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PURPOSE OF REVIEW: Posteromedial elbow impingement is a common pathological entity in the throwing athlete. The posteromedial articulation of the elbow is a significant stabilizer to medial elbow forces and valgus stress noted during repetitive throwing. This current review investigates recent literature regarding the relevant anatomy, diagnosis, and treatment of posteromedial impingement in the thrower. RECENT FINDINGS: Improvements in advanced imaging have provided accurate and detailed diagnostic capability for the assessment of the throwers’ elbow. After failure of conservative measures, arthroscopic treatment of posteromedial elbow impingement with posteromedial osteophyte removal has demonstrated excellent outcomes with a reliable return to play in the competitive thrower. SUMMARY: In addition to a thorough history and physical examination, MRI, MR arthrogram, CT, and dynamic ultrasound imaging modalities are useful in the assessment of a presumed diagnosis of posteromedial impingement. Arthroscopic decompression with posteromedial osteophyte removal provides effective clinical results and return to play. The surgeon should be careful to avoid creating medial ulnar collateral instability by means of over-resection of the posteromedial olecranon.

PURPOSE OF REVIEW: The purpose of this article is to review medial ulnar collateral ligament (UCL) injuries in contact athletes. UCL injuries in overhead throwing athletes are typically chronic attenuation due to repetitive valgus stress on the elbow during the throwing motion. As such, UCL reconstruction is commonly performed for these athletes. In contrast, UCL injuries in contact athletes are usually acute ligament tears or avulsions of a ligament with otherwise normal tissue. Nonoperative treatment is typically the first-line treatment for partial injuries. UCL repair may work well for acute complete injuries and may avoid the donor site morbidity of UCL reconstruction. RECENT FINDINGS: Most of the literature regarding UCL injuries have been performed in baseball players. Historically, UCL repair has had poor outcomes in baseball players due to the chronic ligament attenuation. Therefore, much of the recent literature has focused on outcomes of UCL reconstruction, which are generally excellent. However, there is a paucity of literature studying outcomes of UCL injuries in contact athletes and those studying UCL repair. One recent study looked at a new technique for UCL repair with collagen-coated fiber tape augmentation in baseball players and found good short-term outcomes. SUMMARY: UCL injuries in contact athletes occur typically as acute tears or avulsions. While UCL reconstruction has typically been recommended as the accepted treatment for UCL tears that require operative treatment, UCL repair may be a good alternative in contact athletes.

PURPOSE OF REVIEW: Lower extremity (LE) injuries are a common source of disability and time-loss for overhead athletes, and muscles have been found to be the predominant soft tissue structure affected. The current review highlights the orthopaedic literature examining lower extremity muscle injuries in overhead athletes in regard to epidemiology, diagnosis, and conventional and emerging treatment measures. RECENT FINDINGS: The hamstring muscles have been found to be the most commonly injured lower extremity muscle group in professional baseball, followed by the adductors, quadriceps, iliopsoas, and gastrocnemius-soleus complex. Strains and contusions comprise over 90% of these muscle injuries. Various advanced imaging grading systems have been developed to help characterize the nature of a muscle injury, although a clear and consistent prognostic utility of these systems is still unclear. The vast majority of lower extremity muscle injuries in overhead athletes are managed nonoperatively, and there is promising data on the use of emerging treatments such as platelet-rich plasma and blood flow restriction therapy. SUMMARY: Lower extremity muscle injuries—often referred to as strains—are a relatively common issue in high-demand overhead athletes and can be a significant source of time-loss. Within baseball, position players are affected far more often than pitchers, and sprinting and fielding are the most common activities leading to strains. Magnetic resonance imaging (MRI) is considered the gold standard imaging modality to evaluate these muscle injuries and will allow for a detailed assessment of tissue damage. Nonetheless, return-to-play is often dictated by a given athlete’s progression through a nonoperative rehabilitation protocol, with surgical intervention reserved for less common, select injury patterns.

PURPOSE OF REVIEW: Baseball has become one of the largest data-driven sports. In this review, we highlight the historical context of how big data and sabermetrics began to transform baseball, the current methods for data collection and analysis in baseball, and a look to the future including emerging technologies. RECENT FINDINGS: Machine learning (ML), artificial intelligence (AI), and modern motion-analysis techniques have shown promise in predicting player performance and preventing injury. With the advent of the Health Injury Tracking System (HITS), numerous studies have been published which highlight the epidemiology and performance implications for specific injuries. Wearable technologies allow for the prospective collection of kinematic data to improve pitching mechanics and prevent injury. SUMMARY: Data and analytics research has transcended baseball over time, and the future of this field remains bright.

PURPOSE OF REVIEW: Treatment of overhead athletes requires a systematic approach that will make an accurate diagnosis, deliver effective treatment, and make timely and safe return to sport. RECENT FINDINGS: New data has shown success rates and return to play effectiveness after different types of cervical and lumbar surgery. Cervical foraminotomy has been shown to have the highest rate and fastest return to play, but with the highest incidence of need for revision surgery. Cervical artificial disc replacement has shown promising results in the general population and is being done more commonly in elite athletes, but has an unknown risk for failure. Cervical fusion is a well-established and effective treatment, but has the longest healing time and risk for adjacent level pathology. In the lumbar spine, discectomy has a long and proven track record, fusion is rarely performed but can be effective, and artificial disc replacement is extremely rare in an elite athlete. SUMMARY: An effective and comprehensive approach can diagnose, treat, and return overhead athletes to competitive play.

