Rehabilitation following Tommy John Surgery

We’ve seen it countless times; a pitcher throws a pitch, grabs his elbow and walks off of the field with the athletic trainer. Usually within a few days, media reports indicate the pitcher has fully or partially torn his ulnar collateral ligament (UCL).  MRIs are obtained, orthopedic surgeons consulted, and in many cases the player opts to have Tommy John surgery to reconstruct the UCL. The next 12-18 months are then be filled with countless hours of rehabilitation to build strength, and patience to allow the reconstructed ligament to stabilize the elbow. 

Each orthopedic surgeon has variations to their protocols and each athletic trainer (AT) or physical therapist (PT) may also have some differences based on their individual experience and training. The following is a general guide to the rehabilitation process. For the purpose of this post, I will break the rehab into 5 phases: Acute, Early, Middle, Throwing, and Return to Pitching.

During the Acute phase, immediately following UCL reconstruction and lasting for 7 to 14 days, the elbow is placed in a brace with no movement in a 90-degree position. The player is allowed to move his wrist and shoulder and the main goal is to control pain and maintain motion in the shoulder and wrist.

During the early phase (2 weeks until 6 weeks), the goal shifts to gradually increasing elbow movement so the player has full motion by the end of this phase. This is done by manual therapy or gradual stretching by the AT/PT, range of motion exercises, and increasing the amount of motion the brace allows. Pain control remains important as an increase in pain is often followed by less movement. Gentle shoulder, scapula, and wrist exercises are initiated with an emphasis on regaining normal motion and protecting the elbow. The player generally wears a brace to protect his ligament during this phase.

The middle phase (6 to 18 weeks) is characterized by a mild increase in intensity of exercises including cardiovascular, lower extremity, and core stabilization exercises. The goal remains to protect the elbow and not stress the UCL; however exercises for the shoulder and scapula will also begin to incorporate safe elbow motions and become increasingly more difficult to strengthen and prepare the pitcher to resume throwing. This and future phases contain very few elbow exercises and stretches as the majority of the program consists of scapula, shoulder, lower extremity, and core strengthening and flexibility.  An important component of this phase is to assess and address movement/posture dysfunction and kinetic chain issues to examine what factors led to the injury and address those issues. Otherwise, the pitcher is at risk for additional elbow and shoulder injuries once he resumes throwing.

The throwing (long toss) phase begins at 18-24 weeks and lasts for four to five months. The variations are based on age, surgeon discretion, etc. Throwing begins at 45 feet X 30 throws every other day and progresses to 50 throws at 45 feet within about 2 weeks.  It then progresses to 60 feet and increases by 30-foot increments every 2-3 weeks. The thrower will slowly progress long toss to 100 total throws with 25 of those throws at distances as high as 210 feet for college, professional, and some high school pitchers. Younger pitchers should be able to progress long toss to 150 feet. Once sufficient throwing strength is obtained and the pitcher is long tossing five days per week with good mechanics (keep reading sports doc for my next post on throwing mechanics[b1] ), he progresses to throwing from a mound.  It is important to note that every day will not be perfect; if the pitcher feels sore, he should reduce his workload to only a couple of days. If soreness or pain persists, do not throw and speak to your AT/PT and physician.  Addressing a problem while it is still minor will often reduce the amount of missed throwing days.

The final phase (approximately 8-10 months) is the “return to pitching” phase and involves throwing from a mound. After sufficient long toss to loosen up, pitchers throw 20 to 25 pitch bullpens. They add five pitches every other time and throw two bullpens per week. They continue to long toss three times per week in addition to the bullpens. Once they can throw 40-45 pitch bullpens (about 5-6 weeks) with no soreness, good mechanics, and near normal velocity, they throw a few sessions facing hitters in batting practice (1 inning 15 pitches and adding 10 pitches an outing) and ultimately culminate in pitching in a live game. Pitching at 100% in a game situation should not occur before 11 or 12 months and takes longer for younger pitchers; everyone is different and each situation should be evaluated independently.  

The rehabilitation following Tommy John surgery is a long, tedious road; but with patience and hard work most pitchers are fortunate enough to have a second chance at playing America’s pastime.

Read more Sports Doc for Sports Medicine and Fitness.