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肘关节不稳定

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肘关节不稳术后康复，涵盖外侧（恐怖三联征/外侧副韧带）损伤和投掷（内侧尺侧副韧带）损伤，以保护性早期活动而非固定为核心。

肘部示意图，显示稳定关节的侧副韧带和内侧副韧带。
肘关节外侧（桡侧）和内侧（尺侧）的副韧带，这些韧带在发生不稳定损伤后会被修复或保护。 Kieran Hirpara 4.0

本页面由机器翻译，尚未经临床医生审核。英文版本为权威版本。

本方案由基兰·希尔帕拉（Kieran Hirpara）医生在罗克汉普顿 Mater 私人医院为您提供肘关节不稳术后康复指导。本方案涵盖两种不同类型的不稳，您的主刀医生将告知您属于哪一种：

  • (A) 外侧（外侧面）损伤： 如“恐怖三联征”损伤、骨折脱位，或外侧副韧带（LCL）修复术。此类损伤经稳定处理后，肘关节不再发生半脱位或异位扭转。
  • (B) 投掷（内侧，内侧面）损伤： 尺侧副韧带（UCL）修复或重建术，通常适用于过头运动项目运动员。

整个计划基于一个核心理念：受保护的早期活动，而非制动固定。 长期石膏或夹板固定是导致肘关节永久性僵硬的主要原因，因此目标是在尽早开始安全活动。请将此页面或其 PDF 文件带给您的首次康复治疗师，以确保康复过程协调一致。您的治疗师可能会根据您的恢复进展调整本方案。

如果您术后对伤口有任何疑虑，请联系诊室。拍摄伤口照片并通过电子邮件发送以供审查通常很有帮助。

预期情况

肘关节由关节内侧和外侧的韧带固定。当这些韧带受伤（由脱位、骨折脱位或反复投掷引起）时，关节可能变得不稳定。手术修复或重建受损结构，使关节重新正确对位。

Hirpara 医生的方法避免了使用笨重的外部铰链式支具。如果手术时修复结构在全范围活动内均稳定，您只需佩戴轻便吊带以提供舒适感，并在安全体位内尽早开始活动肘关节。如果需要更多保护，可在手术时植入内部关节稳定器：这是一种小型内部铰链，可从内部保持肘关节正确复位，同时允许您早期进行屈伸活动。由于保护来自内部，您无需使用限制活动弧度的外部支具。如果使用此内部装置，通常在韧带愈合后（约四至六个月）将其取出。

关于伤口、肿胀和瘢痕管理，请参阅诊所的伤口护理指南。

康复过程中最重要的一点是，在尊重外科医生要求避免的体位的前提下，在安全范围内保持活动。以下练习是您的起始方案。

注意事项与限制

保护体位取决于您具体的损伤类型。您的主刀医生和治疗师将为您确认具体的保护体位。

对于外侧（外侧边）损伤（恐怖三联征 / 外侧副韧带 LCL）：

  • 应在活动时保持前臂掌心向下（旋前）；这有助于关节对位并保护外侧修复。
  • 应在身体前方进行手臂锻炼，或在被要求时仰卧并将手臂伸向天花板，以便利用重力帮助维持关节稳定。
  • 不应让手臂向侧面下垂（避免肩关节外展），也不应在早期通过手臂承重；否则重力会将修复处拉开。
  • 不应在获得主刀医生许可之前（约术后 16 周），将肘关节完全伸直与前臂掌心向上（旋后）相结合；此体位可能导致关节再次半脱位。
  • 不应推压或拉伸肘关节至疼痛，并在最初几个月内避免负重和接触性负荷。

对于投掷（内侧，内侧边）损伤（尺侧副韧带 UCL）：

  • 应按照医嘱保持前臂偏向掌心向上（旋后）或中立位。
  • 不应在早期将肩关节置于外旋位并施加负荷；这会增加内侧修复处的应力。通常在术后约 6 周内避免此动作。

您的练习

这些是您讲义中的练习，旨在帮助您在保护肘部的同时，恢复安全活动并保持手部、前臂和肩部的功能。仅在希帕拉医生（Dr Hirpara）和治疗师的指导下开始并逐步推进这些练习；安全的前臂位置和范围取决于您的具体损伤情况。

