Rehabilitation and Return to Sport Criteria Following Ulnar Collateral Ligament Reconstruction: A Systematic Review

Abstract

Background: Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR. Hypothesis: There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR. Study Design: Systematic review; Level of evidence, 4. Methods: All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate. Results: Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR. Conclusion: Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.

Postoperative Return to Play and the Role of Imaging

“…64 Given the tremendous stress applied to the medial elbow with overhead throwing, UCL injuries are most common in baseball players, specifically pitchers. 66 UCL injuries are also frequently encountered in sports requiring repetitive overhead motion of the arm, such as gymnastics, javelin, tennis, and volleyball. 66 Clinical presentation of such injuries is variable but often associated with pain and loss of performance.…”

“…64,65 In patients with UCL insufficiency, UCL reconstruction is the treatment of choice, particularly in the overhead throwing athlete. 66 Although nonoperative approaches with rest, anti-inflammatory medication, icing, and bracing are occasionally pursued, possibly with adjunctive biologic injections such as platelet-rich plasma, UCL reconstruction remains the gold standard treatment in the throwing athlete. This choice likely relates to the disparity in return to sport rates for these management strategies.…”

“…A previous study of return to sport in the throwing athlete with nonoperative management reported a rate of 42%, compared with > 84% with UCL reconstruction. 66,67 Furthermore, complete UCL tears treated with reconstruction were reported to achieve the same or higher level of performance at a rate of 63%. 68 UCL reconstruction was initially described by Dr. Frank Jobe, known in the lay press as the eponymous Tommy John surgery after the successful RTP of the former Major League Baseball pitcher on whom the technique was initially described.…”

“…68 UCL reconstruction was initially described by Dr. Frank Jobe, known in the lay press as the eponymous Tommy John surgery after the successful RTP of the former Major League Baseball pitcher on whom the technique was initially described. 66 Since its debut in 1974, Tommy John UCL reconstruction has surged in frequency and is performed on all levels of athletes, including those involved in youth sports. 65,66 Over the nearly 50 years since the procedure was first reported, multiple permutations now include the use of varying autograft harvest sites, such as the palmaris longus, gracilis, semitendinosus, Achilles, and toe extensor tendons, as well as concurrent ulnar nerve transposition.…”

“…65 No universal rehabilitation protocol is available to determine postoperative RTP, but a 2022 review found that a vast majority (97%) of studies evaluating RTP following UCL reconstruction included a time-based criterion. 66 Additional common features of rehabilitation programs included bracing with progressive range of motion, strengthening, and participation in an interval throwing program. 64,66 Outcome measurements can provide clinical information regarding readiness for RTP, including the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Disabilities of the Arm, Shoulder, and Hand (DASH), and Conway-Jobe Scale.…”