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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Background:Ulnar collateral ligament (UCL) reconstruction is frequently performed in throwing athletes, but outcomes of UCL reconstruction requiring excision of bone, either within the substance of or replacing the UCL, have not been studied.Hypothesis:Clinical outcome for throwing athletes after UCL reconstruction with gracilis tendon will be less favorable for patients requiring concurrent excision of bone from within the substance of the UCL than for patients with no bone excision within, or replacing, the ligamentous anatomy.Study Design:Cohort Study; Level of evidence, 3.Methods:One hundred twenty pitchers of competitive levels between high school and major league who underwent UCL reconstruction using contralateral gracilis autografts completed a phone survey, and their medical charts were reviewed. Follow-up was a minimum of 2 years. Among the 120 patients, 42 (35%) had bone within, or replacing, the substance of the native UCL (bony group), and 78 (65%) had no bony abnormalities (nonbony group). The latter group of 78 underwent UCL reconstruction using gracilis tendon graft due to the absence of a palmaris longus tendon. Clinical outcomes were compared between the 2 study groups using t tests and χ2analyses.Results:There were no statistical differences regarding time to return to throwing, time to return to competition, postoperative complications, or need for additional surgeries. The percentage of patients who returned to the same or higher level was higher in the nonbony group (91%) than in the bony group (81%), but this trend was not statistically significant ( P = .083), likely due to a relatively small sample size. Changes in self-reported pitch control were different ( P = .029) between the 2 groups, with a greater percentage of pitchers experiencing decreased control in the bony group.Conclusion:The presence of bone concomitant with UCL damage can lead to pitch control problems after UCL reconstruction and may also decrease the chance of return to play.

Synopsis Rehabilitation following anterior cruciate ligament surgery continues to change, with the current emphasis being on immediate weight bearing and range of motion, and progressive muscular strengthening, proprioception, dynamic stability, and neuromuscular control drills. The rehabilitation program should be based on scientific and clinical research and focus on specific drills and exercises designed to return the patient to the desired functional goals. The goal is to return the patient's knee to homeostasis and the patient to his or her sport or activity as safely as possible. Unique rehabilitation techniques and special considerations for the female athlete will also be discussed. The purpose of this article is to provide the reader with a thorough scientific basis for anterior cruciate ligament rehabilitation based on graft selection, patient population, and concomitant injuries. J Orthop Sports Phys Ther 2012;42(3):153–171. doi:10.2519/jospt.2012.3741

OBJECTIVE. We are often asked to evaluate the postoperative elbow using MRI. In this article, we present both the normal appearance of the reconstructed ulnar collateral ligament (UCL) and a spectrum of UCL graft abnormalities at MR arthrography. CONCLUSION. The UCL is the primary medial stabilizer of the elbow during flexion and is susceptible to injury, particularly in overhead throwing athletes. In the setting of UCL injury, ligament reconstruction is the principal surgical procedure available to restore stability and function and to relieve pain with activity. We have found MR arthrography useful in assessing the reconstructed UCL.

BackgroundThe anterior bundle of the ulnar collateral ligament (UCL) is the primary anatomical structure providing elbow stability in overhead sports, particularly baseball. Injury to the UCL in overhead athletes often leads to symptomatic valgus instability that requires surgical treatment.HypothesisUlnar collateral ligament reconstruction with a free tendon graft, known as Tommy John surgery, will allow return to the same competitive level of sports participation in the majority of athletes.Study DesignCase series; Level of evidence, 4.MethodsUlnar collateral reconstruction (1266) or repair (15) was performed in 1281 patients over a 19-year period (1988—2006) using a modification of the Jobe technique. Data were collected prospectively and patients were surveyed retrospectively with a telephone questionnaire to determine outcomes and return to performance at a minimum of 2 years after surgery.ResultsNine hundred forty-two patients were available for a minimum 2-year follow-up (average, 38.4 months; range, 24-130 months). Seven hundred forty-three patients (79%) were contacted for follow-up evaluation and/or completed a questionnaire at an average of 37 months postoperatively. Six hundred seventeen patients (83%) returned to the previous level of competition or higher, including 610 (83%) after reconstruction. The average time from surgery to the initiation of throwing was 4.4 months (range, 2.8-12 months) and the average time to full competition was 11.6 months (range, 3-72 months) after reconstruction. Complications occurred in 148 patients (20%), including 16% considered minor and 4% considered major.ConclusionUlnar collateral ligament reconstruction with subcutaneous ulnar nerve transposition was found to be effective in correcting valgus elbow instability in the overhead athlete and allowed most athletes (83%) to return to previous or higher level of competition in less than 1 year.

