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Finger injuries involving the proximal interphalangeal (PIP) joint are common, particularly among athletes. Injury severity is often underappreciated at initial presentation and may be dismissed broadly as a "jammed finger" injury. Delayed diagnosis and treatment of certain injuries can have an important impact on the patient's chance of regaining full function. Central slip and PIP volar plate injuries are frequently encountered injuries that, if left untreated, can lead to the permanent loss of function of the proximal interphalangeal joint. Despite the differing mechanisms of these 2 pathologies, volar plate hyperextension injuries often present with a PIP joint flexion contracture and mild distal interphalangeal joint hyperextension deformity. This is similar to a boutonniere deformity seen after an injury to the central slip, and thus, has been referred to as a "pseudo-boutonnière" deformity. Distinguishing these 2 diagnoses is important, as treatment differs, and highlights the importance of thoroughly understanding the anatomy and relevant clinical applications when evaluating PIP joint injuries.

Shoulder pain due to labral tears and biceps tendonitis is commonly found in softball players. Surgical options include labral repair and biceps tenodesis. While past studies are limited by heterogeneous study groups from multiple sports, this is the first study that assesses clinical outcomes and return to play rates for fast-pitch softball players./Hypothesis: The purpose of this study was to evaluate the clinical outcomes and return to play for fast-pitch softball players treated for a SLAP tear and recalcitrant biceps tendonitis with a biceps tenodesis compared with a traditional SLAP repair. We hypothesized that the biceps tenodesis would have comparable outcomes with a faster return to play compared to SLAP repair.We performed a retrospective analysis on fast-pitch softball players treated surgically for SLAP tear, recalcitrant biceps tendonitis or a combination between 2001 and 2019 at our institution. Inclusion criteria were fast-pitch softball players who underwent biceps tenodesis or a SLAP repair with greater than 2-year follow-up. Exclusion criteria involved slow-pitch softball players, patients with less than 2-year follow-up and patients who had undergone concomitant procedures on the ipsilateral shoulder at the time of SLAP repair or biceps tenodesis. Follow-up was either self-reported through OBERD, a PRO-managing software, or achieved over the phone. Follow-up data included: American Shoulder and Elbow Surgeons Shoulder Score (ASES-S), Andrews Carson Score, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), Numeric Rating Scale for Pain (NRS), and our institution-specific return-to-play questionnaire. We statistically compared players who underwent biceps tenodesis or a SLAP repair, and compared pitchers with position players using Student t-tests and Fisher Exact Test with statistical significance determined to be p0.05.From 60 eligible patients identified, follow-up outcome data were successfully captured for 47 (78%). Of the 18 SLAP repair patients, 17 (94%) returned to full competition at an average of 7.9 months. Of the 29 patients who underwent biceps tenodesis, 27 (93%) returned to full competition at an average of 7.1 months. Statistical analysis of PRO scores for each group found no significant differences between any of the measures used to evaluate patient outcomes, including no statistical difference in pitchers compared with position players.In conclusion, this study demonstrated comparable outcomes between SLAP repairs and biceps tenodesis procedures among our study group of fast-pitch softball players. There was no significant difference between RTP times between the two groups.Level III; Retrospective Cohort Comparison; Treatment Study.

Objectives To determine whether increasing pitching distance for adult baseball pitchers would affect their upper extremity kinetics, full-body kinematics, and pitched ball kinematics (ball velocity, duration of ball flight, vertical and horizontal break, strike percentage). Design Controlled laboratory study. Methods Twenty-six collegiate baseball pitchers threw sets of five full-effort fastballs from three different pitching distances (18.44 m, 19.05 m, 19.41 m) in a randomized order. Ball velocity, horizontal and vertical break, duration of ball flight, and strike percentage were computed by a ball tracking system, while pitching kinetics and kinematics were calculated with a 12-camera optical motion capture system. Repeated measures analysis of variance was utilized to detect significant differences among the three different pitching distances (p Results No significant differences in pitching kinetics and kinematics were observed among the varying pitching distances. Ball velocity and strike percentage were also not significantly different among the pitching distances, however, the duration of ball flight and horizontal and vertical break significantly increased with pitching distance. Conclusions Increasing pitching distance may not alter upper extremity kinetics, full-body kinematics, ball velocity or strike percentage in adult pitchers. However, as pitching distance increases the duration of ball flight and amount of horizontal and vertical break also increase. Increased ball flight duration could be an advantage for the hitter while increased ball break could help the pitcher. In conclusion, it is unlikely that moving the mound backwards would significantly affect pitching biomechanics and injury risk; however, the effects on pitching and hitting performance are unknown.

