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Synopsis There is a growing body of evidence documenting loads applied to the anterior cruciate ligament (ACL) for weight-bearing and non—weight-bearing exercises. ACL loading has been quantified by inverse dynamics techniques that measure anterior shear force at the tibiofemoral joint (net force primarily restrained by the ACL), ACL strain (defined as change in ACL length with respect to original length and expressed as a percentage) measured directly in vivo, and ACL tensile force estimated through mathematical modeling and computer optimization techniques. A review of the biomechanical literature indicates the following: ACL loading is generally greater with non—weight-bearing compared to weight-bearing exercises; with both types of exercises, the ACL is loaded to a greater extent between 10° to 50° of knee flexion (generally peaking between 10° and 30°) compared to 50° to 100° of knee flexion; and loads on the ACL change according to exercise technique (such as trunk position). Squatting with excessiv...

Synopsis Rehabilitation following anterior cruciate ligament surgery continues to change, with the current emphasis being on immediate weight bearing and range of motion, and progressive muscular strengthening, proprioception, dynamic stability, and neuromuscular control drills. The rehabilitation program should be based on scientific and clinical research and focus on specific drills and exercises designed to return the patient to the desired functional goals. The goal is to return the patient's knee to homeostasis and the patient to his or her sport or activity as safely as possible. Unique rehabilitation techniques and special considerations for the female athlete will also be discussed. The purpose of this article is to provide the reader with a thorough scientific basis for anterior cruciate ligament rehabilitation based on graft selection, patient population, and concomitant injuries. J Orthop Sports Phys Ther 2012;42(3):153–171. doi:10.2519/jospt.2012.3741

Context: Although baseball is a relatively safe sport, numerous reports suggest a rapid rise in elbow injury rate among youth baseball pitchers. Evidence Acquisition: PubMed was searched for epidemiologic, biomechanical, and clinical studies of elbow injuries in baseball (keywords: “youth OR adolescent” AND baseball AND pitching AND “ulnar collateral ligament OR elbow”; published January 2000 – April 2012). Studies with relevance to youth baseball pitchers were reviewed. Relevant references from these articles were also retrieved and reviewed. Original data, insight, and recommendations were added. Results: The majority of baseball elbow injuries are noncontact injuries to the dominant arm resulting from repetitive pitching. Five percent of youth pitchers suffer a serious elbow or shoulder injury (requiring surgery or retirement from baseball) within 10 years. The risk factor with the strongest correlation to injury is amount of pitching. Specifically, increased pitches per game, innings pitched per season, and months pitched per year are all associated with increased risk of elbow injury. Pitching while fatigued and pitching for concurrent teams are also associated with increased risk. Pitchers who also play catcher have an increased injury risk, perhaps due to the quantity of throws playing catcher adds to the athlete’s arm. Another risk factor is poor pitching biomechanics. Improper biomechanics may increase the torque and force produced about the elbow during each pitch. Although throwing breaking pitches at a young age has been suggested as a risk factor, existing clinical, epidemiologic, and biomechanical data do not support this claim. Conclusions: Some elbow injuries to youth baseball pitchers can be prevented with safety rules, recommendations, education, and common sense. Scientific and medical organizations have published safety rules and recommendations, with emphasis on prevention of overuse and pitching while fatigued. Strength-of-Recommendation Taxonomy (SORT): A

OBJECTIVE. We are often asked to evaluate the postoperative elbow using MRI. In this article, we present both the normal appearance of the reconstructed ulnar collateral ligament (UCL) and a spectrum of UCL graft abnormalities at MR arthrography. CONCLUSION. The UCL is the primary medial stabilizer of the elbow during flexion and is susceptible to injury, particularly in overhead throwing athletes. In the setting of UCL injury, ligament reconstruction is the principal surgical procedure available to restore stability and function and to relieve pain with activity. We have found MR arthrography useful in assessing the reconstructed UCL.

Case report.Joint stiffness, also called arthrofibrosis, remains the primary complication following any reconstructive knee surgery. Acute anterior cruciate ligament surgery, performed with concomitant multiple ligamentous repair and/or reconstruction, further increases the likelihood of developing impaired knee motion following surgery. The purpose of this case report is to present a criteria-based approach to the postoperative management of a multiligament knee injury.A 25-year-old male professional football player sustained a contact injury to his right knee while making a tackle during a regular season game in 2007. He underwent an acute anterior cruciate ligament reconstruction, with concomitant posterolateral corner repair, biceps femoris/iliotibial band repair, lateral collateral ligament repair, and a medial meniscocapsular junction repair. He completed 17 weeks of a multiphased rehabilitation program that emphasized immediate range of motion, low-load long-duration stretching, therapeutic exercise, neuromuscular reeducation/perturbation training, plyometrics, and sport-specific functional drills. Electrical neurostimulation was implemented during the early stages of rehabilitation to control postoperative pain and to promote a steady progression of therapeutic exercise activity.The patient was cleared to begin sport-specific activity 7 months after major multistructure reconstructive knee surgery. He began the 2008 season on the physically-unable-to-perform list, but was activated midseason and played in every game thereafter. During the 2009 and 2010 seasons, he played all regular season games and all playoff games as a starter, and continues to start as a defensive cornerback in the National Football League.This case report highlights the clinical decision-making process and management involved in an acute multiple ligamentous knee injury/reconstruction.Therapy, level 4.