BackgroundMuscle weakness, particularly of shoulder external rotation, is common after rotator cuff repair surgery. Neuromuscular electrical stimulation has been shown to be an effective adjunct in the enhancement of muscle recruitment.HypothesisShoulder external rotation peak force can be enhanced by neuromuscular electrical stimulation after rotator cuff repair surgery.Study DesignControlled laboratory study.MethodsThirty-nine patients (20 men, 19 women) who had undergone rotator cuff repair surgery were tested a mean of 10.5 days after surgery. Testing consisted of placing patients supine with the shoulder in 45° of abduction, neutral rotation, and 15° of horizontal adduction. Neuromuscular electrical stimulation was applied to the infraspinatus muscle belly and inferior to the spine of the scapula. Placement was confirmed by palpating the muscle during a resisted isometric contraction of the external rotators. Patients performed 3 isometric shoulder external rotation contractions with and without neuromuscular electrical stimulation, each with a 5-second hold against a handheld dynamometer. Neuromuscular electrical stimulation was applied at maximal intensity within comfort at 50 pulses per second, symmetrical waveform, and a 1-second ramp time. The 3 trials under each condition were recorded, and an average was taken. The order of testing was randomized for each patient tested. A paired samples t test was used to determine significant differences between conditions ( P < .05). Each group was also divided based on age, rotator cuff tear size, number of days postoperative, and neuromuscular electrical stimulation intensity. Analysis of variance Models were used to determine the influence of these variables on external rotation force production ( P < .05).ResultsPeak force production was significantly greater ( P < .001) when tested with neuromuscular electrical stimulation (3.75 kg) as opposed to without neuromuscular electrical stimulation (3.08 kg) for all groups tested. There was no significant difference based on the size of the tear, age of the patient, number of days after surgery, or level of neuromuscular electrical stimulation intensity.ConclusionPeak shoulder external rotation force was significantly increased by 22% when tested with neuromuscular electrical stimulation after rotator cuff repair surgery. Neuromuscular electrical stimulation significantly increased force production regardless of the age of the patient, size of the tear, intensity of the current, or the number of days postoperative.Clinical RelevanceNeuromuscular electrical stimulation may be used concomitantly with exercises to enhance the amount of force production and potentially minimize the inhibition of the rotator cuff after repair surgery.