It is unclear how a glenohumeral internal rotation (IR) loss (GIRLoss), a glenohumeral external rotation (ER) gain (GERGain), or a total rotational motion (TRM) deficit (TRMD) predict medial ulnar collateral ligament (MUCL) injury risk among high school (HS), college (COLL), and professional (PRO) baseball pitchers with and without MUCL injury. We hypothesized that pitchers with MUCL injury would have more GIRLoss and TRMD compared with pitchers without MUCL injury, with no differences in IR, ER, TRM, GIRLoss, GERGain, and TRMD.The study equally divided 216 male HS, COLL, and PRO pitchers into the MUCL injury group (n = 108) and a control group (n = 108) without MUCL injury. The control group was matched with the MUCL injury group according to number, level of play, and age. Bilateral shoulder passive IR/ER was measured and GIRLoss, GERGain, TRM, and TRMD calculated. A 2-way analysis of variance (P .05) was used to assess shoulder rotational differences among the 2 groups and 3 pitching levels.Compared with the control group, the MUCL injured group had more GIRLoss (21° ± 14° vs. 13° ± 8°; P .001), GERGain (14° ± 9° vs. 10° ± 9°; P = .004), and TRMD (7° ± 13° vs. 3° ± 9°; P = .008). For all pitching levels, approximately 60% of pitchers in MUCL injury group had GIRLoss18° compared with approximately 30% of those in the control group. Approximately 60% of pitchers in the MUCL injury group had TRMD5° compared with 50% of pitchers in the control group. No differences were observed among HS, COLL, and PRO pitchers for GIRLoss (16° ± 12°, 17° ± 11°, 19° ± 13°, respectively; P = .131), GERGain (11° ± 9°, 11° ± 10°, 13° ± 10°, respectively; P = .171), TRMD (5° ± 11°, 6° ± 11°, 5° ± 14°, respectively; P = .711), and throwing shoulder ER (111° ± 10°, 111° ± 11°, 113° ± 9°, respectively; P = .427), IR (50° ± 11°, 49° ± 11°, 48° ± 10°, respectively; P = .121), and TRM (162° ± 14°, 160° ± 15°, 161° ± 14°, respectively; P = .770).Greater GIRLoss, GERGain, and TRMD in MUCL injured pitchers compared with uninjured pitchers implies these variables may be related to increased MUCL injury risk, especially because GIRLoss18° and TRMD5° demonstrate an increased MUCL injury risk. Shoulder rotational motion and deficits do not vary among HS, COLL, and PRO levels of pitchers.

Elbow injuries in overhead athletes, particularly ulnar collateral ligament (UCL) injuries to baseball pitchers, continue to increase in number. The reasons for these injuries are multifactorial but typically result from a combination of severe and repetitive valgus elbow stress from pitching large volumes and throwing at peak velocities. These factors and the severity of medial elbow injuries to the UCL complex make it critical to employ a proper criteria-based rehabilitation program in combination with a well-structured set of return-to-play criteria. Together, the rehabilitation process and return-to-play program provide a set of guidelines that help ensure a safe and effective process to aid in returning a throwing athlete back to unrestricted competition as efficiently as possible. This article provides the reader with a 4-phased, criteria-based rehabilitation program for the athlete following UCL reconstruction and a structured set of return-to-play guidelines. The return-to-play progression is a 3-step process that assists in advancing an athlete back to unrestricted competition via a performance, practice, and play sequence. This program uses specific criteria and activities to progress a throwing athlete from high-level performance training, to controlled practice participation and then finally back to play. The program uses not only specific steps but also a combination of testing parameters both subjective and objective to guide the return through the entire rehabilitation process from UCL reconstruction surgery back to unrestricted symptom-free throwing.

Barriers to EMS care can result in suboptimal outcomes and preventable morbidity and mortality. Large EMS databases such as the National Emergency Medical Services Information System (NEMSIS) dataset provide valuable data on the relative incidence of such barriers to care.A retrospective cross-sectional analysis was performed using the NEMSIS database. Cases of violent trauma were collected based on gender and racial group. Each group was analyzed for the ratio of cases that involved an EMS barrier to care. Chi-square testing was used to assess associations, and the relative risk was used as the measure of strength of association. For all tests, statistical significance was set at the 0.05 level.719,812 cases of violent trauma were analyzed using the NEMSIS dataset. EMS encountered barriers to care for white and non-white patients was found to be 4.9% and 4.0% respectively. The difference between groups was found to be 0.9% (95% CI [0.7%, 1.1%] p 0.0001). RR was 1.23 for white patients (95% CI [1.19, 1.26]), and 0.82 (95% CI [0.79, 0.84]) for non-white. EMS barriers to care for male and female patients was found to be 6.03% and 3.34%, respectively. The difference between groups was found to be 2.7% (95% CI [2.6%, 2.8%] p 0.0001). RR for male patients was 1.80 (95% Cl [1.76, 1.84]) while RR for female patients was 0.55 (95% CI [0.54, 0.57]).Racially white patients and male patients have a statistically significant higher risk of encountering an EMS barrier to care in cases of violent trauma.

Partial rotator cuff tears in the throwing athlete is a complex problem that can lead to debilitating pain and inability to perform their athletic duties. The etiology and pathogenesis of these tears are multi-factorial and still the topic of much debate. It is known that the act of overhead throwing places significant stress on the glenohumeral joint, requiring the rotator cuff to overcome these forces as it acts to stabilize the glenohumeral joint. Evaluation of an athlete with such pathology includes a thorough history and physical exam, followed by specific imaging modalities. Treatment options include both non-operative and operative. Non-operative measures include activity restriction, physical therapy, and the possibility of corticosteroid or biologic injection. Operative measures include arthroscopic debridement, in-situ repair, and completion of the partial tear followed repair. The purpose of this article is to review the topic of partial rotator cuff tears in throwing athletes and discuss the senior author's (JRA) guide to evaluation and management of these injuries.

