REHAB TO REPLAY IN UPPER LIMB INJURY: EVERYTHING YOU NEED TO KNOW Introduction- Plyometric Training in Rehabilitation: Plyometric training for the upper body plays a crucial role during the rehabilitation phase of upper limb injuries, especially for athletes returning to high-performance levels. However, it’s important to understand that plyometric exercises cannot be introduced at the very beginning of rehab. Certain prerequisites must be achieved before progressing to this advanced stage, which comes under rehabilitation. 1. Why Plyometric Prerequisites Matter Plyometric exercises involve high-velocity, explosive movements that demand excellent strength, stability, and control. Introducing them too early can overload healing tissues and slow recovery.Pain ≤ 1/10 at restPain < 2/10 during ADLs≥ 90% ROM of the shoulder, elbow, and wrist≥ 80% Limb Symmetry Index (LSI) in strengthNo apprehension or instabilityGood scapular rhythmOnly when these foundations are met should plyometrics be included in the program. We should complete the initial phases of rehabilitation and achieve limb symmetry before introducing the plyometrics. Unlocking the Power of Upper-Body Plyometric Training When a patient with a shoulder injury walks into the clinic, the questions that often arise are: Will I be able to return to sport?How will I return to sports? and When will I be ready to play again? The journey back may seem uncertain at first, but the answers unfold as you read through this blog. The Missing Link in Return to Sport - “Plyometrics”. Let’s decode it step by step! 2. How Long Until Plyometrics After Injury? The honest answer is it usually takes 5 to 6 months (depending on the sport and the individual). But more important than the time is the step-by-step journey your body must go through to be truly sport-ready. Let’s look into the standardised protocol required to begin plyometrics for common upper limb injuries (however, it differs according to individual and sport). Rotator Cuff Repair Immobilisation: 3–4 weeks (sometimes longer depending on the tear).Strengthening: 6–12 weeks.Plyometrics: Begin around 12 weeks in the advanced phase if pain-free ROM and good strength. In case of non-surgical/conservative rehab, plyometrics can be started around 8-10 weeks if pain-free ROM and LSI above 80%.Return to sport: 4–6 months (longer in overhead throwers, 6–9 months). Slap Tear Repair Sling: 4–6 weeks.Strengthening: 6 weeks.Sport-specific / throwing: 12–16 weeks.Plyometrics: Typically introduced after 12 weeks when the throwing program begins, once rotator cuff and scapular strength are balanced. In case of non-surgical/conservative rehab, plyometrics can be started around 8-10 weeks.Return to sport: 6 months (overhead athletes often slower) UCL Tear UCL Tear (elbow, but relevant for throwing athletes)Early bracing recommendedStrengthening: 4–7 weeks.Plyometrics: Introduced in advanced strengthening phase (8–14 weeks) – chest pass, side throws, wall dribbles.Return-to-throwing: 16 weeks. Shoulder Instability(Anterior/Posterior) Return to competition: 9–12 months (sometimes longer in elite pitchers).Shoulder Instability (Anterior/Posterior)Sling: 2–6 weeks (varies).Strengthening: 6–12 weeks.Plyometrics: Usually initiated in the advanced strengthening phase (8–12 weeks) if full ROM and stability are present, apprehension test -negativeReturn to sport: 6–8 months. Upper Limb Fracture 0 to 4 weeks immobilisation3 to 6 weeks achieve near full ROM6 to 12 weeks of full ROM and strengtheningPlyometric: Introducing around after 12 weeksReturn to sports: 6 – 8 months 3. Setting the Right Intensity & Volume for Plyometrics ParametersRecommended CriteriaFrequency of training sessions1–2 days per week (depending on the level of sport and the individual)Intensity of exerciseStart with low intensity and progress according to individual thresholdDuration of session20–30 minutesReps≤ 6 (depending on the level of sport and the individual)Sets2–3 setsRest period2–5 minutes (depending on exercise intensity)A well-designed exercise plan strikes the right blend of training load and intensity, helping you improve steadily without burning out.Training once or twice per week is enough for most people to see benefits, while recreational athletes should include at least one intentional, well-planned session to boost their game.Tailor workout intensity to the individual and progress it gradually as their capacity grows. Aim for 20–30 minutes per session, with the focus on movement quality rather than volume.Volume of the plyometrics is determined according to the intensity of the exercise; for