BackgroundThere is currently no widely accepted treatment for massive, irreparable rotator cuff tears.HypothesisAllograft reconstruction to span the remaining defect in massive, irreparable rotator cuff tears will lead to increased functional results and will demonstrate healing of the allograft on follow-up magnetic resonance imaging studies.Study DesignCase series; Level of evidence, 4.MethodsBetween 1989 and 2003, 32 patients underwent allograft reconstruction of massive rotator cuff tears. University of California, Los Angeles shoulder scores were compared preoperatively and postoperatively and analyzed using paired Student t-tests. In addition, 15 patients underwent postoperative magnetic resonance imaging to evaluate the structural integrity of the allograft reconstruction at the greater tuberosity insertion.ResultsOf 32 patients, 28 were available for review at a mean follow-up of 31.3 months; 23 of the 28 patients were satisfied with their outcome. There was 1 postoperative infection and 1 acute allograft rejection. The mean University of California, Los Angeles score increased from 12.1 preoperatively to 26.1 postoperatively (P< .001). All 15 patients evaluated with postoperative magnetic resonance imaging arthrograms demonstrated complete radiographic failure of the allograft rotator cuff reconstruction. Despite radiographic failure, the mean University of California, Los Angeles score increased from 13.2 preoperatively to 28.3 postoperatively in this subset of patients.ConclusionThe functional results of this reconstruction method are similar to those reported for debridement and subacromial decompression alone and are satisfactory, despite magnetic resonance imaging arthrogram evaluation demonstrating failure of the structural integrity of the allograft. Allograft reconstruction carries increased risk of infection and rejection and is technically more difficult than other less expensive treatment options with similar functional results. Therefore, we do not recommend allograft reconstruction of massive and otherwise irreparable rotator cuff tears.

The overhead throwing motion generates enormous force in the elbow. Repetitive near failure loads lead to chronic adaptive changes and occasionally acute injury. The physician caring for the thrower must understand the complex anatomy and function of the elbow joint, along with the biomechanics of throwing, to accurately diagnose and treat elbow pathology. Evaluation of elbow pain in the throwing athlete must begin with a thorough and detailed throwing history including duration of symptoms, location of pain, timing during the phases of throwing motion, and associated symptoms. Physical examination should include inspection, range of motion, palpation, and specific tests to better define the pathology. A detailed history and physical examination will allow the astute clinician to obtain the proper diagnosis and start the appropriate operative or nonoperative treatment often without reliance on ancillary testing. Treatment and rehabilitation of these injuries must be tailored to the pathology present and focused towards a return to the athlete's activity.

This biomechanical cadaver study evaluated the effect of tibial tunnel dilation on the pullout strength of semitendinosus and gracilis tendon grafts in anterior cruciate ligament reconstruction. Fourteen grafts were harvested, and the anterior cruciate ligament was reconstructed in the tibial and femoral tunnels. All femoral tunnels were reamed to the diameter of the graft. In seven knees, the tibial tunnels were reamed to the diameter of the graft. In the remaining seven knees, the tibial tunnels were reamed 2 mm smaller than the diameter of the graft and then serially dilated to the graft size using cannulated smooth dilators. Mechanical testing to graft failure was conducted. All grafts failed by graft pullout from the tibial tunnel. However, mean peak load was significantly higher for the dilated tibial specimens (616±263 N) than for the reamed specimens (453±197 N) (P= .0025).

Valgus extension overload is well described in the throwing athlete. The surgical treatment involves posterior olecranon osteophyte resection. It is not known how much of the posterior olecranon can be resected before increased stress is placed on the ulnar collateral ligament. Ten cadaveric arms underwent posterior olecranon resection in 4-mm increments. After each bone resection, three different valgus loads were applied to the elbow at 70 degrees and 90 degrees of flexion. Ulnar collateral ligament strain significantly increased with each load. Significantly more strain occurred on the ulnar collateral ligament at 90 degrees compared with 70 degrees of elbow flexion. This difference may be the result of the relative importance of the ulnar collateral ligament and the posterior olecranon at different positions of elbow flexion. The strain on the ulnar collateral ligament was slightly higher after the 8-mm and 12-mm cuts but not statistically significant. This study suggests that at moderate quasistatic valgus loads, ulnar collateral ligament strain is not significantly increased with posterior olecranon resection.

