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

Context: Improper baseball pitching biomechanics are associated with increased stresses on the throwing elbow and shoulder as well as an increased risk of injury. Evidence Acquisition: Previous studies quantifying pitching kinematics and kinetics were reviewed. Study Design: Clinical review. Level of Evidence: Level 5. Results: At the instant of lead foot contact, the elbow should be flexed approximately 90° with the shoulder at about 90° abduction, 20° horizontal abduction, and 45° external rotation. The stride length should be about 85% of the pitcher’s height with the lead foot in a slightly closed position. The pelvis should be rotated slightly open toward home plate with the upper torso in line with the pitching direction. Improper shoulder external rotation at foot contact is associated with increased elbow and shoulder torques and forces and may be corrected by changing the stride length and/or arm path. From foot contact to maximum shoulder external rotation to ball release, the pitcher should demonstrate a kinematic chain of lead knee extension, pelvis rotation, upper trunk rotation, elbow extension, and shoulder internal rotation. The lead knee should be flexed about 45° at foot contact and 30° at ball release. Corrective strategies for insufficient knee extension may involve technical issues (stride length, lead foot position, lead foot orientation) and/or strength and conditioning of the lower body. Improper pelvis and upper trunk rotation often indicate the need for core strength and flexibility. Maximum shoulder external rotation should be about 170°. Insufficient external rotation leads to low shoulder internal rotation velocity and low ball velocity. Deviation from 90° abduction decreases the ability to achieve maximum external rotation, increases elbow torque, and decreases the dynamic stability in the glenohumeral joint. Conclusion: Improved pitching biomechanics can increase performance and reduce risk of injury. SORT: Level C.

Background: Biomechanical efficiency, defined as fastball velocity per unit of normalized elbow varus torque, is a relatively new metric applied to improving the performance and health of baseball pitching. Purpose/Hypothesis: The purpose of this work was to evaluate kinematic parameters influencing biomechanical efficiency among professional and collegiate pitchers. Kinematic differences were compared between pitchers of high and low biomechanical efficiency. We hypothesized that professional pitchers would have greater biomechanical efficiency than collegiate pitchers. Study Design: Descriptive laboratory study. Methods: A deidentified biomechanical database of 545 pitchers (447 professional, 98 collegiate) was analyzed. A multivariate linear regression model was used to evaluate significant findings a priori with α = .05. Additionally, biomechanical differences were identified between competition levels and between high and low biomechanical efficiency groups using Mann-Whitney U test (α = .05). Results: Competition level and 11 (of 21) kinematic variables explained 27% of the variance in biomechanical efficiency, with most of the predictors being throwing arm kinematics (elbow flexion at stride foot contact [SFC]: β, −1.47; SE, 0.26; shoulder abduction at SFC: β, −1.78; SE, 0.39; shoulder external rotation at SFC: β, 0.60; SE, 0.22; maximum external rotation [MER] angle: β, 1.82; SE, 0.42; shoulder horizontal adduction at MER: β, −3.42; SE, 0.71) (all P≤ .05). Professional pitchers had greater biomechanical efficiency than collegiate pitchers (711.0 ± 101.0 vs 657.0 ± 99.3, respectively; P < .001; d = 0.53). Compared with the low-efficiency group, the high-efficiency group had significantly lower normalized elbow varus torque with greater weight and height (high: 0.047 ± 0.004 %wt*ht vs. low: 0.063 ± 0.006 %wt*ht, P Conclusion: Professional pitchers had greater biomechanical efficiency than collegiate pitchers. Biomechanical efficiency was also affected by 11 kinematic variables identified in this study. Pitchers with higher efficiency had distinct differences in arm position, trunk side tilt, and lead-knee extension range of motion in the delivery. Thus, pitchers and baseball organizations should focus on these factors to lower normalized elbow varus torque relative to ball velocity.

Background: Ulnar collateral ligament (UCL) surgery continues to demonstrate excellent clinical outcomes and a high return-to-play (RTP) rate with a low complication rate. Recent studies have demonstrated similar clinical outcomes for baseball players who have undergone either UCL reconstruction or UCL repair. In comparison, few studies have assessed the clinical outcomes of UCL surgery for nonthrowing athletes. Purpose/Hypothesis: The primary objective of this study is to provide clinical outcomes of UCL surgery performed in nonthrowing athletes at a single institution with a minimum 2-year follow-up. Our hypothesis was that these patients would have similar clinical outcomes, complication rates, and RTP rates when compared with throwing athletes. Level of Evidence: Case series; Level of evidence, 4. Methods: From our longitudinal elbow registry, 40 nonthrowing athletes were identified who underwent UCL surgery (repair or reconstruction) between 2011 and 2019. Participant characteristics were recorded: age, sex, laterality, arm dominance, sport, level of competition, and type of surgery (UCL repair or reconstruction). Outcomes included RTP rate and average time, American Shoulder and Elbow Surgeons (ASES) scores, and complications. Results: From the 40 patients eligible for inclusion in this study with a minimum 2-year follow-up, 37 (93%) were successfully contacted: 16 male (43%) and 21 female (57%). Mean ± standard deviation age at the time of surgery was 18.0 ± 3.7 years. From the 37 technical procedures, 28 (76%) were UCL repairs and 9 (24%) were UCL reconstructions. For these patients, 15 (41%) had partial tears, 20 (54%) had complete tears, 1 (3%) had a medial epicondyle avulsion, and 1 (3%) had an unspecified pathology. Sports included football (n = 11), gymnastics (11), cheerleading (7), wrestling (4), volleyball (2), basketball (1), and acrobatics (1). Quarterbacks were excluded from the football patients, as quarterbacks are throwing athletes. Level of competition included high school (n = 26), college (8), professional (2), and youth sports (1). The RTP rate was 93% (26/28) at a mean 7.4 months for UCL repair and 100% (9/9) at a mean 10.0 months for UCL reconstruction. Mean ASES scores were 94.4 and 98.7 for UCL repair and reconstruction, respectively. Complications were low, with 2 patients in the UCL repair group requiring ulnar nerve transposition for ulnar nerve paresthesia. Conclusion: In nonthrowing athletes, patients undergoing UCL repair and UCL reconstruction show favorable outcomes at minimum 2-year follow-up. RTP and clinical outcomes are consistent with previous studies in baseball players as well as a parallel ongoing study conducted on non–baseball throwing athletes.

Background: There is a lack of evidence regarding the success of ulnar collateral ligament (UCL) revision reconstruction. Understanding outcomes after UCL revision reconstruction is important in clinical decision making for overhead athletes. Purpose: To evaluate return to play and patient-reported outcomes after UCL revision reconstruction. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent UCL revision reconstruction, attributed to retear of the ligament or pain, between June 2004 and July 2016 at 2 surgical centers were identified. Charts were reviewed for age, sex, date of primary and revision reconstruction, sport played, level of play, graft type, and complications. Patients were contacted by telephone to determine time to return to play, current level of participation, Conway score, Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, and satisfaction. Results: Of the 65 consecutive baseball players who underwent revision UCL reconstruction, 40 (62%) were contacted at a minimum 22 months after surgery. Of these, 38 (95%) were pitchers and 2 (5%) were position players. Time to return to throwing was 6.2 ± 2.3 months (mean ± SD), and the KJOC score was 74.2 ± 20.7. Based on the Conway score, 50% (20/40) had an excellent result, indicating a return to the previous competition level for at least 1 year, and 30% (12/40) had a good result, indicating a return to a lower level for at least 1 year. For those who were able to return to competition, it took 12.7 ± 3.6 months. In pitchers, 47% (18/38) returned to their previous competition levels for at least 1 year, with a KJOC score of 73.7 ± 21.1. Pitchers were able to return to throwing at 6.3 ± 2.3 months and competition at 12.8 ± 3.7 months. Conclusion: Only half of baseball players undergoing UCL revision reconstruction were able to return to their previous levels of competition. Outcomes for revision reconstructions are not as promising as primary procedures. Baseball players should be cautioned that they may not return to their previous levels of play after a revision reconstruction.