PURPOSE OF REVIEW: Golf is a sport that can be played by an athlete of any age, which enhances its popularity. Each golfer’s swing is unique, and there is no “right” way to swing the golf club; however, the professional golfer often has more of a consistent swing as opposed to an amateur golfer. A collaborative, team approach involving the golfer with a swing coach, physical therapist, and physician often can be informative on how to prevent golf injury, but also how to treat golf injury if it occurs. RECENT FINDINGS: As a rotational sport, the golfer needs to be trained and treated with respect for how the body works as a linkage system or kinetic chain. A warm-up is recommended for every golfer before practicing or playing, and this warm-up should account for every segment of the linkage system. Though it has been thought of as a relatively safe sport, injuries can be seen with golfers of any age or skill level, and upper body injuries involving the cervical and thoracic spine, shoulder, elbow, and wrist are common. SUMMARY: A narrative review is provided here of the epidemiology of golf injury and common injuries involving each of these upper body regions. In addition, treatment and injury prevention recommendations are discussed.

Purpose of Review Throwing athletes are vulnerable to elbow injuries, especially in the medial elbow, related to high stress and valgus load in both acute and chronic settings as a result of this complex biomechanical action. This current review details the relevant anatomy and imaging features of common elbow pathology identified with radiographs and MRI in throwing athletes. Recent Findings Although elbow pathology in throwing athletes is well documented, advances in imaging technology and technique, particularly with MRI, have allowed for more detailed and accurate imaging description and diagnosis. Summary Pathology of thrower’s elbow occurs in predictable patterns and can be reliably identified radiologically. Clinical history and physical examination should guide radiologic evaluation initially with radiographs and followed by an MRI optimized to the clinical question. Constellation of clinical, physical, and radiologic assessments should be used to guide management.

PURPOSE OF REVIEW: Offseason training programs are crucial for the baseball athlete. Preparation for the competitive season should be carefully planned to allow long-term athletic success. The two goals of the offseason training program are to optimize performance and reduce injury risk. These goals can only be accomplished with an understanding of the unique physical demands of the sport, and how these demands relate to performance and injury. The purpose of this article is to review the unique demands of baseball training along with current strength and conditioning principles to optimize offseason training for the baseball athlete. RECENT FINDINGS: Traditional strength and conditioning programs used in other sports may not maximize the qualities necessary for optimal baseball performance. Traditional strength and conditioning exercises, such as squat and deadlift, primarily train sagittal plane movement while frontal and transverse plane movements are likely equally as important for baseball players. Biomechanical studies have shown that trunk rotation power has the largest influence on throwing velocity in pitchers. Programs should also be designed to reduce injury risk for common injuries. The most common injuries in baseball include hamstring strains, throwing arm injuries, paralumbar muscle strains, hip adductor strains, and oblique muscle strains. SUMMARY: This review describes the typical periodization phases of the offseason and provides a sample program outlining an offseason program for a professional baseball player from September through February.

PURPOSE OF REVIEW: Traditionally medial elbow injuries in overhead athletes have been treated with ulnar collateral ligament (UCL) reconstruction as first described by Dr. Frank Jobe. Recent literature has shown favorable outcomes in select patients treated with UCL repair. Newer techniques utilizing suture augmentation demonstrate biomechanical profiles as good or better than the native state and/or reconstruction. This review aims to evaluate these biomechanical studies and the clinical outcomes of ulnar collateral ligament repair with suture augmentation. RECENT FINDINGS: UCL repair has favorable outcomes in select patients with specific tear type patterns. Clinical outcomes have shown return to play rates of 92–97% with mean time of 2.5–6 months post-operatively. Biomechanical data comparing UCL repair to reconstruction techniques have shown improved resistance to common forces applied to the elbow during overhead activities. Additionally, suture tape augmentation dramatically improves stability of ligament repair without over-constraining the elbow. SUMMARY: Initial ulnar collateral ligament repair data was poor, and thus UCL reconstruction became the mainstay of treatment for overhead athletes. Recent studies evaluating the biomechanical properties as well as clinical outcomes have demonstrated favorable data when UCL repair is performed. When considering the drawbacks of a prolonged recovery associated with reconstruction, UCL repair is a viable option in select patients.

Purpose of Review General guidelines exist for return to sport after injury. The goal of these guidelines is to outline phases of recovery that will minimize the risk of reinjury and promote an optimal return to function for the athlete. This paper analyzes the current research pertaining to interval return to play programs with a special focus on the tennis athlete. The authors examine the different components of an interval tennis program and work to develop what they feel are the necessary elements of the optimal return to sport guidelines for tennis athletes. These criteria are based on the available literature, research, and preliminary data collection as well as the personal experiences and clinical observations of the authors. Recent Findings Interval sports programs are typically designed to guide the athlete back to competition after an injury. The current research reveals the obstacles present in implementing an appropriate interval sports program including a lack of consensus on which criteria is actually necessary and relevant. Limited research is present for interval tennis programs. Summary Return to sport competition and sports science is continuously evolving. The authors highlight the necessary components in rehabilitation and performance principles for establishing a comprehensive interval tennis program. In addition, the role of technology in sports rehabilitation is assessed as it pertains to return to play. The authors proposed that interval sports program can help guide and direct future clinicians in their rehabilitation of the tennis athlete.

