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Background The ulnar collateral ligament is commonly injured in overhead-throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR. Materials and methods This was a retrospective case-series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from the PITCHf/x system for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated-measures analysis of covariance was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between preoperative and postoperative time frames. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop-ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as a starter, innings pitched as a reliever, and total pitches thrown. Results In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to preoperative or postoperative time frames. In addition, postoperative time frames had clinically insignificant differences in pitch performance metrics. Conclusion Pitch break and performance metrics are not significantly affected in pitchers who return after UCLR.

The prevalence of ulnar collateral ligament injuries and reconstructions among overhead throwing athletes has significantly risen in recent years. Surgical reconstruction has become the main treatment modality for athletes who have failed conservative treatment and wish to return to their sport. There has been an increased interest in graft augmentation in ligament reconstruction surgeries as surgeons search for ways to decrease the chance of graft failure. Augmented graft techniques have been described for other procedures. We present a technique that incorporates a cross-linked suture tape into either a palmaris longus or gracilis tendon autograft or allograft for ulnar collateral ligament reconstruction. This may allow for a biomechanically stronger construct because it appears this is the case in other settings. The goal is that this would lead to decreased rates of failure or possibly allow athletes to return at an accelerated rate.

Bennett lesions, also known as “thrower's exostosis” of the shoulder, involve ossification of the posteroinferior glenoid and are not uncommon in overhead throwing athletes. The literature surrounding the optimal operative management of the symptomatic Bennett lesion is limited. The purpose of this article is to describe the arthroscopic surgical technique for the visualization and excision of the symptomatic extra-articular pathologic ossification involving the posteroinferior glenoid. Because many surgeons may not be familiar with this problem or procedure, we present a straightforward method that allows for identification and excision of the exostosis through an arthroscopic posterior arthrotomy.

Morphological differences between the Neandertal and modern human glenoid fossa are mostly attributed to functional factors. However, the intimate relationship between the pectoral girdle and the shape of the thorax on which it rests calls for a structural analysis of the morphology of the glenoid fossa. Using both 3D Geometric Morphometric techniques and classical osteometry we carry out an analysis of the morphology of Neandertal scapular glenoid fossa, considering the effects that independent parameters such as allometry, sexual dimorphism and laterality could exert on the glenoid fossa shape. We also discuss how the morphological configuration of the thorax together with other functional factors could explain some of the differences between Neandertals and H. sapiens, and we assess the morphological evolution of this structure in the context of the genus Homo. To this end, 3DGM methods were applied in a comparative framework including the new SD-2101 + specimen from the Sidrón site (Spain) dated to 49,000 years ago, other Neandertal, Homo sapiens, KNM-WT 15000 (Homo ergaster/erectus) and Pan troglodytes specimens. A total of 75 sliding semilandmarks were used to collect the morphology of the glenoid fossa. Morphological comparison and variability were assessed through principal component analysis. Our results confirm the metric and morphological features of the Neandertal scapular glenoid fossa and point to a multifactorial effect in the glenoid morphology. We also detect a morphological trait of the Neandertal glenoid fossa that has not been reported previously: the projection of the upper part of the ventral border shared with modern humans and influenced by structural factors related to the configuration of the rib cage and shoulder. These results are consistent with the evolutionary framework of the hominin glenoid fossa, with some morphological changes being caused by functional factors, and others by structural factors such as the configuration of the thorax., This work was funded by the Ministerio de Economía y Competitividad of Spain (CGL2012-36682 and CGL2012-37279)

Purpose To investigate the humeral and soft-tissue adaptations, including humeral retroversion, range of motion, and posterior capsule changes, in overhead throwing athletes. Methods We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase were searched from January 1, 2011, through April 23, 2017, by 2 reviewers independently and in duplicate. The methodologic quality of all included articles was assessed using the Methodological Index for Non-randomized Studies criteria. Interobserver agreement for assessments of eligibility was calculated with the Cohen κ statistic. Descriptive statistics and raw counts were used to summarize data. Results We identified 14 studies (6 Level IV and 8 Level III) including 1,152 overhead throwing athletes. The mean age of the included athletes was 18.37 years (standard deviation, 1.52 years), with 59% of the athletes being pitchers and 41% being position players. Significantly greater humeral retroversion was found across all studies evaluating bony morphology in the dominant arm of overhead throwing athletes (range of mean differences, 9.6°-25.8°). Each of these studies also found decreased internal rotation in the dominant arm (range of mean internal rotation differences, −28° to −7.8°). Five studies found a significant negative correlation between the difference in humeral retroversion between the 2 arms and the difference in internal rotation (range of Pearson correlation coefficients, −0.56 to −0.35). Soft-tissue adaptations were assessed in 5 studies, with 4 identifying significantly thicker posterior capsules and 2 identifying significantly stiffer posterior capsules ( P Conclusions Overhead throwing athletes consistently show several distinct changes in their dominant shoulder. These include increased humeral retroversion and the presence of a thickened and stiff posterior capsule. Concomitantly, there is often reduced internal rotation and increased external rotation of the dominant arm. Level of Evidence Level IV, systematic review of Level III and IV studies.