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

Background: Injury to the ulnar collateral ligament (UCL) of the medial elbow has been treated successfully with ligament repair augmented with internal brace. Previous work has shown that this procedure does not overconstrain the ulnohumeral joint; however, the procedures were conducted by a single surgeon, which controlled for anchor placement and graft tensioning. Purpose/Hypothesis: Our purpose was to evaluate the reproducibility of contact mechanics and joint torque after UCL repair with internal brace as performed by different surgeons compared with repair by a single surgeon. It was hypothesized that there would be no significant difference in elbow contact mechanics, valgus torque, or torsional stiffness between the 2 groups. Study Design: Controlled laboratory study. Methods: Nine pairs of fresh-frozen cadaveric elbows were tested biomechanically under 3 conditions: UCL-intact (UCL-I), UCL-deficient (UCL-D), and UCL-repaired with internal brace augmentation (UCLR-IB). For each pair, 1 elbow was repaired by a single surgeon, and the contralateral elbow was repaired by 1 of 9 other surgeons. Testing consisted of valgus torsion between 0° and 5° with the elbow positioned at 90° of flexion. Ulnohumeral contact mechanics and overall joint torque and stiffness were measured and compared between surgeon groups. Results: There were no statistically significant differences between the single-surgeon and multiple-surgeon groups regarding contact area ( P = .83), contact force ( P = .27), peak pressure ( P = .26), or peak force ( P = .30); however, contact pressure was significantly affected ( P = .02) by surgeon group. Compared with UCL-I, both UCL-D and UCLR-IB conditions had a significant overall effect on contact area ( P = .004) and contact force ( P = .05); however, contact pressure ( P = .56), peak pressure ( P = .27), and peak force ( P = .24) were not affected by injury condition. Measurements of elbow torque ( P = .28) and stiffness ( P = .98) were not significantly different between surgeon groups. Conclusion: UCL repair with internal brace provided consistent results among several surgeons when compared with a single surgeon. The procedure did not lead to joint overconstraint while also returning the ligament to near-intact levels of resisting valgus stress. Clinical Relevance: UCL repair with internal brace augmentation is a reproducible surgical technique that has good clinical outcomes in the literature.

Objectives: All-suture anchor use for rotator cuff repair is increasing. Potential benefits of these anchors include less bone loss from anchor hole drilling and decreased injury to the chondral surface with anchor pullout. Minimal evidence exists comparing clinical outcomes of all suture to solid medial row anchor fixation in double row suture bridge rotator cuff repair. The purpose of this study was to compare patient-reported outcomes for rotator cuff tears treated with all-suture medial row anchors to those treated with more traditional solid anchors. The null hypothesis was that there is no difference in outcomes between the all-suture and solid anchor rotator cuff repairs. Methods: Three sports medicine fellowship trained surgeons performed rotator cuff repairs using the double row suture bridge technique with minimum 3 years of follow up. Patients were separated into two groups based on whether or not they received all-suture or solid anchor fixation for the medial row of their repair. All lateral row fixation was performed with solid anchors. Primary outcomes were evaluated with telephone follow-up and included the American Shoulder and Elbow Surgery Score (ASES), Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS). The Rehabilitation protocol was the same for all subjects in the study. Results: 3 sports medicine fellowship trained orthopaedic surgeons performed 153 rotator cuff repairs. 91 of these subjects had all-suture fixation of the medial row and 62 received solid anchor fixation. Follow up was 3.6 years ± 0.6 for the all-suture group and 3.7 years ± 0.6 in the solid anchor group (p= 0.28). ASES scores were 92 ± 16 in the all-suture group and 90 ± 17 in the solid group (p =0.35). SANE scores were 91 ± 13 in the all-suture and also 91 ± 13 in the solid anchor cohort (p = 0.97). VAS scores were 1.1 ± 2.0 in the all-suture and 0.7± 1.8 in the solid anchor group (p=0.17). There were no significant differences between groups with regards to re-operation rate or anchor configuration. Conclusions: All suture anchors used in medial row fixation for double row suture bridge rotator cuff repairs have similar clinical outcomes to rotator cuff tears treated in similar fashion with solid medial row anchors.

To assess simulated ulnar collateral ligament (UCL) graft length change, using surgically dissected anatomic landmarks, between multiple combinations of humeral and ulnar bone tunnels.Three equidistant humeral and ulnar tunnels were created at each UCL footprint of 10 cadaveric elbows. Suture was passed between 9 possible tunnel combinations for each elbow and affixed to an isometry gauge. Each elbow was moved through an arc of 0, 30, 60, 90, and 120° for each tunnel combination. Changes in isometry gauge spring displacement (and, in effect, tension) were recorded.There was an overall significant effect (P.0001) of tunnel placement at all degrees of flexion. Pairwise comparisons revealed increases in displacement between the central and posterior tunnel positions of the medial epicondyle, with significant differences (P = .0009) occurring when paired with both the central and posterior aspect of the sublime tubercle. Significant differences (P.0001) were noted between the anterior and posterior humeral tunnel positions.Simulated UCL graft isometry is dependent upon optimal bone tunnel placement. No significant differences were noted between ulnar tunnel locations when paired with any given humeral tunnel. Conversely, deviation anterior or posterior from the centroid of the UCL footprint on the medial epicondyle significantly affected isometry at all degrees of flexion recorded with the greatest amount of displacement occurring with pairi4ng of posterior tunnels on both the humeral and ulnar footprints.This anatomic study highlights the importance of medial elbow bone tunnel placement and its effect on simulated UCL graft isometry.

Background: There has been a renewed interest in ulnar collateral ligament (UCL) repair in overhead athletes because of a greater understanding of UCL injuries, an improvement in fixation technology, and the extensive rehabilitation time to return to play. Purpose/Hypothesis: To evaluate the clinical outcomes of a novel technique of UCL repair with internal brace augmentation in overhead throwers. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing a novel technique of UCL repair with internal brace augmentation were prospectively followed for a minimum of 1 year. Potential candidates for repair were selected after the failure of nonoperative treatment when imaging suggested a complete or partial avulsion of the UCL from either the sublime tubercle or medial epicondyle, without evidence of poor tissue quality of the ligament. The final decision on UCL repair or traditional reconstruction was determined intraoperatively. Demographic and operative data were collected at the time of surgery. Return to play, and Kerlan-Jobe Orthopaedic Clinic (KJOC) scores were collected at 1 year and then again at 2 years postoperatively. Results: Of the 111 overhead athletes eligible for the study, 92% (102/111) of those who desired to return to the same or higher level of competition were able to do so at a mean time of 6.7 months. These patients had a mean KJOC score of 88.2 at final follow-up. Conclusion: UCL repair with internal brace augmentation is a viable option for amateur overhead throwers with selected UCL injuries who wish to return to sport in a shorter time frame than allowed by traditional UCL reconstruction.

