UCL Tears
Fibroblastic-Repair Phase
The fibroblastic-repair phase referes to proliferative and regenerative activity leading to formation of scar tissue around the injured tissue, in this case the ulnar collateral ligament. Scar formation is known as fibroplasia and begins roughly a few hours after initial injury and can last up to 4-6 weeks depending on the injury.
As the patient enters the fibroblastic repair phase they will begin to see diminishing signs/symptoms associated early on with initial injury. The formation of connective tissue called granulation tissue occurs with the breakdown of the clotting that occured during the inflammatory response phase. Granulation tissue is consistant of fibroblasts, collagen and capillaries. Fibroblastic cells begin to synthesize an extracellular matrix, consisting of collagen and elastin.
As the collagen continues proliferation, the tensile strength of the scar begins to increase in proportion to collagen synthesis. Increasing in tensile strength means the numbers of fibroblasts begin to diminish, signalling the patient is entering maturation-remodeling phase.
This stage of rehabilitation will follow a progressive timeline based on the patients pain and ability to perform the exercises. This is an approximation of how a typical UCL patient will progress and is not a set in stone guideline to follow due to the uniqueness of each case. By 3-4 weeks post surgery the patient will begin isometric exerciese and progress into light isotonic exercises. Progressive resistance exercises should be incorporated by 9-10 weeks post surgery. After 12 weeks the patient can start to implement high resistive and begining plyometric exercises.
Goals for this phase of rehabilitation include: muscle strength, power, speed, and endurance. Maintaining cardiovascular fitness is also important during this time.
Rehabilitation exercises for this phase include:
Elbow Extension- Isotonics
Elbow extension isometrics can be progressed to isotonic triceps, such as performing triceps pull downs on a weigh machines.
Grip strengthening
Patient performs isometric holds, this included making a fist and trying to squeeze with effort below pain threshold. This exercise can easily be progressed to isotonic exercise by using putty or hand grips. The patient is instructed to make a fist in attempt to squeeze the hand grip to the limit, be sure to exercise at sub-pain threshold.
Elbow Flexion- Isotonics
Elbow flexion isometrics can be progressed to isotonic exercises, making sure the patient keeps their elbow tight to their body or support.
Wall Push-Up
Patient begins with performing isometric holds in a standing push up position against an immovable object such as a wall. Patient will apply pressure to the wall and remain static in motion. This can be progressed to performing full range of motion push ups against the wall. As the athlete gains strength, progress to chair push ups and then full floor push ups. Make sure the patient is performing at sub-pain threshold level of exercise and does not for the elbow into a valgus stress.
PNF Stretching & Patterns
PNF techniques can be helpful during this stage to increase range of motion. Structural integrity must be intact before initiating these exercises. The video is helpful in explaining using the hold-relax PNF technique to increase elbow extension. The D1/D2 patterns are illustrated below.
Short term goals: Increase muscle strength, power, speed endurance.
Long term goals: Regain sports specific needed skills.
To maintain cardiovascular fitness during this stage, biking and swimming are encouraged. Swimming can be completed with or without upper extremity involvment. When the athlete has full range of motion and strength, it is encouraged to complete full body workouts.