PURPOSE OF REVIEW: Arm care programs for baseball players are an increasingly popular area of interest for players, parents, coaches, sports performance staff, and team physicians. Once a general afterthought, the design of arm care programs is now heavily scrutinized in order to maximize performance and help reduce injury risk. Given the recent spike in interest for arm care programs for baseball players of all ages, the purpose of this work is to review the relevant literature regarding the efficacy of arm care programs and to discuss the authors’ preferred, evidence-based principles for arm care programs. RECENT FINDINGS: Arm care programs appear to provide favorable results for performance, maintenance of strength and flexibility, and reduced injury risk. These programs should be tailored to the demands of the athlete, which can change based on the time of year and physical demands of the player’s position. A good program will incorporate flexibility, strengthening, proprioception, and joint mobility for the entire kinetic chain. Appropriate warm-up and cool-down periods are also important. Arm care programs should start with basic movement patterns before progressing to more advanced, coordinated exercises. SUMMARY: Arm care programs are an important piece of a holistic approach to caring for the throwing arm of baseball athletes. In general, they appear to be a safe and efficacious way to help prevent a portion of throwing arm injuries. Further research is needed to determine the optimal arm care program for each athlete.

PURPOSE OF REVIEW: Neurovascular compression in the upper extremity is rare but can affect even those participating in high-level competitive athletics. To assess optimal approaches to treatment, in this review, we evaluate the current literature on neurovascular compressive syndromes affecting the upper extremity, with a special focus on the thoracic outlet syndrome (TOS). RECENT FINDINGS: Neurovascular compression at the thoracic outlet can involve the brachial plexus, subclavian artery, or subclavian vein, each with distinct clinical manifestations. Neurogenic TOS is best treated with surgical decompression, if physical therapy has not improved symptoms. Venous TOS results in acute thrombosis superimposed on chronic venous compression. Treatment is best directed at early anticoagulation, catheter-directed thrombolysis, and surgical decompression, with most patients able to discontinue anticoagulation and return to high-level athletic activity. Arterial TOS is related to aneurysmal degeneration of the subclavian artery with distal embolization, leading to limb-threatening ischemia. This should be aggressively treated with surgery. Similar degenerative changes can occur in the axillary artery and its branches, leading to distal embolization. Prompt recognition of these potential sources of limb-threatening ischemia is critical to limb preservation. SUMMARY: TOS includes rare but important conditions in the overhead athlete. Recent advances in physical therapy and image-guided diagnostic techniques have facilitated more accurate diagnosis. Surgical treatment remains the gold standard to maximize function or for limb preservation, and future research is needed to clarify optimal pain and physiotherapy regimens, as well as to examine novel approaches to neurovascular decompression.

PURPOSE OF REVIEW: To review the current technology available for the prevention and treatment of shoulder and elbow injuries in the overhead athlete. RECENT FINDINGS: Shoulder and elbow injuries are common in recreational and high-level overhead athletes. Injury prevention in these athletes include identifying modifiable risk factors, offering effective preventative training programs, and establishing safe return-to-sport criteria. The advent and use of technologies and wearable devices with concomitant development of software and data analytic programs has significantly changed the role of sports technology in injury identification and prevention. Over the last few decades, leveraging new technologies to better understand and treat patients has become an increasing focus of healthcare. Technologies currently being applied to the treatment of the overhead athlete include kinesiotaping, heart rate monitors, accelerometers/gyroscopes, dynamometers/force plates, camera-based monitoring systems (optical motion analysis), and inertial sensor monitoring units. SUMMARY: Advances in technology have made it possible to acquire large amounts of data on athletes that may be used to guide treatment and injury prevention programs; however, literature validating the clinical efficacy of many of these technologies is limited. Further research is needed to continue to allow team physicians to provide better, cost-efficient, and individualized care to the overhead athlete using technology.

PURPOSE OF REVIEW: There has been a marked increase in the number of ulnar collateral ligament reconstructions performed annually and an associated increase in the amount of recent literature published. It is paramount that surgeons remain up to date on the current literature, as modern indications and surgical techniques continue to improve clinical outcomes. RECENT FINDINGS: Our understanding of ulnar collateral ligament (UCL) injuries, treatment indications, and surgical techniques for UCL reconstruction continues to evolve. Despite the rapidly increasing amount of published literature on the topic, a clear and concise surgical algorithm is lacking. Studies have suggested a trend towards improved clinical outcomes and decreased complications with various modifications in UCL reconstruction techniques. Current sport-specific outcome studies have reported conflicting results regarding the effect of UCL reconstruction on an athlete’s performance upon returning to sport. SUMMARY: With the rising incidence of UCL reconstruction and growing media attention, UCL injuries, reconstruction techniques, and return to sport following UCL surgery are timely topics of interest to clinicians and overhead throwing athletes. Several technique modifications have been reported, and these modifications may lead to improved outcomes and lower complication rates. Studies assessing sport-specific outcome measures will be necessary to provide a more critical and informative analysis of outcomes following UCL reconstruction.