ContextHigh loads in the elbow during baseball pitching can lead to serious injuries, including injuries to the ulnar collateral ligament. These injuries have substantial implications for individual pitchers and their teams, especially at the professional level of competition. With a trend toward increased ball velocity in professional baseball, controversy still exists regarding the strength of the relationship between ball velocity and elbow-varus torque.ObjectiveTo examine the relationship between fastball velocity and elbow-varus torque in professional pitchers using between- and within-subjects statistical analyses.DesignCross-sectional study.SettingMotion-analysis laboratory.Patients or Other ParticipantsUsing the previously collected biomechanical data of 452 professional baseball pitchers, we performed a retrospective analysis of the 64 pitchers (52 right-hand dominant, 12 left-hand dominant; age = 21.8 ± 2.0 years, height = 1.90 ± 0.05 m, mass = 94.6 ± 7.8 kg) with fastball velocity distributions that enabled between- and within-subjects statistical analyses.Main Outcome Measure(s)We measured ball velocity using a radar gun and 3-dimensional motion data using a 12-camera automated motion-capture system sampling at 240 Hz. We calculated elbow-varus torque using inverse-dynamics techniques and then analyzed the relationship between ball velocity and elbow torque using both a simple linear regression model and a mixed linear model with random intercepts.ResultsThe between-subjects analyses displayed a weak positive association between ball velocity and elbow-varus torque (R2 = 0.076, P = .03). The within-subjects analyses showed a considerably stronger positive association (R2 = 0.957, P < .001).ConclusionsWhen comparing 2 professional baseball pitchers, higher velocity may not necessarily indicate higher elbow-varus torque due to the confounding effects of pitcher-specific differences (eg, detailed anthropometrics and pitching mechanics). However, within an individual pitcher, higher ball velocity was strongly associated with higher elbow-varus torque.

Background: Trends over time in the incidence of ulnar collateral ligament (UCL) surgeries in National Collegiate Athletic Association Division I baseball players are currently unknown. Purpose/Hypothesis: The purpose of this study was to evaluate the trends in UCL surgeries over 3 years in Division I baseball programs. We hypothesized that surgical injuries would be consistently high over the course of the study. Study Design: Descriptive epidemiology study. Methods: Athletic trainers from Division I baseball programs were invited to participate in an electronic survey over 3 seasons. A total of 155 baseball programs agreed to participate in 2017, 294 programs participated in 2018, and 296 programs participated in 2019. After each of the 3 collegiate baseball seasons, the athletic trainer from each program entered anonymous, detailed descriptive data and surgical information on injured players into a secured database. Results: During the 3 years of this study, 100% of the enrolled programs successfully completed the survey (155/155 in year 1, 294/294 in year 2, and 296/296 in year 3). This registry of 745 completed surveys over 3 years represented 25,587 player-years from Division I collegiate baseball. The percentage of programs with at least 1 UCL surgery during this time was 57% in 2017, 51% in 2018, and 49% in 2019. The majority of these players were pitchers (84% overall from the 3 years). Seniors underwent a significantly lower percentage of the UCL surgeries (8% in 2017, 10% in 2018, and 13% in 2019) than did underclassmen. Surgeries were performed most often in-season and least often during the preseason. A slight majority of players undergoing surgery originated from warm-weather states, but the number of these players was never significantly higher than was the number of players from cold-weather states. Most surgeries performed each year were UCL reconstruction, but the percentage of UCL repair with ligament augmentation increased each year (10% UCL repairs in 2017, 20% in 2018, and 25% in 2019). Conclusion: UCL injuries requiring surgery were found to be a major source of morbidity in Division I collegiate baseball, supporting our hypothesis. This study can serve as a baseline for tracking long-term trends in UCL surgeries in collegiate baseball.

Objectives: While numerous studies exist evaluating the short-term clinical outcomes for patients who underwent arthroscopy for osteochondritis dissecans (OCD) of the capitellum, literature on long-term clinical outcomes for a relatively high number of this subset of patients from a single institution is limited. We performed a retrospective analysis on all patients treated surgically for OCD of the capitellum at our institution from January 2001 to August 2018. Our hypothesis was that clinical outcomes for patients treated arthroscopically for OCD of the capitellum would be favorable, with improved subjective pain scores and acceptable return to play for these patients. Methods: Inclusion criteria for this study included the diagnosis and surgical treatment of OCD of the capitellum treated arthroscopically with greater than 2-year follow-up. Exclusion criteria included any surgical treatment on the ipsilateral elbow prior to the first elbow arthroscopy for OCD at our institution, a missing operative report, and/or any portions of the arthroscopic procedure that were done open. Follow-up was achieved over the phone by a single author using three questionnaires: American Shoulder and Elbow Surgeons – Elbow (ASES-E), Andrews/Carson KJOC, and our institution-specific return-to-play questionnaire. Results: After the inclusion and exclusion criteria were applied to our surgical database, our institution identified 101 patients eligible for this study. Of these patients, 3 were then excluded for incomplete operative reports, leaving 98 patients. Of those 98 patients, 81 were successfully contacted over the phone for an 82.7% follow-up rate. The average age for this group at arthroscopy was 15.2 years old and average post-operative time at follow-up was 8.2 years. Of the 81 patients, 74 had abrasion chondroplasty of the capitellar OCD lesion (91.4%) while the other 7 had minor debridement (8.6%). Of the 74 abrasion chondroplasties, 29 of those had microfracture, (39.2% of that subgroup and 35.8% of the entire inclusion group). Of the microfracture group, 4 also had an intraarticular, iliac crest, mesenchymal stem-cell injection into the elbow (13.7% of capitellar microfractures, 5.4% of abrasion chondroplasties, and 4.9% of the inclusion group overall). Additional arthroscopic procedures included osteophyte debridement, minor synovectomies, capsular releases, manipulation under anesthesia, and plica excisions. Nine patients had subsequent revision arthroscopy (11.1% failure rate, 5 of which were at our institution and 4 of which were elsewhere). There were also 3 patients within the inclusion group that had ulnar collateral ligament reconstruction/repair (3.7%, 1 of which was done at our institution and the other 2 elsewhere). Lastly, 3 patients had shoulder operations on the ipsilateral extremity (3.7%, 1 operation done at our institution and the other 2 elsewhere). To control for confounding variables, scores for the questionnaires were assessed only for patients with no other surgeries on the operative arm following arthroscopy (66 patients). This group had an adjusted average follow-up of 7.9 years. For the ASES-E questionnaire, the difference between the average of the ASES-E function scores for the right and the left was 0.87 out of a maximum of 36. ASES-E pain was an average of 2.37 out of a max pain scale of 50 and surgical satisfaction was an average of 9.5 out of 10. The average Andrews/Carson score out of a 100 was 91.5 and the average KJOC score was 90.5 out of 100. Additionally, out of the 64 patients evaluated who played sports at the time of their arthroscopy, 3 ceased athletic participation due to limitations of the elbow. Conclusions: In conclusion, this study demonstrated an excellent return-to-play rate and comparable subjective long-term questionnaire scores with a 11.1% failure rate following arthroscopy for OCD of the capitellum. Further statistical analysis is needed for additional comparisons, including return-to-play between different sports, outcome comparisons between different surgical techniques performed during the arthroscopies, and to what degree the size of the lesion, number of loose bodies removed or other associated comorbidities can influence long-term clinical outcomes.

Athletes with medial epicondyle nonunions typically present with medial elbow pain, an elbow flexion contracture, and the inability to compete. The purpose of this study was to evaluate the clinical outcomes of patients who underwent medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair for symptomatic medial epicondyle non-unions. Four patients with a mean age of 15 years (range, 11–19 years) diagnosed with symptomatic medial epicondyle nonunions were evaluated. All were treated with medial epicondyle excision with ulnar collateral ligament and flexor-pronator mass repair. Two of the patients were followed for 12 months, whereas the other 2 patients were followed for 18 months. All patients returned to their preinjury level of sports without difficulty. Two patients with preoperative flexion contracture had residual flexion contractures of 4° and 5° postoperatively, respectively, as measured by a goniometer. All other patients regained full elbow motion equal to that of the contralateral extremity at final follow-up. The patients with preoperative ulnar nerve symptoms had complete resolution postoperatively at a mean follow-up of 18 months. In overhead and upper extremity weight-bearing athletes who have symptomatic medial epicondyle nonunions, fragment excision with flexor-pronator mass repair can yield satisfactory results. [ Orthopedics . 2021;44(3):e337–e342.]

