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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.

Hoewel revalidatie na elleboogletsel in de fysiotherapeutische praktijk nogal eens voorkomt, is er relatief weinig literatuur waarin wordt ingegaan op het revalidatieproces van de geblesseerde elleboog. Het elleboogcomplex is in die zin bijzonder, dat de drie beenderen waaruit het bestaat, zodanig zijn gerangschikt dat ze vier gewrichtsfuncties uitoefenen. Een en ander draagt bij tot een hoge mate van gewrichtscongruentie en confronteert de therapeut, bij diens pogingen de normale elleboogfunctie te herstellen na een letsel, met een veelvoud van klinische problemen. Doel van dit artikel is deze problemen nader toe te lichten en mogelijke oplossingen aan te dragen.

Elbow and shoulder kinetics for 26 highly skilled, healthy adult pitchers were calculated using high-speed motion analysis. Two critical instants were 1) shortly before the arm reached maximum external rotation, when 67 N-m of shoulder internal rotation torque and 64 N-m of elbow varus torque were generated, and 2) shortly after ball release, when 1090 N of shoulder com pressive force was produced. Inability to generate suf ficient elbow varus torque may result in medial tension, lateral compression, or posteromedial impingement in jury. At the glenohumeral joint, compressive force, joint laxity, and 380 N of anterior force during arm cocking can lead to anterior glenoid labral tear. Rapid internal rotation in combination with these forces can produce a grinding injury factor on the labrum. After ball release, 400 N of posterior force, 1090 N of compressive force, and 97 N-m of horizontal abduction torque are gener ated at the shoulder; contribution of rotator cuff muscles in generating these loads may result in cuff tensile fail ure. Horizontal adduction, internal rotation, and superior translation of the abducted humerus may cause sub acromial impingement. Tension in the biceps tendon, due to muscle contraction for both elbow flexion torque and shoulder compressive force, may tear the antero superior labrum.

SummaryThe rehabilitation program following an elbow injury or elbow surgery plays a vital role in ultimate outcome. The unique orientation of the elbow complex, high degree of joint congruence, and capsular configuration contribute to much of the difficulty experienced by the therapist in treating

SummaryRotator cuff injuries in the overhead athlete are frequently seen at all levels of competitive sports. The repetitive, high magnitude forces generated at the capsuloligamentous complex, as well as at the rotator cuff itself, can result in loss of glenohumeral stability and primary as well as

Changes in a range of chlorophyll fluorescence parameters were monitored for leaves of crops of three Zea mays cultivars (MO17, CB3 and LG11) during early canopy development when large fluctuations in air temperatures occur. Crops were sown on 1 May 1993 and measurements made between 17 May and 7 June. Measurements of the ratio of variable to maximal fluorescence of dark-adapted leaves (Fv/Fm) and the quantum efficiency of photosystem II photochemistry (Φ PSII ), the efficiency of excitation energy transfer to open photosystem II reaction centres (Fv'/Fm') and the photochemical quenching coefficient (q p ) for leaves operating at a photon flux density of 250 μmol m -2 s -1 were made during the day at 3 h intervals. Fluctuations were observed in Fv/Fm, Φ PSII and Fv'/Fm' throughout the period and significant decreases occurred during periods of low temperatures and high photon flux densities, indicating chill-induced photoinhibition of photosynthesis. Changes in Fv/Fm were highly correlated with changes in Φ PSII for all three cultivars. Measurements of Φ PSII , Fv'/Fm', q p and the quantum efficiency of CO 2 assimilation (Φ CO2 ) at a photon flux density of 1000 μmol m -2 s -1 were made for leaves at 08.00 h each morning and demonstrated that changes in Φ PSII were highly correlated with changes in CO 2 assimilation. Chill-induced changes in Φ PSII were shown to be correlated with changes in the quenching of excitation energy in the antennae of photosystem II and not with changes in the redox state of the electron acceptors of photosystem II. It is concluded that measurements of Fv/Fm and Φ PSII provide useful, rapid and non-invasive probes of the photosynthetic performance of maize leaves in the field during periods of chill-induced photoinhibition.

