, as well as more  provides the best description of sports specific interval programs.
Pitchers generally are able to advance to throwing off of a mound 8 weeks after they begin a throwing program.

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The return to activity phase is the last part of the process and emphasizes a proper dynamic warm-up, continued exercise loads and managing the progression back to unrestricted activity and competitive throwing [34,35]. The general time frame to return to play following a UCL repair with internal brace is approximately 5 months. Functional testing can aide the return to play decision process. We use the prone ball drop test, developed by the senior author (KEW) which utilizes a 1kg (2 pound) plyoball with the patient prone, shoulder abducted to 90˚, and elbow extended. The patient is instructed to perform as many ball drops and catches as possible in a 30 second timeframe, comparing successful cathese bilaterally seeking a goal of 110% for the throwing side ( Figure   3). At our center, 350 UCL repairs with internal brace have been performed. Of these, 1-year follow-up data is available for 79 throwers, showing 98% of the 1-year follow ups returned to their pre-injury level of activity.

Summary
The UCL is a frequently injured in overhead athletes and these injuries continue to climb in number in youth athletes. Surgical repair of the UCL with internal brace is a viable option in athletes who meet specific findings at the time of surgery. The rehabilitation of this unique surgical procedure has been presented based on our experience treating in excess of 350 athletes over the past 3 years.
The average time required for an athlete to return to participation in our cohort is 7 months which is approximately 5 months less than average return to play times after UCL reconstruction surgery.
Long-term results of this surgery and rehabilitation program are still needed but our initial experience is extremely promising.