Rehabilitation of the Overhead Athlete's Elbow

Osteochondritis Dissecans of the Elbow in Overhead Athletes: A Comprehensive Narrative Review

Osteochondritis dissecans (OCD) of the elbow mainly occurs in overhead athletes (OHAs). This narrative review aimed to comprehensively analyze the epidemiological data, etiological factors, clinical and imaging features, treatment options, and outcomes of OHAs with the diagnosis of elbow OCD. A literature search was performed in PubMed/MEDLINE, Scopus, and Web of Science. Individuals with elbow OCD were usually 10-17 years of age with incidence and prevalence varying between studies, depending on the sport activity of the patients. The etiology of OCD lesions is multifactorial, and the main causes are believed to be repetitive trauma, the biomechanical disproportion of the articular surfaces, poor capitellar vascular supply, and inflammatory and genetic factors. Athletes usually presented with elbow pain and mechanical symptoms. The mainstay for the diagnosis of elbow OCD is MRI. The treatment of elbow OCD lesions should be conservative in cases of stable lesions, while various types of surgical treatment are suggested in unstable lesions, depending mainly on the size and localization of the lesion. The awareness of medical practitioners and the timely diagnosis of OCD lesions in OHAs are key to favorable outcomes.

Biomechanical Basis of Interval Throwing Programs for Baseball Pitchers: A Systematic Review

Background

Interval throwing programs are used in rehabilitation of throwing injuries, especially ulnar collateral ligament injuries. Athletes who are rehabilitating begin by throwing on flat ground progressing through increasing distances, number of throws, and intensity of throwing. If the athlete is a baseball pitcher, the flat-ground throwing phase is followed by pitching on a mound at progressively increased effort. The goal is to build back arm strength and capacity with an emphasis on proper mechanics.

Purpose

To determine whether interval throwing progressively builds joint kinetics (specifically, elbow varus torque) to the level required during full-effort baseball pitching. A secondary purpose was to examine the kinematics produced during interval throwing compared to those seen during baseball pitching.

Study Design

Systematic Review.

Methods

Following PRISMA guidelines, PubMed, Embase, Web of Science, SPORTDiscus, and Google Scholar were systematically searched for biomechanical studies of flat-ground throwing and partial-effort pitching in baseball between 1987 and 2023. Studies that reported the biomechanics of either flat-ground throwing, or partial-effort pitching were included in this review. The AXIS tool was used to assess study quality.

Results

Thirteen articles met the inclusion criteria. Ten studies were determined to be of moderate quality, while three studies were deemed high quality. Elbow varus torque during partial-effort pitching was less than during full-effort pitching. Elbow varus torque for most flat-ground throws did not exceed full-effort pitching torque. While most studies showed increased elbow varus torque with increased flat-ground throwing distance, the distance at which elbow varus torque matched or exceeded full-effort pitching elbow varus torque was not consistent.As flat-ground throwing distance increased, shoulder external rotation angle and shoulder internal rotation velocity increased. Arm slot (forearm angle above horizontal) decreased as flat-ground throwing distance increased. For varied effort pitching, shoulder external rotation angle, shoulder internal rotation velocity, elbow extension velocity, and ball velocity increased as effort increased. While the front knee extended slightly from foot contact to ball release in full-effort pitching, the front knee flexed slightly during partial-effort pitching.

Conclusions

An interval throwing program progressively builds elbow varus torque up to levels produced in full-effort baseball pitching. While differences exist between interval throwing kinematics and pitching kinematics, the patterns are similar in general.

Level of Evidence

2.

Medial Ulnar Collateral Ligament Repair With Augmentation: A Systematic Review and Meta-analysis of Preclinical Studies

Background

Reconstruction is the gold standard treatment for medial ulnar collateral ligament (MUCL) injuries. However, recent studies show a successful and renewed interest in direct suture repair, particularly in young athletes. Repair augmentation with a suture tape may provide greater stability, enabling healing of the MUCL while protecting the repair at higher valgus loads.

Purpose

To perform a systematic review and meta-analysis on whether MUCL repair with augmentation provides a similar biomechanical profile to the traditional MUCL reconstruction.