example, wall push-ups can be done for 12-15 reps as the intensity is low compared to clap push-ups, where repetitions will be fewer. (according to individual capacity) 4. Phases of Upper-Limb Plyometric Training CategoryPHASE 1: BEGINNER(1 Month)PHASE 2: INTERMITTENT(2–3 Months)PHASE 3: ADVANCE(Above 3 Months)1. Reactive Training(Ball Dribble)Limited range of motion (short-arc exercises) using table support:• Supine lying 90–90• Side lying 90–90• Standing 90–90 on wallFull range of motion (full-arc exercises):• Arm off side of table• Prone lying 90–90• Supine lying 90–90• Prone overhead Y, T• Swiss ball dribbles on wall (90–90 & overhead)2. Closed Kinematic Chain(Weight Bearing)• Wall push-up• Kneeling push-up• Clap wall push-up• Clap push-up in quadruped position• Unilateral wall push-up• Eccentric drop push-up• Unilateral push-up in quadruped position• Clap push-up (full position)• Depth push-up• One-arm push-up3. Rate of Force Development• Medicine ball throw• Two-hand chest pass (standing, kneeling, long sitting)• Two-hand overhead soccer throw• Two-hand rotations (side, overhead, underhand)• Medicine ball throw• One-handed chest pass• One-handed overhead throw• One-handed sidearm throw• Rotational throw• One-arm eccentric deceleration follow-through• Two-hand overhead step & throw•Compound explosive movements• Landmine press• Push press• Dumbbell / kettlebell snatch• Clean & jerk• Explosive pull-ups (retro-plyos)•Eccentric–concentric “flip drills”• Power dropAll these Movements can be progressed or regressed using these factorsHeight - RangeWeight – loadAngles – positionMovement Velocity – tempo 5. Interval throwing program: The Interval Throwing Program (ITP) helps athletes slowly regain arm motion, strength, and confidence after an injury or surgery. It increases throwing distance step by step to ensure a safe and controlled recovery.Each step in the ITP should be done without pain before moving to the next. This establishes a criterion-based progression. Progress depends on how well the athlete performs, rather than on a fixed timeline.However, progression varies from athlete to athlete, depending on factors such as injury severity, healing response, and individual ability level. There is no specific timeframe to complete the program, emphasising quality of movement over speed of progression. Program Design: Interval Throwing Program45 FeetStep 1Warm-up throwing → 45 ft (25 throws) → Rest 3–5 min → Warm-up throwing → 45 ft (25 throws)Step 2Warm-up throwing → 45 ft (25 throws) → Rest 3–5 min → 45 ft (25 throws) → Rest 3–5 min → 45 ft (25 throws)60 FeetStep 3Warm-up throwing → 60 ft (25 throws) → Rest 3–5 min → 60 ft (25 throws)Step 4Warm-up throwing → 60 ft (25 throws) → Rest 3–5 min → 60 ft (25 throws) → Rest 3–5 min → 60 ft (25 throws)60 & 75 FeetStep 5Warm-up throwing → 60 ft (25 throws) → Rest 3–5 min → 75 ft (25 throws)Step 6Warm-up throwing → 60 ft (25 throws) → Rest 3–5 min → 75 ft (25 throws) → Rest 3–5 min → 75 ft (25 throws)Step 7Warm-up → 60 ft (10 throws) → 75 ft (15–20 throws) → Rest 3–5 min → 60 ft (10 throws) → 75 ft (15–20 throws)Step 8Warm-up → 60 ft (10 throws) → 75 ft (18 throws) → Rest 3–5 min → 60 ft (10 throws) → 75 ft (18 throws)75 & 90 FeetStep 960 ft (10) → 75 ft (if needed) → 90 ft (10) → 120 ft (15) → Rest 3–5 min → 90 ft (10) → 75 ft (if needed) → 60 ft (10)Step 1060 ft (15) → 75 ft (10) → 90 ft (10) → 120 ft (10) → Rest 3–5 min → 120 ft (10–15) → Pitching mechanics (20–30 throws)Step 1160–90 ft (10–15 throws) → Pitching mechanics (20–30 throws) → Rest 3–5 min → RepeatThrowing Off the Mound (Fastballs Only)Stage 1:Step 1 → 15 throws (50%)Step 2 → 30 throws (50%)Step 3 → 45 throws (50%)Step 4 → 60 throws (50%)Stage 2:Step 5 → 30 throws (50%) + 15 throws (75%)Step 6 → 45 throws (50%) + 15 throws (75%)Step 7 → 60 throws (50%) + 30 throws (75%)Stage 3:Step 8 → 65 throws (50%) + 15 throws (75%)Step 9 → 60 throws (75%) + 15 throws batting practiceStep 10 → 50–60 throws (75%) + 30 throws batting practiceSports where this program is commonly used: Baseball, Softball, Volleyball, Tennis, Badminton, Lacrosse, Handball, Cricket. The ball used in ITP, according to the individual sports, is neither heavier nor lighter.Example: a baseball pitcher uses a baseball. The key variables manipulated are distance, volume (number of throws), frequency, intensity (effort %) and mechanics — not necessarily altering ball weight. 