Objectives: In the medical literature regarding injuries of the ulnar collateral ligament (UCL), baseball players comprise a majority of the athletes studied. Baseball players endure repetitive valgus forces in the elbow that can cause damage to the UCL with the overhead throwing motion. However, there are limited studies in the literature regarding UCL injuries in non-baseball throwing athletes, specifically in softball, football, and javelin throwing. We performed a retrospective analysis of patients treated surgically for UCL injuries at our institution between April 2010 and July 2019. Our hypothesis was that there would be a high success rate of recovery among non-baseball throwing athletes with UCL injuries. Methods: Inclusion criteria for this study included patient who underwent either the surgical repair or reconstruction of the UCL in non-baseball throwing athletes with at least two-year follow-up. We excluded patients that had missing operative reports and any patients that participated in baseball. We retrospectively identified all patients eligible for the study and contacted them by phone to give informed consent and achieve follow-up data. For data collection, we used the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Kerlan-Jobe Orthopaedics Clinic Shoulder and Elbow Score (KJOC), and our institution-specific Return to Play questionnaire. Results: After we applied the exclusion and inclusion criteria to our elbow database search, we identified 66 patients eligible for the study. Of the 66 patients, 34 patients had missing or incomplete operative reports, leaving 32 patients. Of the 32 patients, 26 patients (81%) were successfully contacted and followed up with. Of these 26 patients, 14 (54%) underwent UCL repair, whereas 12 (46%) underwent UCL reconstruction. The average age of participants at the time of surgery was 19.1, and the average post-operative time at follow-up was 4.68 years. Two patients had subsequent revision UCL procedures (6.3% failure rate). The surgical satisfaction in the 26 patients was an average of 9.67 out of 10. The average Andrews/Carson score was 92.5, and the average KJOC score was 90.6. Additionally, out of the 26 patients evaluated who played sports at the time of their arthroscopy, two had ceased athletic participation due to limitations of the elbow. Conclusions: In conclusion, we identified excellent clinical outcomes following UCL procedures in non-baseball throwing athletes with a 92% return to play rate and high surgical satisfaction and functional outcome scores. Further statistical analysis is needed for additional comparisons, including return-to-play between different sports, and outcome comparisons between different surgical techniques performed. However, this study significantly adds to the previously scarce literature on clinical outcomes following surgical treatment for UCL injuries in non-baseball throwing athletes.

Ankle injuries are commonly encountered when caring for athletes. In football, these injuries are extremely prevalent and often require significant time and effort by the physicians, athletic trainers, and athletes in order to properly diagnose, treat, and return the athlete to the field. This chapter focuses on the relevant anatomy, diagnosis, and management of the most frequent injuries encountered by the sports medicine practitioner: lateral ankle sprains, “high ankle” or syndesmosis injuries, and ankle fractures. The use of arthroscopy accelerated rehabilitation protocols, and improved postoperative medical management have allowed for better diagnosis and faster return to play in a spectrum of injuries that have classically kept the patient sidelined from sports for prolonged periods of time.

Background: There has been renewed interest in ulnar collateral ligament (UCL) repair in throwing athletes because of a greater understanding of UCL injuries, improvement in ligament repair technology, and potentially expedited rehabilitation time and return to play relative to UCL reconstruction. Purpose: To evaluate elbow articular contact and overall joint torque after UCL reconstruction and repair augmented with a collagen-coated fiber tape, InternalBrace. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaveric arms (mean age, 41 ± 11 years) were dissected to expose the UCL. Each specimen was secured into a custom test fixture at 90°, and 1 specimen from each pair underwent either a modified Jobe UCL reconstruction or UCL repair with InternalBrace. Each specimen underwent 10 cycles of elbow valgus angular displacement between 0° and 5° at a rate of 1 deg/s in the intact state, after UCL avulsion, and then after UCL reconstruction or repair. Articular contact mechanics and overall joint torque and stiffness were recorded. Results: Contact mechanics of reconstructed and repaired specimens were not significantly different. Both reconstruction and repair procedures returned the overall resistance of the joint to valgus torsion to near-intact levels. UCL repair tended to restore joint torque more closely to the intact state than did reconstruction, given that reconstruction showed a nonsignificant trend toward lower torque than the intact state ( P = .07). Conclusion: Neither UCL reconstruction nor UCL repair with InternalBrace overconstrained the elbow joint, as both groups had similar contact pressures compared with the native joint. Both procedures also restored elbow joint torque and stiffness to levels not statistically different from the intact state. Clinical Relevance: Given the sound biomechanical properties of UCL repair with InternalBrace, it may have a significant role as treatment for UCL injuries.

Objectives: Rotator cuff tears are rare injuries in adolescents, but can be a cause of significant morbidity if unrecognized. Previous literature on rotator cuff repairs in adolescents is limited to small case series, with little data to guide treatment. The purpose of this study was to investigate the clinical information, demographics, and results of surgical treatment of a consecutive series of adolescent athletes who underwent rotator cuff repair with a minimum 2-year follow-up. We hypothesized that adolescent patients would have excellent functional outcome scores and return to the same level of sports participation after rotator cuff repair, but would have some difficulty returning to the same position in overhead sports. Methods: A retrospective search of the practice’s billing records identified all patients with high-grade (>50%) partial-thickness or rotator cuff tears that underwent rotator cuff repair between 2006 and 2014 with an age of less than 18 years at the time of surgery and a minimum of two years of follow-up. Clinical records were evaluated for demographic information, and telephone follow-up was obtained for return to play, performance, other surgeries and complications, a numeric pain rating scale (0-10) for current shoulder pain, American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, and the Western Ontario Rotator Cuff Index (WORC). Statistical analysis was performed with JMP 10 (SAS Institute, Cary, NC) with p < 0.05 for significance. Descriptive statistics were prepared for all variables, and outcomes were compared according to affected tendon and concomitant procedures using two-sided Fisher’s exact tests and Student’s t-tests. Results: Thirty-two consecutive adolescent athletes (28 boys and 4 girls) with a mean age of 16.1 years (range 13.2-17.9 years, SD=1.3) met inclusion criteria. Twenty-nine patients (91%) had a traumatic event associated with the onset of their shoulder pain, and 27 of these patients (93%) had no symptoms prior to the trauma. The most common tendon affected was the supraspinatus (21 patients, 66%). All seven subscapularis injuries were repaired in open fashion, while all other tears were repaired arthroscopically with either a single-row or double-row configuration depending on tear size and anatomy. Of the 18 partial-thickness tears, eight (44%) were measured intraoperatively to be 50-75% of the footprint, and the remaining ten tears (56%) encompassed greater than 75% of the footprint from medial to lateral. Twenty-seven patients (84%) d the outcome questionnaires at a mean of 6.2 years after surgery (range 2-10 years, SD=2.6 years). The mean ASES score was 93 (range 65-100, SD=9), mean WORC was 89% (range 60%-100%, SD=13%), and mean numeric pain rating was 0.3 (range 0-3, SD=0.8). Table 1 Overall, 25 patients (93%) were able to return to the same level of play or higher. In overhead athletes, 13 patients (93%) were able to return to the same level of play, but 8 patients (57%) were forced to switch positions due to difficulty with throwing. There were no surgical complications, but two patients did undergo a second operation during the study period. Conclusion: Surgical repair of high-grade partial-thickness and rotator cuff tears yielded successful outcomes in adolescents, with excellent functional outcomes at mid-term follow-up. However, overhead athletes may have difficulty playing the same position after surgery due to difficulty throwing. Table 1: Patient outcomes and functional scores obtained from telephone follow-up. Patient Outcomes (n = 27 patients) Time from surgery to follow-up 6.2 years (range 2-10 yrs., SD=2.6 yrs.) Return to sport at same level 25 (93%) Play collegiate athletics 8 (30%) Overhead athletes 14 (52%) Return to play at same level 13 (93%) Forced to switch positions 8 (57%) ASES score mean 93 (range 65-100, SD=9) WORC score mean 89% (range 60%-100%, SD=13%) Numeric Pain Rating Scale (0-10) mean 0.3 (range 0-3, SD=0.8)