Background: The effect of an intact fibula on rotational stability after a distal tibial fracture has, to the best of our knowledge, not been clearly defined. We designed a cadaver study to clarify our clinical impression that fixation of the fibula with a plate increases rotational stability of distal tibial fractures fixed with a Russell-Taylor intramedullary nail. Methods: Seven matched pairs of embalmed human cadaveric legs and sixteen fresh-frozen human cadaveric legs, including one matched pair, were tested. To simulate fractures, 5-mm transverse segmental defects were created at the same level in the tibia and fibula, 7 cm proximal to the ankle joint in each bone. The tibia was stabilized with a 9-mm Russell-Taylor intramedullary nail that was statically locked with two proximal and two distal screws. Each specimen was tested without fibular fixation as well as with fibular fixation with a six-hole semitubular plate. A biaxial mechanical testing machine was used in torque control mode with an initial axial load of 53 to 71 N applied to the tibial condyle. Angular displacement was measured in 0.56-N-m torque increments to a maximal torque of 4.52 N-m (40 in-lb). Results: Initially, significantly less displacement (p ≤ 0.05) was produced in the specimens with fibular plate fixation than in those without fibular plate fixation. The difference in angular displacement between the specimens treated with and without plate fixation was established at the first torque data point measured but did not increase as the torque was increased. No significant difference in the rotational stiffness was found between the specimens treated with and without plate fixation after measurement of the second torque data point (between 1.68 and 4.48 N-m). Conclusions: Fibular plate fixation increased the initial rotational stability after distal tibial fracture compared with that provided by tibial intramedullary nailing alone. However, there was no difference in rotational structural stiffness between the specimens treated with and without plate fixation as applied torque was increased. Clinical Relevance: In patients with ipsilateral distal tibial and fibular fractures who are treated with Russell-Taylor intramedullary nailing of the tibia, rotational stability of the tibial fracture can be increased by plate-and-screw fixation of the fibula, which may reduce the risk of valgus malunion.

Background Humeral fracture following subpectoral biceps tenodesis has been previously reported; however, there are no published biomechanical studies reporting the resulting torsional strength of the humerus. Our purpose was to determine if there is an increased risk of humerus fracture after subpectoral biceps tenodesis with an interference screw and to determine if screw size is also a factor. We hypothesized that limbs receiving the procedure would have reduced failure torque and rotation under external rotation compared to untreated controls and that the larger screw size would result in inferior mechanical properties compared to the smaller. Methods Twenty matched pairs of embalmed cadaveric humeri were subjected to subpectoral biceps tenodesis using either a 6.25 or 8.0 mm interference screw, with the untreated contralateral limb serving as a control. Each humerus was mechanically tested in torsional external rotation to failure. Findings Maximum torque and rotation to failure were reduced in the tenodesis group compared to controls; however, there was no difference between screw sizes. When both screw sizes were combined into a single group, paired t-tests also showed similar differences. Interpretation Based on our experiment, there is an increased risk for humerus spiral fracture when subjected to torsional external rotation after subpectoral biceps tenodesis with an interference screw compared to an intact humerus; however, there is not a significant difference between a 6.25 mm and 8.0 mm screw. Surgeons may elect to use alternative fixation methods in patients at high risk (e.g., overhead throwing athletes, etc.) for torsional loads and fracture.

Meniscal injuries commonly occur concomitantly with anterior cruciate ligament (ACL) injuries. Although many types of meniscal injuries have been described in the literature, there has not been much focus on meniscal capsular junction (MCJ) tears. This lack of attention is concerning given that, in a survey of 67 orthopedic surgeons, 88% indicated that MCJ tears could be a source of chronic pain. In addition, we reviewed 781 ACL reconstructions at our clinic and found a 12.3% incidence of MCJ tear with primary ACL injury and a 23.6% incidence of MCJ tear with revision ACL reconstruction. In this article, we describe an arthroscopic repair technique for MCJ tears at the posterior aspect of the medial meniscus root. The repair uses an accessory posterior medial portal. The technique can also be used for significant posterior medial capsular tears.