您的临床方案

本页面其余部分是为您的物理治疗师或手部治疗师提供的临床方案。由于两种损伤的保护方式不同，方案分为两条路径。每个阶段均以标准为导向：在达到里程碑时推进，而非仅依据日历时间。

治疗前，请查阅患者的X光片、手术报告及既往病史，并与主刀医生沟通，了解手术中达到的稳定性、安全活动范围及前臂旋转情况，以及是否植入了关节内稳定器。Hirpara 医生不使用外铰链式支具：对于通过范围稳定的修复，采用简单吊带管理并早期活动以减轻不适；当需要保护稳定性时，关节内稳定器在内部维持复位，同时允许活动至舒适范围。

A 轨 — 恐怖三联征 / 骨折脱位 / LCL（LUCL）修复

目标： 获得一个稳定、同心复位的肘关节，并实现早期活动；预防后外侧旋转性再半脱位。

早期阶段全程的关键注意事项：

  • 对于单纯的外侧损伤，保持前臂旋前（可拉紧外侧结构并使桡骨头-肱骨小头关节复位）。如果内外侧柱均进行了修复，则保持前臂中立位；仅在肘关节屈曲至约 90° 时才允许旋后。
  • 避免内翻应力和肩关节外展： 重力会对侧方修复处施加内翻负荷。进行主动关节活动度训练时，手臂应置于身体前方，或采用仰卧过头位（重力减小位），若修复较为脆弱则采用后者。
  • 在约 16 周内禁止完全伸直伴旋后（这会重现 pivot-shift 现象）。
  • 8–16 周内禁止负重 / 闭链负荷训练。

第 0–2 周：早期活动。 使用简单吊带以提供舒适感。立即开始手指、腕关节和肩关节的主动关节活动度训练。从第 2–3 天开始，在舒适范围内进行肘关节主动和主动辅助关节活动度训练，前臂保持旋前位，手臂支撑于身体前方（若修复较为脆弱，则采用仰卧过头位，使重力压迫关节）。若已植入关节内稳定器，可早期进展至完全舒适范围内的伸直；该装置可保护复位效果；不使用外部支具。

第 2–6 周：恢复活动弧。 进展至完全舒适范围内的屈曲和伸直（全程以舒适为限进行伸直；若存在内稳定器，则允许此操作）。保持旋前倾向；避免内翻负荷。进展标准： 被动活动弧完全恢复，检查或 X 线片无再半脱位，疼痛评分 ≤3/10。

第 6–12 周：强化训练。 一旦临床和影像学显示愈合（约第 6 周），开始渐进性强化训练；若出现挛缩，则引入静态渐进性支具。继续避免内翻负荷。若使用了内稳定器，通常保留至韧带愈合。

第 12–20 周及以上：进阶 / 回归。 渐进性抗阻训练；恢复重体力劳动。接触性运动和过头运动大约在 6–9 个月时恢复（且在移除任何内稳定器之后）。继续避免内翻负荷下的强化训练。

轨迹B — 投掷（内侧）尺侧副韧带（UCL）修复/重建

这是一种慢性过载的内侧问题。Hirpara 博士的偏好是不使用外置铰链支具：缝合带内部支具增强（修复）或肌腱移植物（重建）提供保护，康复训练针对投掷动作。前臂偏向旋前/中立位；避免在约第6周前进行抗阻肩关节外旋，因为这会对移植物产生外翻负荷。

内部支具增强修复（加速方案，与无外置支具方案相匹配）：

  • 早期受控活动至舒适，第0–4周（约第6周时达到全范围活动）。
  • 从约第3周开始进行投掷者十步法（Thrower's Ten）训练；从约第6周开始进行增强式训练。
  • 从约第11周开始进行间隔投掷程序；约5–7个月重返运动。