Background: Recent innovative techniques have led to renewed interest in ulnar collateral ligament (UCL) repair. Although early outcome data regarding the clinical outcome of overhead athletes undergoing UCL repair with augmentation have been encouraging, long-term data are still needed to evaluate both the appropriate indications and success rate for this procedure. Purpose: To describe and evaluate the acute complications seen in a large cohort of patients who underwent UCL repair with internal brace augmentation at a single institution. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective chart review of a prospectively collected database, consisting of all patients who underwent UCL repair with internal brace augmentation utilizing a collagen-dipped FiberTape at our institution from August 2013 to January 2020. Patient characteristics, injury setting, side of surgery, and concomitant ulnar nerve transposition procedures were recorded. Early complications of UCL repair (within 6 months of the procedure) were evaluated and characterized as either minor or major, depending on whether the patient required a return to the operating room. Results: Of the 353 patients who underwent UCL repair at our institution with a minimum of 6-month follow-up, 84.7% (299/353) reported no complications, 11.9% (42/353) reported minor complications—including ulnar nerve paresthesia, postoperative medial elbow pain, and postoperative superficial wound complications—and 3.4% (12/353) required a return to the operating room because of a major complication requiring ulnar nerve exploration/debridement, primary ulnar nerve transposition, or heterotopic ossification excision. Conclusion: The low major complication rate identified in this study further validates the efficacy of the UCL repair with the internal bracing augmentation technique. Longer term follow-up data are needed to more adequately assess the outcomes and durability of this procedure.

Background: Few studies have documented the outcomes of superior labral anterior-posterior (SLAP) repairs in baseball players. Furthermore, the results of these previous studies varied widely and were based on small numbers of patients. Hypothesis/Purpose: The purpose was to report return-to-play (RTP) rates and validated subjective outcome scores for baseball players after SLAP repair. It was hypothesized that RTP rates and outcomes would be significantly different between pitchers and nonpitchers, as well as among baseball levels. Study Design: Case series; Level of evidence, 4. Methods: A series of 216 baseball players was identified who had isolated SLAP repair or SLAP repair with debridement of partial-thickness (Results: Of the 216 baseball players, 133 were reached by phone for follow-up interview (mean, 78 months; range, 27-146 months). Overall, 62% successfully returned to play. There were no differences in RTP rates or subjective outcomes among baseball levels or between procedures. RTP rates were 59% for pitchers and 76% for nonpitchers ( P = .060). Subjectively, the percentage of patients who felt the same or better at follow-up compared to preinjury was significantly higher among nonpitchers (66%) than pitchers (43%). There was no difference in KJOC scores between the pitchers (75.3 ± 19.4) and nonpitchers (76.2 ± 17.4) who successfully returned to play, although these scores were well below the minimum desired score of 90 for healthy baseball players. Conclusion: SLAP repair should continue to be considered as an option for SLAP tear treatment only after nonsurgical management has failed. Some players may be able to return to baseball after SLAP repair, although regaining preinjury health and performance is challenging.

Background:Anterior cruciate ligament (ACL) injuries occur commonly in football. Recent work has reported ACL reconstruction (ACLR) as one of several orthopaedic procedures with unfavorable outcomes for professional athletes. The performance impact to defensive players after surgery has not been quantified.Purpose:To quantify the effect of ACLR on the performance of defensive players by comparing them to a cohort of matched controls as well as to measure the effect of ACLR on athletes’ career length in the National Football League (NFL).Study Design:Case-control and cohort study; Level of evidence, 3.Methods:Thirty-eight NFL defensive players with a history of ACLR from 2006 to 2012 were identified. For each injured player, a matched control player was identified. Demographic and performance statistics were collected from the online NFL player database. Players who returned after ACLR (n = 23) were compared with players who did not return (n = 15) using t tests and chi-squared analyses. Similarly, players who returned after ACLR (n = 23) were compared with their matched controls with t tests and chi-squared analyses. Two-way repeated-measures analysis of variance was utilized to test for significant differences between performance before and after the season of the injury for the players in the ACLR group who returned (n = 23) and for their matched controls. Kaplan-Meier analysis was performed to test for differences in the rate of retirement between the groups. For all analyses, P values Results:Approximately 74% (28/38) of athletes who underwent ACLR returned to play at least 1 NFL game, and 61% (23/38) successfully returned to play at least half a season (ie, 8 games). Athletes in the ACLR group who returned retired from the NFL significantly sooner and more often after surgery than their matched controls. In the seasons leading up to their injury, athletes who successfully returned to play started a greater percentage of their games (81%) and made more solo tackles per game (3.44 ± 1.47) compared with athletes in the ACLR group who did not return to play (54% and 1.82 ± 1.17, respectively) and compared with healthy control players (52% and 1.77 ± 1.19, respectively). After the season of surgery, athletes in the ACLR group who returned to play decreased to 57% games started and 2.38 ± 1.24 solo tackles per game, while their matched controls suffered no significant decreases.Conclusion:Players who successfully returned were above-average NFL players before their injury but comparatively average after their return.

Accurate tunnel placement is important for a successful anterior cruciate ligament (ACL) reconstruction. Controversy exists concerning the preferred method of femoral tunnel preparation, with proponents of both medial portal and transtibial drilling techniques. Current ACL literature suggests that placement of the femoral ACL attachment site posterior or “low” in the ACL footprint leads to more anatomically correct ACL mechanics and better rotational control. There is limited literature focusing on ACL graft displacement through knee range of motion based on specific paired placement of femoral and tibial tunnels. Our purpose was to assess ACL isometry between multiple combinations of femoral and tibial tunnels. We hypothesized that placement of the graft at the posterior aspect of the ACL footprint on the femur would be significantly less isometric and lead to more graft displacement as compared with central or anterior placement. The ACL of matched pairs of cadaveric knees was arthroscopically debrided while leaving the soft tissue footprint on the femur and tibia intact. One knee from each pair underwent notchplasty. In all knees, three femoral and three tibial tunnels were created at the anterior, central, and posterior aspects of the ACL footprint. A suture was passed through each tunnel combination (nine potential pairs), and the change in isometry was measured throughout full knee range of motion. Placement of the femoral tunnel along the posterior aspect of the ACL footprint was less isometric compared with a central or anterior position in the femoral footprint. Placement of a posterior tibial tunnel also led to decreased isometry, but tibial tunnel placement affected isometry to a lesser extent than femoral tunnel placement. The combination of a posterior femoral and posterior tibial tunnel resulted in greater than 1 cm of graft excursion from full flexion to extension. Placement of ACL tunnels at anisometric sites may adversely affect the mechanical properties and behavior of the ACL graft, resulting in either graft laxity in flexion or overconstraint and loss of extension.

