Jan 29, 2015When Elbows Fail
Helping an athlete come back from an ulnar collateral ligament injury is chock full of challenges. Here is one veteran athletic trainer’s approach to this arduous rehab.
By Brainard Cooper
Brainard Cooper, ATC, is the Associate Athletic Trainer at the University of South Carolina, where he provides coverage for the baseball and men’s soccer teams. He can be reached at: [email protected].
Tommy John surgery–three scary words no baseball pitcher wants to hear. But the reality is, more players are having the procedure than ever before. And while the surgery is the focus of most athletes’ fears, the intensive rehabilitation, which can take up to 18 months to fully complete, is equally as challenging.
Though athletes in any sport that involves overhead throwing motions–think of a javelin thrower or tennis player–can sustain an ulnar collateral ligament (UCL) injury, baseball pitchers have the highest rate of injury. Critics have called for pitch counts and inning limits in Little League, high school and college coaches have been berated for allowing pitchers to stay in a game too long, and pro prospects are placed on strict pitch limits. Still, UCL injuries continue unabated.
Over the course of my 25-year career, I have chosen to concentrate on rehabilitation of the upper extremities. In this article, I will explain not only the nature of the injury and dispel some misconceptions about it, but also provide insight into the intricacies of the rehabilitation process.
I cannot count the number of times a baseball player with an elbow injury has asked me, “It’s not the Tommy John ligament, is it?” Despite this common misconception in the baseball community, there is no such thing as a Tommy John ligament.
The surgery, named after the pitcher who in 1974 was the first professional athlete to undergo the procedure, involves replacing or repairing the ulnar collateral “ligament,” which is actually a complex. There are three separate bands involved, similar to the deltoid “ligament” in the ankle. When the injury occurs, one or more of the bands of the UCL complex–which includes the anterior and posterior portions and the transverse band–tear as a result of overhead throwing activities.
The injury can be either acute in nature or gradual in its onset. When we see elbow injuries in the collegiate ranks, more often than not, it shows up via gradual onset.
A baseball player will often describe a history of non-specific elbow issues that have bothered him for a period of time. These are rarely serious enough to stop him from playing, but never fully dissipate after starting. In this scenario, which I call “smoldering elbow,” it’s only a matter of time until the elbow fails.
Another scenario could involve an injury to a totally different region of the body–the back, opposite shoulder, or hip, for example. It is not uncommon for an athlete to suffer an injury to another region of the body, yet still participate in activity. The problem occurs when the deficient body part puts additional stress on the elbow in an attempt to maintain accuracy and velocity when throwing.
For example, with a shoulder injury, the pitcher could subconsciously change his throwing mechanics to compensate for pain. I have seen several athletes have to undergo shoulder surgery after recovery from elbow surgery because the shoulder injury surfaced only after their UCL was fixed. Heavier than normal fatigue, which often occurs with an injury, can also lead to a change in mechanics.
Lower-body injuries are a common trigger for elbow problems. We all know that a pitcher does not get his power from the shoulder or arm. He generates power through his legs, hips, and abdomen. When anything happens to negatively affect these sources of power, additional stress is again placed on the upper extremity in an effort to maintain accuracy and velocity, and the athlete will alter his mechanics to compensate. When mechanics fail, it is only a matter of time before there is a breakdown–and for throwing athletes, that breakdown usually occurs in the elbow.
PICKING A PLAN
Once the decision has been made that the athlete will undergo surgery, you can begin formulating a rehabilitation plan. When I performed my first rehab on a UCL reconstruction about 15 years ago, we kept the athlete’s elbow immobilized for two weeks after surgery before starting any rehab exercises. Now, rehabilitation begins the day following surgery–working not only on distal and proximal muscle group exercises, but also on range of motion (ROM) of the elbow.
Despite the advances we’ve seen in rehabilitation techniques like the above, and in surgical techniques aimed at aiding post-op recovery time, it still generally takes 12 to 18 months for the injured athlete to get that special “it” back. That may sound like a long time, but the recovery from the injury and resulting corrective surgery doesn’t take nearly that long.
Following surgery, the UCL and surgery site is technically healed within six to seven months. But that doesn’t mean the pitcher is ready to start pitching competitively. While the new “ligament” is technically healed, the healing structure has not had time to mature. The tendon that was harvested to construct the new ligament needs time to take on the properties of a ligament, and that ligament then needs time to be acclimatized to the stress of throwing.