Ulnar collateral ligament (UCL) injuries are most commonly reported in baseball players (particularly in pitchers) but have also been observed in other overhead athletes including javelin, softball, tennis, volleyball, water polo, and gymnastics. Partial injuries have been successfully treated with appropriate nonoperative measures but complete tears and chronic injuries have shown less benefit from conservative measures. In these cases, surgical reconstruction has become the treatment modality for overhead athlete who wishes to continue to play. This article discusses the functional anatomy and biomechanics of the UCL as related to the pathophysiology of overhead throwing, as well as the important clinical methods needed to make accurate and timely diagnosis. It also gives an updated review of the current clinical outcomes and complications of surgical reconstruction.

Background: Ulnar collateral ligament reconstruction (UCLR) has afforded baseball players with excellent results; however, previous studies have described only short-term outcomes. Purpose: To evaluate long-term outcomes after UCLR in baseball players. Study Design: Case series; Level of evidence, 4. Methods: All UCLRs performed on competitive baseball players with a minimum 10-year follow-up were identified. Surgical data were collected prospectively and patients were surveyed by telephone follow-up, during which scoring systems were used to assess baseball career and post–baseball career outcomes. Results: Of 313 patients, 256 (82%) were contacted at an average of 12.6 years; 83% of these baseball players (90% pitchers) were able to return to the same or higher level of competition in less than 1 year, but results varied according to preoperative level of play. Baseball career longevity was 3.6 years in general and 2.9 years at the same or higher level of play, but major and minor league players returned for longer than did collegiate and high school players after surgery ( P < .001). Baseball retirement typically occurred for reasons other than elbow problems (86%). Many players had shoulder problems (34%) or surgery (25%) during their baseball career, and these occurrences most often resulted in retirement attributable to shoulder problems ( P < .001). For post–baseball career outcomes, 92% of patients were able to throw without pain, and 98% were still able to participate in throwing at least on a recreational level. The 10-year minimum follow-up scores (mean ± standard deviation) for the Disabilities of the Arm, Shoulder and Hand (DASH), DASH work module, and DASH sports module were 0.80 ± 4.43, 1.10 ± 6.90, and 2.88 ± 11.91, respectively. Overall, 93% of patients were satisfied, with few reports of persistent elbow pain (3%) or limitation of function (5%). Conclusion: Long-term follow-up of UCLRs in baseball players indicates that most patients were satisfied, with few reports of persistent elbow pain or limitation of function. During their baseball career, most of these athletes were able to return to the same or higher level of competition in less than 1 year, with acceptable career longevity and retirement typically for reasons other than the elbow. According to a standardized disability and outcome scale, patients also had excellent results after UCLR during daily, work, and sporting activities.

The treatment of osteochondral fractures and OCD lesions in the knee is controversial. Many new procedures and techniques have been developed recently to address osteochondral lesions, indicating that no single procedure is accepted universally. Our treatment algorithm is based on the age of the patient, skeletal maturity, and the presence of adequate subchondral bone attached to the chondral lesion. Most nondisplaced lesions in the patient with open physes will heal with conservative treatment. The onset of skeletal maturity indicates a need for a more aggressive treatment approach. If adequate cortical bone is attached to the fragment, drilling of stable lesions, or drilling with fixation of unstable or loose fragments is appropriate. Autologous bone graft can be necessary to stimulate healing and properly reconstruct the subchondral bony contour. For failed fixation attempts or lesions not amenable to fixation, each treating surgeon must be proficient and comfortable with an articular surface reconstruction technique. The goal for the reconstructive procedure, to produce a smooth gliding articular surface of hyaline or hyaline-like cartilage, is possible using current techniques including mosaicplasty, osteochondral allograft transplantation, and autologous chondrocyte transplantation. Débridement, drilling, microfracture, and abrasion chondroplasty have been shown to result in fibrocartilage with inferior mechanical properties when compared with hyaline cartilage. No long-term studies have been published, however, to confirm the benefits of replacing osteochondral defects with hyaline cartilage rather than fibrocartilage. Although the results of many reconstructive procedures are quite encouraging with early follow up, the ultimate goal is to prevent long-term degenerative arthritis. Only well-designed prospective studies with long-term follow up will determine the adequacy of these procedures in reaching the ultimate goal. This treatment algorithm is based on the senior author's (WGC) experience with the complex dilemma of osteochondral lesions of the knee.