Background: The probability of returning to competition for injured baseball pitchers is similar after ulnar collateral ligament (UCL) repair as after UCL reconstruction, but the time to return is significantly quicker after UCL repair. Previous research has found no differences in pitching biomechanics between pitchers with and without a history of UCL reconstruction, but pitching biomechanics after UCL repair has not been studied. Hypothesis: There will be significant differences in pitching biomechanics between pitchers returning to play after UCL repair and pitchers with no injury history. Study Design: Controlled laboratory study. Methods: A total of 33 pitchers were tested shortly after UCL repair (9.8 ± 2.6 months) and compared with a matched group of 33 uninjured pitchers. Each group comprised 14 college pitchers and 19 high school pitchers. Shoulder and elbow passive ranges of motion were measured. The biomechanics of 10 fastballs was then collected using a 12-camera automated motion capture system. Ball velocity was measured using a separate 3-camera optical tracking system. Data were compared between the UCL repair group and the control group using the Student t test (significance set at P < .05). Results: There were no differences in passive range of motion or fastball velocity between the 2 groups. There were no differences in joint kinetics during pitching, but 3 kinematic variables showed significant differences. Specifically, the UCL repair group produced less elbow extension (flexion: 27° ± 6° vs 24° ± 4°, respectively; P = .03), less elbow extension velocity (2442 ± 367 vs 2631 ± 292 deg/s, respectively; P = .02), and less shoulder internal rotation velocity (6273 ± 1093 vs 6771 ± 914 deg/s, respectively; P = .049 ) compared with the control group. Conclusion: Elbow extension, elbow velocity, and shoulder velocity differed between pitchers with a recent history of UCL repair and a matched control group, but it is unclear whether this has clinical significance, as there were no differences in ball velocity and passive range of motion. Furthermore, it is unknown whether these few differences in pitching biomechanics resolve with time. Clinical Relevance: Elbow and shoulder kinematics during pitching might not be completely regained within the first year after UCL repair, although passive range of motion and pitch velocity show no difference in comparison to other healthy pitchers.

Objectives: Recent studies in the literature have highlighted the progressive increase in the incidence of ulnar collateral ligament (UCL) injuries to the elbow in baseball players of all levels. However, knowledge of the incidence and other epidemiological factors regarding UCL injuries, specifically in college baseball players, is currently lacking. In 2016, we launched a prospective, multi-year study to evaluate the incidence of UCL injuries requiring surgery in National Collegiate Athletic Association (NCAA) Division I baseball programs. Methods: We invited 157 Division I collegiate baseball programs after the 2017 season, and 155 agreed to participate in the study. After the 2018 season, all 297 programs were invited and 294 participated. At the conclusion of the 2017 and 2018 collegiate baseball seasons, the athletic trainer for each program entered anonymous, detailed information on injured players through an electronic survey into a secured database. Results: We obtained a 100% completion rate in the first two years of this ongoing study (155/155 respondents in the first year, 294/294 in the second year). Of the 5,364 collegiate baseball players tracked in Year 1 (2016-2017), 134 underwent surgery for an injured UCL, resulting in a team surgery rate of 0.86 per program. In Year 2 (2017-2018), there were 230 surgeries reported from 10,019 players tracked, resulting in a team surgery rate of 0.78 per program. A majority of schools experienced at least one surgery during both years (56.8% in Year 1, 50.7% in Year 2). Pitchers experience a vast majority of the surgical injuries (85.8% in Year 1, 84.3% in Year 2). Underclassmen made up 65.7% of surgeries in Year 1, which fell slightly to 56.1% in Year 2. Nearly half of the surgeries occurred during an ongoing baseball season in Year 1 (48.5%), but this fell in Year 2 to 41.3%. In both years, a non-significant majority of players were from warm-weather states (65.4% in Year 1, 52.9% in Year 2). Revision surgical rates remained nearly constant with 3.0% revision surgeries in Year 1 compared with 2.6% revisions in Year 2. Interestingly, the percentage of UCL repairs with internal brace augmentation rose from 9.5% in Year 1 to 19.9% of all procedures in Year 2. Conclusion: The incidence of UCL surgeries in NCAA Division I collegiate baseball players represents substantial morbidity to this young athletic population. This multi-year prospective study has been established to assess the incidence of surgical UCL injuries in collegiate baseball. Also, importantly, with multiple years of data we will identify trends in the demographics of players undergoing surgery and in surgical details over time. Awareness of these factors should be considered in injury prevention programs in the future.

Background:There is limited literature regarding outcomes after operative treatment of displaced medial epicondyle avulsion fractures in adolescent athletes. Most studies have had a relatively small sample size and have not assessed return to play of the overhead athlete.Purpose:To examine return to play and outcomes of youth overhead athletes who underwent open reduction and internal fixation (ORIF) with screw fixation.Study Design:Case series; Level of evidence, 4.Methods:Charts and radiographs were queried between January 2003 and June 2018 for young overhead athletes (age, Results:Overall, 29 patients were included in the study; the mean age at surgery was 14.7 years (range, 12.9-16.5 years). There were 25 baseball players, 3 football quarterbacks, and 1 tennis player. Of the 23 patients with available images at least 3 months after surgery, 96% demonstrated radiographic union at last follow-up. Imaging for the 1 patient with nonunion was taken 3 months after ORIF, and it is unknown if he eventually had union. All patients (100%) were successfully contacted to complete questionnaires at a mean follow-up of 4.8 years (range, 1.0-13.5 years). The mean KJOC score was 93.0, and the mean scores for the American Shoulder and Elbow Surgeons Elbow questionnaire were 8.9, 35.6, and 9.8 for pain, function, and satisfaction, respectively. One overhead athlete did not return to play, while the other 28 returned at a mean 7 months after surgery. No patient underwent revision ORIF, 1 underwent hardware removal, and 1 underwent ulnar nerve transposition. No players underwent ulnar collateral ligament reconstruction after primary ORIF of the medial epicondyle.Conclusion:ORIF of displaced medial epicondyle fractures is a reliable and successful procedure in adolescent overhead athletes with high demands, with relatively low risk of major complications, reinjury, or reoperation.

This article aims to evaluate factors associated with chondral and meniscal lesions in primary and revision anterior cruciate ligament (ACL) reconstructions. ACL reconstructions from 2001 to 2008 at a single institution were retrospectively analyzed. Logistic regression was used to estimate the association between chondral and meniscal injuries and age, gender, tear chronicity, additional ligamentous injuries, sport type, and participation level. Of the 3,040 ACL reconstructions analyzed, 90.4% were primary reconstructions and 9.6% were revisions. Meniscal injuries were significantly lower in the revision group (44.0 vs. 51.9%; p = 0.01), while chondral injuries were significantly higher in the revision group (39.9 vs. 24.0%; p

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

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

Background: Ulnar collateral ligament (UCL) reconstruction is an increasingly common procedure being performed in overhead throwing athletes. Recently, postoperative imaging has revealed the presence of heterotopic ossification (HO) in symptomatic patients. Purpose: To determine the incidence of symptomatic HO after UCL reconstruction as well as the clinical outcomes after nonoperative or operative treatment of HO. Study Design: Case series, Level of evidence, 4. Methods: A search was performed of diagnostic codes for all UCL reconstructions at a single institution between 2002 and 2012, and the charts were then reviewed of patients who returned to clinic for symptomatic HO after UCL reconstruction. All relevant clinical information, imaging findings, and return-to-play data were obtained. Results: Eight patients were found to have developed symptomatic HO after UCL reconstruction. Of the 8 patients, 6 had gracilis tendon autograft at their primary surgery. All 8 patients had HO on the proximal end of their graft. Two patients were treated nonoperatively, and the remainder had excision of HO performed either arthroscopically or open. Six patients were able to return to the same or higher level of competition after treatment of HO. Conclusion: Symptomatic HO after UCL reconstruction is very uncommon but may prove to be a significant complication among athletes. With appropriate treatment, the majority of patients were able to return to the same level of play. Early identification of this complication is important, as revision surgery with excision of osteophytes resulted in a return to a similar level of play in most patients.

The concept of margin convergence for side-to-side strain reduction in massive U-type rotator cuff tears has been used to protect the free margin repair to bone. Data in the literature show favorable outcomes for this method of repair. However, one of the challenges when performing side-to-side repair has been the dog-ear deformity that forms at both the convergence split and marginal ends. We present a method of single-suture convergence using a "shoelace" weaving technique, which seems to decrease the incidence of dog-ear deformity, decreases margin strain, and can be incorporated into current transosseous-equivalent rotator cuff repair configurations. The technique is simple and reproducible for large or massive tear patterns.