PURPOSE OF REVIEW: The purposes of this review are to describe the epidemiology, treatment options, and clinical outcomes of revision medial ulnar collateral ligament reconstruction in baseball pitchers. RECENT FINDINGS: Rates of revision UCL range from 1 to 15% and have slowly increased over the past several years. Revision UCL procedures are associated with higher complication rates, likely due to the distortion of innate anatomy after primary reconstruction. Techniques for reconstruction are largely influenced by the index surgery and integrity of the ulnar and humeral bone tunnels/sockets. Current literature reporting on the outcomes following revision UCL reconstruction is limited to case series and database studies. Mean time between primary reconstruction and revision surgery is approximately 5 years and return to play rates range from 47 to 85%. SUMMARY: Outcomes following revision UCL reconstruction are relatively guarded compared with those of primary UCL reconstruction with the most studies reporting lower return to play rates, decreased workloads compared with pre-injury levels of play, and shorter career longevity following revision surgery. Future research regarding optimal reconstruction techniques and post-operative rehabilitation are needed as the incidence and demand for this procedure is expected to increase.

PURPOSE OF REVIEW: The purpose of this review will be to provide both a historical and recent review of the role of the kinetic chain for the overhead athlete. The kinetic chain concept will then be applied to clinical exercise modifications and integrations for prevention and treatment of shoulder injury. RECENT FINDINGS: The primary conclusion reached through this review is the important role the lower extremity, trunk, and scapular region play in the development of optimal terminal segment acceleration in the overhead throwing and serving motion. Failure of any links in the kinetic chain has implications for shoulder and elbow injury in the overhead athlete. Modifications of traditional shoulder exercises emphasizing activation of the scapular stabilizers and core musculature alongside concomitant rotator cuff activation are recommended and supported in EMG research. SUMMARY: Future research is needed to further identify risk factors and rehabilitation and prevention strategies and key clinical tests for the overhead athlete. The goal is to elucidate the important role the kinetic chain plays in both performance enhancement and injury prevention for the overhead athlete. Understanding the key role all segments of the kinetic chain play in the complex biomechanical segmental rotations required for high-level throwing and serving will assist clinicians who work with overhead athletes.

PURPOSE OF REVIEW: The importance of both the static and dynamic stabilizers of the medial elbow for the throwing athlete has been demonstrated in recent studies. Furthermore, recent anatomic studies have demonstrated the insertion of the anterior bundle (UCL) to be more distal and elongated, which has implications for surgical reconstruction of the UCL. The purpose of this review is to highlight recent anatomic and biomechanical studies evaluating the anatomy and reconstructions of the medial elbow. RECENT FINDINGS: Recent literature has highlighted the crucial role of the dynamic stabilizers in resisting valgus force, especially during the throwing motion. The dynamic stabilizers of the medial elbow include the flexor pronator mass, specifically the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS). The clinical importance of these findings cannot be under stated, as unrecognized dynamic stabilizer injury can lead to increased stress on a native or reconstructed UCL in the throwing athlete. SUMMARY: The medial ulnar collateral ligament complex of the elbow has a crucial role in providing both static and dynamic elbow stability. Most notably, the anterior bundle (UCL) provides the primary resistance to valgus and rotational stresses, especially during throwing motion. An understanding of the humeral and ulnar footprints and their relationships with surrounding structures is necessary to restore the native isometry of the medial complex of the elbow during UCL reconstruction. The flexor pronator musculature plays an essential role in dynamic stability, and the intimate relationship of the FCU and FDS with the ulnar insertion of the UCL should be considered to optimize recovery and outcomes with repair or reconstruction.

PURPOSE OF REVIEW: Overhand (OH) throwers demonstrate a unique motion profile of the shoulder joint complex. This manuscript reviews normal adaptations in the OH thrower and contrast findings with pathologic motion deficits. RECENT FINDINGS: Multiple adaptations in range of motion have been associated with increased risk for arm injury. The use of a more conservative cutoff value for glenohumeral internal rotation deficit and horizontal adduction in younger throwers may help reduce injury risk. Deficits in glenohumeral internal rotation, total range of motion, shoulder flexion, and external rotation insufficiency have all been proposed as means to identify OH throwers at risk for arm injury, but conflicting evidence exists. SUMMARY: Understanding normal adaptation due to repetitive stress of throwing is essential to effective management of these athletes. Adaptive change in bone and soft tissues is normal and contributes to the unique motion profiles expected in throwers. The causative link between normal adaptation and shoulder and elbow injury remains uncertain.

PURPOSE OF REVIEW: The purpose of this article is to review common hand and wrist injuries experienced by tennis players. RECENT FINDINGS: A myriad of different wrist pathologies can be seen in tennis players ranging from metacarpal and carpal stress fractures to triangular fibrocartilage injuries and ulnar impaction. These vary depending upon the nature of the player, stroke mechanics, and time point within the season. SUMMARY: A broad differential should guide work-up and management of wrist pain in tennis players.

PURPOSE OF REVIEW: The goal of this review article is to help medical personnel of all levels and backgrounds identify and appropriately manage on-field acute shoulder and elbow injuries in the baseball athlete. This article discusses the most common acute shoulder and elbow injuries in baseball players along with recommendations for appropriate on-field management. RECENT FINDINGS: Shoulder and elbow injuries are very common in baseball players and can be problematic because of the unique demands placed on the shoulder and elbow during the throwing and swinging motions. While many shoulder and elbow injuries in baseball players are chronic, some acute injuries, including dislocations and fractures, require urgent on-field management. Evaluation should begin with a broad assessment to rule out life-threatening emergencies prior to performing a neurovascular evaluation of the affected extremity. Red-flag signs during examination, such as difficulty breathing, asymmetric pulses, weakness, and limb discoloration, require emergent treatment. In the absence of an emergency, the evaluating medical team should complete a basic neurovascular exam before performing any further on-field care. SUMMARY: Contusions, dislocations, and fractures are the most commonly seen acute shoulder and elbow injuries in baseball athletes. Athletic trainers and physicians caring for these athletes should be familiar with these injuries and their appropriate on-field management.

