Rehabilitation following UCL Reconstruction Lenny Macrina MSPT, SCS, CSCS Champion PT and Performance Waltham, MA

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1 Rehabilitation following UCL Reconstruction Lenny Macrina MSPT, SCS, CSCS Champion PT and Performance Waltham, MA Exercise Program Focus Enhance flexibility Improve dynamic stability Increase muscle strength, power and endurance Careful consideration to avoid loss of ROM and flexibility Ultimate Goal Pain free, unrestricted throwing Introduction Angular velocities (Fleisig 1995) >7000 /sec at shoulder Fastest human movement recorded Elbow >3000 /sec 1.5x body weight with follow-thru Attempting to distract the joint Tremendous strain on dynamic stabilizers Injury= excessive fatigue, weakness, Δ in mechanics, capsular laxity Cocking acceleration UCL sprain Valgus extension overload Flexor/pronator strain Tendonitis vs tendinosis Ulnar nerve Posterior impingement (osteophyte) ROM Side to side differences Capsular laxity Borsa et al Strength Proprioception

2 Osseous configuration Crockett et al AJSM 2002 Osbahr et al AJSM 2002 Reagan et al AJSM 2002 Chant et al JOSPT 2007 Reinold 2008 AJSM08N=67 professional pitchers ER before and after throwing similar 136 versus 135 IR before throwing 54 ± 11 IR after throwing 44 ± hrs later 46.5 ± 10 Lose 3.2 elbow extension irange of Motion Wilk et al AJSM 2002 Average ER = 129 ± 10 Average IR = 61 ± 9 Equal motion bilaterally (ER + IR) within ±5 Best way to measure IR PROMto be consistent throughout Visual inspection Stabilize coracoid process and posterior scapula Stabilize humeral head Visual Inspection= 58 PRO Scapula Stabilized= 46 Humeral Head Stab= 40 Inter-rater VI r= 0.48 SS r= 0.62 HH r= 0.51 Intra-rater VI was 0.47 SS 0.43 HH Wilk, Macrina, Fleisig et al juinjured pitchers IR deficit was 12.9 torthop J Sports Med Jul pitcher-seasons 2.4x risk shoulder/elbow injury 2.8x risk shoulder/elbow injury

3 Immediately after injury or surgery Precautions will vary depending on healing constraints and tissue involvement Or if repair was performed Goals: Decrease pain and inflammation Normalize motion Restore baseline proprioception Initialize light strengthening exercises Full pain-free PROM Sufficient balance of ER/IR strength/rom Progressing proprioceptive and NM control drills to end range Progress to full isotonic strengthening Prepare athlete for return to throwing Criteria Full motion and capsular mobility Good strength and endurance of the upper extremity and scapula musculature Emphasis on soft tissue mobility- particularly on posterior cuff Progressive program Start from the goal and work backwards Timelines and set goals must be achieved Repetitive stresses often lead to tissue breakdown Must not ignore Biggest complaint from my athletes Successful management with a well structured rehabilitation program Scapula stabilizers

4 External rotators Loss of IR/flexion ROM!

5 Average/year = $423 million Range = $136 to $694 million UCL Repair or Reconstruction in 2017: When, Why, How? E. Lyle Cain, Jr., M.D. Total Lost (18 yrs) = $7.6 Billion Last 3 Seasons = $2 Billion UCL Surgery in MLB (Conte) MLB Financial Costs due to Injury (Conte) The average Major League Salary has risen 300% since However, the cost of injured players salary plus replacement have risen 400% since Prevalence of UCLr (Conte) 1 in 4 Major League Pitchers have undergone UCLr 1 in 7 Minor League Pitchers have undergone UCLr. 16% Prevalence Rate for All Pitcher (Major + Minor) Free autogenous tendon graft» Palmaris Longus» Gracilis UCL Revisions (Conte) Major League Players 39 players 38 pitcher UCL Reconstruction

6 Bone tunnels Different fixation techniques UCL Repair UCL Repair: History Conway, Jobe et al, JBJS 1992» 70 patients Repairs to bone, 56 Reconstructions G/E in 10/14 repairs (71%) G/E in 45/56 Reconstructions (80%) 7/14 Repairs (50%) returned to same level 2/7 MLB (29%) 38/56 Reconstructions returned to same level (68%) 12/16 MLB (75%) Argo, Savoie, Field, et al AJSM 2006» UCL repair in 18 female athletes 6-plication, 11-anchors, 1-drill 1 holes Softball, Gymnastics, Tennis Only one pitcher» 16/17 return to previous level (94%) Mean return time of under 3 months 60 pts Average Age 17 UCL Primary Repair