Background: Glenohumeral internal rotation deficit (GIRD) indicates a 20° or greater loss of internal rotation of the throwing shoulder compared with the nondominant shoulder. Purpose: To determine whether GIRD and a deficit in total rotational motion (external rotation + internal rotation) compared with the nonthrowing shoulder correlate with shoulder injuries in professional baseball pitchers. Study Design: Case series; Level of evidence, 4. Methods: Over 3 competitive seasons (2005 to 2007), passive range of motion measurements were evaluated on the dominant and nondominant shoulders for 170 pitcher-seasons. This included 122 professional pitchers during the 3 seasons of data collection, in which some pitchers were measured during multiple seasons. Ranges of motion were measured with a bubble goniometer during the preseason, by the same examiner each year. External and internal rotation of the glenohumeral joint was assessed with the participant supine and the arm abducted 90° in the plane of the scapula, with the scapula stabilized anteriorly at the coracoid process. The reproducibility of the test methods had an intraclass correlation coefficient of .81. Days in which the player was unable to participate because of injury or surgery were recorded during the season by the medical staff of the team and defined as an injury. Results: Pitchers with GIRD (n = 40) were nearly twice as likely to be injured as those without but without statistical significance ( P = .17). Pitchers with total rotational motion deficit greater than 5° had a higher rate of injury. Minor league pitchers were more likely than major league pitchers to be injured. However, when players were injured, major league pitchers missed a significantly greater number of games than minor league pitchers. Conclusion: Compared with pitchers without GIRD, pitchers with GIRD appear to be at a higher risk for injury and shoulder surgery.

Effects of a 4-week youth baseball conditioning program on throwing velocity. This study examined the effects of a 4-week youth baseball conditioning program on maximum throwing velocity. Thirty-four youth baseball players (11-15 years of age) were randomly and equally divided into control and training groups. The training group performed 3 sessions (each 75 minutes) weekly for 4 weeks, which comprised a sport specific warm-up, resistance training with elastic tubing, a throwing program, and stretching. Throwing velocity was assessed initially and at the end of the 4-week conditioning program for both control and training groups. The level of significance used was p < 0.05. After the 4-week conditioning program, throwing velocity increased significantly (from 25.1 ± 2.8 to 26.1 ± 2.8 m·s) in the training group but did not significantly increase in the control group (from 24.2 ± 3.6 to 24.0 ± 3.9 m·s). These results demonstrate that the short-term 4-week baseball conditioning program was effective in increasing throwing velocity in youth baseball players. Increased throwing velocity may be helpful for pitchers (less time for hitters to swing) and position players (decreased time for a runner to advance to the next base).

BackgroundThe anterior bundle of the ulnar collateral ligament (UCL) is the primary anatomical structure providing elbow stability in overhead sports, particularly baseball. Injury to the UCL in overhead athletes often leads to symptomatic valgus instability that requires surgical treatment.HypothesisUlnar collateral ligament reconstruction with a free tendon graft, known as Tommy John surgery, will allow return to the same competitive level of sports participation in the majority of athletes.Study DesignCase series; Level of evidence, 4.MethodsUlnar collateral reconstruction (1266) or repair (15) was performed in 1281 patients over a 19-year period (1988—2006) using a modification of the Jobe technique. Data were collected prospectively and patients were surveyed retrospectively with a telephone questionnaire to determine outcomes and return to performance at a minimum of 2 years after surgery.ResultsNine hundred forty-two patients were available for a minimum 2-year follow-up (average, 38.4 months; range, 24-130 months). Seven hundred forty-three patients (79%) were contacted for follow-up evaluation and/or completed a questionnaire at an average of 37 months postoperatively. Six hundred seventeen patients (83%) returned to the previous level of competition or higher, including 610 (83%) after reconstruction. The average time from surgery to the initiation of throwing was 4.4 months (range, 2.8-12 months) and the average time to full competition was 11.6 months (range, 3-72 months) after reconstruction. Complications occurred in 148 patients (20%), including 16% considered minor and 4% considered major.ConclusionUlnar collateral ligament reconstruction with subcutaneous ulnar nerve transposition was found to be effective in correcting valgus elbow instability in the overhead athlete and allowed most athletes (83%) to return to previous or higher level of competition in less than 1 year.

Purpose: The purpose of this study was to compare cruciate ligament forces between the forward lunge with a short step (forward lunge short) and the forward lunge with a long step (forward lunge long). Methods: Eighteen subjects used their 12-repetition maximum weight while performing the forward lunge short and long with and without a stride. EMG, force, and kinematic variables were input into a biomechanical model using optimization, and cruciate ligament forces were calculated as a function of knee angle. A two-factor repeated-measure ANOVA was used with a Bonferroni adjustment (P < 0.0025) to assess differences in cruciate forces between lunging techniques. Results: Mean posterior cruciate ligament (PCL) forces (69-765 N range) were significantly greater (P < 0.001) in the forward lunge long compared with the forward lunge short between 0[degrees] and 80[degrees] knee flexion angles. Mean PCL forces (86-691 N range) were significantly greater (P < 0.001) without a stride compared with those with a stride between 0[degrees] and 20[degrees] knee flexion angles. Mean anterior cruciate ligament (ACL) forces were generated (0-50 N range between 0[degrees] and 10[degrees] knee flexion angles) only in the forward lunge short with stride. Conclusions: All lunge variations appear appropriate and safe during ACL rehabilitation because of minimal ACL loading. ACL loading occurred only in the forward lunge short with stride. Clinicians should be cautious in prescribing forward lunge exercises during early phases of PCL rehabilitation, especially at higher knee flexion angles and during the forward lunge long, which generated the highest PCL forces. Understanding how varying lunging techniques affect cruciate ligament loading may help clinicians prescribe lunging exercises in a safe manner during ACL and PCL rehabilitation.

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.