Purpose To determine common mechanisms of anterior cruciate ligament (ACL) injury in baseball players and to quantify the rate of return to play after primary surgical reconstruction and review intermediate clinical outcomes. Methods Surgical injuries involving the ACL in youth, high school, collegiate, and professional baseball players were queried for an 11-year period (2001 to 2011). Over the study period, 42 baseball players were identified who had undergone arthroscopically assisted primary ACL reconstruction by 1 of 3 attending surgeons. Retrospective chart review was performed for all 42 patients to evaluate variables of age, level of competition, position, mechanism of injury, graft choice, and associated meniscal injuries. Twenty-six patients were reached for telephone survey and International Knee Documentation Committee questionnaire and they answered questions about their original injury and playing history. Results The most common mechanism of injury was fielding, followed by base running. Infielders and outfielders (32% each) were the most commonly injured position, followed by pitchers (29%). Among the 32 players for whom it could be determined, 30 (94%) were able to return to playing baseball at a mean follow-up of 4.2 years (range 1.0 to 9.9 years). The mean International Knee Documentation Committee score was 84.0 (range 63 to 91). Among the 26 patients contacted for telephone interview, no one required revision ACL surgery, but 3 required a subsequent procedure for meniscal tear. Twenty-five patients (96%) denied any episodes of instability in the knee after reconstruction. Conclusions The overwhelming majority of baseball players that sustain ACL injuries do so while fielding or base running. Outfielders are significantly more likely than infielders to suffer ACL injuries while fielding versus base running. The results with respect to return to play are promising, as nearly all patients were able to return to baseball and none required a revision ACL surgery at a mean follow-up of 4.2 years. Level of Evidence Level IV, therapeutic case series.

At the elite level, pitching has been reported as one of the fastest human movements, occurring at angular speeds of 7250°/s. The repetitive nature of overhead throwing can lead to numerous adaptations in the glenohumeral, scapulothoracic, and hip joints. Owing to these unique changes, a comprehensive and sequential rehabilitation program is dependent on a thorough clinical examination. The rehabilitation program should consist of an individualized plan of care that focuses on shoulder mobility, scapular posture and strength, dynamic stability and neuromuscular control of the shoulder complex, as well as core and lower extremity strength. In this article, the adaptations that commonly occur to the thrower׳s shoulder are described and strategies to address them are discussed. A sequential, multiphased rehabilitation program that addresses restoration of motion, strength, endurance, and power is outlined. It is essential to consider the kinetic chain and involvement of the core and lower extremities with throwing and that these regions should not be ignored in the evaluation and treatment of the thrower׳s shoulder. A 4-phase approach, with specific criteria that direct progression to the next phase, is discussed.

Latissimus dorsi (LD) and pectoralis major (PM) tendon injuries are uncommon injuries in overhead athletes. The unique anatomical and biomechanical characteristics predispose the LD and PM to injuries during overhead activity. Although each overhead sport has different mechanics and phases of overhead activity, many similarities affecting the LD and PM are seen in each sport. Although a thorough history of the athlete’s symptoms and overhead activity is paramount, a keen understanding of each sport’s overhead mechanics may help with establishing the right diagnosis. A physical examination is important to identify these injuries given their low incidence and need for appropriate imaging during the clinical workup. Standard shoulder magnetic resonance imaging techniques may not be sufficiently caudal to demonstrate LD or PM pathology. Operative management is usually recommended for LD and PM tendon tears in other athletes. However, overhead athletes represent a unique population who commonly sustain only partial tears where nonoperative management has demonstrated excellent results. However, in throwing athletes with complete tears and extensive retraction, LD and PM tears may require surgical repair. Rehabilitation should progress with caution to minimize reinjury, which is common in athletes returning too quickly. Although overuse is the most likely reason for LD and PM injuries in overhead athletes, proper mechanics are essential to help reduce the chance of injury.

The act of throwing places significant stresses on the rotator cuff resulting in rotator cuff injuries including rotator cuff strains, rotator cuff tendinosis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. Full-thickness rotator cuff tears are uncommon in the young throwing athlete. It appears that most full-thickness tears are chronic injuries secondary to repetitive tensile, compressive, and shear stresses to the rotator cuff during the throwing motion. Management of full-thickness rotator cuff tears in throwing athletes is challenging. History, physical examination, imaging studies, and an understanding of the athlete’s short-term and long-term goals are critical to developing a management plan for these athletes. If nonoperative treatment fails, we describe our technique for an arthroscopic rotator cuff repair using a transosseous-equivalent double-row or triple-row technique.

Elbow arthroscopy is a useful tool for managing diseases of the elbow, including valgus extension overload, when conservative treatments have failed. Arthroscopic access to the elbow in the supine-suspended position is simple and reproducible with the technique described in this report. Synovial tissue can be cleared, optimizing visualization of the anatomic structures in the elbow including the posterior ulnohumeral joint. This report describes, in detail, arthroscopy of the elbow in the supine-suspended position and basic principles for arthroscopic decompression of the posterior elbow for valgus extension overload.