Recent data support primary plate fixation of displaced midshaft clavicle fractures. The safety and efficacy of this practice have not been well documented in athletes.Plate fixation of clavicle fractures in athletes is a safe and effective procedure, resulting in a reliable and timely return to play.Case series; Level of evidence, 4.A total of 29 patients with displaced midshaft clavicle fractures from athletic activity were treated with plate fixation between January 1, 2003 and December 31, 2008, including 1 patient treated for each clavicle for separate injuries. All 29 patients were contacted for follow-up. At a mean follow-up of 21 months, patients completed a questionnaire focused on the time to return to athletics and treatment course. Patients also completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Radiographs were reviewed to identify fracture comminution, displacement, shortening, and angulation; radiographic union time; and malunion.All of the patients (30/30 cases) returned to sports after open reduction internal fixation of their fracture. The mean time to return to play was 83 days with a range of 13 to 277 days. Seven (23%) of the cases returned to athletics at ≤6 weeks after surgery, and a total of 20 patients (67%) returned at ≤12 weeks after surgery. All patients (100%) were satisfied with their treatment. The QuickDASH scores revealed almost perfect recovery (mean score, 0.8 of 100). Four minor complications were identified. No patient had a refracture, plate fracture, loss of fixation, nonunion, malunion, or deep wound infection.Plate fixation of displaced clavicle fractures in athletes is a safe procedure, resulting in a high satisfaction rating and minimal disability to the upper extremity. An early return (6 weeks) to sports is possible after this treatment; however, the time to return is highly variable.

The patient was a 23-year-old male professional American football player who played wide receiver. He injured his right shoulder 3 days earlier during practice, diving to catch a pass and landing on his right arm while it was outstretched overhead. When he landed on the ground, the patient reported that he felt his right shoulder dislocate. Based on the patient's mechanism of injury and the findings of a physical examination by an orthopaedic surgeon and a physical therapist, radiographs and magnetic resonance imaging were ordered. Though the radiographs were interpreted as normal, magnetic resonance imaging revealed full-thickness infraspinatus and teres minor tendon tears at their insertion sites on the humerus. J Orthop Sports Phys Ther 2013;43(8):583. doi:10.2519/jospt.2013.0414

Purpose The purpose of this study was to review a series of patients who experienced thromboembolic events after shoulder arthroscopy and attempt to identify possible risk factors or associations with thromboembolic phenomena after shoulder arthroscopy. Methods After institutional review board approval, a retrospective database review from 2 fellowship-trained surgeons over a 5-year consecutive period was conducted to identify all patients who underwent shoulder arthroscopy (N = 1,908). Six patients were identified as sustaining thromboembolic events after shoulder arthroscopy (5 deep vein thromboses [DVTs] and 4 pulmonary embolisms [PEs]), but there were no deaths. Patient demographics (age, gender, significant medical history, and body mass index), operative detail (concomitant procedures, positioning, and DVT prophylaxis), and diagnosis and treatment of the thromboembolic events (Doppler ultrasound/chest computed tomography, hypercoagulability testing, and treatment with Coumadin [Bristol-Myers Squibb, New York, NY]) were recorded. Results Over a 5-year period, from 2002 to 2006, there were 6 patients known to have had thromboembolic events (5 documented DVTs and 4 PEs) after shoulder arthroscopy at the 2 institutions participating in the study. The total number of shoulder arthroscopies performed was 1,908. The mean patient age was 47 years (range, 18 to 71 years). All patients were evaluated with Doppler ultrasound, chest radiography, and chest computed tomography. Patients were treated with Coumadin, after bridging with low–molecular weight heparin. For the 5 documented DVTs, all lesions occurred on the same side as the operated extremity. There were 3 upper extremity lesions and 2 lower extremity lesions. Conclusions Postoperative DVT and PE are unusual and potentially fatal consequences of arthroscopic shoulder surgery. We report a low prevalence (0.31%), but all patients in this series required hospitalization and subsequent anticoagulation. All patients who had arthroscopic shoulder surgery during this study period—those with and without thromboembolic events—were in the lateral decubitus position with arm traction. Thromboembolic complications included both ipsilateral upper and lower extremity DVTs, as well as a high percentage of PEs (4 of 6 patients). A wide age range was seen in the patients with thromboembolic complications, and 3 of the patients had known identifiable risk factors. Level of Evidence Level IV, therapeutic case series.