PURPOSE OF REVIEW: Injury to the ulnar collateral ligament is the most common, significant injury affecting the medial elbow of the overhead athlete. However, there are many other significant sources of pathology that should be considered. This review seeks to present a broad range of conditions that providers should consider when evaluating the overhead athlete with medial elbow pain. RECENT FINDINGS: Recent biomechanical studies have deepened understanding of the anatomy and function of the anterior bundle of the ulnar collateral ligament germane to the overhead athlete. Orthobiologics hold potential for expanding the role of non-operative treatment for ulnar collateral ligament injuries. SUMMARY: In addition to injury to the ulnar collateral ligament, providers should be prepared to diagnose and treat valgus extension overload, proximal olecranon stress fracture, ulnar nerve pathology, common flexor - pronator mass injury, and, in adolescents, medial epicondylar avulsion, when managing medial elbow pain in the overhead athlete.

PURPOSE OF REVIEW: Overhead throwing is a particularly violent motion that requires a complex sequence of timed muscle activations to efficiently transfer energy up the kinetic chain to throw a ball. Long-toss has long been utilized as a means of increasing shoulder range of motion, strength, and endurance, as well as an important component of rehabilitation in interval throwing programs. The purpose of this review is to assess the current literature on the science and biomechanics of long-toss. RECENT FINDINGS: While long-toss is ubiquitously utilized in throwing programs for pitchers of all ages, the definition of long-toss, as well as its primary function in a throwing program, is debated. Throwing biomechanics in long-toss differ from that of mound pitching, although much of the variation is determined by the type of long-toss: shorter distance and on a line versus maximum distance and not on a line. Biomechanical factors including the kinematic changes of increased maximum glenohumeral external rotation, increased maximum elbow flexion, decreased trunk forward flexion at front foot contact, kinetic changes of increased shoulder internal rotation torque, increased elbow varus torque, and increased elbow extension velocity can occur with maximum distance long-toss throwing. SUMMARY: Long-toss is a highly variable training supplement that is used in throwing programs at all levels of baseball competition. Current literature has demonstrated a number of kinetic and kinematic changes in the throwing arm and throwing motion related to increasing long-toss distances. However, the exact benefits of long-toss are difficult to quantify due to the numerous definitions and various utilizations of long-toss.

PURPOSE OF REVIEW: During overhead throwing, there are tremendous forces placed on the medial elbow that can result in injury to the ulnar nerve. The purpose of this article is to review the anatomy, biomechanics, and appropriate clinical care of an overhead throwing athlete suffering from injury to their ulnar nerve. The authors preferred clinical work-up; non-operative and operative care are included in this review. RECENT FINDINGS: More recent findings support the use of subcutaneous transposition instead of the submuscular transpositions and only to perform a transposition in the setting of specific pre-operative findings. Subcutaneous transpositions have led to decreased rates of post-operative symptoms and complications. SUMMARY: Understanding the complexity of the medial elbow is essential to making an accurate diagnosis of ulnar neuritis/neuropathy in the overhead throwing athlete. In general, non-operative management has shown to be successful; however, in those refractory or recurrent cases of ulnar neuritis, ulnar nerve decompression with or without transposition provides these athletes with a surgical procedure that has shown to provide patients with excellent outcomes. Continued refinement surgical indications and surgical technique will allow for a high percentage of athletes who return to competitive sports following surgery for ulnar neuropathy.

PURPOSE OF REVIEW: Injuries to the elbow ulnar collateral ligament (UCL) are especially common in the overhead throwing athlete. Despite preventative measures, these injuries are occurring at increasing rates in athletes of all levels. UCL reconstruction techniques generally require a prolonged recovery period and introduce the potential for intraoperative complications prompting investigations into more conservative treatment measures based on specific patient and injury characteristics. The purpose of this review is to describe the current literature regarding the use of biologic augmentation in the management of UCL injuries. Specifically, this review will focus on the basic science background and clinical investigations pertaining to biologic augmentation utilizing platelet-rich plasma (PRP) and autologous stem cells. RECENT FINDINGS: Despite some evidence supporting the use of PRP therapy in patients with partial UCL tears, there is no current consensus regarding its true efficacy. Similarly, due to a lack of clinical investigations, no consensus exists regarding the utilization of autologous stem cell treatments in the management of UCL injuries. SUMMARY: Management of UCL injuries ranges from non-operative treatment with focused physical therapy protocols to operative reconstruction. The use of biologic augmentation in these injuries continues to be investigated in the orthopedic community. Currently, no consensus exists regarding the efficacy of either PRP or autologous stem cells and further research is needed to further define the appropriate role of these treatments in the management of UCL injuries.

PURPOSE OF REVIEW: The purpose of this review article is to discuss the evolution of surgical reconstruction of the anterior bundle of the UCL, otherwise known as Tommy John surgery, from Dr. Jobe’s initial description in 1986 to present day. In particular, the unique changes brought forth by each new surgical technique, and the reasons that these changes were implemented, are highlighted. RECENT FINDINGS: The incidence of UCL reconstruction surgery continues to increase significantly, particularly in the 15- to 19-year-old age group. New anatomic understanding of the anterior bundle of the UCL, including the importance of the central fibers and the broad and tapered ulnar insertion, may affect optimal UCL reconstruction techniques in the future. Although return to play rates are generally quite high (80–95%), the mean time to return to play (typically 12–18 months for pitchers) is longer than desired. Accordingly, many authors feel that there remains room for improvement in the treatment of this common injury. SUMMARY: The Tommy John surgery has evolved in many ways with the development of novel techniques over the last 35 years. Currently, overhead throwing athletes undergoing UCL reconstruction have high return to play and low complication rates. Future modifications to the surgery may aim to further improve outcomes and, more importantly, expedite the length of postoperative rehabilitation.