Study Design

Systematic review.

Methods

The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("ulnar collateral ligament" OR "medial ulnar collateral ligament") AND ("internal brace" OR "augmentation" OR "suture tape"). Data pertaining to certain biomechanical properties (gap formation, failure to torque [ultimate load to failure], stiffness, degree of valgus opening, and modes of failure) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. A total of 203 abstracts were identified through the aforementioned databases.

Results

After abstract and full-text screening, 6 biomechanical studies were included. All were on cadaveric elbows, with 53 repairs with augmentation and 53 reconstructions compared. There were no differences between the 2 in regard to ultimate load to failure (standard mean difference [SMD], -0.34 N·m; 95% CI, -1.36 to 0.68; P = .51) and rotational stiffness (SMD, 0.26; 95% CI, -1.14 to 1.66; P = .72). Despite a trend in resistance to gapping with augmented repair, this was not significant (SMD, -0.53; 95% CI, -1.08 to 0.01; P = .06). Augmented repairs were more likely to fail by pullout or at the suture-tendon/anchor-suture interface (odds ratio [OR], 12.19; 95% CI, 4.17 to 35.62; P < .00001), while failure by fracture was more common with reconstruction (OR, 5.75; 95% CI, 2.07 to 15.99; P = .0008).

Conclusion

MUCL augmented repair establishes the required time-zero structural properties without the need for a tendon graft. However, future clinical studies are necessary to determine its true effectiveness as well as its success at higher levels of professional sport.

Effects of Repetitive Pitching on Trunk Muscle Endurance and Thoracic and Shoulder Kinematics

Background

Baseball players are aware of the potential of shoulder problems due to repetitive throwing. However, few studies have examined how pitching repeatedly affects the thoracic spine and shoulder.

Purpose

This study aimed to determine the effects of pitching repeatedly on the endurance of trunk muscles and kinematics of the thoracic spine and shoulder.

Study design

Cohort study.

Methods

Trunk muscle endurance was assessed in flexion, extension, and lateral flexion positions in 12 healthy amateur baseball players. The positions of stride foot contact (SFC) during the early cocking phase and maximal shoulder external rotation (MER) during the late cocking phase were used to compute the thoracic and shoulder kinematics in degrees. Participants were then asked to throw 135 fastballs (~9 innings with 15 throws per inning). Throwing motions were monitored throughout the first, seventh, eighth, and nine innings, whereas trunk muscular endurance was assessed before and after the repetitive throwing activity. Ball speed during pitching was measured using a radar gun. All outcome measures were statistically compared to examine differences over time.

Results

The trunk muscle endurance declined after the throwing task. In the eighth inning, compared with the first inning, the thoracic rotation angle at the SFC increased toward the throwing side. In contrast, the shoulder horizontal adduction angle at MER decreased in the seventh and ninth innings.

Conclusion

With repeated pitching, trunk muscle endurance gradually declines, and repetitive throwing significantly altered kinematics of the thoracic rotation at SFC and shoulder horizontal plane at MER.

Level of Evidence

2a.

Forearm Flexor Tendon Injury in Adolescent Athletes: Risk Factors, Treatment, and Prevention

ABSTRACT

Injury to the flexor pronator mass is a common condition that is especially prevalent in overhead throwing athletes. The increasing incidence of these injuries has promoted considerable efforts in research to better understand the pathology, risk factors, and potential mechanisms to prevent injury in these athletes. While there are numerous intrinsic and extrinsic factors associated with injury, a common theme involves chronic overuse and microtrauma with inadequate resting intervals between performances. The purpose of this review is to discuss medial elbow injuries in young athletes with a particular focus on the flexor pronator mass.

The Management of Valgus Extension Overload Syndrome Experienced with Hitting in a High School Baseball Player: A Case Report

Background

Valgus extension overload syndrome (VEOS) of the elbow is a condition associated with overhead athletes. However, the non-surgical management of these individuals is not well documented.

Purpose

To discuss the unique presentation, management, and outcomes of an adolescent baseball player with a chronic history of VEOS experienced during hitting.