The overhead throwing motion is an extremely skillful and intricate movement. When pitching, the overhead throwing athlete places extraordinary demands on the shoulder complex subsequent to the tremendous forces that are generated. The thrower's shoulder must be lax enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability. We refer to this as the "thrower's paradox." This balance is frequently compromised and believed to lead to various types of injuries to the surrounding tissues. Frequently, injuries can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program. The key to successful nonoperative treatment is a thorough clinical examination and accurate diagnosis. Rehabilitation follows a structured, multiphase approach, with emphasis on controlling inflammation, restoring muscles' balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing. Athletes often exhibit numerous adaptive changes that develop from the repetitive microtraumatic stresses occurring during overhead throwing. Treatment should include the restoration of these adaptations.Level 5.

OBJECTIVE. The objective of this article is to report and describe the clinical and imaging features of an avulsion fracture of the medial epicondyle after ulnar collateral ligament (UCL) reconstruction.CONCLUSION. Avulsion fracture of the medial epicondyle is a rare complication of UCL reconstruction with distinct radiographic and MRI findings.

Elite overhead throwing athletes with rotator cuff tears represent a unique group of patients with an ultimate goal of returning to their previous level of competition. We hypothesized debridement of small partial-thickness rotator cuff tears would return the majority of elite overhead throwing athletes to their previous level of competition. Preoperative and intraoperative findings on 82 professional pitchers who had undergone debridement of partial-thickness rotator cuff tears were evaluated using our database. We obtained return to play data on 67 of the 82 players (82%); 51 (76%) were able to return to competitive pitching at the professional level and 37 (55%) were able to return to the same or higher level of competition. Of the 67 patients, 34 pitchers returned a questionnaire with a minimum followup of 18 months (mean 38 months; range 18 to 59 months). SF-12 scores were above average with a mean PSF-12 and MSF-12 of 55.04 and 56.49 respectively. An Athletic Shoulder Outcome Rating Scale score of greater than 60 was found in 76.5% of pitchers. Debridement of small partial-thickness rotator cuff tears allowed a majority of elite overhead throwing athletes to return to competitive pitching, however, returning to their previous level of competition remains a challenge for many of these players. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Postoperative rehabilitation programs following articular cartilage repair procedures will vary greatly among patients and need to be individualized based on the nature of the lesion, the unique characteristics of the patient, and the type and detail of each surgical procedure. These programs are based on knowledge of the basic science, anatomy, and biomechanics of articular cartilage as well as the biological course of healing following surgery. The goal is to restore full function in each patient as quickly as possible by facilitating a healing response without overloading the healing articular cartilage. The purpose of this paper is to overview the principles of rehabilitation following articular cartilage repair procedures. Furthermore, specific rehabilitation guidelines for debridement, abrasion chondroplasty, microfracture, osteochondral autograft transplantation, and autologous chondrocyte implantation will be presented based upon our current understanding of the biological healing response postoperatively.