Background: Recent reports have highlighted the progressive increase in the incidence of ulnar collateral ligament (UCL) injuries to the elbow in baseball players of all levels. However, knowledge of the incidence and other epidemiological factors regarding UCL injuries, specifically in college baseball players, is currently lacking. Purpose: To evaluate, over a period of 1 year, the incidence of UCL injuries requiring surgery in National Collegiate Athletic Association (NCAA) Division I baseball programs. Study Design: Descriptive epidemiology study. Methods: A total of 155 Division I collegiate baseball programs agreed to participate in the study. Demographics (position, year, background [location of high school]) for all players on these rosters were obtained from public websites. At the conclusion of the 2017 collegiate baseball season, the athletic trainer for each program entered anonymous, detailed information on injured players through an electronic survey into a secured database. Results: All 155 teams enrolled in the study completed the electronic survey. Of the 5295 collegiate baseball players on these rosters, 134 underwent surgery for an injured UCL (2.5% of all eligible athletes), resulting in a team surgery rate of 0.86 per program for 1 year. These 134 players came from 88 teams, thus 56.8% of the study teams underwent at least 1 surgery during the year. The surgery rate was 2.5 per 100 player-seasons for all players and was significantly higher among pitchers (4.4/100 player-seasons) than nonpitchers (0.7/100 player-seasons). The surgery rate was also significantly higher in underclassmen (3.1/100 player-seasons among freshmen and sophomores) than upperclassmen (1.9/100 player-seasons among juniors and seniors) (incidence rate ratio, 1.7; 95% CI, 1.1-2.4). Players from traditionally warm-weather states did not undergo UCL surgery at a significantly different rate from players from traditionally cold-weather states (2.7/100 player-seasons vs 2.1/100 player-seasons, respectively). Nearly half of surgeries (48.5%) were performed during the baseball season. Conclusion: The incidence of UCL surgeries in NCAA Division I collegiate baseball players represents substantial morbidity to this young athletic population. Risk factors for injuries requiring surgery include being a pitcher and an underclassman. Awareness of these factors should be considered in injury prevention programs. Furthermore, this initial study can serve as a foundation for tracking these surgical injuries in future years and then identifying trends over time.

Objectives: Injuries involving fractures of the metacarpals are common among football players of all levels. These injuries are typically treated conservatively with casting or splinting among non-in-season athletes, a method that involves a relatively lengthy recovery time (four weeks). To our knowledge, there are no previous reports documenting return to play in elite football players after operative management of metacarpal fractures. The purpose of this study was to retrospectively review and describe the results of operative treatment of metacarpal shaft fractures in 19 high level football players with respect to return to play. We hypothesized that in-season football players with metacarpal fractures treated surgically would be able to return to play more quickly than the typical recovery time following non-operative treatment. Methods: Surgically treated metacarpal fractures in elite football players were queried over a three-year period (2009-2012) from a database maintained by American Sports Medicine Institute (ASMI) in Birmingham, AL. Over the study period, 19 football players were identified who underwent open reduction internal fixation of metacarpal fractures by one of three attending surgeons. Retrospective chart review and phone interviews with the patient and their athletic trainers were performed to identify player position, level of competition, mechanism of injury, return to play, post-operative bracing, and re-fracture event. Radiographs were used to classify the fractures, and operative reports were reviewed for implant choice. Numerical means were calculated for in-season return to play as well as for brace time. Results: Ten high school players (53%) and nine college players (47%) were injured. The most common injured positions were wide receivers and defensive backs (26% each). Most injuries occurred through player to player contact (63%) at a game (37%) or practice (47%). The long finger (58%) was the most commonly involved metacarpal. Two players (11%) had multiple metacarpal fractures. The most common location was mid-diaphyseal (74%). Twelve patients were stabilized with plates and screws, five of whom underwent lag screw augmentation. Six patients were stabilized with a metacarpal nail and one was stabilized with only lag screws. All athletes were able to return to their pre-injury level of play without recurrence of fracture. Return to play for in-season athletes (N=11) was 6.3 days. The average time to return to play for in-season high school football players (N=6) was 9.2 days and 2.8 days for in-season collegiate football players (N=5). All in-season athletes returned to play with protective equipment in the form of a padded glove, bivalve padded cast, padded club cast, or padded splint. The protective equipment was used for an average of 21 days. Conclusion: This study provides support for the surgical treatment of displaced metacarpal shaft fractures with immediate return to play as tolerated for in-season football players. No re-fractures or complications were identified with the use of a plate, nail, or with lag screws. Elite football players can return to play with or without protective bracing depending on the position played and within a week of operative fixation.

Olecranon stress fractures are rare conditions that have been described in overhead or throwing athletes. The condition is known to occur due to repetitive valgus extension overload during throwing and/or repetitive triceps activity during weightlifting. The mechanism of injury is often due to the olecranon making a traumatic impact within the posterior compartment toward full extension, leading to the condition of valgus extension overload syndrome. The injury is typically first treated with non-surgical management; however, when that fails surgical intervention with an open reduction and internal fixation can be utilized with a high rate of success. Following surgery, the rehabilitation process usually lasts from around 14-16 weeks, and then the patient can once again begin full activity.

Background: Knee injuries, including articular cartilage damage, are common in football players and are potentially career threatening. The rate of return to play (RTP) as well as the factors affecting return after arthroscopic chondroplasty of the knee is performed in National Football League (NFL) athletes are not known. Purpose: To determine the rate of return to regular season NFL competition after arthroscopic knee surgery including chondroplasty of articular cartilage lesions. In addition, identification of factors that influence successful return was investigated. Study Design: Case series; Level of evidence, 4. Methods: Athletes in the NFL who underwent arthroscopic chondroplasty at a single institution were identified. Retrospective chart review and review of the NFL online database were utilized to determine the rate of RTP and factors affecting an athlete’s ability to return. Chi-square and Student t tests were used to assess differences among players who were and were not able to RTP, and logistic regression was employed to determine a player’s odds of return. Results: There were 52 patients (54 procedures) identified from the surgical database who met the inclusion criteria for the study operated on between August 1, 2001, and March 31, 2011. Of these players, 36 (67%) were able to return to regular season NFL game play at an average of 8.2 months, including 13 (24%) who were still active in the NFL. The average time to follow-up was 5.9 years, and all players were allowed at least 2 years of follow-up. There was no significant correlation of RTP to athlete age, lesion size, lesion location, position played, or round selected in the NFL draft. Players who underwent concomitant microfracture were 4.4 times less likely to return to the NFL than were those who did not undergo this procedure (95% CI, 1.3-15.5). Athletes who played more than 11.6 games per season were 4.7 times more likely to RTP than were those who played fewer games per season (95% CI, 1.4-16.6). Athletes who returned to play competed in 56 fewer games, 3.3 fewer seasons, and played in 3.2 fewer games per season compared with their level of competition before surgery. Conclusion: A majority (67%) of NFL players are able to RTP after arthroscopic knee surgery including chondroplasty of articular cartilage lesions. Athletes who play more games per season are more likely to RTP after chondroplasty of articular cartilage lesions of the knee, but those undergoing concomitant microfracture are less likely to return. No statistical significance was determined when comparing the athletes who returned to play with respect to age at surgery, lesion location, lesion size, lesion grade, position that the athlete played, or draft round.