Purpose To report a large number of highly active patients who underwent arthroscopic Bankart repair at our institution over the last decade. Methods A retrospective analysis of patients who underwent primary and revision arthroscopic Bankart repairs using bioabsorbable anchors was performed. Outcome measures included recurrence of dislocation, American Shoulder and Elbow Scores (ASES), Rowe, visual analog scale (VAS), return to sports, and satisfaction scores. Results A total of 94 shoulders met the inclusion criteria. The recurrence rate was 6/94 (6.4%) at a mean follow-up of 5 years (range, 3 to 8.3). The mean postoperative scores were as follows: ASES = 91.5/100; Rowe = 84.3/100; VAS = 0.8/10; satisfaction = 8.8/10. In those who attempted to return to sports, 82.5% were able to return to the same level of competition. Statistical analyses revealed a significant increase in risk of recurrence among high school and recreational athletes. No recurrences were observed among professional or college-level athletes. No significant difference in recurrence rates was observed in regards to age, time to surgery, type of athlete (collision v limited contact), repair of SLAP lesion, number of anchors, or revision surgery. Conclusions Although several repair techniques exist for traumatic anterior shoulder instability, arthroscopic repair remains a viable option even in a highly active patient population. This study uniquely identified high school and recreational athletes at higher risk for recurrence. This is perhaps due to inferior shoulder development and technique as well as to limited access to postoperative physical therapy. Level of Evidence Level IV, therapeutic case series.

Purpose To evaluate the accuracy of Blumensaat's line (BL) in predicting the tendinous graft length and tibial tunnel length (TTL) in an independent-tunnel anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) allograft. Methods Eighteen ACLRs were performed on cadaveric specimens using an anteromedial portal technique. All knees had no previous surgeries or deformities. Lateral knee radiographs of each specimen were taken prior to the ACLR, and BL was measured. Length-specific allografts for the tendinous portion of the grafts were then ordered by adding 20 mm to the length of BL. The TTL was predicted by subtracting BL and femoral tunnel length (FTL) from the overall graft length. Graft-tunnel mismatch (GTM) was recorded for each specimen. Statistical analysis compared overall results with the gold standard (0 mm) of GTM. Results The average lateral femoral condyle width measured in line with the femoral tunnel was 33 ± 3.43 mm. The average FTL was 25 ± 0.54 mm. The average intra-articular distance (IAD) between femoral and tibial tunnel apertures was 31 ± 3.65 mm. The average TTL was 35 ± 2.21 mm. The difference between the predicted TTL and the actual TTL was not statistically significant (P = .3). The mean GTM was −0.9 ± 3.15 mm. There was no statistically significant difference between the BL method and the gold standard (P = .45). The mean percent difference between BL and the IAD was 5.2%. Conclusions The BL method can accurately predict the desired length for the tendinous portion of a BTB allograft as well as the TTL, thereby potentially minimizing GTM during arthroscopic BTB allograft ACLR. Patient-specific allografts can be ordered preoperatively based on BL. Clinical Relevance This method provides the surgeon a way to avoid GTM preoperatively by ordering patient-specific grafts prior to performing an independent-tunnel BTB allograft ACLR.

Much has transpired in the world of sports medicine since Herodicus, a Thracian physician of the fifth century BC, rendered his foundational theories on the use of therapeutic exercise for the maintenance of health and the treatment of disease. Unfortunately, as basic knowledge advances, history abounds in inconsistencies in regard to the proper and most effective delivery of sports medicine. This article traces the development of sports medicine and its relation to high school, college, and Olympic sports over the last centuries, and provides glimpses into what the future of the field may hold.

Joint range of motion and physical capacities have been shown to change with age in both throwing athletes and non-athletes. The age of professional baseball pitchers could span from late teens to mid-40s. However, the effects of age on the pitching kinematics among professional baseball pitchers are still unknown. In this study, 67 healthy professional baseball pitchers were tested using a 3D motion analysis system. Their mean age was 23.7+/-3.3 years (range 18.8-34.4). The 12 pitchers more than one standard deviation older than the mean (i.e., older than 27.0 years) were categorized into the older group, and the 10 pitchers more than one standard deviation younger than the mean (i.e., younger than 20.4 years) were defined as the younger group. In all, 18 kinematic variables (14 position and 4 velocity) were calculated, and Student's t-tests were used to compare the variables between the two groups. Six position variables were found to be significantly different between the two groups. At the instant of lead foot contact, the older group had a shorter stride, a more closed pelvis orientation, and a more closed upper trunk orientation. The older group also produced less shoulder external rotation during the arm cocking phase, more lead knee flexion at ball release, and less forward trunk tilt at ball release. Ball velocity and body segment velocity variables showed no significant differences between the two groups. Thus, differences in specific pitching kinematic variables among professional baseball pitchers of different age groups were not associated with significant differences in ball velocities between groups. The current results suggest that both biological changes and technique adaptations occur during the career of a professional baseball pitcher.