Cruciate ligament injuries are common and may lead to dysfunction if not rehabilitated. Understanding how to progress anterior cruciate ligament and posterior cruciate ligament loading, early after injury or reconstruction, helps clinicians prescribe rehabilitation exercises in a safe manner to enhance recovery. Commonly prescribed therapeutic exercises include both weight-bearing exercise and non-weight-bearing exercise. This review was written to summarize and provide an update on the available literature on cruciate ligament loading during commonly used therapeutic exercises. In general, weight-bearing exercise produces smaller loads on the anterior cruciate ligament and posterior cruciate ligament compared with non-weight-bearing exercise. The anterior cruciate ligament is loaded less at higher knee angles (i.e. 50–100°). Squatting and lunging with a more forward trunk tilt and moving the resistance pad proximally on the leg during the seated knee extension unloads the anterior cruciate ligament. The posterior cruciate ligament is less loaded at lower knee angles (i.e. 0–50°), and may be progressed from level ground walking to a one-leg squat, lunges, wall squat, leg press, and the two-leg squat (from smallest to greatest). Exercise type and technique variation affect cruciate ligament loading, such that the clinician may prescribe therapeutic exercises to progress ligament loading safely, while ensuring optimal recovery of the musculoskeletal system.

The assessment of physiologic mobility of the glenohumeral joint in overhead athletes has received significant attention in recent literature.¶ In particular, internal rotation (IR) range of motion (ROM) of the glenohumeral joint and tightness of the posterior glenohumeral joint capsule have been the focus of many discussions.2,3The dominant shoulder of overhead athletes exhibits significantly greater external rotation and a decrease in IR in comparison to the nondominant shoulder.1,3,4,9,10,12,19 Several theories exist regarding the cause of this unique motion characteristic of the overhead athlete. These include posterior capsular tightness,5,7,8 osseous adaptation,3,9,16 and muscular tightness.3,19 Controversy exists regarding the exact mechanism of loss of IR. However, most authors agree that a significant loss of IR may lead to several pathologies. Warner et al17 noted a significant decrease in glenohumeral joint IR in patients with subacromial impingement. Wilk and Andrews18 reported a reverse capsular pattern in patients with subacromial impingement syndrome in whom IR was most limited, followed by a loss of abduction and then external rotation. Burkhart et al5 stated that an asymptomatic shoulder that exhibits a moderate degree of IR loss was more susceptible to developing pathologies such as “dead arm” syndrome and superior labral anterior and posterior (SLAP) lesions. Furthermore, these authors described an acronym for the clinical observation of decreased IR, termed glenohumeral IR deficit (GIRD). Recently, Wilk et al (unpublished data, 2008) reported a correlation between GIRD and shoulder injuries in professional baseball pitchers followed over a 3-year period. Furthermore, they reported that pitchers with GIRD exhibited a 2.4-times greater risk of shoulder injuries than pitchers without GIRD. These findings support the importance of accurately assessing IR in the overhead athlete. Although the importance of assessing glenohumeral joint IR ROM has been well established, controversy exists regarding the most accurate method to measure this motion. Several techniques and corresponding values of IR ROM have been reported, including active ROM assessed in regard to the vertebral level that can be reached behind the back1 and passive ROM measured at 90° of shoulder abduction. Numerous authors have emphasized the importance of using scapulothoracic joint stabilization to restrict scapular movement.7,10,14 Unfortunately, in many instances, the illustrations and/or descriptions were not clearly stated by the investigators. Consequently, tremendous variability exists in published mean ROM values, from 83° in asymptomatic pitchers by Brown et al,4 to 62° in professional pitchers by Wilk and Andrews,18 to 36° in throwers by Meister et al.14 Thus, the lack of a uniform method of measuring IR makes it difficult to compare passive ROM data from one study to another, or to compare patient clinical findings to those of published studies. There exist 3 methods of assessing IR passive ROM of the glenohumeral joint at 90° of shoulder abduction. These methods include providing stabilization of the scapula, stabilization of the humeral head, or visual inspection only (with no stabilization). Clinically, it has been our observation that each method renders significantly different IR passive ROM values compared to the other methods, and thus the 3 are not comparable. The purpose of this study was to determine the reliability and compare the results of 3 different methods of assessing glenohumeral joint IR passive ROM in asymptomatic overhead athletes. We hypothesized that significant differences exist in the amount of IR ROM between these 3 clinical techniques.

The overhead throwing athlete is an extremely challenging patient in sports medicine. The repetitive microtraumatic stresses imposed on the athlete’s shoulder joint complex during the throwing motion constantly place the athlete at risk for injury. Treatment of the overhead athlete requires the understanding of several principles based on the unique physical characteristics of the overhead athlete and the demands endured during the act of throwing. These principles are described and incorporated in a multiphase progressive rehabilitation program designed to prevent injuries and rehabilitate the injured athlete, both nonoperatively and postoperatively.