Case Description

A 15-year-old right-handed high school baseball catcher presented with a six-month history of right-sided ulnar elbow pain. Elbow MRI w/ contrast was consistent with VEOS. The initial examination demonstrated excessive resting right-sided humeral external rotation compared to his left. Valgus stress testing in the subject's hitting position reproduced symptoms, which were alleviated with retest while correcting excessive humeral external rotation. Weakness of the humeral internal rotators and stiffness/shortness of the posterior shoulder were found and thought to relate to the humeral contribution to his elbow movement dysfunction. Rehabilitation emphasized addressing impairments contributing to excessive humeral external rotation with reintegration into batting.

Outcomes

After five weeks of physical therapy, the subject returned to soft toss hitting at approximately 75% velocity for the first time since symptom onset, without pain. At seven months after discharge, a phone conversation confirmed that the subject had returned to baseball without limitations.

Discussion

Despite the concept of 'regional interdependence', common proximal impairments are often assumed to contribute to elbow pain without a clear biomechanical rationale. Future research demonstrating the specific biomechanical effects of the shoulder on the elbow is needed, in addition to more accessible examination strategies to assess their relationship.

Level of Evidence

5.

Elbow rehabilitation using intelligent medical devices

The purpose of this paper is to demonstrate that the process of elbow joint rehabilitation can be monitored and improved using intelligent medical devices. During the study, an orthosis-type medical device was developed that monitors the mobility of the elbow joint in case of pathology. This device is useful in monitoring flexion movements (forward and backward), as well as internal and external rotation. For this purpose, a set of sensors were used that will capture the necessary and specific information, and the extracted data will be transmitted to a microcontroller for processing. The orthosis is one that can be customized according to the patient's pathology because it will analyse the data collected and interpret the values according to the calibration performed on the patient. The orthosis can be used both in the evaluation of joint dysfunctions at the elbow and in a rehabilitation program to avoid vicious positions. The positioning of the orthosis will be done together with the specialist doctor or in the presence of a physiotherapist, following the detailed clinical examination, so that the calibration of the sensors can be performed correctly. The device can emit warning sequences that will depend on the movements that the patient will perform, movements that can be sudden or accidental. Keywords: elbow joint, orthesis, physiokinetotherapist, rehabilitation, health improvement,

Elasticity of the Flexor Carpi Ulnaris Muscle After an Increased Number of Pitches Correlates With Increased Medial Elbow Joint Space Suppression

ABSTRACT

Saito, A, Namiki, Y, and Okada, K. Elasticity of the flexor carpi ulnaris muscle after an increased number of pitches correlates with increased medial elbow joint space suppression. J Strength Cond Res 35(9): 2564-2571, 2021-This study aimed to measure the medial elbow joint space and elasticity of the forearm flexor-pronator muscles in repetitive pitching and to determine which of the forearm flexor-pronator muscles contribute to elbow valgus stability during pitching. Twenty-six collegiate baseball players performed 7 sets of 15 pitches. The medial elbow joint space and elasticity of the pronator teres, flexor carpi radialis, flexor digitorum superficialis (FDS), and flexor carpi ulnaris (FCU) were measured using ultrasonography before pitching and after every 15 pitches. Correlations among the rate of change of these parameters were analyzed using Pearson's correlation coefficients. The medial elbow joint space increased after 60 or more pitches compared with that before pitching (all p < 0.001; effect size [ES]: 0.44-1.22). FDS and FCU elasticity increased after 45 and 60 pitches or more in contrast to that before pitching, respectively (FDS: p = 0.047 and p < 0.001, respectively; ES: 1.05-1.42, FCU: p = 0.011 and p < 0.001, respectively; ES: 1.11-1.48). After 75 or more pitches, the rate of change of FCU elasticity correlated negatively with that of the medial elbow joint space (r = -0.395, r = -0.454, and r = -0.404, after 75, 90, and 105 pitches, respectively). Increased FCU elasticity after repetitive pitching correlated with suppression of the increase of the medial elbow joint space. The FCU may be the primary dynamic stabilizer against the elbow valgus force, and evaluation of the FCU elasticity may be important for preventing elbow injuries.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 2: Ulnar Collateral Ligament of the Elbow Procedures

Background:

There is a lack of consensus to guide patient return to sport (RTS) after elbow ulnar collateral ligament surgery (eUCLS).