7 Repaired with suture anchors 58/60 (97%) returned to play at avg 6 months May be option for young, healthy ligament with Acute Injury Very little historical evidence» Grand total of under 200 patients Early techniques did not have the benefit of modern anchor and suture technology» Nor the clinical experience with UCL surgery that we now have Rehabilitation protocols have changed 16 athletes 5 major league UCL Reconstruction - Original Jobe Technique 10/16 (62%) returned to same level 5/16 (31%) with ulnar nerve complications 78 pts No detachment of the flexor mass Subcutaneous ulnar nerve transposition 33 pts 93% good/ excellent results at 2 yrs 32/36 (92%) returned to same level Andrews Modification Muscle Splitting Technique Docking Technique

8 AJSM UCL procedures, 1265 reconstructions Follow-up on 79% (743 patients) 95% baseball players ( 89% pitchers) Average follow-up: 49.1 months ü 83% returned to same level (recon) 63% of repairs returned to same level competition Return to competition: 11.6 months ITP initiated 4.4 months AJSM UCL reconstructions included in study ü 148 returned to play 83% returned to same level ü Only 5 pitchers were not able to return to play ü Return to competition: 20 months ü Length of career 3.9 months ü Pitchers performance improved after surgery AJSM 2014 UCL reconstruction in throwing athletes a minimal 10 year follow-up 256 of 313 (82%) ) available for F/U Average follow up 12.6 yrs yrs 90% were pitchers ü 83.5% of overhead throwers RTP AJSM 2014

9 Longevity of career after UCLr 3.6 yrs for all levels 86% retired due to something else than UCL 98% still throwing UCL Repair with Internal Brace Augmentation A Novel Technique UCL Repair with Augmentation Adolescent and Young Adults These athletes typically have end-avulsions of the UCL or partial tears of the ligament. Rarely is the UCL tissue deficient or deteriorated from chronic repetitive injury IS UCL RECONSTRUCTION NECESSARY in THIS POPULATION? Novel Construct for UCL Repair 2 x 3.5 mm corkscrew PEEK anchors Collagen-coated Fiber Tape Size 0 Ticron suture UCL Surgery Repair 2 x 3.5 mm corkscrew PEEK anchors Collagen-coated Fiber Tape Size 0 supersuture (Ticron) One limb of FiberTape and suture placed through the eyelet of the first anchor First anchor placed at the site of avulsion Suture used to repair avulsed ligament Both limbs of tape placed through through eyelet of the second anchor Second anchor placed at other insertion UCL Caution on tension of tape

10 AJSM 2016 Current Clinical Study Recent success by Savoie with UCL repair Basic science showing time-zero success First patient underwent UCL repair with internal brace augmentation ation 8/8/2013 Total of 82 performed through 5/31/2016 First 40 with minimum 1-year 1 follow-up Ages (Avg Age 17.7 yrs) Baseball 30 (23/30 pitchers) Softball 3 (2/3 pitchers) Tennis 1 Football 1 Javelin 3 Demographics 40 patients (>1yr F/U) Cheer 1 Rock Climbing - 1 Throwing Athletes 3 Javelin Softball Baseball» 1-HS, 1-NCAA, 1 1-Olympic1» 2-HS (1-catcher, 1-pitcher), 1 1-NCAA 1 (pitcher)

11 » 22-HS (18 pitchers), 8 College (5 pitchers) Results Post-op op Course Patients achieved full ROM by weeks w post surgery in all cases Plyometric exercises initiated after wk 6 when ROM is FULL. Throwing program initiated after 4 weeks of plyometrics (avg beginning of week 11) RTP average WEEK 21 after surgery in baseball» Just under 6 months. Results to date 39/40 have returned to at least their pre-surgical level of sports participation, given the opportunity» Rock Climber cannot climb due to elbow 4 went from HS to College during 1 st year No statistically significant difference in KJOC score between proximal vs distal OR partial vs complete avulsion. Too Much Hype Too Soon? Limited # of patients, and only 1 yr f/u» Longer follow-up in progress Limitations Only high school and collegiate athletes» No Professionals to date, but would now feel comfortable No Professionals to date, but would now feel comfortable if the ligament injury was amenable» First MLB pitcher done 6/20/16 with this technique (Seth Maness- Paletta)» NCAA pitcher just pitched 2 games in CWS (TCU)