Throwing velocity is an important baseball performance variable for baseball pitchers, because greater throwing velocity results in less time for hitters to make a decision to swing. Throwing velocity is also an important baseball performance variable for position players, because greater throwing velocity results in decreased time for a runner to advance to the next base. This study compared the effects of 3 baseball-specific 6-week training programs on maximum throwing velocity. Sixty-eight high school baseball players 14-17 years of age were randomly and equally divided into 3 training groups and a nontraining control group. The 3 training groups were the Throwers Ten (TT), Keiser Pneumatic (KP), and Plyometric (PLY). Each training group trained 3 d·wk(-1) for 6 weeks, which comprised approximately 5-10 minutes for warm-up, 45 minutes of resistance training, and 5-10 for cool-down. Throwing velocity was assessed before (pretest) and just after (posttest) the 6-week training program for all the subjects. A 2-factor repeated measures analysis of variance with post hoc paired t-tests was used to assess throwing velocity differences (p < 0.05). Compared with pretest throwing velocity values, posttest throwing velocity values were significantly greater in the TT group (1.7% increase), the KP group (1.2% increase), and the PLY group (2.0% increase) but not significantly different in the control group. These results demonstrate that all 3 training programs were effective in increasing throwing velocity in high school baseball players, but the results of this study did not demonstrate that 1 resistance training program was more effective than another resistance training program in increasing throwing velocity.

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 excessive forward movement of the knees beyond the toes and with the heels off the ground tends to increase ACL loading. Squatting and lunging with a forward trunk tilt tend to decrease ACL loading, likely due to increased hamstrings activity. During seated knee extension, ACL force decreases when the resistance pad is positioned more proximal on the anterior aspect of the lower leg, away from the ankle. The evidence reviewed as part of this manuscript provides objective data by which to rank exercises based on loading applied to the ACL. The biggest challenge in exercise selection post-ACL reconstruction is the limited knowledge of the optimal amount of stress that should be applied to the ACL graft as it goes through its initial incorporation and eventual maturation process. Clinicians may utilize this review as a guide to exercise selection and rehabilitation progression for patients post-ACL reconstruction.

The overhead throwing motion is a high-velocity, extremely stressful athletic movement. Its repetitive nature places tremendous demands on the entire body, frequently resulting in injury to the throwing shoulder. Such injuries, whether managed nonoperatively or surgically, require a multiphased approach beginning with exercises to restore muscular strength and proprioception, and advancing to more demanding exercises to improve power, endurance, and dynamic control. This article presents a new and innovative approach to the rehabilitation of the overhead throwing athlete, The Advanced Throwers Ten Exercise Program. This expanded program incorporates throwing motion-specific exercises and movement patterns performed in a discrete series, utilizing principles of coactivation, high-level neuromuscular control, dynamic stabilization, muscular facilitation, strength, endurance, and coordination, which all serve to restore muscle balance and symmetry in the overhead throwing athlete. This program is a continuation of the Throwers Ten Exercise Program, which has been utilized with excellent results in clinical practice and in athletic performance training. This unique combination of advanced exercise techniques bridges the gap between rehabilitation and training, facilitating a kinetic linking of the upper and lower extremities and providing a higher level of humeral head control necessary for the overhead throwing athlete's symptom-free return to sports.

The histology and arthroscopic anatomy of the ulnar collateral ligament of the elbow were studied in cadav eric specimens. The capsule consists of two layers of collagen fibers, with two distinct ligamentous bundles corresponding to anterior and posterior portions of the ulnar collateral ligament. The posterior bundle consists of distinct collagen bundles within the layers of the cap sule ; the anterior bundle consists of a similar thickening within the capsular layers, with an additional ligament complex superficial to the capsular layers. With arthros copy only the anterior 20% to 30% of the anterior bundle of the ulnar collateral ligament could be visualized via the anterior portal. Only the posterior 30% to 50% of the posterior bundle could be seen via the posterior portals. After sectioning of the anterior bundle, joint instability was noted arthroscopically by an increased opening in the ulnohumeral joint with application of valgus stress. At arthroscopy ulnar collateral ligament tears may be visualized in part or not at all. To diagnose a tear or laxity in the ulnar collateral ligament, a demonstration of an increase in the opening of the ulnohumeral joint in re sponse to valgus stress is useful.