PURPOSE OF REVIEW: Glenohumeral internal rotation deficit (GIRD) is a term used in the literature to describe the physiological adaptation that occurs in the dominant arm of the overhead-throwing athlete. The meaning of this term and the clinical significance and the rationale for its treatment have all been described with some ambiguity within the literature. GIRD as a measurement is multivariate. There is an adaptive bony component in humeral retroversion (HR) and muscular contributions in the form of thixotropy which can confound the capsular component of GIRD. Emerging diagnostic tools such as ultrasound can help differentiate between the bony and soft tissue contributions as well as provide a dynamic assessment in the throwing shoulder. The purpose of this review is to describe and differentiate between anatomical GIRD (aGIRD) and pathological GIRD (pGIRD), discuss the clinical significance of pGIRD and values reported within the literature, and describe its measurement and clinical treatment. RECENT FINDINGS: Recent literature has demonstrated that GIRD alone is not associated with injury risk of the upper extremity in the overhead athlete. Although past literature has demonstrated pGIRD as increasing injury risk, other variables such as external rotation (ER) deficit, horizontal adduction deficit, and shoulder flexion deficit have been associated with injury of the upper extremity while GIRD did not. Further, an appreciation for the difference between adaptive GIRD and pathologic GIRD has recently been emphasized to ensure optimal treatment addresses the pathologic portion of GIRD. The recent focus on early treatment approaches to pGIRD may play a role in its diminished risk association. SUMMARY: This review offers the term humeral retroversion (HR) Corrected GIRD as a more clinically sensitive value that may provide the clinician a more precise rationale for the treatment of pGIRD. Currently, diagnostic ultrasound is a reliable and valid method for measuring HR in the overhead-throwing athlete. Future research that validates clinical methods for assessing HR could provide utility for clinical decision-making in the absence of diagnostic ultrasound.

Swimmer’s shoulder is the term used to describe the problem of shoulder pain in swimmers. Originally described as supraspinatus tendon impingement under the coracoacromial arch, it is now understood that several different pathologies can cause shoulder pain in competitive swimmers, including subacromial impingement syndrome, overuse and subsequent muscle fatigue, scapular dyskinesis, and laxity and instability. Swimmers may develop increased shoulder laxity over time due to repetitive use. Such excessive laxity can decrease passive shoulder stability and lead to rotator cuff muscle overload, fatigue, and subsequent injury in order to properly control the translation of the humeral head. Generalized laxity can be present up to 62% of swimmers, while a moderate degree of multi-directional instability can be present in the majority. Laxity in swimmers can be due to a combination of underlying inherent anatomical factors as well as from repetitive overhead activity. The role of excessive laxity and muscle imbalance are crucial in the swimmer’s shoulder and should be well understood since they are the primary target of the training and rehabilitation program.

Professional football quarterbacks are at particular risk for upper extremity injuries due to the physical demands of their position coupled with the inherent risks associated with professional football. This review sought to evaluate current clinical literature to better characterize the injury profile unique to this athletic population. Shoulder injuries are the most prevented upper extremity injury among professional football quarterbacks. The quarterback position is disproportionately impacted by shoulder injuries when compared to professional athletes at other positions. Moreover, contrary to other professional throwing athletes, the majority of upper extremity injuries in the professional quarterback result from direct contact as opposed to the throwing motion. The injury profile among professional quarterbacks is unique compared to other positions and other overhead professional throwing athletes. Overall, a paucity of high quality clinical evidence exists to support the management of injuries in this elite population.

This review examines recent literature on injury epidemiology and prevention in the sport of baseball from youth to professional levels. Overuse is the predominant mechanism of injury in youth baseball players. Newer stretching and exercise protocols may help prevent these injuries. At the professional level, however, overuse has not been proven to correlate with increased injury incidence, but pitch counts are still monitored. There continues to be a rise in operations performed for baseball-related injuries, including ulnar collateral ligament (UCL) reconstruction, particularly in younger athletes. As the level of play increases, there is significant loss of participation due to injuries, such as the UCL in the upper extremity and the hamstrings in the lower extremity. Baseball is a widely popular sport, which has led to a focus on injury epidemiology and prevention. While the majority of research regarding baseball injuries focuses on pitchers, fielders and catchers are also at risk. In an attempt to decrease non-contact injuries in the upper and lower extremities, stretching and strengthening exercises are vitally important. Because injury profiles demonstrate significant variability from youth to professional baseball, unique prevention strategies are likely necessary at each level. More research is needed to develop and validate appropriately targeted injury prevention programs.