Controlled laboratory study using a repeated-measures, counterbalanced design.To test the ability of 8 Swiss ball exercises (roll-out, pike, knee-up, skier, hip extension right, hip extension left, decline push-up, and sitting march right) and 2 traditional abdominal exercises (crunch and bent-knee sit-up) on activating core (lumbopelvic hip complex) musculature.Numerous Swiss ball abdominal exercises are employed for core muscle strengthening during training and rehabilitation, but there are minimal data to substantiate the ability of these exercises to recruit core muscles. It is also unknown how core muscle recruitment in many of these Swiss ball exercises compares to core muscle recruitment in traditional abdominal exercises such as the crunch and bent-knee sit-up.A convenience sample of 18 subjects performed 5 repetitions for each exercise. Electromyographic (EMG) data were recorded on the right side for upper and lower rectus abdominis, external and internal oblique, latissimus dorsi, lumbar paraspinals, and rectus femoris, and then normalized using maximum voluntary isometric contractions (MVICs).EMG signals during the roll-out and pike exercises for the upper rectus abdominis (63% and 46% MVIC, respectively), lower rectus abdominis (53% and 55% MVIC, respectively), external oblique (46% and 84% MVIC, respectively), and internal oblique (46% and 56% MVIC, respectively) were significantly greater compared to most other exercises, where EMG signals ranged between 7% to 53% MVIC for the upper rectus abdominis, 7% to 44% MVIC for the lower rectus abdominis, 14% to 73% MVIC for the external oblique, and 16% to 47% MVIC for the internal oblique. The lowest EMG signals were consistently found in the sitting march right exercise. Latissimus dorsi EMG signals were greatest in the pike, knee-up, skier, hip extension right and left, and decline push-up (17%-25% MVIC), and least with the sitting march right, crunch, and bent-knee sit-up exercises (7%-8% MVIC). Rectus femoris EMG signal was greatest with the hip extension left exercise (35% MVIC), and least with the crunch, roll-out, hip extension right, and decline push-up exercises (6%-10% MVIC). Lumbar paraspinal EMG signal was relative low (less than 10% MVIC) for all exercises.The roll-out and pike were the most effective exercises in activating upper and lower rectus abdominis, external and internal obliques, and latissimus dorsi muscles, while minimizing lumbar paraspinals and rectus femoris activity. J Orthop Sports Phys Ther 2010;40(5):265-276, Epub 22 April 2010. doi:10.2519/jospt.2010.3073.

Background: The number of adolescent anterior cruciate ligament (ACL) injuries is rising with increased participation in higher level athletics at earlier ages. With an increasing number of primary ACL reconstructions (ACLRs) comes a rise in the incidence of revision ACLRs. Purpose: To evaluate the clinical results of revision ACLR across a group of high-level adolescent athletes with at least 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of 21 adolescent athletes (age range, 10-19 years) who underwent revision ACLR with at least 2-year follow-up was conducted. Patient-reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm knee scoring scale, Tegner activity level scale, and modified Cincinnati Knee Rating System. Return to sport (RTS) and overall patient satisfaction were also assessed. Results: The mean age at the time of surgery was 16.5 years (range, 14-19 years), and the mean follow-up was 46.4 months (range, 24-97 months); 42.9% of patients were female, and 52.4% of patients participated in collision sports. The mean time to failure after primary ACLR was 13.1 ± 8.0 months, and the most common mechanism of failure was noncontact in at least 66.7% of cases. The revision graft type included bone–patellar tendon–bone (BPTB) in 71.4% of cases; 26.7% of BPTB grafts were from the contralateral extremity. Concomitant procedures were performed for intra-articular lesions in 71.4% of patients. The mean patient satisfaction rate was 95.3%. There were 3 cases of a graft reinjury at a mean of 25 months postoperatively. The mean PROM scores were as follows: IKDC, 87.5 ± 12.7; Tegner, 7.2 ± 2.0; Lysholm, 93.7 ± 9.8; and Cincinnati, 93.4 ± 10.0. Of those attempting to RTS, 68.4% of patients successfully returned at the same level of competition. Patients with a lateral compartment chondral injury were less likely to RTS ( P < .05). Independent variables shown to have no significant relationship to PROMs or RTS included age, follow-up, sport classification, associated meniscal tears, revision graft size/type, and concomitant procedures. Conclusion: Revision ACLR can be an effective surgical option in adolescents participating in collision and contact sports, with good to excellent subjective outcome scores. At a minimum 2-year follow-up, a graft rupture after revision ACLR occurred in 14% of cases. Of the athletes attempting to RTS, 68.4% returned to their preinjury level of competition.

There is concern among sports medicine practitioners that the number of youth baseball pitchers with elbow injuries appears to be increasing. Research points to overuse as the principle risk factor. The risk of elbow pain in youth pitchers is correlated with the number of pitches thrown in a game and in a season. Adolescents who competitively pitch more than 85 pitches per game, more than 8 months out of a year, or with arm fatigue are several times more likely to require elbow surgery. Poor pitching mechanics also appear to contribute to injury risk. Existing research does not show a significant correlation between curveballs and injury. Adults should help youth pitchers avoid fatigue, overuse, and improper mechanics. If elbow pain develops, the youth pitcher should be evaluated by a sports medicine physician.

The rotator cuff performs multiple functions during shoulder exercises, including glenohumeral abduction, external rotation (ER) and internal rotation (IR). The rotator cuff also stabilizes the glenohumeral joint and controls humeral head translations. The infraspinatus and subscapularis have significant roles in scapular plane abduction (scaption), generating forces that are two to three times greater than supraspinatus force. However, the supraspinatus still remains a more effective shoulder abductor because of its more effective moment arm. Both the deltoids and rotator cuff provide significant abduction torque, with an estimated contribution up to 35-65% by the middle deltoid, 30% by the subscapularis, 25% by the supraspinatus, 10% by the infraspinatus and 2% by the anterior deltoid. During abduction, middle deltoid force has been estimated to be 434 N, followed by 323 N from the anterior deltoid, 283 N from the subscapularis, 205 N from the infraspinatus, and 117 N from the supraspinatus. These forces are generated not only to abduct the shoulder but also to stabilize the joint and neutralize the antagonistic effects of undesirable actions. Relatively high force from the rotator cuff not only helps abduct the shoulder but also neutralizes the superior directed force generated by the deltoids at lower abduction angles. Even though anterior deltoid force is relatively high, its ability to abduct the shoulder is low due to a very small moment arm, especially at low abduction angles. The deltoids are more effective abductors at higher abduction angles while the rotator cuff muscles are more effective abductors at lower abduction angles. During maximum humeral elevation the scapula normally upwardly rotates 45-55 degrees, posterior tilts 20-40 degrees and externally rotates 15-35 degrees. The scapular muscles are important during humeral elevation because they cause these motions, especially the serratus anterior, which contributes to scapular upward rotation, posterior tilt and ER. The serratus anterior also helps stabilize the medial border and inferior angle of the scapular, preventing scapular IR (winging) and anterior tilt. If normal scapular movements are disrupted by abnormal scapular muscle firing patterns, weakness, fatigue, or injury, the shoulder complex functions less efficiency and injury risk increases. Scapula position and humeral rotation can affect injury risk during humeral elevation. Compared with scapular protraction, scapular retraction has been shown to both increase subacromial space width and enhance supraspinatus force production during humeral elevation. Moreover, scapular IR and scapular anterior tilt, both of which decrease subacromial space width and increase impingement risk, are greater when performing scaption with IR ('empty can') compared with scaption with ER ('full can'). There are several exercises in the literature that exhibit high to very high activity from the rotator cuff, deltoids and scapular muscles, such as prone horizontal abduction at 100 degrees abduction with ER, flexion and abduction with ER, 'full can' and 'empty can', D1 and D2 diagonal pattern flexion and extension, ER and IR at 0 degrees and 90 degrees abduction, standing extension from 90-0 degrees , a variety of weight-bearing upper extremity exercises, such as the push-up, standing scapular dynamic hug, forward scapular punch, and rowing type exercises. Supraspinatus activity is similar between 'empty can' and 'full can' exercises, although the 'full can' results in less risk of subacromial impingement. Infraspinatus and subscapularis activity have generally been reported to be higher in the 'full can' compared with the 'empty can', while posterior deltoid activity has been reported to be higher in the 'empty can' than the 'full can'.