Injury to the medial collateral ligament (MCL) of the elbow is a debilitating condition in overhead throwing athletes, particularly baseball pitchers. In order to restore the primary ligamentous restraint against valgus stress at the elbow, MCL reconstruction is increasingly performed in both adolescent and elite throwing athletes in order to return to competition. We describe the pertinent surgical anatomy and indications for ligament reconstruction. Although various surgical techniques have been reported, we describe our preferred reconstruction with the docking technique through a muscle-splitting approach, which allows for secure graft fixation over bone bridges, identification and treatment of intra-articular pathology, and minimization of ulnar nerve-related complications. Excellent outcomes have been reported in approximately 90% of patients following MCL reconstruction with the docking technique.

Background The frequency of citations for a journal article is a reflection of its academic impact. The purpose of this study was to identify and characterize the top 50 cited journal articles related to overhead throwing athletes in the published literature. Methods The Web of Science database was searched on January 18, 2016, using the terms "throwing athlete," "baseball," and "pitcher" to identify the top 50 cited articles related to overhead throwing athletes using the all-database function. The type of study, country of origin, publishing journal, and year published were reviewed for each article. Results The top 50 articles identified were cited between 95 and 471 times and were published in 13 journals between 1969 and 2011. Most of the articles were small case series or nonsystematic literature reviews. The shoulder was the most common body region studied in the top 50 articles (33 of 50 [66%]). Among original studies (n = 43), there was a good representation of surgical management of shoulder and elbow pathology in overhead athletes (9 of 43 [20.9%]); however, most of the articles reported on shoulder and elbow kinematics (19 of 43 [44.2%]) and pathoanatomy (15 of 43 [34.9%]). Conclusion The greater prevalence of nonsurgical articles may reflect a continued effort to better understand the different pathologies specific to overhead throwing athletes. An understanding of the variable content and quality of frequently cited articles on overhead throwing athletes may serve as a stepping stone for future studies to advance the diagnosis and management of complex elbow and shoulder injuries in these high functional individuals.

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

Alteration of elbow range of motion (ROM) has been observed in baseball pitchers. This study aims to compare dominant elbow ROM between early-puberty, late-puberty, and young-adult pitchers.We recruited 62 pitchers, consisting of 17 early-puberty (mean age 13.1 years old), 22 late-puberty (mean age 17.7 years old), and 23 young-adult players (mean age 19.4 years old). Dominant elbow ROMs was measured. One-way ANOVA was used to compare the differences in elbow ROM variables between 3 groups.Late-puberty pitchers exhibited a significantly lower elbow hyperextension and flexion than early-puberty or young-adult pitchers (P .05). Valgus angle was significantly lower in young-adult (7.7°±5.5°) versus early-puberty (12.1°±2.3°) and late-puberty pitchers (13.0°±4.1°; P .05). Young-adult pitchers had the largest forearm supination range (101.2°±18.1°), followed by early-puberty (82.5°±6.5°; P .05) and late-puberty pitchers (70.6°±15.8°). Elbow flexion-hyperextension total range was smallest in late-puberty pitchers (130.3°±7.4°), followed by young-adult (142.6°±9.3°) and early-puberty pitchers (144.6°±8.3°; P .05). Forearm pronation-supination total range was also smallest in late-puberty pitchers (142.0°±20.3°), followed by early-puberty (159.8°±9.5°) and young-adult pitchers (177.2°±20.8°; P .05).These results indicate that careful monitoring of the elbow and forearm range of motion should be undertaken in adolescent baseball pitchers to prevent and or minimize injury risk.

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.

The elbow is a complex joint which requires a balance of static and dynamic structures in order to maintain the stability needed to complete an overhead throwing motion. The repetitive nature of overhead throwing and the unique forces imparted upon the elbow joint result in pathology unique to this specific population. Given the myriad of clinical elbow pathologies in throwers, special attention must be given to the anatomy in order to both correctly diagnose and treat the overhead throwing athlete. Additionally, an understanding of the intimate anatomical relationships in the elbow are critical to surgical treatment and successful outcomes.

The throwing motion involves the entirety of the kinetic chain from the lower extremities to the fingertips. This activity subjects the elbow joint in particular to tremendous forces which risk overwhelming the static and dynamic stabilizers which protect the joint. Failure of these structures results in a predictable pattern of injuries common to overhead throwers, which can serve as a framework for the clinician caring for overhead throwing athletes. An understanding of the anatomy and biomechanics of the elbow coupled with a thorough history, comprehensive physical examination of the entirety of the kinetic chain, and judicious imaging studies allows the clinician to accurately diagnose and optimally manage elbow injury in the overhead throwing athlete.

The rehabilitation of the overhead throwing athlete is a complex and often lengthy process. After completion of the intial phases of rehab involving strength and motion recovery, sports specific throwing rehabilitation and graduated return to throwing are required. Safe and timely return to throwing following shoulder surgery in baseball players requires sophisticated coordination and communication between clinicians, coaches, and players. Strict adherence to underlying principles of an interval throwing program would afford players the best chance of successfully returning to his or her preinjury level of performance. Open and constant communication between players, trainers, and coaches would ensure that any soreness or pain experienced by the player would be reported and assessed in a timely manner. Such reporting would minimize the chance of delaying progress through the interval throwing program.