To review the recent literature regarding the epidemiology of tennis injuries at all levels of play, and to discuss recent findings in injury surveillance by the Association of Tennis Professionals (ATP). Following the release of a consensus statement in 2009 calling for standardized documentation and analysis of tennis-related injuries, multiple studies have been published describing longitudinal injury incidences at Grand Slam tournaments and the Davis Cup. Recent efforts by the ATP have further elucidated injury patterns on tour. There have also been recent high-quality studies on injury trends among collegiate and elite junior tennis players, bringing attention to musculoskeletal injuries and systemic illnesses that young tennis players may be susceptible to. Recent efforts in injury surveillance by the ATP and at the collegiate and junior levels have highlighted injury trends that will help guide injury prevention strategies at various levels of play.

This review aims to describe the nonreconstructive options for treating ulnar collateral ligament (UCL) injuries ranging from nonoperative measures, including physical therapy and biologic injections, to ligament repair with and without augmentation. Nonoperative options for UCL injuries include guided physical therapy and biologic augmentation with platelet-rich plasma (PRP). In some patients, repair of the UCL has shown promising return to sport rates by using modern suture and suture anchor techniques. Proximal avulsion injuries have shown the best results after repair. Currently, there is growing interest in augmentation of UCL repair with an internal brace. The treatment of UCL injuries involves complex decision making. UCL reconstruction remains the gold standard for attritional injuries and complete tears, which occur commonly in professional athletes. However, nonreconstructive options have shown promising results for simple avulsion or partial thickness UCL injuries. Future research comparing reconstructive versus nonreconstructive options is necessary.

To review the etiology, classification, presentation, evaluation, treatment strategy, and outcomes in overhead athletes with partial thickness rotator cuff tears. Despite advances in surgical repair techniques, return to play following surgical repair of partial rotator cuff tears remains modest at best. Overhead athletes may be particularly prone to rotator cuff pathology due to the supraphysiological strains within the tendon during the throwing motion, as well as mechanical stress with contact between the undersurface of the rotator cuff and the glenoid. The true prevalence of partial tears may be underestimated given the high incidence of asymptomatic tears. Both dynamic ultrasound and enhanced contrast MRI have improved our understanding of this pathology. For most overhead athletes, nonoperative management is the most common course. Despite advances in imaging, diagnosis, and surgical techniques, our ability to return these patients to their elite level is modest at best when nonoperative management fails and surgical treatment is performed. If a surgical route is needed, debridement alone is the most frequent procedure given concerns of over constraint and poor return to play with surgical repair of the partial thickness rotator cuff tear.

PURPOSE OF REVIEW: This review will outline scapular function in throwing, discuss scapular dyskinesis as an impairment of function that can be associated with throwing injuries and altered performance, and present an algorithm that encompasses guidelines for evaluation and can serve as a basis for treatment. RECENT FINDINGS: Optimal scapular function is integral to optimal shoulder function. Multiple roles of the scapula in arm function and throwing have been identified while scapular dysfunction continues to be associated with various shoulder pathologies. Although scapular motion alterations may be common in overhead athletes, various reports have shown that identification and management of the alterations can result in improved rehabilitation and performance outcomes. SUMMARY: Baseball throwing occurs as the result of integrated, multisegmented, sequential joint motion, and muscle activation within the kinetic chain. The scapula is a key component link within the chain through its function to maximize the scapulohumeral rhythm and efficient throwing mechanics. Evaluation and management beginning with the scapula can produce improved outcomes related to shoulder pathology in overhead athletes.

PURPOSE OF REVIEW: Primarily reported in the overhead throwing athlete, ulnar collateral ligament (UCL) injuries have been extensively studied since Dr. Frank Jobe first described his technique for ulnar collateral ligament reconstruction on professional baseball pitcher Tommy John. While the framework for our understanding of UCL injury was initially established studying the repetitive valgus loading of the throwers’ elbow, other sport-related activities in non-throwing athletes can impart similar valgus stress on the medial elbow placing the UCL at risk for injury. The purpose of this review is to evaluate the current literature on UCL injury specifically in the non-throwing athlete. RECENT FINDINGS: In the four decades since Dr. Jobe’s seminal description of UCL reconstruction, an abundance of literature has been published on UCL injury in the throwing athlete. The evidence evaluating the UCL specifically in the non-throwing athlete, however, is quite scarce. Several small retrospective studies have demonstrated good results with high rates of return to play with focused rehabilitation and non-operative management in non-throwing athletes. Recent evidence has also demonstrated that surgical repair and/or reconstruction of the UCL in this population can produce good outcomes. SUMMARY: The level of evidence of these published studies is low and consists primarily of case series without control groups. Further investigation is warranted to determine the optimal treatment algorithm for UCL injury in the non-throwing athlete.

PURPOSE OF REVIEW: This review examines recent literature regarding analysis of the throwing motion in baseball players and how modern technology may be used to predict or prevent injury. RECENT FINDINGS: Proper throwing technique is vitally important to prevent injury and it is easier to correct poor mechanics prior to foot strike. Recent findings suggest that the inverted-W position may not lead to an increased risk of injury, but incorrect trunk or pelvis rotation does. Three-dimensional motion analysis in a laboratory setting is most commonly used to evaluate the throwing motion, but it does not allow for assessment in real game scenarios. Wearable monitors allow for this and have proven to reliably assess pitching workload, kinematics, and kinetics. SUMMARY: Injuries in youth baseball pitchers have increased along with the trend towards more single sport specialization. To prevent injury, assessment of a pitcher’s throwing motion should be performed early to prevent development of poor mechanics. Classically, three-dimensional motion analysis has been used to evaluate throwing mechanics and is considered the gold standard. Newer technology, such as wearable monitors, may provide an alternative and allow for assessment during actual competition.