Background: Baseball pitchers who undergo superior labrum anterior-posterior (SLAP) repair often have trouble returning to their previous level of performance. While the reason is often assumed to be diminished shoulder range of motion or other mechanical changes, differences in pitching biomechanics between baseball pitchers with a history of SLAP repair and pitchers with no injury history have not been studied previously. Hypothesis: The primary hypothesis was that compared with the control group, the SLAP group would exhibit compromised shoulder range of motion (external rotation and horizontal abduction) and internal rotation torque during pitching. Study Design: Controlled laboratory study. Methods: Pitching biomechanics were compared retrospectively between a group of 13 collegiate and professional pitchers with a history of a SLAP tear and a control group of 52 pitchers with no history of surgery; groups were matched by age, height, weight, and pitch velocity. Data were collected with an automated 3-dimensional motion analysis system while participants threw fastballs from the windup. Biomechanics of the shoulder (horizontal abduction and external rotation), elbow (flexion, extension velocity, and flexion torque), and body (stride length, shoulder horizontal adduction, and forward trunk tilt) were compared between the 2 groups. For each variable, a Student t test was used at an α level of .05. Results: Pitchers in the SLAP group exhibited significantly less shoulder horizontal abduction (10.0° ± 13.2° vs 21.0° ± 11.7°, respectively; P = .013) and shoulder external rotation (168.3° ± 12.7° vs 178.3° ± 7.3°, respectively; P = .016) than those in the control group. In addition, players in the SLAP group pitched with a more upright trunk, demonstrated by a less forward trunk tilt at the instant of ball release (30.2° ± 6.3° vs 34.4° ± 6.6°, respectively; P = .048). Conclusion: Pitchers with a history of SLAP repair produce less shoulder horizontal abduction, shoulder external rotation, and forward trunk tilt during pitching than do pitchers with no history of injury. Clinical Relevance: To facilitate normal pitching mechanics, shoulder external rotation and horizontal abduction at 90° should be primary objectives in surgical repair and rehabilitation after SLAP repair. In addition, pitchers should work with their pitching coaches to ensure proper forward trunk tilt.

Background: Lateral meniscal injury is a common and possibly career-threatening injury among players in the National Football League (NFL). The rate of return to play (RTP) and factors that affect RTP after lateral meniscal injury in NFL players are currently not defined. Purpose: The aims of this study were to determine the rate of RTP to regular-season NFL game play of NFL players after arthroscopic partial lateral meniscectomy and to identify factors that can predict the ability to return to play. Study Design: Case series; Level of evidence, 4. Methods: Seventy-two patients undergoing 77 arthroscopic lateral partial meniscectomies were followed to determine the rate of RTP (defined as successful RTP in at least 1 regular-season NFL game after meniscectomy) and factors predicting players’ ability to return to play. Perioperative variables were recorded using retrospective chart review. Players’ heights and weights, dates of return, draft rounds, and counts of games, starts, and seasons both before and after meniscectomy were all collected from statistical databases maintained by the NFL. Chi-square and Student t tests were performed to assess differences among covariates with respect to an athlete’s ability to return to play, and odds ratios were calculated as appropriate. All percentages were calculated as percent of total procedures performed (n = 77). Results: Of the 77 partial lateral meniscectomies performed, 61% (n = 47) resulted in the athlete returning to play at his previous level of competition with an average length of time to RTP of 8.5 months; 19 (40%) of those who returned were still active in the NFL at the time of follow-up. Age at time of surgery, games and seasons played before surgery, and individual position were not significantly different between those who did and did not return to play. Undergoing a concomitant procedure did not affect an athlete’s ability to return to play, nor did concurrent arthroscopic anterior cruciate ligament reconstruction affect a player’s likelihood to return to play. Players drafted in the first 4 rounds of the NFL draft were 3.7 times more likely to return to play than players drafted after the fourth round, and players who started more than 46.2% of their games played (the mean value for this population) were 2.8 times more likely to return to play. Speed-position players (running backs, receivers, linebackers, and defensive backs) were 4.0 times less likely to return to play than non–speed position players (linemen and tight ends). Conclusion: The majority of NFL players undergoing arthroscopic lateral meniscectomy are able to return to play. Players selected earlier in the NFL draft and who are listed as starters in more of their games are more likely to return to play, as are linemen and tight ends. It is significantly more difficult for running backs, receivers, linebackers, and defensive backs to return to play.

Case report.Traumatic glenohumeral dislocations with concomitant rotator cuff and capsular injuries present a unique and challenging surgical and rehabilitative condition, particularly in the overhead-throwing athlete. Multiple injuries of the shoulder complex create the potential for complications in the course of recovery and place a full return to high-level sport at risk. The purpose of this case report is to present the multiphased rehabilitation approach of an elite professional quarterback after an acute 330° capsulolabral reconstruction and rotator cuff repair as a result of a luxatio erecta injury.A 26-year-old male professional football player, a quarterback, sustained a right luxatio erecta shoulder dislocation while trying to recover a fumble during a regular-season game. The injury occurred when he was hit in the back of his throwing shoulder, which was in an abducted and externally rotated position, while lying on the ground. Five days postinjury, he underwent a 330° capsulolabral repair, with concomitant rotator cuff repair and subacromial decompression. He completed 28 weeks of a multiphased rehabilitation program.The patient returned to play in the National Football League (NFL) 8 months later, for the start of the next season, during which he had his most productive year as a professional quarterback, leading the league in passing yards and finishing third in the league for the number of touchdowns. Since the injury, the patient has played 6 consecutive seasons, starting over 96 consecutive, regular-season games and maintaining a very high level of play.This case report highlights the clinical decision-making process and management of this rare, severe injury.

The ulnar collateral ligament (UCL) is the primary static restraint to valgus stress at the elbow. Since Jobe pioneered reconstruction in 1974, thousands of throwers have undergone UCL reconstruction, and good results have been achieved. The high-profile nature of the elite pitcher has brought this technique into the spotlight, and extensive research has been performed with new techniques emerging. The standard reconstruction, modified only slightly since Jobe's original description, remains the gold standard for treatment of UCL insufficiency. Throwers are able to return to the same or even higher levels of competition in the majority of cases. In this article, we present our standard technique and results and discuss emerging techniques for treatment of UCL injuries.

Controversy continues whether curveballs are stressful for young baseball pitchers. Furthermore, it is unproven whether professional baseball pitchers have fewer kinematic differences between fastballs and off-speed pitches than lower level pitchers. Kinematic and kinetic data were measured for 111 healthy baseball pitchers (26 youth, 21 high school, 20 collegiate, 26 minor league, and 18 major league level) throwing fastballs, curveballs, and change-ups in an indoor biomechanics laboratory with a high-speed, automated digitising system. Differences between pitch types and between competition levels were analysed with repeated measures ANOVA. Shoulder and elbow kinetics were greater in fastballs than in change-ups, while curveball kinetics were not different from the other two types of pitches. Kinematic angles at the instant of ball release varied between pitch types, while kinematic angles at the instant of lead foot contact varied between competition levels. There were no significant interactions between pitch type and competition level, meaning that kinetic and kinematic differences between pitch types did not vary by competition level. Like previous investigations, this study did not support the theory that curveballs are relatively more stressful for young pitchers. Although pitchers desire consistent kinematics, there were differences between pitch types, independent of competition level.

The activities required during overhead sports, particularly during baseball pitching, produce large forces at the elbow joint. Injuries to the elbow joint frequently occur in the overhead athlete because of the large amount of forces observed during the act of throwing, playing tennis, or playing golf. Injuries may result because of repetitive overuse, leading to tissue failure. 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 following injury or postsurgical, must follow a progressive and sequential order, building on the previous phase, to ensure that healing tissues are not compromised. Emphasis is placed on restoring full motion, muscular strength, and neuromuscular control while gradually applying loads to healing tissue. In addition, when one is creating a rehabilitation plan for athletes, it is imperative to treat the entire upper extremity, core, and legs to create and dissipate the forces generated at each joint.

Context: The ulnar collateral ligament of the elbow (UCL) is frequently injured in throwing athletes, most commonly baseball pitchers. The ligament is reconstructed through bone tunnels using palmaris longus or gracilis autograft. Results: This study highlights the following technique for UCL reconstruction in over 2000 athletes. 2 Conclusion: When conservative management fails, ligament reconstruction can allow the athlete to return to their sport. 1