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Background: Baseball pitchers employ various contralateral trunk tilt (CTT) positions when pitching depending on if they have an overhand, three-quarter, or sidearm delivery. There are no known studies that have examined how pitching biomechanics are significantly different in professional pitchers with varying amounts of CTT, which may provide insight into shoulder and elbow injury risk among pitchers with different CTT. Purpose: To assess differences in shoulder and elbow forces and torques and baseball pitching biomechanics in professional pitchers with maximum 30° to 40° CTT (MaxCTT), moderate 15° to 25° CTT (ModCTT), and minimum 0° to 10° CTT (MinCTT). Study Design: Controlled laboratory study. Methods: In total, 215 pitchers were examined, including 46 pitchers with MaxCTT, 126 pitchers with ModCTT, and 43 pitchers with MinCTT. All pitchers were tested using a 240-Hz, 10-camera motion analysis system, and 37 kinematic and kinetic parameters were calculated. Differences in kinematic and kinetic variables among the 3 CTT groups were assessed with a 1-way analysis of variance ( P < .01). Results: Maximum shoulder anterior force and maximum elbow proximal force were significantly greater in ModCTT (403 ± 79 N) than MaxCTT (369 ± 75 N) and MinCTT (364 ± 70 N), while maximum elbow flexion torque and shoulder proximal force, respectively, were significantly greater in ModCTT (69 ± 11 N·m and 1176 ± 152 N, respectively) than MaxCTT (62 ± 12 N·m and 1085 ± 119 N, respectively). During arm cocking, maximum pelvis angular velocity was greater in MinCTT than MaxCTT and ModCTT, and maximum upper trunk angular velocity was greater in MaxCTT and ModCTT than MinCTT. At ball release, trunk forward tilt was greater in MaxCTT and ModCTT than MinCTT and greater in MaxCTT than ModCTT, while arm slot angle was less in MaxCTT and ModCTT than MinCTT and less in MaxCTT than ModCTT. Conclusion: The greatest shoulder and elbow peak forces occurred in ModCTT, which occurs in pitchers who throw with a three-quarter arm slot. More research is needed to assess if pitchers with ModCTT are at a higher risk of shoulder and elbow injury compared with pitchers with MaxCTT (overhand arm slot) and MinCTT (sidearm arm slot), although in the pitching literature, excessive elbow and shoulder forces and torques have been shown to correlate with elbow and shoulder injuries. Clinical Relevance: The results from the current study will help clinicians better understand if differences in kinematic and kinetic measures differ with pitching, or if differences in force, torque, and arm position occur at different arm slots.

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: 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.

Background: Baseball pitching injuries are increasing at an alarming rate. While weighted ball throwing programs may be effective at increasing pitching velocity, previous research has identified a 24% injury rate and a 3.3° increase in shoulder external rotation (ER) range of motion (ROM) after performing a 6-week program. However, previous research has not investigated, separately, the immediate effects of throwing underloaded and overloaded balls on ROM. The purpose of this study was to examine the acute effects of throwing differently weighted baseballs on shoulder ROM. By analyzing these differences, it may be possible to determine the specific weight range that may lead to the greatest increase in ROM and potential injury risk. Hypothesis: Throwing with weighted balls will result in an increase in shoulder ER ROM. Study Design: Randomized controlled trial. Level of Evidence: Level 2. Methods: A total of 16 male high school baseball pitchers agreed to participate in this study. The participants were (mean ± SD) 17.1 ± 1.0 years of age, 1.81 ± 0.09 m tall, and had a mass of 79.2 ± 11.1 kg. Each participant was tested on 3 different days, 1 week apart, with 3 different conditions in random order: (1) underload throwing, using regulation 5-oz baseballs and 4- and 2-oz balls; (2) overload throwing, using 5-, 6-, and 9-oz balls; and (3) extreme overload throwing, using 5-, 16-, and 32-oz balls. Each testing session began by measuring passive shoulder ROM (external rotation and internal rotation) using standard goniometric measurements. Participants then performed 3 throws with each weighted ball from 3 different positions (kneeling, rocker, and run-and-gun) for a total of 27 throws each test session. ROM measurements were repeated at the end of each test session. The effect of each throwing condition on ROM was compared from pre- to posttraining using a paired t test ( P ≤ 0.05). Results: There was no significant difference in ER after throwing at underloaded weights. The overload condition showed a statistically significant increase of 3.3° in external rotation ( P = 0.05). The extreme overload condition showed a statistically significant increase in ER of 8.4° ( P < 0.001). There were no differences in internal rotation for any group. Conclusion: A significant increase in shoulder ER was observed immediately after throwing overload weighted balls. This effect increased as the weights of the balls increased. Clinical Relevance: Throwing with overload weighted baseballs causes an immediate increase in shoulder ER ROM. It is unknown why these changes occur; however, the results may explain both the increase in velocity and injury rates previously observed from throwing weighted balls. The current study results may be used to develop more scientifically validated weighted ball programs. Heavier balls should be used with caution, and ROM should be monitored during implementation of these programs.

