Rehabilitation after medial ligament reconstruction – throwers

Author: Tanya Anne Mackenzie, Manchester Shoulder Clinic

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All advice is general and you are advised to consult with your own physiotherapist and coach before undertaking any exercises.

Phase 1 Maximum Protection (0 to 14 Days)
Aims Protect healing tissue

Decrease pain and inflammation

Prevent muscle atrophy

Initiate elbow ROM

Precautions Avoid valgus force or position during exercises

ROM exercises are gentle active or active assisted.

No shoulder external rotation

Treatment Week one

  • Immobilization in sling with 90 of elbow flexion
  • Ice to reduce pain and inflammation
  • In forearm supination active wrist flexion and extension ROM.
  • Full finger range of motion
  • Full wrist radial and ulnar deviation
  • Full cervical spine ROM(flex, ext, rotation, and side flexion)

Week two

  • In supine lying: Active assisted or active elbow flexion and extension in range 30 to 100 degrees with foreman supination
  • elbow pronation and supination ROM
  • Initiate wrist isometrics
  • Initiate elbow flexion and extension isometrics
  • Active shoulder flexion and abduction ROM in the sling keep forearm in 90 degrees flexion and in supination. NO SHOUDER EXTERNAL ROTATION.
  • Shoulder girdle elevation and depression. Shoulder girdle pro- and re-traction.
Phase 2 Active Range of Motion and Early strengthening (2 – 6 weeks).
Aims Gradually increase elbow ROM

Protect repair

Introduce shoulder girdle function

Regain and improve muscular strength as a secondary goal

Scar tissue management and scar mobility

Precautions Avoid valgus force or position during exercises

ROM exercises are gentle active or active assisted.

Avoid passive and resisted shoulder ER until 6 weeks.

Treatment Week 3

  • In supine lying, active elbow flexion and extension 30 to 120 with forearm supination.
  • Towards end of week 3 progress slowly on to full elbow ROM as tolerated
  • Active scapular stabilisation exercises
  • Begin grip strength and finger strength
  • Whole body motion with core work while in sling
  • Shoulder isometrics (IR, abd, and biceps, avoid resisted shoulder ER)
  • Maintain shoulder ROM, introduce 90% of gentle active shoulder ER.
  • Scar tissue management
  • Restore scar mobility
  • If scar sensitive desensitise program.
  • Begin grip strength

Weeks 4 to 5

  • Isotonic shoulder and scapular strengthening avoiding valgus stress
  • Start isotonic shoulder ER strength (hand stays on medial side of elbow to avoid valgus strain)

Weeks 5 to 6

  • Progress shoulder program strength
  • Progress elbow ROM
  • Core stabilisation program
  • Aim for full ROM in elbow
  • Elbow ROM 0-145 degrees
  • Walking and stationary bike with sling on permitted. But no treadmill and no running or jarring activities (ensure that  incision is closed i.e. no risk of infection from perspiration)
Phase 3 Strengthening Phase (6  – 10 weeks)
Aims Increase strength power and endurance

Maintain full elbow ROM

Gradually initiate sport activity

Precautions There should be no pain on doing the strength exercises. Post exercise soreness should be mild and relived within a few hours of stopping exercises
Treatment Weeks 6 to 8

  • Wean from sling
  • Restore/maintain full elbow range of motion
  • Light resistance ex for arm (half one lbs): wrist curls and extensions, forearm pro- and supination, elbow extension and flexion.
  • Advance shoulder strengthening program
  • Proprioception and neuromuscular control drills
  • Light manual resistance in PNF patterns with proximal stabilization

Week 8-10

Concentric and eccentric biceps and triceps

Stabilisation of wrist flex/pronators

Isotonic forearm and wrist program

Shoulder program introduce resisted shoulder external rotation

Evaluate upper limb ANT and restore normal neurodynamics

Scapular muscle function

Initiate plyometrics starting with 2 hand drills close to the body-chest and side throw

Week 9:

Diagonal PNF patterns,

shoulder rotations in neutral and in abduction and scaption,

Scapular retractors, posterior tilt, and upward rotation with resistance.

Introduce upper limb weight bearing into isometric holds in the press up and push up positions.

Other Week 11 onwards: Can start to swim, and walking, stationary bike with brace off. Continue to avoid running or jumping
Phase 4 Advanced Strengthening (12 16 weeks)
Precautions There should be no pain on doing the strength exercises. Post exercise soreness should be mild and relived within a few hours of stopping exercises.

Control the speed of the movements carefully

  • Initiate rhythmic stabilisation drills in protected positions i.e. at the side. Avoid valgus strain.
  • Initiate closed kinetic chain exercises
  • Two-armed rebounder drills, progressing to one-armed off a wall.
  • Introduce one hand plyometric 90/90 throws
Other – throwers Initiate plyometrics starting with 2 hand drills first further from the body

Start slow motion air throws

Running and sprinting can be introduced gradually.(50%-75% speed)

Start hand wall dribbles

Phase 5 Interval throwing Program (16- 20 weeks)
Aims Increase strength and power and endurance of upper limb musculature
precaution There should be no pain on throwing. If there is soreness after throwing it should be mild and subside within a few hours.
Treatment Gradual return to sport program

  • Initiate interval throwing program based on advice below and particular to type of sport
  • Dynamic neuromuscular control with shoulder stabilisation
  • Check throwing mechanics
  • Strengthen the muscles involved in throwing, with attention to core
  • Plyometric progressions over a period of 4 weeks. Progress from 2 arms in sagittal plane to 1 arm in the sagittal plane, then to 2 arm rotational movements then 1 arm rotational movements).
  • Start throwing. Use an interval return to throwing program with the intention to return to 100% throwing only at 28 weeks. Please refer to the guidelines for interval return to throwing program.
  • Address hip, calf and core strength.

Week 16: running allowed but monitor environment to minimise falls.

Guide        Return to full work capacity and competitive throwing from 28 weeks