6. Return to sport criteria: The 3P Model 3 P Program: Practice, participation and Performance. Return to Practice The athlete begins practice and training after the injury.Focus on mimicking sport-specific movements (e.g., cricket bowling practice, badminton practice).No competitive play yet — controlled, progressive exposure. Return to Participation The athlete starts joining team activities such as friendly matches or low-stakes games.The aim is to test coping, tolerance, and functional ability in real-game situations.Still under careful monitoring for pain, performance, or re-injury signs. Return to Performance Athlete progresses to full competitive play. Restores abilities to previous standards (or close to them). Focus shifts from safety to effectiveness, consistency, and competition success. S. No Return to Practice Criteria Return to Participation Criteria Return to Performance Criteria 1 Appropriate time from injury or surgery for healing Western Ontario Shoulder Index (WOSI) Shoulder Score ≥ 90 Western Ontario Shoulder Index (WOSI) Shoulder Score ≥ 95 2 Successful completion of a formal rehabilitation program Ball Drop Test: ≥ 90% involved to uninvolved Ball Drop Test: 100% involved to uninvolved 3 Full sport-specific, non-painful range of motion Push-up Test: Ability to perform more repetitions in the second testing bout Push-up Test: Ability to perform more repetitions in the second testing bout 4 Excellent stability with no pain during special tests (e.g., apprehension test) Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) ≥ 21 repetitions Closed Kinetic Chain Upper Extremity Stability Test ≥ 25 repetitions 5 Strength meets sport-specific participation criteria with satisfactory functional test scores Bench Press ≥ 75% of pre-injury 1 repetition maximum (1RM) without substitution Bench Press ≥ 95% of pre-injury 1 repetition maximum (1RM) without substitution 6 Sport-specific testing Unilateral Pulling Assessment ≥ 95% limb symmetry index Unilateral Pulling Assessment ≥ 100% limb symmetry index 7 No kinesiophobia (assessed using Tampa Kinesiophobia Index) Unilateral Pushing Assessment ≥ 95% limb symmetry index Unilateral Pushing Assessment ≥ 100% limb symmetry index Conclusion Returning to sport after an upper-limb injury is not about rushing through pain or simply regaining basic movement. It is a stepwise, criterion-driven process that ensures the athlete regains:MobilityStrengthControlPowerHigh-speed reactivitySport-specific endurancePlyometrics are the often-missed link that prepares athletes for real-game demands—unpredictable forces, rapid accelerations, and explosive actions.By progressing through the 3P model and integrating plyometrics at the right time, athletes return to sport safer, stronger, and more resilient than before.With structured progression and patience, they don’t just return to play— they return ready to perform. References Schwank A, Blazey P, Asker M, Møller M, Hägglund M, Gard S, Skazalski C, Haugsbø Andersson S, Horsley I, Whiteley R, Cools AM, Bizzini M, Ardern CL. 2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels. J Orthop Sports Phys Ther. 2022 Jan;52(1):11-28. doi: 10.2519/jospt.2022.10952. PMID: 34972489. Wang, Jian, and Qi Xu. “Single-session upper limb plyometric training is as effective as two sessions for improving muscle strength, power, and serve velocity in male youth tennis players: a randomised parallel controlled study.” Frontiers in psychology vol. 16, 1539739. 27 Jan. 2025, doi:10.3389/fpsyg.2025.1539739 Garcia-Carrillo, Exal et al. “Effects of Upper-Body Plyometric Training on Physical Fitness in Healthy Youth and Young Adult Participants: A Systematic Review with Meta-Analysis.” Sports medicine - open vol. 9,1 93. 13 Oct. 2023, doi:10.1186/s40798-023-00631-2 Stien, Nicolay et al. “Upper body rate of force development and maximal strength discriminates performance levels in sport climbing.” PloS one vol. 16,3 e0249353. 26 Mar. 2021, doi:10.1371/journal.pone.0249353 Memon, Muzammil et al. “Return to sport following arthroscopic Bankart repair: a systematic review.” Journal of shoulder and elbow surgery vol. 27,7 (2018): 1342-1347. doi:10.1016/j.jse.2018.02.044 Davies, George J., Bryan L. Riemann, and Robert Manske. "Current Concepts of Plyometric Exercise." The International Journal of Sports Physical Therapy 10.6 (2015): 760–786 Oak, Sameer R., et al. "Rehabilitation and Return to Play of the Athlete after an Upper Extremity Injury." Arthroscopy, Sports Medicine, and Rehabilitation, vol. 4, no. 1, 2022, pp. e163–e173. Elsevier, doi:10.1016/j.asmr.2021.09.033 Longo, Umile Giuseppe, et al. "Conservative versus Accelerated Rehabilitation after Rotator Cuff Repair: A Systematic Review and Meta-Analysis." BMC Musculoskeletal Disorders, vol. 22, no. 1, 2021, p. 637. Springer Nature, doi:10.1186/s12891-021-04397-0