Note: This pathway is designed to serve as a guide to rehabilitation. Indications for progression should be based on patient’s complete operative procedure, functional capacity and response to treatment.

Immediate Post-Op General Precautions

  • Patient is typically casted or splinted in a position of semi-flexion for 1st week if transportation has been performed
  • Protect the surgical site
  • Protect the flexor-pronator origin. Avoid simultaneous wrist extension and supination
  • Avoid periods of sustained elbow flexion, heat activity with the involved upper extremity including gripping, pushing, pulling, carrying, etc., leaning or weight bearing onto elbow whether in or out of splint

Rehabilitation Phase | Weeks 1-4

Goals:

  • Protect and promote healing of soft tissues and relocated nerve
  • Aggressive return of full elbow motion, avoiding forced or prolonged full flexion
  • Control edema and decrease pain (cry, elevation, retrograde massage, compression sleeve/wrap)
  • Avoid flexor carpi ulnas and triceps stretching

Weeks 1-2

  • Light gripping activities/wrist AROM allowed initially in position of wrist flexion and pronation
  • Avoid simultaneous wrist extension and supination
    • Wrist extension AROM is done in pronated position initially
    • Forearm supination is done with wrist flexed initially
  • Begin AAROM into elbow flexion and extension avoiding forced flexion
  • Begin forearm pronation/supination initially with elbow flexed 90 degrees
  • Begin sub-maximal isometrics of rotator cuff
  • Begin ulnar nerve gliding program
  • Begin scar massage/mobilization once staples/sutures removed
  • Scapular strengthening may be done with resistance applied proximally to the elbow

Weeks 3-4

  • Restore full ROM by week 4 at latest, emphasizing terminal extension
  • Avoid forced flexion positions
  • Continue with the above exercises, edema and pain management, and scar mobilization
  • Light isotonic exercises in patterned motion such as PNF patterns/functional motions involving the whole kinetic chain are encouraged

Rehabilitation Phase | Weeks 4-10

Goal

Continue with above exercises, ulnar nerve glides, edema management, and scar mobilization.

Week 4

  • Progress ROM as needed
  • Add flexor carpi ulnaris and triceps stretching
  • Gradually resume normal ADL’s

Week 6

  • End-range stretching for shoulder, elbow, wrist in all planes
  • Initiate rotator cuff resisted strengthening program, proprioception and neuromuscular control activities
  • Non-athletes typically can be discharged at this point assuming full motion obtained

Week 8 (Athletes)

  • Initiate eccentric strengthening program
  • Plyometric training drills with ply ball/rebounder start with both arms then progress to single arm
  • Address any remaining impairments, restore full flexibility/mobility of the involved UE

Week 10 (Athletes)

  • If throwing athlete, initiate interval throwing program
  • Progress plyometric drills and eccentric training as appropriate for healing and requirements for occupation/recreation