Purpose:

To describe the reported RTS criteria after eUCLS in the athletic population.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

This scoping review was performed by adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. We searched 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced) and the gray literature for English-language studies that reported at least 1 RTS criterion in athletes after eUCLS. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation.

Results:

Included were 14 studies and 1335 athletes with a mean age of 21.4 ± 1.1 years. Time from surgery (range, 6-16 months) was the most common RTS criterion used, and it was reported by all 14 of the included articles. RTS criteria reported less often were pain (3/14; 21%), successful completion of a throwing program (3/14; 21%), muscle strength of the forearm muscles (1/14; 7%), and “normal” range of motion and muscle strength of the elbow and shoulder joints on the operated upper extremity (1/14; 7%). All studies used 1 to 5 of the above RTS criteria.

Conclusion:

Only 14 studies reported 1 or more RTS criteria after eUCLS in athletes, and time was the most common RTS criterion used. Our results highlight the need for a coordinated effort among surgeons, physical therapists, and athletic trainers in order to establish evidence-based RTS criteria after eUCLS in athletes so athletes can safely to sport and prolong their athletic careers.

Postoperative rehabilitation in elbow surgery

Postoperative rehabilitation plays a crucial role in the treatment of elbow pathology. Depending on the type of surgery, the elbow may need to be protected. As a general rule, the elbow should not be immobilized for a prolonged period after surgery. A removable splint can be used to protect the soft-tissues immediately postoperative and the patient is encouraged to remove the splint several times daily to mobilize the elbow. Dynamic articulated braces can be used to encourage movement while ligament or tendon repairs are being protected. Literature on postoperative elbow rehab is scarce. In this paper we provide practical guidelines for specific surgical procedures.

Evaluation and management of elbow injuries in the adolescent overhead athlete

With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7–33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete’s stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.

Nonsurgical Management of Ulnar Collateral Ligament Injuries

Ulnar collateral ligament (UCL) injuries are a common source of pain and disability in the overhead athlete and often result in notable loss of time from competition. Over the past 10 to 15 years, the prevalence of UCL injury and reconstruction has undergone a dramatic increase, making it imperative to determine which patients may benefit from a nonsurgical regimen. Nonsurgical treatment involves a multidisciplinary approach of rehabilitation with tailored physical therapy programs and, in certain cases, biologic adjuncts. Physical therapy protocols should focus on strengthening the periscapular muscles, rotator cuff, core musculature, and flexor pronator mass to help stabilize the injured elbow and prevent injury recurrence before the initiation of a progressive throwing program. The implementation of injury prevention programs has shifted the focus from just the elbow and have included the shoulder, legs, and core in an effort to help decrease the stress on the upper extremity. In addition, biologic therapies such as platelet-rich therapy are promising modalities to augment the conservative treatment of UCL injuries but remain under investigation. The purpose of this study is to review available strategies and outcomes for conservatively treating UCL injuries.

Rehabilitation Following Ulnar Collateral Ligament Reconstruction in Overhead-Throwing Athletes

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The prevalence of ulnar collateral ligament (UCL) injury and UCL reconstruction (UCL-R) continues to rise, causing morbidity in overhead-throwing athletes.

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Postoperative rehabilitation protocols are essential for proper healing of the reconstructed ligament and safely returning athletes to competition, yet there is no uniformly accepted standard of care.

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UCL-R rehabilitation has traditionally been guided by expert opinion and conventional wisdom rather than scientific studies, resulting in substantial variability in rehabilitation practices, time to return to play, and outcomes.

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Current research efforts aim to closely investigate the biomechanical implications of UCL-R and overhead throwing to better guide rehabilitation and to improve competitive performance and outcomes.

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Additional biomechanical and scientific studies on rehabilitation modalities and timing are warranted for systematic analysis, optimization, and standardization of UCL-R rehabilitation.