PURPOSE OF REVIEW: To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes. RECENT FINDINGS: The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. SUMMARY: Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.

PURPOSE OF THE REVIEW: To review the relevant literature surrounding acromioclavicular (AC) joint injuries particularly pertaining to overhead athletes. RECENT FINDINGS: The AC joint is a unique anatomic and biomechanical portion of the shoulder that can be problematic for athletes, particularly throwers, when injured. Treatment of these injuries remains a topic in evolution. Low-grade injuries (Rockwood types I & II) are typically treated non-operatively while high-grade injuries (types IV, V, and VI) are considered unstable and often require operative intervention. Type III AC separations remain the most controversial and challenging as no clear treatment algorithm has been established. A wide variety of surgical techniques exist. Unfortunately, relatively little literature exists with regard to overhead athletes specifically. SUMMARY: Treatment of AC joint injuries remains challenging, at times, particularly for overhead athletes. Operative indications and techniques are still evolving, and more research is needed specifically surrounding overhead athletes.

PURPOSE OF REVIEW: Tears of the latissimus dorsi and teres major are uncommon but significant injuries, most frequently seen in high-level, overhead throwing athletes. Diagnosis can be challenging, as there are no pathognomonic signs, symptoms, or physical exam findings associated with latissimus dorsi/teres major tears, and the clinician must have a high suspicion for this injury. While many of these tears can be treated non-operatively, a subset of these benefits from surgical intervention. Rehabilitation following operative and non-operative treatments of these injuries is extensive, and timing of return to sport can be variable from 3 to 12 months. RECENT FINDINGS: The literature surrounding latissimus dorsi/teres major injuries is sparse. Several small studies have shown good results in patients with mild to moderate tears that were treated non-operatively. Recent evidence has shown good results following operative repair of larger tears, with excellent return to sport rates. Furthermore, focused rehabilitation is imperative when treating patients with latissimus dorsi/teres major injuries to allow these athletes to return to sport. SUMMARY: Latissimus dorsi/teres major tears are uncommon but significant injuries in the throwing athlete. Prompt diagnosis, proper treatment, and focused rehabilitation will allow these patients to return to sport in a safe and efficient manner.

PURPOSE OF REVIEW: The purposes of this review are to discuss the management of shoulder and elbow fractures in athletes to optimize the return to sport and to highlight treatment impact on the return to play. RECENT FINDINGS: Fractures of the shoulder and elbow can have profound implications in an athlete career. Recent technique of fractures management trended toward to preserve soft tissue which is critical for an early recovery in athletic population. Arthroscopy presents a strong interest for the treatment of intra-articular fracture, and minimally invasive approach as developed in humeral shaft fracture can be considered to avoid soft tissue damage. SUMMARY: Non-articular, stable, and minimally displaced fractures are mainly treated conservatively. However, we encourage a more aggressive approach in shoulder and elbow injuries in the athletes including minimally invasive and stable fixation to preserve vascularity and muscle environment.

PURPOSE OF THE REVIEW: To review the most recent literature on osteochondritis dissecans (OCD) lesions of the capitellum in overhead athletes and describe a treatment algorithm based on current best evidence and surgeon experience. RECENT FINDINGS: Recent research has included larger cohort studies with longer follow-up as well as quality systematic reviews and meta-analyses. These studies have focused on understanding how lesion characteristics such as size, location, and appearance on advanced imaging can predict treatment success. Current literature continues to support nonoperative management for stable lesions. Operative intervention is generally required for unstable lesions and treatment strategies are largely dictated by lesion size and location: debridement or reparative techniques for small lesions while larger lesions or those in high-stress locations are better served by bone and/or cartilage restoration procedures. There has been a rising interest in the use of allograft materials and cell-based therapies. SUMMARY: Overhead athletes are uniquely predisposed to capitellar OCD due to the nature of forces applied to the radiocapitellar joint during repeated activity in the overhead position. Despite improvements in operative techniques, successful use of alternative graft materials, and a better understanding of how lesion characteristics influence results, there is still much to learn about this challenging disorder. Future research should focus on comparing operative techniques, refining their indications, and further developing a reliable treatment algorithm that best serves the overhead athlete.

Throwing places high demands on the human body, and specific characteristics are developed over time unique to these athletes. When returning to throw after injury, it is important to follow a criterion-based progression that allows the body to be prepared appropriately for the stresses that throwing will require. There is currently a void in the literature for criteria-based progression that helps these athletes return to the highest level of play. As injury rates continue to rise in baseball, there is increased evidence showing contributions of the core and lower extremity to the baseball pitch. There is also additional data showing pitcher specific characteristics such as range of motion and scapular position in this unique population. The rehab professional should take into account every phase of the pitch starting from balance through ball release when designing a comprehensive return-to-throwing program. Returning an athlete back to a throwing sport can be an overwhelming task. The rehabilitation specialist must have a sound understanding of the throwing motion as well as any biomechanical implications on the body, contributions throughout the kinetic chain, range of motion, and strength characteristics specific to the thrower as well as proper tissue loading principles. It is important that these athletes are not progressed too quickly through their programs and that a criteria-based progression is followed. They should have normalized range of motion, strength, and scapular mechanics, followed by a sound plyometric progression. Once this is achieved, they are advanced to an interval throwing program with increasing distance, effort, and volume which should be tracked for workload, making sure they do not throw more than their body is prepared for.

With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures. Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement. With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex. A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.