Rehabilitation Guidelines for Ulnar Collateral Ligament

Reconstruction (Palmaris Longus Graft, Gracilis Graft)

This protocol is intended to guide clinicians through the post-operative course for Ulnar Collateral Ligament
Reconstruction (Palmaris Longus Graft, Gracilis Graft). This protocol is time based (dependent on tissue healing) as well
as criterion based. Specific intervention should be based on the needs of the individual and should consider exam
findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary
based on surgeon’s preference, additional procedures performed, and/or complications. If a clinician requires assistance
in the progression of a post-operative patient, they should consult with the referring surgeon.

The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic
interventions should be included and modified based on the progress of the patient and under the discretion of the
clinician.

Considerations for the Post-operative

Many different factors influence the post-operative UCL reconstruction rehabilitation outcomes, including whether a
palmaris longus or gracilis graft was performed and individual co-morbidities. It is recommended that clinicians
collaborate closely with the referring physician.

If you develop a fever, excessive drainage from incision, severe heat and/or redness along incision, uncontrolled pain, or
any other symptoms that concern you please call your doctor.

PHASE I: IMMEDIATE POST-OP PHASE (0-3 WEEKS AFTER SURGERY)

Rehabilitation • Protect healing tissue
Goals • Reduce pain and inflammation
• Protect graft site
• Reduce muscle atrophy
Brace • Week 1 – Immobilized in Posterior splint at 90 degrees of Elbow Flexion
• Week 2: Hinged Brace: 25-100 degrees
• Week 3: Hinged brace: 15-115 degrees
• Elbow Post-op compression dressing for 5-7 days
• Palmaris Longus Graft – Wrist post-op compression for 5-7 days
Precautions • Shoulder External rotation isometrics
• Valgus stress to the Elbow
Intervention Manual therapy
• Soft tissue mobilization, retrograde massage for swelling

Modalities
• Ice and compression

Gripping Exercises:
• Squeeze towel, putty or foam with varying types of grips

Isometrics
• Performed with brace on
• Day 1

Massachusetts General Brigham Sports Medicine

 o Shoulder: Flexion, ABD, IR - Avoid External Rotation
Performed with arm at side, gently push against a wall or opposite hand
o Elbow Flexion
Performed at 90 degrees elbow flexion
• Day 7
o Elbow Extension
Performed at 90 degrees elbow flexion

Range of Motion
• Wrist AROM
o Flexion,
o Extension
o Radial deviation
o Ulnar deviation
• Thumb opposition
• Elbow PROM
o Flexion and extension
o Performed to tolerance, making sure the elbow is staying relaxed.
• Shoulder AROM
o Performed with brace on
o Full Can
• Elbow AROM: Begin day 14
• Low load, long duration stretching:
o Use when elbow extension range of motion is lacking
o Supine with towel roll under distal humerus.
o Add a light weight
o Must be pain-free
o Hold 10-15 minutes up to 4 times a day, totaling 60 minutes a day

• Gracilis Graft – Knee ROM immediately post-op; Bike on week 3

Criteria to • Elbow ROM: at least 15-115 degrees

Progress • At least 4/5 elbow MMT scores

PHASE II: PROTECTION PHASE (4-6 WEEKS AFTER SURGERY)

Rehabilitation • Gradual increase to full ROM by week 6
Goals • Promote healing of repaired tissue
• Regain and improve muscular strength – slow integration of exercises
• Restore full function of graft site
Brace • Week 4: 0-125 degrees
• Week 5: 0-135 degrees
• Week 6: 0-145 degrees
• Discontinue use of brace at week 6 if achieved full ROM, unless walking in crowds or slippery
surfaces
Precautions • No valgus stress to the graft
• No ER strengthening until week 6
• Gracilis graft – Do not initiate progressive resistive hamstring strengthening until week 6
Additional Manual therapy
Intervention • Soft tissue and scar mobilization
*Continue with
Phase I Modalities
interventions • Continue with ice and compression