Valgus extension overload is well described in the throwing athlete. The surgical treatment involves posterior olecranon osteophyte resection. It is not known how much of the posterior olecranon can be resected before increased stress is placed on the ulnar collateral ligament. Ten cadaveric arms underwent posterior olecranon resection in 4-mm increments. After each bone resection, three different valgus loads were applied to the elbow at 70 degrees and 90 degrees of flexion. Ulnar collateral ligament strain significantly increased with each load. Significantly more strain occurred on the ulnar collateral ligament at 90 degrees compared with 70 degrees of elbow flexion. This difference may be the result of the relative importance of the ulnar collateral ligament and the posterior olecranon at different positions of elbow flexion. The strain on the ulnar collateral ligament was slightly higher after the 8-mm and 12-mm cuts but not statistically significant. This study suggests that at moderate quasistatic valgus loads, ulnar collateral ligament strain is not significantly increased with posterior olecranon resection.

The role of thermal capsular shrinkage in treating various forms of pathology continues to evolve. The addition of thermal capsular shrinkage to the treatment regimen of standard pathologies in the thrower's shoulder has increased the rate of return to play even at the highest levels. Our data indicate an approximate 20% improvement in the rate of return to play with the addition of thermal capsular shrinkage to traditional treatments. These data represent relatively short-term follow-up. Longer duration of follow-up and increased numbers of patients will further enable us to make recommendations regarding the future use of this technology. As our understanding of the pathology that occurs in the thrower's shoulder continues to improve, so too will our understanding of the effect of applying thermal energy to the joint capsule.

The throwing athlete's shoulder is unique in many ways. The forces generated in the rotator cuff are extreme and can lead to injury due to either compression or tension. The evaluation of the thrower's shoulder must take into account the abnormalities inherent to these athletes. The information presented here represents our approach to throwers and the rotator cuff problems which are commonly encountered. Of particular importance is the attempt to treat every thrower conservatively. Only after failure of conservative measures will surgical intervention be considered. At the time of surgery, efforts are directed at not only relieving pain but also correcting any underlying pathology as it relates to pathologic laxity.

Purpose: To determine if reducing glenohumeral translation by arthroscopic thermal shrinkage would improve the results of arthroscopic treatment of internal impingement in baseball players. Type of Study: Retrospective review. Introduction: Traditional treatment of internal impingement does not address the pathophysiology. Baseball players' shoulders routinely have glenohumeral laxity. Addressing this laxity by thermal capsulorrhaphy may improve the results in the treatment of these patients. Traditional treatment of labral and rotator cuff debridement and/or repair has had marginal results in regard to the most important criterion, return to competition. Methods: Charts of all patients undergoing surgical arthroscopy of the shoulder for suspected internal impingement were analyzed. Patients were divided into 2 groups: traditional treatment (non–heat-probe group, NHP, n=51) or traditional treatment plus thermal capsulorrhaphy (heat-probe group, HP, n=31). Internal impingement was confirmed by physical examination and arthroscopic criteria. All participants were baseball players and follow-up was 30 months. Data were analyzed for initial return to play and continued participation 30 months after surgery. Results: Mean time for return to competition was 7.2 months in the NHP group and 8.4 months in the HP group; 80% of the NHP group returned to competition compared with 93% of the HP group. At 30 months after surgery, 67% of the NHP group was back to competition compared with 90% of the HP group ( P =.01). The HP group averaged 7° less external rotation than before surgery. There were no significant complications in either group. Conclusions: Thermal capsular shrinkage can be safely used in the treatment of internal impingement in the throwing athlete. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 573–577

Operative treatment of anterior glenohumeral instability in the overhead athlete requires the surgeon to restore shoulder stability without compromising motion. Open stabilization procedures designed for anterior instability in the nonthrowing athlete, including the classic technique of Bankhart, the Rowe modification, Bristow, Putti-Platt, and Magnuson-Stack procedures, often result in the loss of shoulder external rotation and difficulty in returning to overhead sports. Newer arthroscopic techniques may allow adequate stabilization with minimal motion loss; however, athletes with severe instability or failed arthroscopic procedures often require open reconstruction. This article focuses on the anatomic capsular shift procedure for the open treatment of anterior shoulder instability in the overhead athlete.

Nonoperative treatment is generally the choice for Type I and II acromioclavicular (AC) joint injuries. The situation issomewhat more controversial when Type III AC dislocations are considered, particularly with respect to athletes and heavy laborers. A number of recent studies have supported conservative treatment in these groups. There is general consensus as to the need for surgical intervention for Type IV, V, and VI AC injuries. Integral to any form of management, nonoperative or operative, is a rehabilitation program that addresses range of motion, strength, and neuromuscular control. We describe our program, which is divided into four phases: (1) Pain control and immediate protected range of motion and isometric exercises; (2) strengthening exercises using isotonic contractions and proprioceptive neuromuscular facilitation (PNF) exercises; (3) Unrestricted functional participation with the goal of increasing strength, power, endurance, and neuromuscular control; and (4) return to activity with sport specific functional drills. An athlete is ready to return to competitive sports once the following criteria are met: full range of motion (ROM), no pain or tenderness, satisfactory clinical exam, and demonstration of adequate strength on isokinetic testing. The unique considerations in a throwing athlete with an AC injury are also addressed. The primary goal of the nonoperative treatment protocol is to return the athlete to full activities as quickly and as safely as possible.