12 No control group» Relative to known experience with UCL-recon Conclusions My Thoughts UCL Repair vs Reconstruction Reconstruction with Graft Published outcomes Known long-term results at all levels of play Repair with Augmentation: Less Morbidity Faster Return (6 mos vs mos) No long term results Concerns: stress shielding of ligament, suture/tape failure, anchor pull-out, difficult revision?? My Algorithm UCL Repair vs Reconstruction Always try Non-surgical treatment first (6wks-6 6 mos) Healthy tissue or Short Time mandatory for return (summer before HS senior yr, last year of f JuCo, no opportunity to play if misses upcoming season) : Primary Repair with internal brace augmentation (6 mos RTP) My Algorithm UCL Repair vs Reconstruction Chronic Attenuated ligament or Complete tear: UCL reconstruction with autograft ( mos RTP) High Level Pitcher (Major league, or Long career expectations/ High draft choice): UCLR with Autograft (18 mos RTP

13 Keys to Tommy John Rehabilitation Mike Reinold 1 2 Keys to Tommy John Rehab Mike Reinold, PT, DPT, SCS, CSCS Tommy John Injuries are Common Velocity and Elbow Stress Correlation between velocity and elbow stress has been shown High School Hurd: Sports Health 12 Professional Bushnell: AJSM Probably Not Going Away Anytime Soon 5 Principles of Tommy John Rehabilitation Principle #1: Avoid Loss of Motion Avoid Loss of Motion Immediate Postop Goals Minimize effects of immobilization Decrease pain, inflammation, & swelling Reestablish ROM Avoid Loss of Motion Immediate Postop Goals Minimize effects of immobilization MikeReinold.com EliteBaseballPerformance.com 1

14 Keys to Tommy John Rehabilitation Mike Reinold Immediate Postop Goals Minimize effects of immobilization Decrease pain, inflammation, & swelling Reestablish ROM Avoid Loss of Motion Immediate Postop Goals Minimize effects of immobilization Decrease pain, inflammation, & swelling Reestablish ROM Avoid Loss of Motion Immediate Postop Goals Minimize effects of immobilization Decrease pain, inflammation, & swelling Reestablish ROM Avoid Loss of Motion Immediate Postop Goals Minimize effects of immobilization Decrease pain, inflammation, & swelling Reestablish ROM Range of Motion Guidelines Gradual ROM progression Week 2: degrees Week 3: degrees Week 4: degrees Gradually push flexion from there It s Much Easier to Prevent Loss of Motion than to Force Motion later MikeReinold.com EliteBaseballPerformance.com 2

15 Keys to Tommy John Rehabilitation Mike Reinold If You Get Behind in the First Month, You Tend to Stay Behind Principle #2: Work on Imbalances During Early Phases Work on Imbalances Early phases are boring Focus on alignment, posture Soft tissue restrictions Shoulder flexion linked to UCL injuries Wilk: AJSM Pics of loss of ER and Flexion Prepare the Body for Advanced Phases of Rehab Principle #3: Focus on the Shoulder and Scapula Tommy John Rehab is 80% Shoulder and 20% Elbow Focus of Shoulder and Scapula Proper positioning Deceleration of forces Focus of Shoulder and Scapula Begin strengthening program week 3 Progress to full shoulder/elbow program week 5-6 Advanced to 90/90 position week 8 This allows 2+ months of a good strength program prior to throwing MikeReinold.com EliteBaseballPerformance.com 3

16 Keys to Tommy John Rehabilitation Mike Reinold This allows 2+ months of a good strength program prior to throwing Shoulder strength correlated to UCL injuries in HS athletes Tyler: AJSM Weak and Tight Shoulders are VERY Common Principle #4: Enhance Elbow Dynamic Stability Dynamic Valgus Stability FDS, FCU, FCR, PT Calculated elbow muscle moment arms Muscles provide greatest resistance to valgus: An J Biomech 81 Anatomically positioned over UCL Davidson AJSM 95 Dynamic Valgus Stability FDS, FCU, FCR, PT Calculated elbow muscle moment arms Muscles provide greatest resistance to valgus: An J Biomech 81 Anatomically positioned over UCL Davidson AJSM 95 Dynamic Valgus Stability FDS, pronator teres, FCU all active stabilizers Udall: JSES 09 Increasing force output of elbow muscles reduced strain on UCL Buffi: Ann Biomed Eng 14 Muscles fatigue of elbow during pitching Wang: J Sports Sci 15 A Weak Muscle Can t Stabilize MikeReinold.com EliteBaseballPerformance.com 4

17 Keys to Tommy John Rehabilitation Mike Reinold Principle #5: Gradually Apply Loads Gradually Apply Loads Don t skip steps Sequence of events Weeks don t tell the whole story Progressive application of loads Slow and gradual throwing progression Resist the urge to rush Slow Gradual Progression Rehab Straight Forward MikeReinold.com EliteBaseballPerformance.com 5