The purpose of the current study was to identify the biomechanical features of elite female baseball pitching. Kinematics and kinetics of eleven elite female baseball pitchers were reported and compared with eleven elite male pitchers. Results suggested that females share many similarities with males in pitching kinematics, with a few significant differences. Specifically, at the instant of stride foot contact, a female pitcher had a shorter and more open stride and less separation between pelvis orientation and upper torso orientation. From foot contact to ball release, a female pitcher produced lower peak angular velocity for throwing elbow extension and stride knee extension. Ball velocity was lower for the female. Foot contact to ball release took more time for a female pitcher. Maximal proximal forces at the shoulder and elbow joints were less for a female pitcher.

Injuries to the ulnar collateral ligament (UCL) in throwing athletes frequently occurs from the repetitive valgus loading of the elbow during the throwing motion, which often results in surgical reconstruction of the UCL requiring a structured postoperative rehabilitation program. Several methods are currently used and recommended for UCL reconstruction using autogenous grafts in an attempt to reproduce the stabilizing function of the native UCL. Rehabilitation following surgical reconstruction of the UCL begins with range of motion and initial protection of the surgical reconstruction, along with resistive exercise for the entire upper extremity kinetic chain. Progressions for resistive exercise are followed that attempt to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers, in addition to the distal upper extremity musculature, to allow for a return to throwing and overhead functional activities. Rehabilitation following UCL reconstruction has produced favorable outcomes, allowing for a return to throwing in competitive environments.

Context: Baseball pitching kinematics, kinetics, ball velocity, and injuries at the shoulder and elbow are related. Evidence Acquisition: PubMed and Sport Discus were searched for original studies published between 1994 and 2008. Relevant references in these studies were retrieved. Inferential studies that tested relationships between kinematics and kinetics were included, as were studies that tested relationships between kinematics and ball velocity. Descriptive studies that simply quantified kinematics and/or kinetics were excluded. Results: Several kinematic parameters at the instant of foot contact were associated with increased upper extremity kinetics: front foot position, front foot orientation, shoulder abduction, and shoulder horizontal adduction. The timing of shoulder external rotation, pelvis rotation, and upper trunk rotation was associated with increased kinetics and decreased ball velocity. Low braking force of the lead leg and a short stride were associated with decreased ball velocity. Decreased maximum shoulder external rotation, shoulder abduction, knee extension, and trunk tilt were also associated with decreased ball velocity. As pitchers develop, kinematic values remain similar, their variability reduces, and kinetic values gradually increase. Slight kinematic variations were seen among pitch types, although the kinetics of fastballs and curveballs were relatively the same; changeup kinetics were the lowest. As pitchers fatigued, kinetic values remained constant, but increases in arm pain were reported. Conclusions: Several kinematic parameters were related to joint kinetics and ball velocity. To enhance performance and reduce injury risk, pitchers need to learn proper fastball mechanics at an early age. A changeup is recommended as a safe secondary pitch to complement the fastball; the curveball can be added after fastball and changeup mechanics are mastered. Avoiding overuse and pitching while fatigued is necessary to minimize the risk of arm injury.

Controlled laboratory biomechanics study using a repeated-measures, counterbalanced design.To compare patellofemoral joint force and stress between a short- and long-step forward lunge both with and without a stride.Although weight-bearing forward-lunge exercises are frequently employed during rehabilitation for individuals with patellofemoral joint syndrome, patellofemoral joint force and stress and how they change with variations of the lunge exercise are currently unknown.Eighteen subjects used their 12-repetition maximum weight while performing a short- and long-step forward lunge both with and without a stride. Electromyography, ground reaction force, and kinematic variables were put into a biomechanical optimization model, and patellofemoral joint force and stress were calculated as a function of knee angle.Visual observation of the data show that during the forward lunge, patellofemoral joint force and stress increased progressively as knee flexion increased, and decreased progressively as knee flexion decreased. Between 70 degrees and 90 degrees of knee flexion, patellofemoral joint force and stress were significantly greater when performing a forward lunge with a short step compared to a long step (P.025). Between 10 degrees and 40 degrees of knee flexion, patellofemoral joint force and stress were significantly greater when performing a forward lunge with a stride compared to without a stride (P.025).When the goal is to minimize patellofemoral joint force and stress during the forward lunge performed between 0 degrees to 90 degrees knee angles, it may be prudent to perform the lunge with a long step compared to a short step and without a stride compared to with a stride, because patellofemoral joint force and stress magnitudes were greater with a short step compared to a long step at higher knee flexion angles and were greater with a stride compared to without a stride at lower knee flexion angles.