重建（移植物）轨迹，如果使用（较慢）：

  • 约第6周达到全范围活动；第14–16周进行间隔投掷；从投手丘投掷不早于6个月；竞争性重返运动通常为9–16个月。

重返工作与活动

您重返工作的速度取决于您所受的损伤类型以及您工作或运动的需求。

  • 外侧损伤（恐怖三联征/外侧副韧带）： 可在安全体位内尽早恢复轻量的办公和自我护理任务。通常在术后约6周，当肘关节在临床和X线检查中显示已愈合后，开始进行力量训练。接触性运动和过头运动通常需推迟至约6–9个月，若植入了内部关节稳定器，则需在移除该稳定器之后进行。在您的外科医生许可之前，避免通过手臂承重或向侧面施加负荷。
  • 投掷损伤（尺侧副韧带）： 对于采用内部支带增强的修复术，结构化的分期投掷计划通常在术后约11周开始，重返运动的时间约为5–7个月。对于重建术，重返竞技性投掷的速度较慢，通常为9–16个月。

当您能够舒适、安全地将手臂从悬吊带中移出并控制它，且您的外科医生在复查时确认适宜后，即可恢复驾驶。您的治疗师将根据您的个人目标，逐步加强您的力量训练以及针对运动或工作的特定训练。

协议之后

本协议与诊所的一般康复建议并行；请参阅术后疼痛管理和伤口护理。您的持续康复由您的物理治疗师或手部治疗师根据您的肘部进展情况和所受伤势进行个体化指导。本协议的临床医生专用证据摘要与该页面一同保存。

Reviewed by Dr Kieran Hirpara · 18 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

Elbow Instability — Rehabilitation Evidence (Lateral / Terrible Triad / LCL and Throwing / UCL)

Topic scope: Post-operative rehabilitation after surgery for elbow instability, in two distinct tracks: (A) complex lateral instability — "terrible triad" / fracture-dislocation and lateral (ulnar) collateral ligament [LCL/LUCL] repair & reconstruction for posterolateral rotatory instability (PLRI); and (B) overhead-throwing ulnar (medial) collateral ligament [UCL] reconstruction & repair ("Tommy John").

Defining principle: the crux of every track is protected motion, not immobilisation. Restore enough stability to permit early range of motion (within ~1 week), because prolonged immobilisation is the dominant cause of disabling flexion contracture and stiffness. Dr Hirpara's stance: he does not use an external hinged brace. A repair that is stable through-range at surgery is managed with a simple sling for comfort plus early motion to comfort within positional precautions. Where stability needs protecting, he implants an internal joint stabiliser (an internal hinge) that holds the elbow reduced from the inside while permitting full flexion and extension to comfort — so the patient still moves early without an external arc-limiting brace. The device is typically removed once the ligaments have healed (~4–6 months). The published external-hinged-brace extension-block arcs below are retained as reference for what they represent biomechanically, not as Dr Hirpara's management.

(A) Terrible triad / complex fracture-dislocation / LCL (LUCL) repair & reconstruction

Forearm-rotation rule (the key precaution)

  • Lateral-sided (LCL/LUCL) injury → keep the forearm PRONATED. Pronation tightens the lateral structures and seats the radiocapitellar joint, protecting the lateral repair. Terminal extension is performed pronated; supination near full extension reproduces the pivot-shift and is avoided.
  • Medial-sided (MCL/UCL) injury → keep the forearm SUPINATED (Rockwood & Green; Green's Operative Hand Surgery).
  • If both columns are repaired (many terrible triads), the forearm is held neutral.
  • Early supination, when allowed, is done only with the elbow flexed to ~90° (flexion stabilises the ulnohumeral joint and protects the lateral reconstruction).