18 Keys to Tommy John Rehabilitation Mike Reinold Rehab the Pitcher Not the Elbow Trustworthy information and resources to advance the game of baseball EliteBaseballPerformance.com Thank You! MikeReinold.com EliteBaseballPerformance.com 6

19 TOMMY JOHN SURGERY: SURGICAL INTERVENTION, REHABILITATION AND RETURN TO THROWING CSM 2018 New Orleans Advanced Strengthening and Return to Play Following Tommy John Surgery Dan Lorenz, DPT, PT, ATC/L, CSCS Introduction What is the RTP rates for UE athletes after UE surgeries? SLAP tears, RCR, and UCL reconstructions Surgical/Rehab considerations Primary repair/reconstruction or revision Stage of rehabilitation Concomitant injuries Individual athlete considerations Injury history Pre-injury activity level Pre-injury physical condition Sport and position played Competitive level Athlete goals/needs/desires Adolescent athlete training age? Biological age? Psychosocial considerations Program Design Considerations What resources are available for athlete performance training? What are their current deficits?

20 What is their training history? How many days per week can they commit to training? Screening/Testing Is your athlete ready for performance training and return to play? Begin with a needs analysis Generalized hypermobility Beighton Scale Bilateral Shoulder Flexion injury Sakata et al, AJSM 2017 As little as 5 loss increases UE injury risk Wilk et al Increased thoracic kyphosis found to be risk factor in medial elbow Gleohumeral joint ROM, scapula, and thoracic spine all contribute to max ER Konda et al, AJSM 2015; Miyashita et al, AJSM 2010 Bilateral Wall Angel Thoracic Rotation ROM Johnson et al, J Ath Train 2012 Rotator Cuff strength Wilk et al AJSM 2002; Wilk et al AJSM 1993; Ellenbecker et al, J Ath Train 2000 Are they mentally ready? UE Data lacking!! Glazer, J Ath Train 2010; Webster et al, Phys Ther Sport 2008; Ardern et al, BJSM x more likely to get injured if anxious about symptoms before competition Timka et al, BJSM Lots of screening models exist, including FMS and SFMA Tarara et al, IJSPT 2014; McKeown et al, IJSPT 2014; Haitz et al, JOSPT 2013 Single leg step down performance shows strong correlation between hip abductor muscle function and single leg balance McCurdy et al, J Sport Sci Med 2006; Crossley et al, AJSM 2011 Deep Squat Cook, 1998

21 Hip Rotation Range of Motion deficits found in overhead athletes and have correlated to injury McCulloch et al, OJSM 2014; Ellenbecker et al, AJSM 2007; Young et al, AJSM 2014; Li et al, Orthop Rev 2015; Saito et al, OJSM 2015; Robb et al, AJSM 2010 Y Balance Test Only test associated w/ injury risk compared to 13 other tests Hegedus et al, BJSM 2015 Deficits linked to injury in D1 athletes Wright et al, J Physiother 2016 Reliable test of balance and strength in the LE Plisky et al, JOSPT 2006; Dobija et al APMR 2016; Plisky et al, NAJSPT 2009 Single leg balance prior Hannon et al, IJSPT 2014 Link between balance and shoulder stability Radwan et al, IJSPT 2014 Balance improvements noted after UCL reconstruction compared to Core stability/strength many LINKS to performance but nothing definitive How should we test? Discharge/RTP decisions Creighton et al, CJSM 2010 How to we define performance in the athlete after Tommy John surgery What does the current data show? 2013 Lower body field tests correlate to throwing velocity Lehman et al, JSCR Push off force and ball speed Oyama & Meyers, JSCR 2017; McNally, JSCR 2015 Relationship between trunk rotation, dynamic stability and pitch velocity Bullock et al, JSCR 2017 Excessive contralateral trunk tilt reveals compensations Oyama et al, Clin J Sports Med 2017 Predictors of throwing velocity in young pitchers Sgroi et al, JSES 2015 Performance metrics after TJ surgery Makhni et al, AJSM 2014 Power determines elite athlete performance in the same sport Lorenz et al, Sports Health

22 Weight Room considerations Physical qualities of Performance Strength Power 3 Types of Strength 3 Ways to train strength Speed-Strength key in baseball Elastic Strength Speed Modifications to weight training activities Consider pulling derivatives Eliminate catch phase of OL Specific training considerations The ankle was 50% of the extension for the broad jump and 40% for the vertical need a mobile, strong ankle Robertson and Fleming, Can J Sport Sci 1987 Train fast to be fast! Building work capacity with fatigue, throwers have less knee flexion, trunk more upright and arm slot lowers AJSM 2017 Train from the ground up Build mobile and stable hips and spine