BackgroundMuscle weakness, particularly of shoulder external rotation, is common after rotator cuff repair surgery. Neuromuscular electrical stimulation has been shown to be an effective adjunct in the enhancement of muscle recruitment.HypothesisShoulder external rotation peak force can be enhanced by neuromuscular electrical stimulation after rotator cuff repair surgery.Study DesignControlled laboratory study.MethodsThirty-nine patients (20 men, 19 women) who had undergone rotator cuff repair surgery were tested a mean of 10.5 days after surgery. Testing consisted of placing patients supine with the shoulder in 45° of abduction, neutral rotation, and 15° of horizontal adduction. Neuromuscular electrical stimulation was applied to the infraspinatus muscle belly and inferior to the spine of the scapula. Placement was confirmed by palpating the muscle during a resisted isometric contraction of the external rotators. Patients performed 3 isometric shoulder external rotation contractions with and without neuromuscular electrical stimulation, each with a 5-second hold against a handheld dynamometer. Neuromuscular electrical stimulation was applied at maximal intensity within comfort at 50 pulses per second, symmetrical waveform, and a 1-second ramp time. The 3 trials under each condition were recorded, and an average was taken. The order of testing was randomized for each patient tested. A paired samples t test was used to determine significant differences between conditions ( P < .05). Each group was also divided based on age, rotator cuff tear size, number of days postoperative, and neuromuscular electrical stimulation intensity. Analysis of variance Models were used to determine the influence of these variables on external rotation force production ( P < .05).ResultsPeak force production was significantly greater ( P < .001) when tested with neuromuscular electrical stimulation (3.75 kg) as opposed to without neuromuscular electrical stimulation (3.08 kg) for all groups tested. There was no significant difference based on the size of the tear, age of the patient, number of days after surgery, or level of neuromuscular electrical stimulation intensity.ConclusionPeak shoulder external rotation force was significantly increased by 22% when tested with neuromuscular electrical stimulation after rotator cuff repair surgery. Neuromuscular electrical stimulation significantly increased force production regardless of the age of the patient, size of the tear, intensity of the current, or the number of days postoperative.Clinical RelevanceNeuromuscular electrical stimulation may be used concomitantly with exercises to enhance the amount of force production and potentially minimize the inhibition of the rotator cuff after repair surgery.

The purpose of the study was to compare golf swing kinematics between female and male professional golfers, with particular focus on areas where different risks of injury exist and variables that may be related to driving distance. Twenty-five LPGA golfers and twenty-five PGA golfers were tested. Customized computer software was developed to analyze kinematic data obtained with an optoelectronic system at 240 Hz. At the peak of back swing, significant differences were found in trunk forward tilt (LPGA: 25 +/- 4 degrees and PGA: 31 +/- 4 degrees ), and in pelvis orientation (LPGA: 49 +/- 8 degrees and PGA: 42 +/- 7 degrees ). Significantly different pelvis rotation at the ball impact was found (LPGA: - 52 +/- 11 degrees and PGA: - 42 +/- 12 degrees ). The LPGA group produced significantly less angular velocities of the club shaft (2049 +/- 512 degrees /s), the left wrist (816 +/- 186 degrees /s), the right wrist (864 +/- 198 degrees /s) and the elbow extension (705 +/- 109 degrees /s) than the PGA group. The results of this study show there are differences in the swing mechanics for men and women at the professional level. Major differences were found at the wrist and elbow, where different incidences of injury were previously reported.

The use of suture anchors has made arthroscopic repair of the torn rotator cuff possible. However, objective evaluations have demonstrated high failure rates. The goal of this study was to compare the modes and rates of failure of two double-row arthroscopic repair techniques and the mini-open double-row technique.Thirty pairs of fresh-frozen human shoulders were used in this study. The specimens were prepared to simulate a cuff defect, which was then repaired. The repairs were done with three different lateral row techniques (Mason-Allen sutures passed through transosseous tunnels, the knotless anchor method, and the corkscrew suture anchor method) with the same medial row technique (corkscrew suture anchors). Cyclic tests were conducted at 33 mm/s with a cyclic force of 10 to 180 N. Specimens were cycled to 5000 cycles or to failure as defined as formation of a 10-mm gap at the repair. Failure rates and failure modes of the suture, tendon, and bone-anchor interface were compared for the medial and lateral rows and among the three techniques.Fourteen of the twenty repairs made with the transosseous technique, fifteen of the twenty repairs made with the knotless anchor technique, and ten of the twenty repairs made with the corkscrew anchor technique survived 5000 cycles. The failure rates for the medial row were not significantly different among the three repair techniques. For the lateral row, there was a significant difference (p0.01) in the rate of failure among individual transosseous tunnel-suture complexes (32%), knotless anchor-suture complexes (48%), and corkscrew anchor-suture complexes (75%), with a similar suture-tendon failure rate for all three techniques. The tendon and repair complexes with corkscrew suture anchors had the smallest displacement both at the first and the 5000th cycle.Although repairs made with the anchor techniques had higher individual failure rates, the survival rates for the anchor techniques at the 5000th cycle were similar to that for the transosseous technique during cyclic tests. Suture failure was the main failure mode for the transosseous technique, whereas failure at the anchor-bone interface was the main failure mode for the anchor techniques.

The overhead throwing motion creates significant valgus and extension moments at the elbow, which can result in unique injury patterns seen in the throwing athlete. These abnormal forces can result in a multitude of distinct injuries, including ulnar collateral ligament tears and sprains, flexor-pronator mass tears and strains, ulnar neuritis, posteromedial impingement, olecranon stress fractures, osteochondritis dissecans (OCD) of the capitellum, and medial epicondyle apophyseal injuries. Accurate diagnosis and proper treatment of elbow injuries in the throwing athlete requires a thorough understanding of elbow function and anatomy, as well as an understanding of throwing mechanics and pathomechanics. The preoperative evaluation should focus on a thorough history and physical examination, followed by use of specific diagnostic imaging modalities. Recent advances in both nonoperative and operative treatment, including arthroscopic techniques, have afforded the athlete a successful return to competition.