It is important to examine the functional relationships between commonly performed clinical tests and to resolve inconsistencies in previous investigative results. The purpose of this study was to determine if a correlation exists between three commonly performed clinical tests: isokinetic isolated knee concentric muscular testing, the single-leg hop test, and the subjective knee score in anterior cruciate ligament reconstructed knees. To determine if a relationship exists would be beneficial to clinicians in determining patient progression, treatment modification, and return-to-sport objective parameters. Several investigators have analyzed two of these parameters, but no one has investigated three parameters to date. Additionally, this study explored the concept of limb acceleration and deceleration during high-speed isokinetics and its relationship to function. Fifty patients were randomly selected (29 males) with a mean age of 23.7 years (range 15-52). The subjects completed a subjective knee score questionnaire that rated symptoms (pain, swelling, giving way) and specific sport function and completed an overall knee score assessment. The patients were then evaluated performing three one-legged functional tests: 1) hop for distance, 2) timed hop, and 3) cross-over triple hop. Isokinetic testing was performed on a Biodex dynamometer at 180, 300, and 450 degrees/sec for knee extension/flexion. The patients' mean value of the self-assessed knee rating was 86 points. Sixty-four percent of the patients exhibited normal limb symmetry (within 85%) on all three single-leg hop tests. Sixteen percent exhibited quadriceps strength at least 90% of the contralateral limb isokinetically. A positive correlation was noted between isokinetic knee extension peak torque (180, 300 degrees/sec) and subjective knee scores, and the three hop tests (p0.001). A statistical trend was noted between knee extension acceleration and deceleration range at 180 and 300 degrees/sec for the timed hop test and triple cross-over hop (r = 0.48, r = 0.49, r = 0.51, r = 0.49). No positive correlations were found for isokinetic test results for the knee flexors.

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.

To study the usefulness of stress radiography for evaluation of injury to the medial collateral ligament (MCL).Forty-two injured athletes and four healthy athletes without symptoms underwent examination performed with a stress device. The increase in joint space width between the medial epicondyle and coronoid process, measured on anteroposterior radiographs obtained after 0 and 15 daN force was applied to the lateral elbow joint, was used to assess the extent of ligament tear. The validity of this technique was tested with study of selectively severed cadaveric MCLs.All complete and large partial tears were correctly diagnosed with stress radiography when the increase in joint space width was larger by 0.5 mm in the affected elbow compared with the opposite normal elbow. In subjects with values less than 0.5 mm, the MCLs were normal or showed a small tear that could be managed conservatively.Stress radiography of the MCL enables accurate diagnosis of large and complete tears and distinction between such tears and small partial tears and normal ligaments.

Nineteen consecutive cases of posttraumatic arthrofi brosis of the elbow secondary to a fracture or fracture- dislocation and treated with arthroscopic debridement and manipulation were retrospectively reviewed. All of the patients had pain and stiffness in their elbows, and all had failed a conservative therapy program. All 19 patients were followed postoperatively for an average of 29 months (range, 12 to 51). One hundred-point scoring systems were used to evaluate subjective (pain, swell ing, locking, and activities) and objective (range of mo tion) results.The average preoperative subjective score of 39 im proved to 91 postoperatively (P= 0.0001); the objective score improved from 46 preoperatively to 81 postop eratively (P = 0.0001). Extension improved from a mean of 29° to 11 °; flexion improved from an average of 123° to 134°. Fourteen patients had limitations in their sports activity preoperatively; 11 were able to return to their preinjury levels of activity after surgery.This study demonstrated good-to-excellent overall re sults in 79% of the patients treated with arthroscopic debridement for posttraumatic elbow arthrofibrosis. Al though complete return of preinjury motion was not ob tained, each patient showed a significant improvement in motion and subjective symptoms.