Under the most pressing circumstances, I will allow a pitcher to return to competitive pitching after nine months. This could include a scenario in which the competitive season is right around the corner and the injured player has only one year of eligibility remaining. Or the player may see himself as a draft-eligible pitcher and want to get back on the mound to show professional scouts that he is not only able to pitch for a game here and there, but for an entire season. Though coaches don’t make return-to-play decisions, I do take their concerns into consideration. Does the team really need the injured pitcher back? All of these things factor into rehab time.
However, if a pitcher returns to play only nine months after surgery, he will not recover as quickly between outings as his injury-free teammates, so he needs to be on a restricted pitch count. I will also ask that he be kept on a limited count should he experience lingering elbow pains that “nag” at him during the competitive season. I suggest to our coaches a 50-pitch count in all preseason scrimmages and a 75-pitch count in the player’s first three outings of the regular season. Ideally, the pitcher would gradually increase from 75 pitches so that by the end of the regular season, he is throwing 100 to 110 pitches per appearance. If we are fortunate enough to make the postseason, I give the coaches and pitchers the green light to pitch with no limits.
The ideal time frame for return to participation is a 12-month rehab program. On this schedule, the athlete is almost assured of a problem-free return. When taking less time than this, I’ve found the athlete can be apprehensive and less confident upon his return. I also believe a restricted pitch count early on only adds to this lack of confidence. I’d much rather have the athlete “chomping at the bit” to get out there and throw.
Regardless, a quicker return is often demanded. Right now, for example, we have a catcher with only one year of eligibility remaining who had Tommy John surgery in October. He is concerned that if he waits an entire year until the fall of 2011 to return, he will have lost his “edge” and won’t make the 2012 roster. So he’d like to come back in time to play summer ball in 2011–that gives us just nine months to get him ready.
REHAB TIME UCL surgery rehabilitation is broken down into four basic phases. Here is what my nine-month rehab program looks like:
Phase one. The acute post-surgical phase lasts from weeks zero to six, and the basic goal is to protect the surgical site and increase ROM. During this time the athlete is restricted in a hinged brace (such as the DJ Ortho ROM Elbow Deluxe) and keeping the surgical site protected is paramount. Only gentle ROM work can begin, and only if it doesn’t interfere with the healing site.
The athlete can perform gentle wrist and forearm work as well as light shoulder and scapula stabilizer work. Initial exercises should be static or isometric, and shoulder isometrics in the neutral position can be performed in flexion, extension, and/or abduction. For the forearm, I like to do isometric exercises by applying manual resistance in flexion and extension of the wrist. I never do any internal or external rotation in phase one–there is plenty of time to work on these muscles in the coming weeks.
Toward the later part of the six weeks, you can progress to some more dynamic exercises such as the Jobe’s or Thrower’s 10 program. (These programs can be found by simply typing “Thrower’s 10” or “Jobe exercises” into any Internet search engine. A variety of different programs are at your disposal.)
Phase two. The chronic or intermediate post-surgical phase covers weeks seven to 16, and the goal is to increase strength in the musculature of the upper extremity and maintain ROM gains. After six weeks the brace is removed and the athlete should begin dynamic strength training in earnest. This increase can be achieved by adding weight and repetitions to the exercises the athlete is already performing. A modified, limited weightroom workout can also be implemented at this time to prevent de-conditioning in the rest of the body. Shoulder and forearm exercises that were initiated in phase one should continue with heavier weight to build strength.
After 12 weeks, we begin using the Plyoback and other plyometric exercises. At about the 12-week mark I like to begin using the BioDex. Not only does the BioDex give you finite numbers to refer to when gauging strength and power, but it also breaks the monotony of performing the same type of exercise day after day.
During this phase, the athlete can begin performing sport-related activities such as swinging a baseball bat or playing golf, but not throwing. For a position player, batting practice would also be okay at this point, and I allow athletes to start running.
Phase three. The advanced phase runs from week 17 to 32, and here we continue increasing strength and power, maintaining ROM gains, and gradually start return-to-sport activities. Exercises in phase three should alternate between the elbow, shoulder, and core from day to day. A typical week might look like this: Monday and Friday we do a dumbbell shoulder and wrist/forearm workout based off of the Thrower’s 10 program. Tuesday and Thursday are BioDex days with a Plyometric ball program. Wednesday is a light day when I have the athlete perform a Theraband program. The weekend is “free time” when he can do whatever exercises in the program he wants to, or none if he chooses. All the while, he is participating in a modified weightroom program with his teammates.
