Peer Editing: Elbow Rehabilitation Program
Tommy John surgery or ulnar collateral ligament reconstruction is a common procedure seen among athletes who sport typically require them to throw overhead. Different from softball, baseball players typically throw the same way the pitcher does. "The ulnar collateral ligament (UCL) is the primary restraint to valgus force exerted on the elbow during the late cocking and early acceleration phases of throwing. Repetitive overhead throwing can result in attenuation, insufficiency, or rupture of the UCL, which typically manifests as medial elbow pain and decreased throwing performance evidenced by reduced velocity, poor control, and decreased endurance" (Camp et al., 2016). Most occurrences I have seen in baseball players with this injury, the athlete threw side armed.
Advancements in technology and medicine have made the rehabilitation and recovery process for this surgery successful. "Since Frank Jobe performed the first ulnar collateral ligament (UCL) reconstruction in 1974 on Tommy John, the procedure has been successful in returning athletes to their former level of play. With refinements in technique and increased experience with the procedure, return to play at the same level or higher has been reported between 83% and 95%" (Dugas et al., 2019). Following the rupturing of a college baseball players ulnar collateral ligament of the left arm, I have provided a rehabilitation program in which the goal is complete recovery with full, unrestricted function; and to be able to perform sport specific activity without discomfort or restrictions.
Post operation Rehabilitative Phase 1: Weeks 1-4 goals will include promoting healing and reducing pain, inflammation, and swelling around the ligament. We will also want to begin restoring the range of motion. "The modified Jobe procedure utilizes a muscle-splitting approach that does not interrupt the flexor/pronator origin, thereby allowing more aggressive early range of motion of the wrist and forearm, as well as the initiation of the submaximal isometric exercises. Knowledge of the surgical approach is important to guide the early ROM and resistive exercise progressions"(Ellenbecker, 2009). The athlete will be given home exercises that can be performed at home and that should be performed at home responsibly according to recommendations. Scapula isometrics and gripping items area couple of the exercises that can be performed solo. Under no circumstances should the brace be taken off. There should also be no passive range of motion of the elbow. In order for advancement to the next phase of the rehabilitative process, elbow range of motion should be between 30°-90° and accompanied with minimal pain or swelling.
Post operation Rehabilitative Phase 2: Weeks 4-6 goals include improving range of motion of the ulnar collateral ligament to approximately 15°-115°. The brace must still be worn. Although the brace is worn the athlete should be participating in active range of motion within the brace. The athlete may also gradually begin pain-free isometrics: wrist flexion and extension and elbow flexion and extension, manual scapula stabilization exercises with proximal resistance. "At this stage in the rehabilitation program, resistance exercise is progressed with range of motion. From isometric exercises in the immediate postoperative phase, progression including light- resistance isotonic exercises occurs at week 4 for the wrist and forearm. Progression to the full Throwers Ten Program is targeted by week 6"
Post operation Rehabilitative Phase 3: Weeks 6-12 goals include restoring a full range of motion. At this phase we also want to restore upper extremity endurance."The patient is progressed from the posterior splint to an elbow ROM brace at 7 days postoperative to initially allow 30° to 100° of extension/flexion ROM. Motion is increased each week by 5° of extension and 10° of flexion. Full passive range of motion (PROM; 0°-145°) is expected by the end of week 6. The brace is discontinued between week 6 and week 8 in most patients. A more rapid return of PROM with acute UCL injuries may be appropriate, with full PROM by week 5 or week 6. For the chronic tears, full PROM is restored more slowly, usually 6 to 8 weeks, postoperatively"(Ellenbecker, 2009). Exercises at this phase can be performed moderately in sets of 1 to 2 with 5 to 10 repetitions.