A prospective study was completed on 25 baseball play ers with medial side elbow pain. They were evaluated preoperatively with both computed tomography arthro gram and magnetic resonance imaging examinations of the elbow to assess the ulnar collateral ligament. At surgery, 16 of 25 patients had an abnormal ulnar col lateral ligament and 9 patients had a normal ulnar col lateral ligament. The computed tomography arthrogram detected abnormalities in 12 of the 14 patients with ulnar collateral ligament tearing (sensitivity, 86%). The mag netic resonance imaging scan indicated abnormalities in 8 of 14 patients (sensitivity, 57%). The specificity of the computed tomography arthrogram was 91 % and the magnetic resonance imaging was 100%. A newly described "T-sign" was seen on the com puted tomography arthrogram in the patients with an undersurface tear of the ulnar collateral ligament. This represented the dye leaking around the detachment of the ulnar collateral ligament from its bony insertion but remaining contained within the intact superficial layer of the ulnar collateral ligament and capsule. Both the computed tomography arthrogram and the magnetic resonance imaging scan were accurate in di agnosing a complete tear of the ulnar collateral ligament preoperatively in all cases. The main advantage of the computed tomography arthrogram was in evaluating the partial undersurface tear.

Controlled laboratory study.To test for kinematic and kinetic differences between baseball pitching from a mound and long-toss on flat ground.Long-toss throws from flat ground are commonly used by baseball pitchers for rehabilitation, conditioning, and training. However, there is controversy over the biomechanics and functionality of such throws.Seventeen healthy, college baseball pitchers pitched fastballs 18.4 m from a mound to a strike zone, and threw 37 m, 55 m, and maximum distance from flat ground. For the 37-m and 55-m throws, participants were instructed to throw "hard, on a horizontal line." For the maximum-distance throw, no constraint on trajectory was given. Kinematics and kinetics were measured with a 3-dimensional, automated motion analysis system. Repeated-measures analyses of variance, with post hoc paired t tests, were used to compare the 4 throw types within pitchers.At foot contact, the participant's shoulder line was nearly horizontal when pitching from a mound and became progressively more inclined as throwing distance increased. At arm cocking, the greatest amount of shoulder external rotation (mean ± SD, 180° ± 11°), elbow flexion (109° ± 10°), shoulder internal rotation torque (101 ± 17 Nm), and elbow varus torque (100 ± 18 Nm) were measured during the maximum-distance throws. Elbow extension velocity was also greatest for the maximum-distance throws (2573°/s ± 203°/s). Forward trunk tilt at the instant of ball release decreased as throwing distance increased.Hard, horizontal, flat-ground throws have biomechanical patterns similar to those of pitching and are, therefore, reasonable exercises for pitchers. However, maximum-distance throws produce increased torques and changes in kinematics. Caution is, therefore, advised in the use of these throws for rehabilitation and training.

Concerns about the processes used to evaluate disability in injured military service members continues today with the ongoing conflicts in Operation Iraqi Freedom and Operation Enduring Freedom. This study will attempt to analyze the Physical Disability Evaluation System (PDES) in the Army and make recommendations to transform and revolutionize the current system. The current Disability Evaluation System (DES) is inadequate and does not effectively support volunteer force and requires maintaining a large number of Wounded, III and Injured (WII) Service Members in uniform while they navigate an inefficient system of disability adjudication. The value of the study is its potential benefit for Soldiers undergoing disability review, and to the United States Army personnel and medical system. Recommendations in this study could benefit the medical community by possibly decreasing the time Soldiers remain on protracted active duty in the Military Treatment Facility without decrement in the access of quality of medical care provided to wounded, ill and injured Soldiers. Recommendations could also benefit Soldiers by enabling returning to duty or being allowed to enter the civilian community in a more expeditious manner. Lastly, the recommedations could also positively affect the overall readiness of our Army.

Because of the popularity of sports participation, sports physical therapists must recognize in the athlete the many clinical conditions that occur about the elbow. The purpose of this paper is to present the most common elbow problems that an athlete may encounter and to provide information to facilitate recognition of elbow pathology. This information is essential before initiating treatment. An attempt is made to include sprains, strains, neuropathies, dislocations, fractures, contusions, vascular insults, and skin problems in the distal humerus, elbow, and proximal forearm of both the immature and mature athlete. Comprehension of the mechanism of injury aids clinical evaluation and rehabilitation and enhances early return to activity.

Techniques that both enable family members and assist in accomplishing the goals of the Individual Family Service Plan (IFSP) are described in the context of family-centered early intervention services. The techniques to be described are from the field of family therapy and have been adapted by the authors, a family therapist and a speech-language pathologist, for use by early intervention professionals.