Background: An analysis of the demographics and training of head team physicians (HTPs) in professional sports would be valuable for evaluating training programs and as a resource for aspirant HTPs. Purpose: To outline common characteristics among professional sport HTPs. Study Design: Cross-sectional study. Methods: In June 2021, publicly available directories and news articles were used to identify the head orthopaedic HTPs and primary care HTPs for every team in Major League Baseball (MLB), the National Basketball Association (NBA), and the National Football League (NFL). Data regarding HTP characteristics were collected via internet-based sources. Age, sex, years from fellowship completion to current team role, and years in current team role were compared across sports with chi-square analyses and analyses of variance; comparisons between orthopaedic and primary care HTPs were performed with Fisher exact tests and Student t tests. The most frequently attended residency and fellowship training programs were also calculated. The productivity of fellowship programs was calculated as the number of current HTPs from that institution divided by the number of fellowship positions currently offered. Results: We identified 181 HTPs: 171 (94%) men and 10 (6%) women. The mean age was 55.4 years (range, 33-79 years); the mean time from fellowship training completion to first year in current team role was 9.8 years (range, 0-29 years); and the mean time spent in current team role was 14.1 years (range, 0-39 years). There were 94 orthopaedic HTPs and 87 primary care HTPs. The rate of fellowship training was significantly higher in orthopaedic HTPs (95%) than in primary care HTPs (67%; P < .001). The fellowship programs that produced the largest number of current HTPs were the Hospital for Special Surgery (n = 16; productivity = 2.3), the American Sports Medicine Institute (11; 1.8), and the Kerlan-Jobe Orthopaedic Clinic (11; 1.2). The years from fellowship to HTP varied significantly by sport: 7.2 for MLB, 10.0 for the NFL, and 11.7 for the NBA ( P = .048). Conclusion: Almost all orthopaedic HTPs were fellowship trained, as compared with two-thirds of primary care HTPs. Of the 94 orthopaedic HTPs, 62% were trained at 6 specific fellowship programs. Men accounted for a majority of HTPs.

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.

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.

Background: Plantar fasciitis is the most common cause of heel pain in adults. Multiple conservative treatment plans exist; however, some cases do not obtain significant clinical improvement with conservative treatment and require further intervention. This retrospective case study evaluated the success rate of percutaneous plantar fasciotomy and confounding comorbidities that negatively affect outcomes. Methods: A series of 41 patients treated with percutaneous plantar fasciotomy using the Topaz EZ microdebrider coblation wand were invited to participate in this retrospective follow-up study, and 88% ( N = 36) participated. A limited chart review was completed and the patients answered a survey with the visual analog scale (VAS) for pain and the Foot and Ankle Ability Measure (FAAM) questionnaire. Average outcomes were calculated and 45 variables were analyzed to determine if they were statistically significant confounders. Patients had symptoms for an average of 3 years before the procedure and were contacted for follow-up at an average of 14 months after the procedure. Results: The average VAS for pain score was 1.3 ± 1.8 and the average FAAM score was 92 ± 15. Eighty-nine percent of patients had a successful outcome, defined as FAAM greater than 75. In addition, patients at 18 months postprocedure reported complete or near-complete resolution of symptoms with an FAAM score greater than 97. Concurrent foot pathologies (eg, tarsal tunnel syndrome), oral steroid treatment prior to the procedure, and immobilization with a boot prior to the procedure were statistically significant negative confounders ( P < .05). Being an athlete was a positive confounder ( P = .02). Conclusion: Percutaneous plantar fasciotomy using a microdebrider coblation was an effective treatment for plantar fasciitis, particularly without concurrent foot pathology, with a low risk of complications. Level of Evidence: Level IV, retrospective case series.