Phased timeline

  • Week 0–2 — Immediate post-op / early motion. Posterior splint at ~90° flexion in injury-appropriate forearm rotation for 7–14 days in the published protocols; the practical aim is early motion. Begin digit/wrist/shoulder AROM immediately and gentle elbow AROM/AAROM in the surgeon-defined stable arc within days (Brigham fracture-dislocation guideline starts elbow/forearm AROM at day 2–3). A supine/overhead protocol is an option where the lateral repair is tenuous — gravity compresses and stabilises the ulnohumeral joint (Green's; Lee 2013).
  • Week 2–6 — Protected motion / restore the arc. Published external-hinged-brace protocols open an extension block ~10°/week, forearm pronated (Denver/Eichinger: 30° at wk2 → 20° wk3 → 10° wk4 → 0° wk5), reaching full extension by ~week 5–6. Dr Hirpara replaces this external brace with a simple sling (through-range stable repair) or an internal joint stabiliser permitting extension to comfort. Precautions: avoid varus stress and shoulder abduction; avoid combined full-extension-with-supination for up to ~16 weeks; no weight-bearing/closed-chain for 8–16 weeks.
  • Week 6–12 — Intermediate / strengthening. Full PROM, joint mobilisations. Strengthening starts ~week 6 once clinical and radiographic healing is confirmed (Brigham PRE 6–8 wk; Rockwood & Green). Static-progressive splinting if a contracture is developing (Müller 2013).
  • Week 12–20+ — Advanced / return. Progressive resistance; avoid varus-loaded strengthening. Contact/overhead sport often delayed to ~6–9 months for reconstruction (Green's: unrestricted use ≥6 months for graft incorporation; Eichinger: up to 9 months).

Nonoperative (stable terrible triad) caveat: if the joint is concentrically reduced with a stable arc to ≥30° of extension (no radial-head block, small coronoid), nonoperative early-motion management is reasonable (Rockwood & Green / Chan criteria; Najd Mazhar 2017).

(B) UCL reconstruction / repair — throwing athlete ("Tommy John")

Rehabilitation is uniformly described in 4 phases (Brotzman-Wilk lineage; ASMI/Andrews; Mass General). The forearm is biased toward supination/neutral (medial-sided injury); no shoulder external-rotation loading early (it valgus-loads the graft).

  • Phase I — Week 0–3. Posterior splint at 90° week 1, then progressive ROM. Wrist AROM, gripping, submax shoulder isometrics (no ER), submax biceps isometrics from week 1–2.
  • Phase II — Week 4–6/8. Progress to full ROM by ~week 6. Light wrist/forearm strengthening, rotator-cuff isotonics; resisted shoulder ER avoided until ~week 6 to protect the graft.
  • Phase III — Week 6/9–12/13. Progressive elbow/forearm strengthening, eccentrics from ~wk9, Thrower's Ten, plyometrics ~wk9 if appropriate.
  • Phase IV — Week 14–26+. Interval throwing program ~week 14–16; long-toss ramp 45→60 ft, +30 ft increments to 180 ft; mound throwing ≥6 months; return to competitive throwing ~6 months for return-to-throw, but full competitive RTS typically 9–16 months (≥12 months a common criterion). ~83–97% RTS in throwers.

Internal-brace–augmented UCL REPAIR (accelerated track) — the recent shift

For acute/avulsion tears with good tissue, UCL repair with internal brace allows a markedly accelerated protocol (Dugas/ASMI; SLU/JOSPT 2019):

  • Mobilise early to comfort; full/unrestricted ROM by ~wk4, brace off by wk6.
  • Thrower's Ten from ~wk3; plyometrics from ~wk6.
  • Interval throwing as early as ~wk11; return to sport ~5–7 months (vs ≥9–12+ for reconstruction). Dugas 2025 (AJSM) head-to-head: repair ~2–3 weeks accelerated for ROM/strengthening and ~5–9 weeks accelerated for starting the interval throwing program, with comparable outcomes in appropriately selected athletes.

Phased-timeline summary

Phase / window Track A — lateral (terrible triad / LCL) Track B — throwing (UCL, internal-brace repair)
Weeks 0–2 Sling for comfort; elbow AROM/AAROM to comfort from day 2–3, forearm pronated, arm supported in front / supine-overhead Early protected motion to comfort; submax shoulder (no ER) + biceps isometrics; grip/wrist work
Weeks 2–6 Restore full comfortable arc; extension to comfort (internal stabiliser permits); maintain pronation, avoid varus Progress to full arc by ~wk6; Thrower's Ten from ~wk3
Weeks 6–12 Strengthening once healed (~wk6); static-progressive splint if contracture Plyometrics from ~wk6; progressive strengthening
Weeks 12–20+ Progressive resistance; contact/overhead sport ~6–9 mo Interval throwing ~wk11; RTS ~5–7 mo (reconstruction: 9–16 mo)