This essay argues that the debate over British intervention in the American Civil War allowed for realignment of the parameters of the rhetorically constructed notion of “national interests.” Such constructions prior to the speech under investigation limited moral considerations; the context of the recognition debate afforded the opportunity to situate morality within the dominant sphere of consciousness of “interest.” A close reading of John Bright's speech in opposition to Confederate recognition demonstrates the ways this opportunity was exploited and reveals the speech as an instantiation of the rhetorical shift in the meaning of national interests.

Background: The risk of elbow or shoulder injury for young baseball pitchers is unknown. Purpose/Hypothesis: The purpose of this study was to quantify the cumulative incidence of throwing injuries in young baseball pitchers who were followed for 10 years. Three hypotheses were tested: Increased amount of pitching, throwing curveballs at a young age, and concomitantly playing catcher increase a young pitcher’s risk of injury. Study Design: Cohort study; Level of evidence, 3. Methods: In sum, 481 youth pitchers (aged 9 to 14 years) were enrolled in a 10-year follow-up study. Participants were interviewed annually. Injury was defined as elbow surgery, shoulder surgery, or retirement due to throwing injury. Fisher exact test compared the risk of injury between participants who pitched at least 4 years during the study and those who pitched less. Fisher exact tests were used to investigate risks of injury for pitching more than 100 innings in at least 1 calendar year, starting curveballs before age 13 years, and playing catcher for at least 3 years. Results: The cumulative incidence of injury was 5.0%. Participants who pitched more than 100 innings in a year were 3.5 times more likely to be injured (95% confidence interval = 1.16 to 10.44). Pitchers who concomitantly played catcher seemed to be injured more frequently, but this trend was not significant with the study sample size. Conclusion: Pitching more than 100 innings in a year significantly increases risk of injury. Playing catcher appears to increase a pitcher’s risk of injury, although this trend is not significant. The study was unable to demonstrate that curveballs before age 13 years increase risk of injury. Clinical Relevance: The risk of a youth pitcher sustaining a serious throwing injury within 10 years is 5%. Limiting the number of innings pitched per year may reduce the risk of injury. Young baseball pitchers are encouraged to play other positions as well but might avoid playing catcher.

An os subtibiale is an accessory bone separated from the distal medial tibia proper. Subtalar tarsal coalition is a failure of joint formation between the talus and calcaneus during hindfoot maturation. The patient in this case report has large bilateral os subtibiale and subtalar coalitions, which were undiagnosed throughout his soccer career until recently when he began having anteriorlateral ankle pain. After failing conservative treatment the patient underwent ankle arthroscopy, which revealed a fully separated, large articular portion of the medial malleolus. The hypertrophic synovium and cartilage were debrided and the patient had a full recovery, returning to soccer 8 weeks after surgery. Os subtibiale is a rare but well-described entity in the radiology and orthopaedic liturature. To our knowledge, bilateral os subtibiale this large has not been described. In addition, an os subtibiale with concomitant subtalar coalition has never been reported. This report will hopefully alert clinicians about these 2 rare anatomic findings and encourage them to use caution when evaluating suspected fractures of the medial malleolus that could be functional os subtibiale ossicles. In addition, we hope to shed some light on the complicated coupling of motion between the ankle and subtalar joint. These may have developed together to allow more normal coupled motion between the ankle and subtalar joint in this high-level college soccer player, and may be relevant to future reports or research in this area.

Background Rupture of the anterior cruciate ligament (ACL) is a common and potentially career-threatening injury in the National Football League (NFL). The return to play (RTP) percentage and the factors affecting RTP after ACL reconstruction in NFL players are not well defined. Purpose To determine the actual rate of return to professional football play in the NFL after ACL reconstruction surgery and to determine what factors can predict ability to RTP. We hypothesize that the RTP percentage in this unique patient population will differ from previously reported populations. Study Design Case series; Level of evidence, 4. Methods Forty-nine NFL athletes who had undergone primary ACL reconstruction at our institution were followed to determine their RTP percentages and factors predicting RTP. Results Sixty-three percent (31 of 49) of NFL athletes returned to NFL game play at an average of 10.8 months after surgery. Age at time of surgery, position, and the type and number of procedures were not significantly different between those who did and did not return to play. The average number of games before surgery was 51 for those who did return to play and 28 for those who did not (P = .039). The odds ratio favoring RTP was 5.5 (P = .016) for those players who had more than 4 years of NFL experience before surgery. The average NFL draft round was 3.4 for the group who returned to play and 6.4 for those who did not (P < .001). The odds ratio favoring RTP was 12.2 (P < .001) for those players drafted in the first 4 rounds of the NFL draft compared with those drafted after the fourth round. Conclusions The RTP rates after ACL reconstruction in NFL football players are lower than previously perceived. More experienced and established athletes are more likely to return to competition at the same level after this procedure than those with less professional experience. Being selected in the first 4 rounds of the NFL draft was highly predictive of RTP.