Injuries of the knee joint are the most common problem seen by the sports medicine clinician. The medial collateral ligament (MCL) and medial capsular structures are frequently the site of many injuries in sports. Conversely, injuries to the lateral and posterolateral capsular structures are less common than those of the medial capsule, but can produce significant functional limitations and dysfunction. Either the medial or lateral capsule may be injured in isolation or in combination with other supporting structures. The nonoperative treatment and postoperative treatment of medial and lateral knee capsular injuries is based on several critical factors. These factors include the accurate determination of an isolated injury, status of the cruciate ligaments, type of onset, degree of instability, status of dynamic stabilizers, and patient's activity level. The treatment of isolated MCL injuries has been subject to considerable evolution and diversity. The rehabilitation of isolated MCL injuries is extremely aggressive with emphasis on immediate motion, strengthening, and early functional exercise drills. Conversely, the rehabilitation approach for posterolateral and/or lateral capsular injuries tends to be slightly slower. In this article the rehabilitation of the medial and lateral capsular structures nonoperatively and after surgical repair will be discussed.

Rehabilitation after an injury or surgery to the elbow joint complex is common when treating the overhead throwingathlete. The unique anatomical configuration of the elbow joint complex provides a significant challenge to the sports medicine team in rehabilitating throwers after elbow surgery. The programs discussed in this report emphasize immediate controlled motion following surgery and the importance of establishing full elbow extension as expeditiously as possible. This to prevent a frequently encountered side effect of elbow surgery, a flexion contracture. A strengthening program is initiated immediately after surgery in the form of isometrics. The strengthening program is progressed from isometrics to isotonics, then to an advanced strengthening phase consisting of plyometrics, neuromuscular control drills, proprioceptive training, and high speed muscle training. The advanced strengthening phase is instituted to train the throwing athlete to control the potentially harmful stresses imparted onto the elbow joint during the throwing motion. A functional progression for the overhead thrower is discussed. In this report, we will discuss postoperative rehabilitation following elbow arthroscopy, ulnar collateral ligament reconstruction, arthroscopic arthroplasty, uInar nerve subcutaneous transposition, and arthroscopic arthrolysis.

Elite throwers subject the elbow to extremely high forces that, over long periods of time, may cause significant injury.Surgical techniques developed to treat these injuries have allowed many athletes to resume careers that might have otherwise ended. In this article, open surgical techniques and the indications for surgery to the elbow are presented in detail. Included in the discussion is a detailed description of ulnar collateral ligament reconstruction.

The elbow is a vital part of the complicated and intricate mechanism known as throwing. The athlete that participates in a throwing sport walks a fine line between success and injury. It is this line that the clinician must monitor. When an athlete admits that an injury has occurred, it is up to the physician to listen, observe, and examine the player in great detail. Injuries that involve the elbow are complex and difficult to evaluate; therefore, it is essential that a thorough, complete, and reproducible evaluation be performed every time. Not only is this important initially, but is invaluable when following up on the athlete over the course of the injury. The patient's history is the initial tool used to narrow the differential diagnoses. Questioning is concise, structured, and not leading. The result is a workable list of possible diagnosis that will aid the examiner when the physical examination is performed. The physical, like the history, is well outlined and defined. This methodology allows the clinician to be structured when evaluating the results. In the end, a complete history and physical examination may not be enough to draw a final conclusion to the etiology of the athlete's elbow injury. Ancillary studies should then be evaluated for their value and effectiveness in aiding the examiner to achieve a correct diagnosis. The purpose of this report is to provide the clinician a template that will give consistent results and aid in the diagnosis of elbow injuries.

Elbow arthroscopy is becoming a mainstream orthopedic procedure. Through multiple portals, a thorough evaluation of the entire elbow joint is possible. However, an understanding of normal arthroscopic anatomy is essential for orientation and alienation of pathologic processes.

An accurate diagnosis of an isolated PCL injury may be difficult, especially in the acute setting. A detailed history emphasizing the mechanism of injury is crucial as is a careful, complete examination of the knee. Plain and stress radiographs may be helpful in establishing the diagnosis; however, MR imaging is currently the most sensitive ancillary study available to evaluate the integrity of the posterior cruciate ligament. Failure to recognize and treat appropriately an isolated PCL disruption may result in the development of symptomatic irreversible articular surface injury.

A poorly diagnosed and treated wrist injury could become a career-ending injury. Optimal treatment begins on the playing field, not the operative field. A careful, thorough field evaluation is mandatory to ensure prompt recognition of a potentially debilitating injury. Suspected fractures or ligamentous disruption require immediate referral to a physician for definitive early treatment. When the trainer and physician work as a team, early diagnosis, treatment, and rehabilitation of wrist injuries can be instituted to reach the goal of maintaining functional healthy wrists for future athletic endeavors.