Range of Motion
• Elbow PROM – Focus on restoration of full elbow extension

Massachusetts General Brigham Sports Medicine 2

 Strengthening
• Wrist and forearm strengthening:
o Curls/Extensions – Start with 1 lb.
o Pronation/Supination – Start with dowel
• Biceps curl – Begin with 1lb
• Triceps Extension
• Scapula stabilization: Start at 1 lb
o Prone Row
o Prone Shoulder horizontal abduction
o Prone Shoulder extension
• Resistance band
o Low rows
o Shoulder internal rotation (at side)
• Standing scaption (start with 1lb, do not exceed 10 lbs.)
Criteria to • Full Range of Motion
Progress • At least 70% of strength of wrist and shoulder of uninvolved arm – HHD, MMT or isokinetic
testing
• Good tolerance to all exercises with no pain

PHASE III: STRENGTHENING PHASE (6-12 WEEKS AFTER SURGERY)

Rehabilitation • Increase strength/endurance/power
Goals • Maintain full elbow ROM especially extension
Precautions • No Throwing
• No valgus stress to the elbow
Additional Manual Therapy:
Intervention • Soft tissue mobilizations as needed
*Continue with
Phase I-II Range of motion
Interventions • Elbow PROM as needed
o Maintain full elbow extension

Strengthening
• Gracilis graft: Begin slow progression of hamstring strengthening
• Forearm strengthening:
o Emphasis on flexion and pronation
• Elbow Strengthening:
o Eccentric flexion and extension
o Varied resistance and speed of contractions - (start slow build to fast)
• Thrower’s 10 program: Begin at week 6
o Initiate Advanced Thrower’s 10 at Week 8 – as appropriate
• UBE
• Rows
• Lat pull down
• PNF exercises
o Rhythmic stabilization/manual resistance: (side-lying ER and diagonals)

Criteria to • Maintain full pain-free ROM

Progress • At least 85% strength of uninvolved arm – HHD, or isokinetic testing
• Good tolerance to all exercises with no pain

PHASE IV: ADVANCED STRENGTHENING PHASE (12-16 WEEKS AFTER SURGERY)

Rehabilitation • Progress power/endurance
Goals • Normalize shoulder/forearm strength

Massachusetts General Brigham Sports Medicine 3

 • Initiate plyometric exercises
• Gradually initiate sports/functional exercises
Precautions • No Throwing
• No valgus stress to elbow
Additional Strengthening
Intervention • Advanced throwers ten program
*Continue with • Body blade – ER/IR, push/pull
Phase II-III • Seated bench press
interventions as • Supine dumbbell bench press
appropriate • Begin a hitting program (if applicable to sport)
o Initiate week 12

Plyometric Program
• Week 12:
o 2-handed drills only: 6-8 lbs. (emphasis on full extension)
• Chest pass
• Side throw close to body
• Week 14:
o 2 hands away from body
• Side to side throws
• Soccer throws
• Side throws
o Begin 1-arm plyometrics
• 1-handed stationary
• Wall dribble: 1-2lb. medicine ball
• Baseball throws into wall
• Rhythmic stabilization in scapular plane with medicine ball on wall
Criteria to • Full, painless elbow/wrist ROM
Progress • Shoulder total ROM within 5° of non-throwing shoulder
• > 40° horizontal adduction of throwing shoulder
• < 15° Glenohumeral IR deficit
• Elbow, shoulder and wrist strength with MMT, HHD or isokinetic:
o ER/IR ratio: 72-76%
o ER/ABD ratio: 68-73%
o Throwing shoulder IR: > 115% of non-throwing shoulder
o Throwing shoulder ER: > 95% of non-throwing shoulder
o Elbow flexion/extension: 100-115% of non-throwing shoulder
o Wrist flexion/extension: 100-115% of non-throwing shoulder
• Functional test Scores:
o Prone Drop ball test – 110% of non-throwing side
o 1-arm balls against wall @ 90/90:
• 2lb ball
• 30 seconds with no pain
• 115% of throwing side
o Single arm step down test:
• 8-inch
• 30 seconds
• Satisfactory score on Kerlan-Jobe Orthopedic Clinic shoulder and elbow score (KJOC) throwers
assessment.
• Physician Clearance

