Ulnar Collateral Ligament (UCL) Reconstruction Protocol (Tommy John Surgery)

An Ulnar Collateral Ligament (UCL) reconstruction, commonly known as Tommy John Surgery, is a surgical procedure to repair a torn ligament on the inner side of the elbow. This protocol outlines a structured progression to protect the reconstructed graft, restore joint mobility, and safely guide the patient back to throwing or overhead activities.

Phase 1: Protection & Immediate Motion (Weeks 0–6)

The primary focus of this phase is protecting the healing graft, minimizing pain and inflammation, and initiating gentle range of motion within safe parameters.

• Goals: Protect the healing ulnar collateral ligament graft; control pain and swelling; maintain hand, wrist, and shoulder mobility; gradually increase elbow range of motion.
• Precautions & Restrictions: Wear the posterior splint for the first week, then transition to a hinged elbow brace. No active elbow flexion. Strictly avoid valgus stress on the elbow (no external shoulder rotation stretching, no resisted forearm rotation). Do not lift objects with the affected arm.
• Suggested Exercises: Hand and finger range of motion exercises, wrist flexion and extension active exercises, shoulder isometric strengthening (avoiding external rotation), passive and active-assisted elbow motion within brace limits (Weeks 1-2: 30° to 100°; Weeks 3-4: 15° to 115°; Weeks 5-6: 0° to 130°).
• Criteria to Progress: Full wrist range of motion, elbow range of motion of 0° to 130° without pain, stable ulnar collateral ligament on clinical exam, minimal swelling.

Phase 2: Progressive Joint Mobility & Strengthening (Weeks 6–12)

This phase aims to restore full elbow extension and flexion while initiating light resistance exercises to rebuild strength in the arm and shoulder girdle.

• Goals: Achieve full, pain-free elbow range of motion; initiate light strengthening for the forearm, elbow, and shoulder; maintain core and lower extremity conditioning.
• Precautions & Restrictions: Avoid aggressive passive elbow extension stretching. Avoid activities that place valgus force on the elbow. Discontinue any exercise that causes medial elbow pain.
• Suggested Exercises: Active-assisted and active elbow range of motion exercises to achieve full extension; light dumbbell exercises for wrist flexion/extension and forearm pronation/supination; rotator cuff and scapular strengthening (scapular retractions, internal/external rotation with arm at the side); biceps and triceps light strengthening.
• Criteria to Progress: Full, pain-free elbow range of motion; muscle strength at least 4/5 for elbow flexion and extension; no pain or tenderness along the medial elbow joint line.

Phase 3: Advanced Strengthening & Early Activity (Weeks 12–18)

The focus shifts to restoring muscular power, endurance, and neuromuscular control of the entire upper extremity, preparing the joint for high-velocity activities.

• Goals: Restore full upper extremity strength and endurance; improve dynamic stability of the shoulder and elbow; initiate early plyometric training.
• Precautions & Restrictions: No throwing or overhead athletic activities. Avoid sudden, uncontrolled loading of the elbow joint.
• Suggested Exercises: Progressive resistance exercises for the chest, back, and shoulders (chest press, rows, shoulder press); eccentric elbow flexion and extension training; two-handed plyometric exercises (medicine ball chest passes, side throws); advanced rotator cuff and scapular stabilization drills (P1/P2 patterns).
• Criteria to Progress: Upper extremity strength matches at least 85% of the opposite side; complete absence of pain or instability during advanced strengthening and plyometric exercises; clearance from the surgeon.

Phase 4: Return to Sport & Interval Throwing (Weeks 18–26+)

This final phase outlines a structured return to sport or manual labor, utilizing an Interval Throwing Program (ITP) to safely reload the graft.

• Goals: Complete a structured interval throwing program; restore full functional sport-specific capacity; maintain comprehensive upper extremity conditioning.
• Precautions & Restrictions: Perform throwing drills only on non-consecutive days; always warm up thoroughly; immediately stop throwing if any medial elbow pain or soreness develops.
• Suggested Exercises: Interval throwing program (starting at 45 feet, progressing to 60 feet, 90 feet, and 120 feet, before transitioning to pitching or sport-specific drills); continuation of upper extremity strength, power, and flexibility maintenance programs.

These guidelines represent a standard rehabilitation protocol. Individual recovery rates vary significantly depending on the size of the repair, bone/tissue quality, and general patient health. Your surgeon may modify this protocol specifically for you.

Disclaimer: This protocol is for educational purposes and is not a substitute for professional medical advice. Always consult your surgeon or physical therapist before performing any exercises or modifying activity restrictions.