A careful field evaluation is mandatory to ensure prompt recognition of a potentially debilitating hand injury. The major responsibility of the examination is to rule out any possible serious injury prior to returning the athlete to competition. This article deals with both on-the-field evaluation and recognition and sideline management of injuries to the hand.

Intraarticular ankle anatomy may be better visualized arthroscopically than with an arthrotomy. Ankle arthroscopy was crucial in locating a simple bone cyst and directing therapeutic curettage of the lesion.

This article briefly describes the various pathologic lesions seen in the throwing athlete's shoulder. The pathologic conditions discussed include primary and secondary impingement, tensile lesions of the rotator cuff and biceps-labral complex, glenohumeral laxity, labral tears, and AC joint injuries. Mechanism of injury, indications, and arthroscopic management of these lesions are discussed.

Throwing and overhead racquet motion is stressful activity that places great physical demands on the athlete's shoulder. This article focuses on glenoid labral tears as a consequence of this dynamic activity. These labral lesions may be present as an isolated entity or may be in association with glenohumeral instability.

This article examines the diagnosis and treatment of lesions of the posterior compartment of the elbow, along with the anatomy and biomechanics of the elbow of the throwing athlete. An indepth evaluation of specific lesions and a detailed description of elbow arthroscopy are also presented.

Over the past 20 years, the anterior cruciate ligament (ACL) has been studied as much as any orthopedic structure. A literature search through PubMed reveals almost 5000 articles published over the past two decades. Research in anatomy, biomechanics, epidemiology, graft sources, fixation methods, and clinical outcomes of the ACL and its reconstruction has led to an explosive understanding of this ligament, as well as the ability to consistently and predictably reconstruct it. ACL injuries were once considered to be careerending. These days, they are often a mere blip in an athlete’s career path, and surgical reconstruction commonly allows a return to preinjury levels of performance. Moreover, clearer understandings are evolving regarding how ACL injuries occur in noncontact situations and why women are significantly more predisposed to ACL ruptures; from this, techniques are being developed to precondition the knee to decrease the rate of injury. As with many orthopedic procedures, there is more than one way ‘‘to skin a cat’’ when it comes to ACL reconstruction. An understanding of the anatomy, adherence to sound biomechanical principles, and appropriate rehabilitation programs ensure good results—more so than the choice of a particular graft or fixation method. Also important is the increasing knowledge of the biomechanics of the ACL-deficient knee and the potential for long-term damage, or lack thereof, depending on activity level. This knowledge has helped the orthopedist and patient make better decisions regarding the ultimate need for ACL reconstruction. As surgical techniques (arthroscopic, in particular) improve, the ability to tackle increasingly complex problems evolves. Complex decisions regarding meniscal repair and transplantation and cartilage repair and regeneration are now commonplace, as are decisions regarding the need for osteotomies in arthritically unstable knees. Our mission in developing this two-part series on ACL reconstruction for the Orthopedic Clinics of North America was to compile all of this information into a definitive, up-to-date reference. Having reviewed all of the articles, we were most impressed with the depth and clarity the authors brought to their work. We are extremely grateful to our contributors, many of whom are groundbreakers in the science of ACL reconstruction, for their commitment of time and effort time taken away from their practices and families. In the procedure-related articles, we asked that the authors describe their surgical procedures in a way such that the reader would be able to reproduce the technique, complete with tips on avoiding pitfalls and pearls obtained through years of experience. In each case this request was followed to a fault. We are also indebted to Deb Dellapena of W.B. Saunders for her support, expertise, and gentle per

Part II of ACL reconstruction in Orthopedic Clinics of North America picks up where Part I left off, with a comprehensive review of the different techniques for ACL reconstruction. The last three chapters of Part I described three different approaches for the use of patella tendon autograft. Part II presents step-by-step approaches to hamstring, quadriceps, allograft, and press-fit techniques for ACL reconstruction, including a chapter focusing on the challenges of hamstring tendon harvesting. As scientific and technical advances in ACL reconstruction have occurred, our ability to handle increasingly difficult and challenging cases has dramatically increased. Meniscal repairs and transplants, cartilage cell implantation, osteochondral transplants and osteotomies are all part of the ‘‘modern’’ ACL surgeon’s armementarium. The latter half of this volume addresses these issues, providing both technical expertise as well as an algorithm to tackle these problems. Most orthopedic procedures, and ACL reconstructions in particular, will not have a successful outcome without appropriate rehabilitation. We have included an extensive and comprehensive chapter on rehabilitation following ACL reconstruction that is upto-date in terms of concepts and time-lines. The final chapter ties together the scientific principles and technical details presented in this two part series through six challenging case studies reviewed and discussed by four ACL experts. The goal is to give the reader a ‘‘real life’’ look at the decision-making involved in some complicated clinical cases. Our goal in developing this two part series was to create the most complete and up-to-date reference available for the orthopedist interested in the ACL and its reconstruction. We are satisfied, after reviewing the two volumes, that we have accomplished this goal. We are extremely grateful to all our ‘‘ACL experts’’, for the dedication they put into their contributions, and for their willingness to impart pearls and perils based on their cumulative experiences. We are also very thankful to our editor, Deb Dellapena, whose unwavering support and gentle, yet persistent, prodding helped bring this project to fruition.