Key controversies

  1. Early vs protected motion (complex instability). Strong consensus favours early motion (≤7 days), BUT the two 2024 systematic reviews (Ahmed Kamel, JSES; Larwa, Shoulder & Elbow) found no RCT and high heterogeneity (immobilisation 1–76 days, weighted mean ~42–47). "Early" is biomechanically favoured, not Level-I proven; over-aggressive motion risks re-subluxation in a marginally stable repair.
  2. Brace necessity & utility. A hinged orthosis is the published standard, but Manocha/King (JHS 2018) showed it adds little stability with the arm overhead (gravity already compresses the joint), supporting overhead/supine rehab over brace reliance for lateral injuries (Lee 2013). This underpins Dr Hirpara's no-external-brace approach.
  3. Forearm-rotation dogma. Pronation-for-lateral / supination-for-medial is biomechanically grounded and widely taught, but Selley 2025 found forearm rotation at graft tensioning did not change postoperative medial gapping — questioning how rigidly rotation must be controlled in UCL cases.
  4. Accelerated vs conservative UCL return-to-throw. Time-to-RTS varies 4–16 months with no consensus threshold; Erickson 2017 found earlier RTS did not raise revision risk in MLB pitchers, undercutting strict "wait ≥12 months" dogma.
  5. Internal brace enabling faster rehab. The biggest recent shift: suture-tape/internal-brace augmentation gives superior time-zero biomechanics and supports repair (not reconstruction) in selected throwers with a 5–9-week-faster throwing timeline. Durability in elite pitchers and mid-substance tears is still maturing (Level III–IV).

Evidence strength flags

  • (A) Complex instability / LCL: LOW–MODERATE. No RCTs; guidance is biomechanical + expert-consensus + Level III/IV case series and two 2024 systematic reviews. Internal-joint-stabiliser data (Orbay/Mighell lineage; Dunning/Morrey biomechanics) are device-specific case series — Consensus / Moderate.
  • (B) UCL throwing: MODERATE. Large case series, multiple systematic reviews, and concordant institution-standard protocols (Brigham/Brotzman-Wilk, Mass General, ASMI/Andrews) for the phased arc and interval-throwing timeline. Internal-brace augmentation is newer (Level III–IV, growing).
  • Rehabilitation protocols themselves: CONSENSUS / WEAK — phase timings derive from published institutional protocols, not rehab RCTs.

Citations

RAG corpus (180,000+ Orthopaedic articles)

