One of the most crucial aspects of Tommy John surgery is the rehabilitation.  The doctor can perform the operation perfectly, but it is up to the athlete to follow through with all of the steps to recovery.  The protocol generally used is demanding and requires a motivated athlete with his or her mind set on returning.  The following procedure is followed by the Cleveland Indians and has been outlined by Wilk et al. (1995) and Azar et al. (2000).

Phase I-Immediate Postoperative Phase (Weeks 0-3)

Goals:

1.      Protect healing tissue

2.      Decrease pain/inflammation

3.      Retard muscular atrophy

Activities:

            Post-Op Week I

1.      Posterior splint at 90 degrees elbow flexion

2.      Wrist AROM (active range of motion)-extension/flexion

3.      Elbow compression dressing (2-3 days)

4.      Exercises

a.       Gripping

b.      Wrist range of motion

c.       Shoulder isometrics (no shoulder external rotation)

d.      Biceps isometrics

5.      Cryotherapy

 Post-Op Week 2

1.      Application of functional brace, 30-100 degrees flexion

2.      Initiate wrist isometrics

3.      Initiate elbow flexion/extension isometrics

4.      Continue above exercises

5.      Scar Tissue Massage

6.      Begin cardiovascular conditioning program with injury modifications according to the Cleveland Indians Physical Development program

 Post-Op Week 3

1.      Advance brace to 15-110 degrees flexion (gradually increase range of motion 5 extension/10 flexion per week)

Phase II-Intermediate Phase (Weeks 4-8)

Goals:

1.      Gradual increase in range of motion

2.      Promote healing of repaired tissue

3.      Regain and improve muscular strength

Criteria to Progress to Phase II:

1.      Minimal pain and tenderness

Activities:

            Post-Op Week 4

1.      Functional brace set to 10-120 degrees flexion

2.      Begin light resistance exercises for arm (1 lb.)

a.       Wrist curls

b.      Wrist extensions

c.       Wrist pronation/supination

d.      Elbow extension/flexion

3.      Progress shoulder program, emphasize rotator cuff strengthening (avoid external rotation until week 6

4.      Initiate strength program with injury modifications according to the Cleveland Indians Physical Development Program

Post-Op Week 6

1.      Functional brace set to 0-130 degrees flexion, active range of motion 0-145 degrees flexion (without brace)

2.      Progress elbow strengthening exercises

3.      Initiate shoulder external rotation strengthening

4.      Progress shoulder program

Phase III-Advanced Strengthening Phase (Weeks 9-13)

Goals:

1.      Increase strength, power, endurance

2.      Maintain full elbow range of motion

3.      Prepare athlete for gradual return to functional activities

4.      Prepare athlete to begin to throw

Criteria to Progress to Phase III:

1.      Full non-painful range of motion

2.      No pain or tenderness

Activities:

            Post-Op Week 9

1.      Initiate eccentric elbow flexion/extension

2.      Continue isometric program; forearm and wrist

3.      Continue shoulder program

4.      Manual resistance diagonal programs

5.      Initiate plyometric exercise program to include trunk rotation and plyoball with mini tramp

Post-Op Week 11

1.      Continue previous exercises

2.      May begin light sport activities (golf, swimming)

3.      Isokinetics

Phase IV-Return to Activity Phase (Weeks 14-26)

Goals:

1.      Continue to increase strength, power, and endurance of upper extremity musculature.

2.      Prepare athlete for full functional return.

Criteria to Progress to Phase IV

1.      Full, non-painful range of motion

2.      2 weeks of pain-free plyometrics

3.      Satisfactory isokinetic evaluation

4.      Satisfactory clinic exam, Physicians approval

Activities:

            Post-Op Week 14

1.      Initiate interval throwing program, throw and train on the same days

2.      Continue strengthening program

3.      Continue with plyometrics

4.      Continue with isokinetics

Post-Op Week 22-26

1.      Return to competitive throwing

Throwing Program

     In a report released by Seto et al. in 1991, a throwing program for baseball players recovering from ulnar collateral ligament reconstruction was outlined.  The programs were tailored for outfielders, infielders, and pitchers to help them best readjust to playing their positions.  Each step is suggested for approximately two weeks, however this leads to an overall time scale of twelve months from surgery to return.  Dr. John Bergfeld, of The Cleveland Clinic, stated Rehabilitation exercises have been perfected and most [players] feel ready to step back into the game in just seven months.  For cautions sake, most players refrain from play for almost a year. (Dawkins 2000). 

     Matt Beech, a player for the Philadelphia Phillies, was making his third rehabilitation start eleven months out of Tommy John surgery when he partially tore his new ligament.  He underwent a second UCL reconstruction in 2000, and when asked about his situation, Beech said I could have taken it a bit slower, I was really aggressive in my throwing program all the way up until I reinjured myself if I could have waited a couple more months I probably would have been OK. (Greenfield and Rogers 2000).  Beech has not returned to baseball since his second surgery.  Therefore, the following plan may be accomplished quicker than two weeks per step, however optimal results are attained when the recovery is not hurried.