Overhead athletes are susceptible to shoulder joint pathology due to the repetitive nature of throwing activities and the unique and sports-specific pattern of the sporting activities. Extreme forces are placed upon the glenohumeral joint as a result of anterior shear forces that approach 50 % body weight that occur as a result of high angular velocities that reach 7250°/s during the throwing motion [1–3]. High levels of muscular activity are generated during the throwing motion that approaches 120 % maximal volitional isometric contraction (MVIC) [4]. A delicate balance between adequate mobility and inherent shoulder stability is required to effectively perform overhead activities and to minimize the potential for shoulder pathology.

Background It has long been thought by many baseball coaches and players that throwing the fastball from the stretch is more stressful to the shoulder and elbow than throwing the fastball from the wind-up. However, no research has compared the biomechanics of these 2 pitch variations. Hypothesis There are differences in shoulder and elbow kinetics, kinematic position at front-foot contact, timing, and ball velocity between the 2 pitching variations. Study Design Controlled laboratory study. Methods Twenty-eight professional baseball pitchers (aged 22.1 ± 2.8 years) pitched fastballs from both the wind-up and stretch positions in an indoor laboratory setting. Three-dimensional motion-analysis systems were employed to capture the pitching motion. Kinetic variables, kinematic variables at lead-foot contact, and temporal variables of the 2 pitching variations were compared. Results There was no significant difference between the 2 pitch variations for the kinetic, kinematic, or temporal variables. The difference between the ball velocities was statistically significant, but the mean difference was only 0.2 m/s. Conclusions The pitching biomechanics between the wind-up and stretch fastball showed no statistical differences in joint kinetics, kinematics, or timing, and clinically insignificant differences in ball velocity. Clinical Relevance The current results suggest that pitching the fastball from the stretch is not necessarily more stressful to the shoulder and elbow.

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.

Background Magnetic resonance imaging (MRI) arthrography has been considered the gold standard for imaging ulnar collateral ligament (UCL) injuries. No classification system has been described for UCL tears to help discuss and guide treatment options. We propose that an MRI-based UCL classification system would correlate with valgus laxity and help predict surgical management. Methods The MRIs from 240 patients who underwent UCL reconstruction were reviewed and classified according to a system based on severity and location of the UCL injury. Bilateral elbow valgus stress radiographs were used to compare the amount of valgus laxity associated with each grade of UCL injury. Additional data from the imaging review included intraligamentous calcifications, T-sign presence, and a newly described “vacuum sign.” Results The amount of valgus stress opening increased with the classification severity as follows: type I, 0.13 mm; type II, 0.20 mm; type III, 0.63 mm; and type IV, 0.76 mm. Conclusions We propose a new classification for UCL injuries based on MRI findings that helps predict valgus laxity, improve communication, and guide treatment for UCL pathology in throwing athletes.

Background: A relatively high number of active professional baseball pitchers have a history of ulnar collateral ligament reconstruction (UCLr) on their throwing elbow. Controversy exists in the literature about whether professional baseball pitchers regain optimal performance after return from UCLr. It has been suggested that pitchers may have different biomechanics after UCLr, but this has not been previously tested. Hypothesis: It was hypothesized that, compared with a control group without a history of UCLr, professional pitchers with a history of UCLr would have (1) significantly different throwing elbow and shoulder biomechanics; (2) a shortened stride, insufficient trunk forward tilt, and excessive shoulder horizontal adduction, characteristics associated with “holding back” or being tentative; (3) late shoulder rotation; and (4) improper shoulder abduction and trunk lateral tilt. Study Design: Controlled laboratory study. Methods: A total of 80 active minor league baseball pitchers (and their 8 Major League Baseball organizations) agreed to participate in this study. Participants included 40 pitchers with a history of UCLr and a matched control group of 40 pitchers with no history of elbow or shoulder surgery. Passive ranges of motion were measured for each pitcher’s elbows and shoulders, and then 23 reflective markers were attached to his body. The pitcher took as many warm-up pitches as desired and then threw 10 full-effort fastballs for data collection. Ball speed was recorded with a radar gun. The reflective markers were tracked with a 10-camera, 240-Hz automated motion analysis system. Eleven biomechanical parameters were computed for each pitch and then averaged for each participant. Demographic, range of motion, and biomechanical parameters were compared between the UCLr group and the control group by use of Student t tests (significance set at P < .05). Results: All hypotheses were rejected, as there were no differences in pitching biomechanics between the UCLr group and the control group. There were also no differences in passive range of motion between the 2 groups. Conclusion: Compared with a control group, active professional pitchers with a history of UCLr displayed no significant differences in shoulder and elbow passive range of motion and no significant differences in elbow and shoulder biomechanics. Clinical Relevance: Clinical studies have previously shown that 10% to 33% of professional pitchers do not return to their preinjury level; however, the current study showed that those pitchers who successfully return to professional baseball after UCLr pitch with biomechanics similar to that of noninjured professionals.

Summary: Injuries to the elbow joint are becoming more and more prominent in today’s sporting society. This is largely because of the biomechanical demands during popular sports such as baseball, softball, and tennis; wherein the majority of elbow injuries occur. Implications for injuries in these sports range from overuse to incorrect mechanics, which cause increased loads at the elbow joint. This can be seen in the overhead throwing motion where a large varus torque leads to tensile injuries in the medial elbow and compressive injuries in the lateral elbow. The tennis serve produces large varus torque like in baseball pitching, but significantly less elbow extension velocity and elbow flexion torque. In cricket, elbow biomechanics play a very important role, as the rules prohibit elbow flexion during the arm acceleration of bowling. Windmill softball pitchers were once thought to not be at high risk for injury because of their style of throw. However, studies of windmill pitching reveal rapid kinematics and high kinetic loads that are leading to increased amounts of injuries. To improve on surgical treatment, physical therapy, and even prevention of elbow injuries, one must have a good understanding of the biomechanics of the elbow during these activities. This article presents recent advances in understanding elbow biomechanics during sports, based on studies published since the year 2000.