  • Szekeres M, Chinchalkar SJ, King GJ. Optimizing Elbow Rehabilitation After Instability. Hand Clin. 2008.
  • Wilk KE, Arrigo CA. Rehabilitation of Elbow Injuries. Clin Sports Med. 2020.
  • Ahmed Kamel S, Shepherd J, Al-Shahwani A, et al. Postoperative mobilization after terrible triad injury: systematic review and single-arm meta-analysis. J Shoulder Elbow Surg. 2024;33(3):e116–e125.
  • Larwa J, Buchanan TR, Janke RL, et al. Characteristics of rehabilitation protocols following operative treatment of terrible triad elbow injuries and the influence of early motion: systematic review and meta-analysis. Shoulder Elbow. 2024.
  • Najd Mazhar F, Jafari D, Mirzaei A. Evaluation of functional outcome after nonsurgical management of terrible triad injuries of the elbow. J Shoulder Elbow Surg. 2017;26(8):1342–1347.
  • Manocha RH, King GJ, Johnson JA. In Vitro Kinematic Assessment of a Hinged Elbow Orthosis Following Lateral Collateral Ligament Injury. J Hand Surg Am. 2018.
  • Lee AT, Schrumpf MA, Choi D, et al. The influence of gravity on the unstable elbow. J Shoulder Elbow Surg. 2013;22(1).
  • Dunning CE, et al. (Morrey lineage). Ligamentous Repair and Reconstruction for Posterolateral Rotatory Instability of the Elbow. 2006. (LCL/LUCL stabiliser biomechanics.)
  • Müller AM, Sadoghi P, Lucas R, et al. Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: systematic review/meta-analysis of 13 studies. J Shoulder Elbow Surg. 2013. (Static-progressive stretch for stiffness.)
  • Selley RS, Lawton CD, Owusu-Akyaw K, et al. Forearm Rotation at the Time of Elbow UCL Reconstruction Graft Tensioning Does Not Affect Postoperative Medial Elbow Joint Gapping. Orthop J Sports Med. 2025.
  • Erickson BJ, Cvetanovich GL, Frank RM, et al. Do Clinical Results and RTS Rates After UCL Reconstruction Differ Based on Graft Choice and Surgical Technique? Orthop J Sports Med. 2016.
  • Erickson BJ, Chalmers PN, Bach BR, et al. Length of time between surgery and RTS after UCL reconstruction in MLB pitchers does not predict need for revision. J Shoulder Elbow Surg. 2017.
  • Kemler BR, Rao S, Willier DP, et al. Rehabilitation and Return to Sport Criteria Following UCL Reconstruction: A Systematic Review. Am J Sports Med. 2021.
  • Griffith R, Bolia IK, Fretes N, et al. RTS Criteria After Upper Extremity Surgery, Part 2: UCL of the Elbow. Orthop J Sports Med. 2021.
  • Dugas JR, Froom RJ, Mussell EA, et al. Clinical Outcomes of UCL Repair With Internal Brace Versus UCL Reconstruction in Competitive Athletes. Am J Sports Med. 2025.
  • Dugas JR, Looze CA, Capogna B, et al. UCL Repair With Collagen-Dipped FiberTape Augmentation in Overhead-Throwing Athletes. Am J Sports Med. 2019;47(5).
  • Jackson GR, Opara O, Tuthill T, et al. Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes. Arthroscopy. 2023.
  • Cain EL, Dugas JR, Wolf RS, et al. Elbow Injuries in Throwing Athletes: A Current Concepts Review. Am J Sports Med. 2003.
  • Erickson BJ, Bach BR, Verma NN, et al. Treatment of Ulnar Collateral Ligament Tears of the Elbow. Orthop J Sports Med. 2017.
  • Rockwood and Green's Fractures in Adults. 2019. — long-arm splint 7–10 d; lateral injury → forearm pronated, medial → supinated; avoid shoulder abduction/varus for lateral injury; strengthening ~6 wk.
  • Green's Operative Hand Surgery. 2021. — supination only with elbow maximally flexed; overhead/supine protocol option; isometric strengthening 8–10 wk; unrestricted use ≥6 mo.

Published protocols (literature URLs)

  • Brigham & Women's Hospital — Elbow Fracture/Dislocation Post-Op ORIF Hand Therapy Guideline (2021). https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/elbow-fracture-orif-hand-therapy-protocol.pdf
  • Brigham & Women's Hospital — UCL of the Elbow Reconstruction Using Autogenous Graft Protocol (Brotzman-Wilk modification). https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/elbow-ulnar-collateral-ligament-reconstruction-protocol-bwh.pdf
  • Massachusetts General Hospital Sports Medicine — Rehabilitation Protocol for UCL Reconstruction (rev. Nov 2018). https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-UCL.pdf
  • Saint Louis University Sports Medicine / JOSPT 2019 — Rehabilitation s/p UCL Repair with Internal Brace. https://www.slu.edu/medicine/orthopaedic-surgery/sports-medicine/-pdf/ucl-repair-guidelines-final.pdf
  • Eichinger MD — Rehabilitation Guidelines for Elbow Lateral Collateral Ligament Repair (2018). https://www.josefeichingermd.com/pdf/rehab-for-lateral-collateral-ligament-repair-3-4-18.pdf
  • Denver Shoulder — Rehabilitation Protocol: Lateral Collateral Ligament Repair (extension block 30°→20°→10°→0° wk2–5, forearm pronated; supination only at 90° flexion). https://www.denvershouldersurgeon.com/pdf/lcl-repair-protocol.pdf
  • Orthopaedic Medical Group of Tampa Bay — Elbow Dislocation Rehab Protocol. https://www.omgtb.com/wp-content/uploads/pdfs/elbow-dislocation-rehab.pdf

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