By week 8 the athlete can begin internal/external rotation strengthening, forearm pronation/supination, neuromuscular drills, proprioceptive neuromuscular facilitation patterns when strength is adequate, Incorporate eccentric training when strength is adequate, low-intensity/long-duration stretch for extension, and isotonic exercises for scapula, shoulder, elbow, forearm, wrist 1 set of 10 repeitions. Return to play following ulnar collateral ligament reconstruction includes pain-free movement, a full elbow range of motion, full upper extremity strength, advance internal/external to 90/90 position, neuromuscular drills, and pain free sport specific program, in this case, throwing and hitting pain free. "Emphasizing proximal scapular stabilization early in the rehabilitation program and continuing this emphasis using a low-resistance, high-repetition program restores the necessary proximal stabilization to promote an optimal return to uncompensated throwing. This includes scapular stabilization via manual resistance to elicit serratus anterior and trapezius/rhomboid muscle activation without compromising the repair" (Ellenbecker, 2009).
References
Camp, C. L., Dines, J. S., Voleti, P. B., James, E. W., & Altchek, D. W. (2016). Ulnar collateral ligament reconstruction of the elbow: The docking technique. arthroscopy techniques, 5(3), e519–e523. https://doi.org/10.1016/j.eats.2016.02.013
Dugas, J. R., Looze, C. A., Capogna, B., Walters, B. L., Jones, C. M., Rothermich, M. A., Fleisig, G. S., Aune, K. T., Drogosz, M., Emblom, B. A., & Cain, E. L. (2019). Ulnar collateral ligament repair with collagen-dippedfibertape augmentation in overhead-throwing athletes. American Journal of Sports Medicine, 47(5), 1096–1102.
Ellenbecker, T. S., Wilk, K. E., Altchek, D. W., & Andrews, J. R. (2009). Current concepts in rehabilitation following ulnar collateral ligament reconstruction. Sports health, 1(4), 301–313. https://doi.org/10.1177/1941738109338553
Peer Editing Tool
Instructions for peer editors: Answer each of the following questions. Remember to provide feedback that is accurate, thorough, direct and succinct, and practical and useful. It’s important to tell a peer what s/he is doing well, as well as what s/he could do better. The peer editing assignment space in Canvas is a discussion board-type tool. Respond to your partner by clicking “reply” and let him/her know that you completed your review; then remember to attach a copy of this completed peer editing tool to your reply and invite him/her to join you in further discussion if necessary.
Writer’s Name: _______________
Peer Reviewer’s Name: _______________
Scenario: __________________________
1. Elbow rehabilitation program.
a. Is the program relevant to the injury, gender, age, and sport? Yes or No ?
b. If no, what is not relevant?
c. If yes, are the exercises clearly described?
d. If no, what is unclear or understated?
e. Are the exercises under the best stages of care? Yes or No ?
f. If no, where should they be moved to?
g. Are benchmarks created to know when progression of the exercises and phases is necessary? Yes or No?
h. What needs to be done to improve these items?
Additional feedback/comments:
2. Communication
a. Put yourself in the role of the athlete. Are the exercises easy to understand or seem too complicated? Yes or No?
b. If no, what is missing, unclear or over/understated? Where does the communication break down and/or which exercise(s) and/or phase(s) is/are problematic and why?
Additional feedback/comments:
3. Program planning considerations
a. Did the writer take healing timelines and tissues injured into consideration when creating the program? Yes or No?
· If no, what information is missing?
b. Did the writer:
· explain why s/he chose this/these exercises? Yes or No?
· address why s/he believes the exercises will be useful in addressing the issues identified in the scenario? Yes or No?
i. If yes, did the writer accurately apply the exercises to the scenario? Yes or No?
ii. If yes, what clues in the program tell you that the exercises were applied accurately to the rehab phases?
iii. If no, what direction would you give the writer to strengthen this program?
Overall Summary:
a. What is the best part of the program? Why?
Which area(s) of the case study need the most improvement (e.g., the application of content to the questions in the case study, the organization, sentence structure, word choice, evidence to support claims/rationale)? Be specific so the writer knows where to focus his or her energy.