The purpose of this project was to study the anatomy of the anterior bundle of the ulnar collateral ligament and provide anatomic measurements not previously described. Thirteen fresh-frozen cadaver elbows were dissected. A 3-dimensional, electromagnetic, digitizing device was used to measure several anatomic parameters of the anterior bundle of the ulnar collateral ligament. The width of the ligament was not uniform, increasing distally toward the insertion. The average area of the origin was 45.5 mm2, and the average area of the insertion was 127.8 mm2. The edge of the insertion was separated from the ulna articular margin by an average of 2.8 mm. The study provides quantitative data describing the anatomy of the anterior bundle of the ulnar collateral ligament. This information may prove useful in surgical techniques designed to reproduce the anatomy and biomechanics of the elbow after injury.

Overhead throwing motion imparts enormous forces on the elbow. Repetitive near-failure loads lead to chronic adaptive changes and occasionally acute injury to bone, ligaments, and the elbow's muscle-tendon complexes. Physicians treating the thrower must thoroughly understand the complex anatomy and function of the elbow joint and throwing biomechanics to diagnose and treat elbow pathology. Evaluation of elbow pain begins with a thorough, detailed throwing history, including symptom duration, location of pain, timing during phases of throwing motion, and associated symptoms. Physical examination should include inspection, range of motion, palpation, and specific tests to better define the pathology. A detailed history and physical examination often lead the astute clinician to the proper diagnosis and treatment without reliance on ancillary testing.

Background The incidence of ulnar collateral ligament injury has increased in baseball, especially at the high school level. Hypothesis Ulnar collateral ligament injury in high school baseball players is associated with overuse, high-velocity throwing, early throwing of breaking pitches, and improper warm-ups. Study Design Retrospective cohort study. Methods Follow-up physical examination and questionnaire data were collected at an average of 35 months after ulnar collateral ligament reconstruction from 27 former high school baseball players. Six potential risk factors were evaluated: year-round throwing, seasonal overuse, event overuse, throwing velocity more than 80 mph, throwing breaking pitches before age 14, and inadequate warm-ups. Results Overall, 74% returned to baseball at the same or higher level. Patients averaged 3 potential risk factors, and 85% demonstrated at least one overuse category. Of the pitchers, the average self-reported fastball velocity was 83 mph, and 67% threw breaking pitches before age 14. Conclusions The success rate of ulnar collateral ligament reconstruction in high school baseball players is nearly equal to that in more mature groups of throwers. Overuse of the throwing arm and throwing breaking pitches at an early age may be related to their injuries. Special attention should be paid to elite-level teenage pitchers who throw with high velocity.

Repetitive overhead throwing imparts high valgus and extension loads to the athlete's elbow, often leading to either acute or chronic injury or progressive structural change. Tensile force is applied to the medial stabilizing structures with compression on the lateral compartment and shear stress posteriorly. Common injuries encountered in the throwing elbow include ulnar collateral ligament tears, ulnar neuritis, flexor-pronator muscle strain or tendinitis, medial epicondyle apophysitis or avulsion, valgus extension overload syndrome with olecranon osteophytes, olecranon stress fractures, osteochondritis dissecans of the capitellum, and loose bodies. Knowledge of the anatomy and function of the elbow complex, along with an understanding of throwing biomechanics, is imperative to properly diagnose and treat the throwing athlete. Recent advantages in arthroscopic surgical techniques and ligament reconstruction in the elbow have improved the prognosis for return to competition for the highly motivated athlete. However, continued overhead throwing often results in subsequent injury and symptom recurrence in the competitive athlete.

With the increasing number of anterior cruciate ligament (ACL) reconstructions being performed each year in the United States, sound surgical technique and preoperative planning are essential to decrease complications. Most intraoperative complications associated with ACL surgery are preventable with adequate planning and a reproducible surgical technique. When an autogenous bone-patellar tendon-bone graft is used for ACL reconstruction, pitfalls may occur at each step during the surgical procedure--preoperative assessment, graft harvest, notch preparation, tunnel preparation, graft passage and fixation, and rehabilitation. An array of options should be available for fixation of a patellar tendon graft, as well as alternative graft sources and graft preparation techniques.