Articular cartilage lesions of the knee joint are common in patients of varying ages. Some articular cartilage lesions are focal lesions located on one aspect of the tibiofemoral or patellofemoral joint. Other lesions can be extremely large or involve multiple compartments of the knee joint and these are often referred to as osteoarthritis. There are numerous potential causes for the development of articular cartilage lesions: joint injury (trauma), biomechanics, genetics, activities, and biochemistry. Numerous factors also contribute to symptomatic episodes resulting from lesions to the articular cartilage: activities (sports and work), joint alignment, joint laxity, muscular weakness, genetics, dietary intake, and body mass index. Athletes appear to be more susceptible to developing articular cartilage lesions than other individuals. This is especially true with specific sports and subsequent to specific types of knee injuries. Injuries to the anterior cruciate ligament and/or menisci may increase the risk of developing an articular cartilage lesion. The treatment for an athletic patient with articular cartilage lesions is often difficult and met with limited success. In this article we will discuss several types of knee articular cartilage injuries such as focal lesions, advanced full-thickness lesions, and bone bruises. We will also discuss the risk factors for developing full-thickness articular cartilage lesions and osteoarthritis, and describe the clinical evaluation and nonoperative treatment strategies for these types of lesions in athletes.

Because youth athletes are smaller and weaker than their adult counterparts, smaller equipment and fields are often used in youth sports. Previous research has shown that youth baseball pitchers use similar motions to older pitchers, but generate lower kinetics and angular velocities at the shoulder and elbow. The purpose of this study was to determine potential biomechanical benefits for youth pitchers to use lighter baseballs. Thirty-four youth (11.1 ± 0.7 years) pitchers pitched both standard [5 ounce (142 g)] and lightweight [4 ounce(113 g)] baseballs in a laboratory setting. Kinematic and kinetic parameters were measured with a six-camera high-speed motion analysis system. Three repeated measures MANOVAs were used to compare (p > 0.05) position, velocity, and kinetic parameters between the standard and lightweight baseballs. Subjective data were also collected. Pitching the lightweight ball produced no difference in arm position, but greater shoulder, elbow, and ball velocities. With the lightweight ball, pitchers produced decreased kinetics.Post-hoc analysis of the kinetic data revealed significant decreases in elbow varus torque and shoulder internal rotation torque. The data suggest that playing with lightweight baseballs may reduce the risk of overuse injury in the youth pitcher and also help develop arm speed. However, before introducing lightweight baseballs into the youth game, the effect of lighter, faster pitched balls for the batters and fielders should also be considered.

BackgroundThere is little evidence supporting current safety recommendations for adolescent pitchers.HypothesisPitching practices of adolescent pitchers without history of arm injury will be significantly different from those of adolescent pitchers who required shoulder or elbow surgery.Study DesignCase control study; Level of evidence, 3.MethodsNinety-five adolescent pitchers who had shoulder or elbow surgery and 45 adolescent pitchers who never had a significant pitching-related injury completed a survey. Responses were compared between the 2 groups using t tests and analyses. Multivariable logistic regression models were developed to identify the risk factors.ResultsThe injured group pitched significantly more months per year, games per year, innings per game, pitches per game, pitches per year, and warm-up pitches before a game. These pitchers were more frequently starting pitchers, pitched in more showcases, pitched with higher velocity, and pitched more often with arm pain and fatigue. They also used anti-inflammatory drugs and ice more frequently to prevent an injury. Although the groups were age matched, the injured group was taller and heavier. There were no significant differences regarding private pitching instruction, coach's chief concern, pitcher's self-rating, exercise programs, stretching practices, relieving frequency, pitch type frequency, or age at which pitch types were first thrown.ConclusionPitching practices were significantly different between the groups. The factors with the strongest associations with injury were overuse and fatigue. High pitch velocity and participation in showcases were also associated with increased risk for injury.Clinical RelevanceNew recommendations were made based on these results. Adherence to the recommendations may reduce the incidence of significant injury to adolescent pitchers.

Elbow varus torque is a primary factor in the risk of elbow injury during pitching. To examine the effects of shoulder abduction and lateral trunk tilt angles on elbow varus torque, we conducted simulation and regression analyses on 33 college baseball pitchers. Motion data were used for computer simulations in which two angles— shoulder abduction and lateral trunk tilt—were systematically altered. Forty-two simulated motions were generated for each pitcher, and the peak elbow varus torque for each simulated motion was calculated. A two-way analysis of variance was performed to analyze the effects of shoulder abduction and trunk tilt on elbow varus torque. Regression analyses of a simple regression model, second-order regression model, and multiple regression model were also performed. Although regression analyses did not show any significant relationship, computer simulation indicated that the peak elbow varus torque was affected by both angles, and the interaction of those angles was also significant. As trunk tilt to the contralateral side increased, the shoulder abduction angle producing the minimum peak elbow varus torque decreased. It is suggested that shoulder abduction and lateral trunk tilt may be only two of several determinants of peak elbow varus torque.

Pathology of the superior aspect of the glenoid labrum (SLAP lesion) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important to determine the most appropriate nonoperative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum, while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions, including 3 newly described tests. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

To reach the level of elite, most baseball pitchers need to consistently produce high ball velocity but avoid high joint loads at the shoulder and elbow that may lead to injury. This study examined the relationship between fastball velocity and variations in throwing mechanics within 19 baseball pitchers who were analyzed via 3-D high-speed motion analysis. Inclusion in the study required each one to demonstrate a variation in velocity of at least 1.8 m/s (range 1.8–3.5 m/s) during 6 to 10 fastball pitch trials. Three mixed model analyses were performed to assess the independent effects of 7 kinetic, 11 temporal, and 12 kinematic parameters on pitched ball velocity. Results indicated that elbow flexion torque, shoulder proximal force, and elbow proximal force were the only three kinetic parameters significantly associated with increased ball velocity. Two temporal parameters (increased time to max shoulder horizontal adduction and decreased time to max shoulder internal rotation) and three kinematic parameters (decreased shoulder horizontal adduction at foot contact, decreased shoulder abduction during acceleration, and increased trunk tilt forward at release) were significantly related to increased ball velocity. These results point to variations in an individual's throwing mechanics that relate to pitched ball velocity, and also suggest that pitchers should focus on consistent mechanics to produce consistently high fastball velocities. In addition, pitchers should strengthen shoulder and elbow musculature that resist distraction as well as improve trunk strength and flexibility to maximize pitching velocity and help prevent injury.