The demands that throwing places on the vulnerable immature elbow frequently produce multiple injuries. Significant clues in the history include persistent medial elbow soreness, stiffness, and discomfort that lead to poor performance. Diagnosis involves identifying the injury sites by palpation and x-rays that pinpoint growth-plate separation or osteochondral changes. Nonoperative treatment, which can proceed if growth-plate separation at the medial apophysis is less than 3 mm, involves stretching, strengthening, sport-specific activities, and interval throwing. Prevention includes conditioning, limiting the number of pitches, and using age guidelines for learning new pitches.

Rehabilitation following anterior cruciate ligament reconstruction surgery has changed significantly in the past 5 yr. Today, rehabilitation protocols emphasize immediate motion, immediate weight bearing, and early strengthening exercises. An aggressive rehabilitation program based on the healing rate, biomechanics of the knee joint, and principles of muscle physiology is imperative for successful rehabilitation. This study reports the isokinetic muscular performance data of 100 male recreational athletes collected 6 months postsurgery. The results demonstrated statistically significant differences (p < 0.001) for all knee extension parameters, including peak torque to body weight, total work to body weight, and average power to body weight ratios at 180 deg/sec and 300 deg/sec. In contrast, knee flexion testing exhibited no significant differences in any of the above

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.

We propose that learning proper hitting kinematics should be encouraged at a young age during youth baseball because this may help reinforce proper hitting kinematics as a player progresses to higher levels of baseball in their adult years. To enhance our understanding between youth and adult baseball hitting, kinematic and temporal analyses of baseball hitting were evaluated with a high-speed motion analysis system between 12 skilled youth and 12 skilled adult baseball players. There were only a small number of temporal differences between youth and adult hitters, with adult hitters taking significantly greater time than youth hitters during the stride phase and during the swing. Compared with youth hitters, adult hitters a) had significantly greater (p < .01) lead knee flexion when the hands started to move forward; b) flexed the lead knee over a greater range of motion during the transition phase (31 degrees versus 13 degrees); c) extended the lead knee over a greater range of motion during the bat acceleration phase (59 degrees versus 32 degrees); d) maintained a more open pelvis position at lead foot off ground; and e) maintained a more open upper torso position when the hands started to move forward and a more closed upper torso position at bat-ball contact. Moreover, adult hitters had greater peak upper torso angular velocity (857 degrees/s versus 717 degrees/s), peak left elbow extension angular velocity (752 degrees/s versus 598 degrees/s), peak left knee extension angular velocity (386 degrees/s versus 303 degrees/s), and bat linear velocity at bat-ball contact (30 m/s versus 25 m/s). The numerous differences in kinematic and temporal parameters between youth and adult hitters suggest that hitting mechanics are different between these two groups.

The triple-row modification of the suture-bridge technique improves the surgeon's ability to restore rotator cuff anatomy for the repair of large and massive tears.

The aim of this study was to compare within-individual variability in baseball pitching among various levels of competition. It was hypothesized that variability decreases as level of competition increases. Five fastballs were analysed for 93 healthy male baseball pitchers (20 youth, 19 high school, 20 college, 20 Minor League, and 14 Major League level pitchers). Eleven kinematic, four temporal, and six kinetic parameters were quantified with a 240-Hz automated digitizing system. Three multiple analyses of variance were used to compare individual standard deviations for kinematic, temporal, and kinetic parameters among the five competition levels. There was a significant overall difference in kinematics and in six of the eleven kinematic parameters analysed: foot placement, knee flexion, pelvis angular velocity, elbow flexion, shoulder external rotation, and trunk forward tilt. Individual standard deviations tended to be greatest for youth pitchers, and decreased for higher levels of competition. Thus pitchers who advanced to higher levels exhibited less variability in their motions. Differences in temporal variation were non-significant; thus variability in pitching coordination was not improved at higher levels. Differences in kinetic variation were non-significant, implying no particular skill level has increased risk of injury due to variation in joint kinetics.