Background: The variability of throwing metrics, particularly elbow torque and ball velocity, during structured long-toss programs is unknown. Hypotheses: (1) Elbow torque and ball velocity would increase as throwers progressed through a structured long-toss program and (2) intrathrower reliability would be high while interthrower reliability would be variable. Study Design: Descriptive laboratory study. Level of Evidence: Level 3. Methods: Sixty healthy high school and collegiate pitchers participated in a structured long-toss program while wearing a validated inertial measurement unit, which measured arm slot, arm velocity, shoulder rotation, and elbow varus torque. Ball velocity was assessed by radar gun. These metrics were compared within and between all pitchers at 90, 120, 150, and 180 ft and maximum effort mound pitching. Intra- and interthrower reliabilities were calculated for each metric at every stage of the program. Results: Ball velocity significantly changed at each progressive throwing distance, but elbow torque did not. Pitching from the mound did not place more torque on the elbow than long-toss throwing from 120 ft and beyond. Intrathrower reliability was excellent (intraclass correlation coefficient >0.75) throughout the progressive long-toss program, especially on the mound. Ninety-one percent of throwers had acceptable interthrower reliability (coefficient of variation Conclusion: Based on trends in elbow torque, it may be practical to incorporate pitching from the mound earlier in the program (once a player is comfortable throwing from 120 ft). Ball velocity and elbow torque do not necessarily correlate with one another, so a degree of caution should be exercised when using radar guns to estimate elbow torque. Given the variability in elbow torque between throwers, some athletes would likely benefit from an individualized throwing program. Clinical Relevance: Increased ball velocity does not necessarily equate to increased elbow torque in long-toss. Some individuals would likely benefit from individualized long-toss programs for rehabilitation.

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.

Background: Pitching injuries continue to be a serious problem, with adolescents now representing the group with the most injuries. Some have proposed that lowering or eliminating the pitching mound in youth baseball may reduce joint stress and subsequent injuries. Another potential risk factor is advancing from youth to adult pitching distance without an intermediate distance. Hypotheses: It was hypothesized that for a group of young pitchers, pitching kinetics and kinematics would change with mound height. It was also hypothesized that pitching kinetics and kinematics would change with pitching distance. Study Design: Controlled laboratory study. Methods: Twenty-one young (12.6 ± 0.5 years) baseball pitchers pitched 5 full-effort fastballs each from 5 different conditions, in random order: 14.02-, 16.46-, and 18.44-m distances from a 25 cm–high mound, 16.46-m distance from a 15 cm–high mound, and 16.46-m distance from flat ground. Pitching biomechanical values were collected with a 12-camera automated motion capture system. Ball velocity and 31 other parameters were computed for each pitch. Data were compared between the 3 mound heights at 16.46 m by use of repeated-measures analysis of variance and paired post hoc t tests ( P < .05). Similarly, data were compared between the 3 distances from the 25-cm mound via repeated-measures analysis of variance and paired post hoc t tests ( P < .05). Results: No differences were found in ball velocity, shoulder kinetics, or elbow kinetics associated with mound height. Ten kinematic parameters differed with mound height, including 8 parameters at lead foot contact. Maximum shoulder horizontal adduction torque and maximum shoulder anterior force increased with pitching distance. Only 3 kinematic parameters showed significant differences with pitching distance. Conclusion: The hypothesis that shoulder and elbow kinetics would change with mound height was not supported by the data. Several kinematic differences were found, but the majority were at lead foot contact before the rapid, dynamic phases of pitching. Change in pitching distance was associated with slight increase in shoulder kinetics as well as a few kinematic differences. Clinical Relevance: Lowering or eliminating pitching mounds in youth baseball would not significantly decrease joint stress and injury risk to young pitchers. However, when available, transition from 14.02-m to 16.46-m to 18.44-m pitching distance may reduce stress on the young throwing shoulder.

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: Likely due to the high level of strain exerted across the elbow during the throwing motion, elbow injuries are on the rise in baseball. To identify at-risk athletes and guide postinjury return-to-throw programs, a better understanding of the variables that influence elbow varus torque is desired. Purpose: To describe the within-subject relationship between elbow varus torque and arm slot and arm rotation in professional baseball pitchers. Study Design: Descriptive laboratory study. Methods: A total of 81 professional pitchers performed 82,000 throws while wearing a motusBASEBALL sensor and sleeve. These throws represented a combination of throw types, such as warm-up/catch, structured long-toss, bullpen throwing from a mound, and live game activity. Variables recorded for each throw included arm slot (angle of the forearm relative to the ground at ball release), arm speed (maximal rotational velocity of the forearm), arm rotation (maximal external rotation of the throwing arm relative to the ground), and elbow varus torque. Linear mixed-effects models and likelihood ratio tests were used to estimate the relationship between elbow varus torque and arm slot, arm speed, and arm rotation within individual pitchers. Results: All 3 metrics—arm slot (χ2 = 428, P < .001), arm speed (χ2 = 57,683, P < .001), and arm rotation (χ2 = 1392, P < .001)—were found to have a significant relationship with elbow varus torque. Within individual athletes, a 1-N.m increase in elbow varus torque was associated with a 13° decrease in arm slot, a 116 deg/s increase in arm speed, and an 8° increase in arm rotation. Conclusion: Elbow varus torque increased significantly as pitchers increased their arm rotation during the arm cocking phase, increased the rotational velocity of their arm during the arm acceleration phase of throwing, and decreased arm slot at ball release. Thus, shoulder flexibility, arm speed, and elbow varus torque (and likely injury risk) are interrelated and should be considered collectively when treating pitchers. Clinical Relevance: It is well established that elbow varus torque is related to ulnar collateral ligament injuries in overhead throwers. This study describes the relationship of arm slot, arm speed, and arm rotation to elbow varus torque in an attempt to identify modifiable risk factors for injury.