Background The pathogenesis of superior labral anterior posterior lesions remains controversial. Hypothesis The biceps anchor is more vulnerable to loading with a posterior vector as opposed to an in-line pull. Study Design Controlled laboratory study. Methods Eight pairs of cadaveric shoulders were dissected, and the biceps tendon was loaded to failure in 1 of 2 loading patterns. Loading pattern A was meant to simulate the eccentric load of the biceps in the deceleration phase of throwing; loading pattern B was meant to simulate the posterior biceps load of the late cocking phase. Results The biceps anchor demonstrated significantly increased ultimate strength with in-line loading (group A, 508 N) as opposed to posterior loading (group B, 262 N, P < .001). All group B specimens failed at the biceps anchor, resulting in a type II superior labral anterior posterior lesion. Specimens in group A did not create a superior labral anterior posterior lesion. Conclusions Direction of biceps loading resulted in significant differences in the ultimate strength of the biceps anchor and the generation of superior labral anterior posterior lesions. The biceps anchor was significantly weaker when loaded with a posterior vector. Relevance The superior labrum may be most vulnerable to injury in late cocking. The reproducible generation of type II superior labral anterior posteriorlesions may have applications as a biomechanical model.

The thrower’s exostosis or Bennett lesion is a unique finding in throwing athletes. The presentation of posterior shoulder pain is a finding with many eitiologies. Too often, the thrower’s exostosis is overlooked as a cause for posterior inferior shoulder pain. This osteophyte found on the p

Background Low back pain is fairly prevalent among golfers; however, its precise biomechanical mechanism is often debated. Hypothesis There is a positive correlation between decreased lead hip rotation and lumbar range of motion with a prior history of low back pain in professional golfers. Study Design A cross-sectional study. Methods Forty-two consecutive professional male golfers were categorized as group 1 (history of low back pain greater than 2 weeks affecting quality of play within past 1 year) and group 2 (no previous such history). All underwent measurements of hip and lumbar range of motion, FABERE's distance, and finger-to-floor distance. Differences in measurements were analyzed using the Wilcoxon signed rank test. Results 33% of golfers had previously experienced low back pain. A statistically significant correlation (P < .05) was observed between a history of low back pain with decreased lead hip internal rotation, FABERE's distance, and lumbar extension. No statistically significant difference was noted in nonlead hip range of motion or finger-to-floor distance with history of low back pain. Conclusions Range-of-motion deficits in the lead hip rotation and lumbar spine extension correlated with a history of low back pain in golfers.

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 elbow joint is susceptible to injuries in the overhead athlete due to the large amount of forces observed during the act of throwing. Injuries often occur due to repetitive microtrauma nature of throwing. Rehabilitation following injury or surgery to the throwing elbow is vital to fully restore normal function and return the athlete to competition as quickly and safely as possible. Rehabilitation of the elbow, whether post-injury or postsurgical, must follow a progressive and sequential order to ensure that healing tissues are not overstressed. Emphasis is placed on restoring full motion, muscular strength, and neuromuscular control. The purpose of this article is to provide an overview of a multiphased rehabilitation program for the thrower's elbow. In addition, rehabilitation for specific nonoperative and postoperative pathologies often observed in the throwing athlete is discussed.

Descriptive postoperative follow-up research.The purpose of this investigation was to describe the return-to-competition rate and functional outcome of overhead athletes following arthroscopic thermal-assisted capsular shrinkage (TACS).Traditional open procedures to correct instability in overhead athletes, such as capsulolabral repairs and capsular shifts, have produced less-than-favorable results, which have led to the development of TACS. Currently there are no long-term follow-up studies documenting the efficacy of this procedure in groups greater than 31 subjects or for a time period greater than 27 months.Two hundred thirty-one consecutive overhead athletes who due to symptoms of hyperlaxity had previously undergone a TACS procedure from 1997 to 1999 were selected for inclusion in the study. During a 1-month period, 130 of these athletes (mean age +/- SD, 24 +/- 6 years; 113 male, 17 female) were contacted by phone for follow-up at a mean of 29.3 months postoperatively (range, 15.4-46.6 months). Of the 130, 105 participated in baseball (80 pitchers), 14 in softball, 4 in football (quarterbacks), 4 in tennis, and 3 in swimming. Fifty-four (42%) subjects were professional, 49 (38%) collegiate, 16 (12%) high school, and 11 (8%) recreational athletes. One hundred twenty-three of the 130 (95%) underwent 1 or more concomitant procedure(s) at the time of TACS. Most commonly performed were labral debridements (69%), rotator cuff debridements (65%), and superior labral repairs (35%). Subjects who returned to competition were retrospectively evaluated using a modified Athletic Shoulder Outcome Rating Scale to subjectively assess pain, strength and endurance, stability, intensity, and performance. Overall results were based on a 90-point scale with scores of 80 to 90 representing excellent, 60 to 79 good, 40 to 59 fair, and less than 40 poor results.One hundred thirteen out of 130 subjects (87%) returned to competition. Mean (+/-SD) time from surgery to return to competition was 8.4 +/- 4.6 months. Mean outcome score for all subjects was 79/90; 75 (66%) subjects had excellent, 24 (21%) good, 11 (10%) fair, and 3 (3%) poor result. The mean outcome score for males was 80/90 and for females was 70/90.The majority of overhead athletes (87%) successfully returned to competition following a TACS procedure with good-to-excellent long-term outcomes (88%). Based on the results of this study, TACS of the glenohumeral joint is a viable option for overhead athletes with pathological instability.

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.