PHASE V: EARLY RETURN TO SPORT - UNRESTRICTED RETURN TO SPORT (16+ WEEKS

AFTER SURGERY)

Massachusetts General Brigham Sports Medicine 4

 Rehabilitation • Increase strength, power and endurance
Goals • Safely initiate sport specific training program
• Safely progress to full sport.

Additional • Interval Throwing Program: 16 weeks after surgery – unless indicated otherwise by surgeon
Intervention • ***Refer to return-to-sport protocol/throwing protocol for further detail
*Continue with
Phase II-IV
interventions
Criteria to • Last stage, no additional criteria
Progress
Revised 6/2021

Contact Please email [email protected] with questions specific to this protocol

References:

1. Biz C, Crimì A, Belluzzi E, et al. Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review.
Orthopaedic Surgery. 2019;11(6):974-984. doi:10.1111/os.12571
2. Ellenbecker TS, Wilk KE, Altchek DW, Andrews JR. Current concepts in rehabilitation following ulnar collateral ligament reconstruction. Sports Health.
2009;1(4):301-313.
3. Evans JP, Smith CD, Fine NF, et al. Clinical Rating systems in elbow research – a systematic review exploring trends and distributions of use. Journal of
Shoulder and Elbow Surgery. 2018;25:98-106.
4. Glogovac G, Kakazu R, Aretakis AC, Grawe BM. Return to Sport and Sports-Specific outcomes following Ulnar Collateral Ligament reconstruction in
adolescent athletes: A Systematic review. HSS Journal. 2019;16:242-249. Doi: 10.1007/s11420-019-09689-9.
5. Hodgins JL, Vitale M, Arons RR, Ahmad CS. Epidemiology of Medial Ulnar Collateral Ligament Reconstruction. The American Journal of Sports Medicine.
2016;44(3):729-734. doi:10.1177/0363546515622407
6. Lightsey HM, Trofa DP, Sonnenfeld JJ, et al. Rehabilitation variability after elbow Ulnar Collateral ligament reconstruction. The Orthopedic Journal of
Sports medicine. 2019;7(3): 1-7. Doi: 10.1177/2325967119833363.
7. Olds M, Coulter C, Marrant D, Uhl T. Reliability of a shoulder arm return to sport test battery. Physical Therapy in Sport. 2019;39:16-22.
8. Peters SD, Bullock GS, Goode AP, Garrigues GE, Ruch DS, Reiman MP. The success of return to sport after ulnar collateral ligament injury in baseball: a
systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2018;27(3):561-571. doi:10.1016/j.jse.2017.12.003
9. Saper M, Shung J, Pearce S, Bompadre V, Andrews JR. Outcomes and Return to Sport after Ulnar Collateral ligament reconstruction in adolescent baseball
players. The Orthopedic Journal of Sports Medicine. 2018;6(4):1-7. Doi: 10.1177/2325967118769328.
10. Wilk KE, Arrigo CA, Dugas JR, Cain EL, Andrews JR. Rehabilitation and Return-to-Play Criteria Following Ulnar Collateral Ligament Reconstruction.
Operative Techniques in Sports Medicine. 2017;25(3):154-171. doi:10.1053/j.otsm.2017.07.004
11. Wilk KE, Arrigo CA, Arrigo RJ. Rehabilitation following UCL repair with Internal Brace. Orthopedics and Sports Medicine. 2019;3(1): 212-217. Doi:
10.32474/OSMOAJ.2019.03.000151.

Massachusetts General Brigham Sports Medicine 5