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.

Background: Weighted-ball throwing programs are commonly used in training baseball pitchers to increase ball velocity. The purpose of this study was to compare kinematics and kinetics among weighted-ball exercises with values from standard pitching (ie, pitching standard 5-oz baseballs from a mound). Hypothesis: Ball and arm velocities would be greater with lighter balls and joint kinetics would be greater with heavier balls. Study Design: Controlled laboratory study. Methods: Twenty-five high school and collegiate baseball pitchers experienced with weighted-ball throwing were tested with an automated motion capture system. Each participant performed 3 trials of 10 different exercises: pitching 4-, 5-, 6-, and 7-oz baseballs from a mound; flat-ground crow hop throws with 4-, 5-, 6-, and 7-oz baseballs; and flat-ground hold exercises with 14- and 32-oz balls. Twenty-six biomechanical parameters were computed for each trial. Data among the 10 exercises were compared with repeated measures analysis of variance and post hoc paired t tests against the standard pitching data. Results: Ball velocity increased as ball mass decreased. There were no differences in arm and trunk velocities between throwing a standard baseball and an underweight baseball (4 oz), while arm and trunk velocities steadily decreased as ball weight increased from 5 to 32 oz. Compared with values pitching from a mound, velocities of the pelvis, shoulder, and ball were increased for flat-ground throws. In general, as ball mass increased arm torques and forces decreased; the exception was elbow flexion torque, which was significantly greater for the flat-ground holds. There were significant differences in body positions when pitching on the mound, flat-ground throws, and holds. Conclusions: While ball velocity was greatest throwing underweight baseballs, results from the study did not support the rest of the hypothesis. Kinematics and kinetics were similar between underweight and standard baseballs, while overweight balls correlated with decreased arm forces, torques, and velocities. Increased ball velocity and joint velocities were produced with crow hop throws, likely because of running forward while throwing. Clinical Relevance: As pitching slightly underweight and overweight baseballs produces variations in kinematics without increased arm kinetics, these exercises seem reasonable for training pitchers. As flat-ground throwing produces increased shoulder internal rotation velocity and elbow varus torque, these exercises may be beneficial but may also be stressful and risky. Flat-ground holds with heavy balls should not be viewed as enhancing pitching biomechanics, but rather as hybrid exercises between throwing and resistance training.

Objectives: The variability of throwing metrics, particularly elbow torque and ball velocity, during structured long-toss programs is yet to be fully elucidated. The primary aims of this study were to assess various throwing metrics through a structured long-toss program using wearable technology and to quantify the intra and inter thrower variability of these metrics at each stage of throwing. Methods: This was a descriptive laboratory study in which 60 high school and collegiate pitchers participated in a predetermined, structured, progressive long-toss program. All players wore a motusBASEBALL sleeve (Motus Global, Inc.; Rockville Centre, NY), which measured arm slot, arm velocity, shoulder rotation, and elbow varus torque. Radar guns were used to measure ball velocity. These metrics were compared within and between all pitchers at each of the following throwing distances: 90 ft, 120 ft, 150 ft, 180 ft, and maximum effort mound pitching. Intra- and inter- thrower reliabilities were calculated for each throwing metric at every stage of the program. Excellent intra-thrower reliability was defined by an Intra-class coefficient (ICC) >0.750. Acceptable inter-thrower reliability was defined by a Coefficient of Variation (CV) Results: Ball velocity significantly changed at each progressive throwing distance, but this did not consistently correlate with an increase in elbow torque. Pitching from the mound did not place more torque on the elbow than throwing from 120 ft and beyond. Intra-thrower reliability was excellent throughout the progressive long-toss program for each throwing metric. Ninety-one percent of throwers had acceptable inter-thrower reliability for ball velocity, whereas only 79% of throwers had acceptable inter-thrower reliability for elbow torque. Conclusion: Based on trends in elbow torque, it may be practical to incorporate pitching from the mound earlier in the program (once a player is comfortable throwing from 120 ft). Ball velocity and elbow torque do not necessarily correlate with one another, so a degree of caution should be exercised when using radar guns to estimate elbow torque. Given the variability in elbow torque between throwers, some athletes would likely benefit from an individualized throwing program.

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.

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.