This is an exciting time for the athlete since we begin rehab throwing with the Interval Throwing Program. There are precautions to be taken, however. Recovery time must be built in between each step, and I like to repeat each step twice before moving on. Allowing at least two days between each throwing episode is also a good idea. Remember that the purpose is to introduce the new “ligament” to the stress of throwing.
One issue to stress is the importance of the clinician observing the athlete while he is performing this throwing. If I do not monitor the athlete, he invariably will throw too long or too hard, which can damage the healing site and delay recovery.
Phase four. The final phase can be modified to begin anywhere from the 32 to 36 week mark, and its goal is to return to regular activity. This phase can begin as early as 28 weeks post-op and last up to week 54, depending on the athlete’s progress.
The athlete now begins preparing his body for re-entry into athletic competition. By now, he should be performing all of his strengthening and endurance exercises at a high level. The elbow is ready for work off the mound, starting with an interval throwing program.
A progressive interval pitching program is not geared toward power, but to reintroduce the athlete’s elbow to proper mechanics. This routine needs to be performed under the guidance of the team’s pitching coach so he can see the pitcher’s mechanics. When this phase is completed without complication, the athlete is ready to return to full participation.
A successful recovery following Tommy John surgery is dependent on four major aspects: ROM, time, direct observation, and outside factors. I believe the most important immediate post-op goal should be the reestablishment of ROM–something I learned from renowned orthopedic surgeon Dr. James Andrews.
If an athlete has full ROM prior to surgery, he should be able to regain that range following surgery and rehab. Time and again, whenever I see athletes who have recently had UCL reconstruction I advise them to tell their therapist or athletic trainer to push ROM because they are almost always lagging behind. When I see an athlete who is eight to 12 weeks post-surgery and he is carrying his elbow at a 30-degree bend while walking around, I know he needs to work on ROM. I begin every workout for a Tommy John patient with 15 minutes in a 110-degree whirlpool to begin activating ROM.
The next factor critical to a successful outcome is time. The repaired UCL needs time to heal. Though the injury is technically healed in six to seven months, that doesn’t mean the healing site has matured enough to withstand throwing activities–tossing a ball maybe, but not significant throwing. The new UCL needs time to mature, take on the properties of a ligament, and develop the tensile strength necessary to withstand the rigors of pitching.
Direct observation ensures that not only is the athlete’s technique in performing exercises correct, but it also ensures that the athlete doesn’t do too much too soon. When in physical therapy facilities and other athletic training rooms, I often see patients who are unattended, just going through the motions and not performing the exercises correctly. It makes me wonder how good their outcome will be.
Finally, we must look at outside factors that might have contributed to the failure of the elbow in the first place. Was the injury caused by too much pitching? Was there a physical condition that predisposed the athlete to being injured? Was another injury at fault?
I am very keen on monitoring pitchers with shoulder, back, knee, or ankle injuries. During Tommy John rehab, I look at these areas closely to see if there was a condition that may have been overlooked. If as athletic trainers, we address the whole kinetic chain and not simply focus on the elbow while addressing these four aspects of rehabilitation, I believe the chances for a successful outcome are greatly improved.
Sidebar: MENTAL GAME
When any injury occurs, there is a mental challenge that accompanies the physical setback. Generally, an athlete is angry or sad after they are initially hurt and those feelings can stick with them until they are back on the competition field. But with an ulnar collateral ligament (UCL) injury that requires Tommy John surgery, those feelings can be magnified because of the arduous rehabilitation process.
It is a long and even boring road to recovery and it can be a great challenge for athletes to remain positive over their months of rehab. Some athletes can become despondent or exhibit signs of depression following a UCL injury if their sense of worth is tied to their ability to perform. Many times I’ve seen an athlete’s schoolwork suffer or some other sign of disassociation.
Here at the University of South Carolina, we try to combat those negative feelings. Our coaching staff, for example, makes an effort to keep the injured player involved with team activities. And I play a support role, too.
I find, as I am sure many other athletic trainers have, that keeping the athlete involved in team activities has a huge positive effect on his psyche. I always encourage the athlete to take part in weightroom training with his teammates. The coaches make sure they have jobs for the injured player during scrimmages and regular practice sessions.
And I also believe that getting the athlete active as soon as possible is critical to helping him maintain a positive outlook during the rehabilitation process, so I print a calendar up for every athlete I work with following Tommy John surgery. The calendar contains a start date (date of surgery) and a target completion date (generally nine months later). Together, we then write down each day’s activity so the athlete has something to look at and refer to when he has questions regarding his progress. It allows them to see the progress they’re making and there is an end goal they can look toward as well–getting back to the mound.