Variability of Rehabilitation Protocols for Ulnar Collateral Ligament (UCL) Reconstruction

Sana Cheema BA, Christina Hermanns BS, Reed Coda BS, Armin Tarakemeh BS, Jeffrey Randall MD, Vincent Key MD, John Paul Schroeppel MD, Scott Mullen MD, Bryan Vopat MD

University of Kansas School of Medicine

E-poster 100 Disclosure Information The authors of this paper have nothing to disclose. • UCL tears are common in athletes who are required to throw or use overhead arm.

• was the first Major League player to undergo this surgery performed by Dr. Frank Jobe in 1974.1 Background • Between 1974 and 2016: 1429 players underwent UCL reconstruction.2

• Rehabilitation is crucial for the success of UCL reconstruction outcomes.

1. Erickson B, Harris J, Chalmers P, Back Jr. B, Verma N, Bush-Joseph C, Romeo A. Ulnar Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes. Sports Health 2015; 7(6): 511-317. 2. Camp C, Conte S, D’Angelo J, Fealy, S. Epidemiology of ulnar collateral ligament rec2. Camp C, Conte S, D’Angelo J, Fealy, S. Epidemiology of ulnar collateral ligament reconstruction in Major and Minor League Baseball pitchers: comprehensive report of 1429 cases. JSES 2018; 27: 871-878. The purpose of this study is to assess the variability of online published rehabilitation Objective protocols for UCL reconstruction. – Publicly available rehabilitation protocols from US academic orthopedic surgery programs were collected using the Fellowship and Residency Electronic Interactive Database Access (FREIDA)3.

– Search term: “[Program/affiliate hospital/affiliate Methods medical school name] UCL reconstruction rehabilitation protocol.”

– Private practice protocols were added using Google search

3. Makhni E, Crump E, Steinhaus M. Quality and Variability of Online Available Physical Therapy Protocols From Academic Orthopaedic Surgery Programs for Anterior Cruciate Ligament Reconstruction. Arthroscopy 2016; 32(8): 1612-1621. Academic orthopedic surgery Private orthopedic practices with programs from FREIDA searched published UCL reconstruction (n=183) rehabilitation protocols (n=18) Identification

Academic orthopedic surgery programs with published protocols (n=12)

Screening Total rehabilitation Private practice excluded protocols (n=2) Flow Chart (n=30) Eligibility

Protocols included in qualitative synthesis (n=28)

Protocols included in

Included quantitative synthesis (n=28) Comparison of protocols based on rehabilitation components

Rehabilitation Component Total number of protocols Percent of protocols

Passive ROM 9 32% Active ROM 18 64% Full ROM 26 93% Results Shoulder Strengthening 26 93% Elbow Strengthening 27 96% Brace Immobilization 26 93% Interval Throwing Program 23 82% Return to Sport 28 100% 1 This chart compares the rehabilitation recommendations made by the protocols included in this study. While return to sport recommendation is included in 100% of protocols, passive (range of motion) ROM and active ROM recommendations are included in far less percentage of protocols. Passive ROM 60% 56% 50% 40% 30% 22% 20% 11% 11%

% protocols% 10% 0% 0% 0% Results 0% 0 1 2 3 4 5 6 weeks

While there is variability in the recommendation, 5 of 9 (56%) protocols recommended initiating passive ROM of elbow at 2 weeks. Active ROM 30% 28% 25% 22% 20% 17% 17% 15% 11% 10% 6% Results protocols% 5% 0% 0% 1 2 3 4 5 6 7 weeks

There was great variability in active ROM recommendations between protocols, and 5 of 18 (28%) protocols recommended initiating active ROM of elbow at 6 weeks. Full ROM 50% 42% 40%

30% 23% 20% 12% 12%

Results protocols% 8% 10% 4% 0% 4 5 6 7 8 9 weeks Initiating full ROM of elbow at 6 weeks was recommended by 11 of 26 (42%) protocols. Elbow Strengthening 60% 52% 50% 40% 37% 30% Results 20% % protocols% 10% 4% 4% 4% 0% 0% 0% 3 4 5 6 7 8 9 weeks

14 of 27 (52%) protocols recommended initiating elbow strengthening at 6 weeks. Brace Use 80% 69% 70% 60% 50% 40% 30%

Results protocols% 20% 12% 12% 10% 4% 4% 0% 0% 0% 0% 0% 4 5 6 7 8 9 10 11 12 weeks

18 of 26 (69%) protocols recommended brace immobilization for 6 weeks. Interval Throwing Program 40% 35% 35% 30% 26% 25% 22% 20% Results 15%

% protocols% 10% 4% 4% 4% 5% 0% 0% 12 14 16 18 20 21 24 weeks 8 of 23 (35%) protocols recommended initiating Interval Throwing Program at 16 weeks. Return to Sports 12.00% 11% 11%11% 11% 10.00% 8.00% 7% 7% 6.00% 5% Results 4.00% 4% 4% 4% 4% 4% 4% % protocols% 2.00% 0% 0.00% 8 14 16 18 20 21 22 24 28 30 35 36 40 48 weeks While return to sport recommendations were included in 100% of protocols, there was wide variability in the timing of that recommendation. • A high degree of variability was found between rehabilitation protocols. • There was considerable variation in the depth of detail of rehabilitation steps. • Many academic programs do not have a UCL joint Discussion reconstruction rehabilitation protocols published online. • Most protocols need to use medical terminology and physical therapy abbreviations that are easy for patients to follow-> as rehabilitation is transitioning to more patient-directed therapy. • Less variability between protocols if more protocols were identified.

Limitations • Private practice protocols were located using a simple Google search.

• It is possible that many programs have rehabilitation protocols that are not published online. Thank you for viewing this presentation.

Thank you to AANA for giving us the opportunity to present our work.