Phase I: Protection and Early Mobilisation (0–2 Weeks)

Immobilisation:

• Arm supported in a standard sling at all times (including during sleep)

• In selected cases, repair/reconstruction supported by a backslap for the first 2 weeks

Precautions:

Overhead Elbow Protocol in supine position:

• Shoulder flexed to 90°, adducted, and in neutral to slight external rotation

• This eliminates gravitational varus stress and allows isometric healing of the lateral collateral ligament complex

• Elbow varus precautions: avoid positions or movements that apply inward (varus) stress

• No lifting, pushing, pulling, or axial loading

• No passive stretching beyond assisted range

Therapy:

Initiate elbow motion exercises in supine:

• Active-assisted elbow flexion without restriction

• Active or active-assisted elbow extension, limited to 30° short of full extension

• Active-assisted pronation/supination with elbow flexed to 90°

• Begin wrist, hand, and shoulder ROM (pain-free only)

• Oedema control and scar management once wound permits

Criteria to Progress:

• Well-healed wound

• Minimal swelling and pain

• Tolerance of protected ROM in supine with compliance to precautions

Phase II: Controlled Motion Phase (2–6 Weeks)

Immobilisation:

• Sling use gradually weaned beginning week 2; discontinue by end of week 6

• In selected cases, repair/reconstruction supported with a hinged elbow brace, locked at 30° short of full extension with full flexion, until end of Week 6.

Precautions:

• Continue elbow varus precautions

• Avoid resisted forearm rotation and extension

• Maintain supine positioning for all exercises until week 6

Therapy:

• Progress active-assisted to active elbow ROM

• Full elbow flexion and extension limited to 30° short of full extension

• Continue pronation/supination in flexed position

• Begin gentle isometric strengthening for wrist and shoulder musculature

• Scar desensitisation and soft tissue mobilisation as indicated

Criteria to Progress:

• Full pain-free active elbow ROM (or near-full)

• No signs of instability

• Compliance with precautions and exercise progression

Phase III: Strengthening Phase (6–12 Weeks)

Immobilisation:

• Sling discontinued

Precautions:

• Avoid heavy lifting and resisted elbow or forearm exercises until cleared

• Avoid varus stress positions during daily activity or exercise

Therapy:

• Increase extension gradually from 30° to full as tolerated

• Initiate gentle resistance exercises for elbow flexion, extension, pronation, and supination

• Begin light functional strengthening exercises

• Progress scapular and shoulder stability exercises

• Gradual return to light daily tasks below shoulder level

Criteria to Progress:

• Good elbow strength without pain

• Tolerance of light resisted activity

• Confidence and control in functional movement patterns

Phase IV: Advanced Strengthening & Functional Return (3–6 Months)

Precautions:

• Avoid contact sports or high-risk activities until cleared

Therapy:

• Progress elbow and forearm strengthening

• Incorporate proprioception and endurance training

• Begin activity-specific drills as indicated

Criteria to Discharge:

• Near/full strength and ROM

• Return to full work or sport-specific activities without instability or pain

General Recommendations

Work:

• Office/desk work may resume after 2–4 weeks if pain is well controlled

• Manual labour should be deferred until 3–6 months depending on job demands

Driving:

• It is important that you are medically fit to return to driving and you feel safe to control the vehicle and take evasive action if needed.

Sports and Leisure:

• Lower-limb activities may resume as comfort allows.

• Light upper limb activities may resume from approximately 6–8 weeks.

• Progressive return to gym and functional activities from 8–12 weeks.

• Throwing, racquet sports, and higher-demand activities from approximately 3–4 months as strength and stability improve.

• Contact or high-impact activities typically from 4–6 months or longer with full recovery and surgeon clearance.

Disclaimer: This protocol is intended as a general rehabilitation guide only. Rehabilitation progression should always be individualised and may be modified by A/Prof Ernstbrunner and the treating rehabilitation team based on the patient’s clinical progress, surgical findings, and individual circumstances.