Little is known about the role that a torn superior labrum (SLAP) plays in glenohumeral stability after biceps tenodesis. This biomechanical study evaluated the contribution of a type II SLAP lesion to glenohumeral translation in the presence of biceps tenodesis. The authors hypothesize that subsequent to biceps tenodesis, a torn superior labrum does not affect glenohumeral stability and therefore does not require anatomic repair in an overhead throwing athlete.Baseline anterior, posterior, and abduction and maximal external rotation glenohumeral translation data were collected from 20 cadaveric shoulders. Translation testing was repeated after the creation of anterior (n = 10) and posterior (n = 10) type II SLAP lesions. Translation re-evaluation after biceps tenodesis was performed for each specimen. Finally, anatomic SLAP lesion repair and testing were performed.Anterior and posterior SLAP lesions led to significant increases in glenohumeral translation in all directions (P.0125). Biceps tenodesis showed no significance in stability compared with SLAP alone (P .0125). Arthroscopic repair of anterior SLAP lesions did not restore anterior translation compared with the baseline state (P = .0011) but did restore posterior (P = .823) and abduction and maximal external rotation (P = .806) translations. Repair of posterior SLAP lesions demonstrated no statistical difference compared with the baseline state (P.0125).With no detrimental effect on glenohumeral stability in the presence of a SLAP lesion, biceps tenodesis may be considered a valid primary or revision surgery for patients suffering from symptomatic type II SLAP tears. However, biceps tenodesis should be considered with caution as the primary treatment of SLAP lesions in overhead throwing athletes secondary to its inability to completely restore translational stability.

Introduction: On shoulder examination, asymmetric scapular posture is often associated to abnormalities of the shoulder complex joint. However, shoulder asymmetries may also be related to adaptations to sports practice. The overhead throwing motion is a highly repetitive skilled motion performed at high velocities. Due to overuse of the dominant overhead-throwing shoulder, athletes may develop some kind of overhead throwing shoulder adaptation pattern that possibly includes scapular asymmetry at the resting position. Purpose: To quantify the asymmetry between dominant and non-dominant resting scapular posture in 3 groups of healthy subjects (volleyball players, team-handball players and a control group). Methods: Bilateral 3D scapular kinematics with the arm at rest was measured using a 6 degrees-offreedom electromagnetic tracking device. Results: In handball athletes, the dominant scapula was more in internal rotation and anteriorly tilted than in volleyball players. Between athletes and non-athletes groups, the dominant scapula was more anteriorly tilted in the athletes. Conclusions: Clinicians should be aware that some degree of scapular asymmetry may be normal in some athletes. It should not be considered automatically as a pathological sign but rather an adaptation to sports practice and extensive use of upper limb.

Optimal performance of the overhead throwing task requires precise mechanics that involve coordinated kinetic and kinematic chains to develop, transfer, and regulate the forces the body needs to withstand the inherent demands of the task and to allow optimal performance. These chains have been evaluated and the basic components, called nodes, have been identified. Impaired performance and/or injury, the DTS, is associated with alterations in the mechanics that are called pathomechanics. They can occur at multiple locations throughout the kinetic chain. They must be evaluated and treated as part of the overall problem. Observational analysis of the mechanics and pathomechanics using the node analysis method can be useful in highlighting areas of alteration that can be evaluated for anatomic injury or altered physiology. The comprehensive kinetic chain examination can evaluate sites of kinetic chain breakage, and a detailed shoulder examination can assess joint internal derangement of altered physiology that may contribute to the pathomechanics. Treatment of the DTS should be comprehensive, directed toward restoring physiology and mechanics and optimizing anatomy. This maximizes the body’s ability to develop normal mechanics to accomplish the overhead throwing task.

Partial-thickness articular-surface rotator cuff tears in overhead throwing athletes have been previously described,and the most commonly reported treatment method has been arthroscopic debridement. As arthroscopic techniques have evolved, methods for a minimally invasive anatomic repair have become possible.

Objectives : To compare upper limb musculoskeletal profile and throwing speed in adolescent baseball players and matched controls. Participants : Fourteen elite early adolescent (13–16 years) baseball players and 14 age, height and weight matched control subjects. Main outcome measures : Joint range of motion, isometric muscle strength and overhead throwing speed. Results : No significant differences in shoulder or elbow joint range of motion were found, though there was a significant increase in pronation ( P =0·03) in the baseball group compared to the control group. No significant differences in shoulder and elbow isometric muscle strength were found between the groups. However, the baseball players threw the ball approximately 50% faster than control subjects. Conclusions : Fast throwing speeds may be achieved in well-trained early adolescent baseball players without changes in isometric muscle strength and with changes in only some ranges of motion. Greater emphasis on the achievement of fast throwing speed by the use of sound overhead throwing technique, particularly in the early stages of a baseball career, may minimize the development of upper limb joint range and muscle strength imbalances which possibly predispose baseball players to injury.