A few of the major and more common overuse syndromes are considered, including patellofemoral stress syndromes, shin splints, and Achilles tendinitis. Cessation of sports activity is not the answer to these problems; rather, the prevention of overuse syndromes can and should overshadow the treatment.

Kimberlite intrusions at three localities have been mapped in detail. Dyke intrusion in the Nigerdlikasik area follows an en-echelon pattern maintaining a constant coast-parallel trend through Precambrian gneisses. Impersistent flat-lying sheets in the Pyramidefjeld granite complex extend beyond the granite contact into similar gneisses. On Midternaes further low-angle sheet development passes from gneissose basement across an unconformity into a Proterozoic supracrustal succession. The present thickness of dykes and sheets reflects the injection of several phases of kimberlite. Trachytic flow textures, widespread dissemination and sedimentation of deepseated xenoliths and localized carbonate metasomatism suggest a very fluid magma. Zones of pronounced platy jointing, sometimes extending up to 10 m in width are a common feature of the host rocks immediately adjacent to both the dyke and sheets and their development is associated with the kimberlite emplacement. The intrusion of the kimberlites is interpreted as being controlled by the prevailing external stress field and it is suggested that the disposition of dykes and sheets reflects the stress system generated during the early stages of continental rifting between Greenland and Canada.

The skeletally immature athlete sustains upper extremity injuries unique to the epiphyseal plate, articular cartilage, musculotendinous units, and specific to the sport itself. Specific shoulder and elbow conditions can be predicted based on the biomechanics of the sport and age of the patient. In the young athlete, recognition of these unique injury patterns with early activity modification and treatment can prevent permanent deformity and functional disability.

Detailed mineralogical and petrological investigations have been carried out on a suite of micaceous kimberlite dykes and sheets of early Mesozoic age intruded into Precambrian gneisses, supracrustal rocks and a granite complex. Forty-two electron microprobe analyses of kimberlite olivines demonstrate a compositional range from Mg92Mg74, with frequent examples of both normal and reverse zoning. Calcite, iron-rich serpentine and phlogopite are important rock-forming phases with accessory apatite and perovskite. Diopside occurs in certain intrusions (up to 25% vol.%). Opaques are commonly composite grains of chromite and magnetite with limited ulvospinel solid-solution. Eight microscopic diamonds have been recovered from four samples. Xenolith suites are dominated by lherzolitic peridotites, but include rare crustal rocks. Analyses from six garnet peridotites, three spinel peridotites and five phlogipite peridotites demonstrate significant compositional differences between their respective pyroxenes: the Al in diopside of spinel peridotites is 10 times that of diopside in phlogopite peridotites while Al in diopside of garnet peridotites is intermediate in amount. Diopside from phlogopite peridotites is depleted in Ti. These variations are interpreted as evidence of equilibrium between diopside and coexisting garnet, spinel, or phlogopite. With one exception the diopsides are calcic with limited solid solution towards enstatite; kimberlite diopsides are generally significantly more calcic than varieties in peridotite. Pyroxenes from individual peridotite nodules have similar Fe Mg ratios although this ratio varies within the xenolith population. Olivine has a restricted compositional range (about Mg91). Large crystals in dunite mylonites are significantly more iron-rich. Garnet and spinel peridotites are interpreted as unmodified representatives of the Upper Mantle. Some phlogopite peridotites probably recrystallized during and after incorporation into the kimberlite magma.

This article describes the surgical technique of arthroscopy of the ankle and the indications for its use. In addition to describing the common anterolateral and anteromedial arthroscopic portals, a discussion is also given regarding portal anatomy of ankle arthroscopy and the various neurovascular structures that lie in close proximity to the arthroscopic portals. Arthroscopy of the ankle has a definite role in the management of certain lesions of the ankle, such as loose bodies, or osteochondral or chondral defects of the talus. Ankle arthroscopy is a technically demanding surgical procedure and great attention to detail is required to perform this procedure in a safe and reproducible fashion.

In summary, this classification and the clinical tests that accompany it are presented to help clarify a commonly used language for these instabilities. The clinical examination of the knee is based on the anatomy; if one grasps the anatomy, functions, and rotations, one can comprehend the knee joint.

A concept of the "knee at risk" has been discussed. Such knees with acute anterolateral rotatory instability require stabilization. The combination procedure of arthroscopy for diagnosis and treatment of internal derangement with an extra-articular reconstruction has been described. In a follow-up study of 69 cases so treated, objective results were 94 per cent acceptable, and subjective results were 93 per cent acceptable. There was no apparent difference either objectively or subjectively between 12 to 24 months and 24 to 65 months postoperatively in this series. The high incidence (80 per cent) of meniscal lesions in this series re-emphasizes the need for a high index of suspicion of internal derangement in acute knee ligament injuries.

The efficacy of arthroscopy of the shoulder has been demonstrated as both a diagnostic and an operative tool. The throwing athlete has benefited greatly from this procedure. Intra-articular pathology resulting from throwing motion overuse can be visualized and treated, with relatively little morbidity and a rapid rehabilitation phase.