Interval Return to Play Programs for the Tennis Athlete

PURPOSE OF REVIEW

General guidelines exist for return to sport after injury. The goal of these guidelines is to outline phases of recovery that will minimize the risk of reinjury and promote an optimal return to function for the athlete. This paper analyzes the current research pertaining to interval return to play programs with a special focus on the tennis athlete. The authors examine the different components of an interval tennis program and work to develop what they feel are the necessary elements of the optimal return to sport guidelines for tennis athletes. These criteria are based on the available literature, research, and preliminary data collection as well as the personal experiences and clinical observations of the authors.

RECENT FINDINGS

Interval sports programs are typically designed to guide the athlete back to competition after an injury. The current research reveals the obstacles present in implementing an appropriate interval sports program including a lack of consensus on which criteria is actually necessary and relevant. Limited research is present for interval tennis programs. Return to sport competition and sports science is continuously evolving. The authors highlight the necessary components in rehabilitation and performance principles for establishing a comprehensive interval tennis program. In addition, the role of technology in sports rehabilitation is assessed as it pertains to return to play. The authors proposed that interval sports program can help guide and direct future clinicians in their rehabilitation of the tennis athlete.

INFLUENCE OF FOAM ROLLING ON ELBOW PROPRIOCEPTION, STRENGTH, AND FUNCTIONAL MOTOR PERFORMANCE

CONTEXT

Foam rolling has recently been used frequently to increase flexibility. However, its effects on proprioception, strength and motor performance are not well known. In addition, very few studies have examined the effects of foam rolling in the upper extremity.

OBJECTIVE

To investigate the effects of foam rolling on elbow proprioception, strength, and functional motor performance in healthy individuals.

DESIGN

Randomized controlled study.

SETTING

Exercise laboratory of X Department, X University.

PATIENTS OR OTHER PARTICIPANTS

Sixty healthy participants (mean age=22.83±4.07 years).

INTERVENTION(S)

We randomly assigned participants into two groups: the foam rolling group (FRG) (4 weeks of foam rolling for the biceps brachii muscle) and control group (CG) (no foam rolling).

MAIN OUTCOME MEASURE(S)

We evaluated proprioception (joint position sense [JPS] and force matching), biceps brachii muscle strength, and functional motor performance (modified pull-up test [MPUT], closed kinetic chain upper extremity stability test [CKCUEST], and push-up test) at the baseline, and at the end of the 4th week and 8th week.

RESULTS

JPS at 45° elbow flexion, muscle strength, CKCUEST, and push-up test results improved after foam rolling and improvement was maintained at the follow-up (p<0.017). While the changes in groups for the results of proprioception and CKCUEST were similar among the three time points (p>0.05), there were significant improvements for the muscle strength from baseline to the second evaluation, and from baseline to the follow-up (p<0.001) in the FRG compared to the CG (p=0.004). The FRG was superior to the CG in the improvement of push-up test results among the three time points (p=0.040, p=0.001, p<0.001). Other data did not change (p>0.05).

CONCLUSION

Foam rolling is effective in improving elbow JPS in small flexion angles, biceps brachii strength, and some parameters of upper extremity functional motor performance. These effects are maintained 4 weeks after application.

THE NONOPERATIVE REHABILITATION OF A TRAUMATIC COMPLETE ULNAR COLLATERAL LIGAMENT TEAR OF THE ELBOW IN A HIGH SCHOOL WRESTLER: A CASE REPORT

Background and Purpose

Injuries frequently occur in competitive wrestling, with the elbow joint representing about 25% of all injuries. Specific to the elbow, the ulnar collateral ligament (UCL) can be injured traumatically from takedowns in wrestling. In athletes with complete UCL tears, surgical management is often recommended with nonoperative management resulting in less favorable outcomes. The purpose of this case report is to present a nonoperative criterion-based rehabilitation program for a high school wrestler with a complete UCL tear of the elbow.

Case Description

A 17-year-old male wrestler presented to outpatient physical therapy with a complete UCL tear sustained from falling on an outstretched hand during a wrestling match. He presented with limited elbow range of motion (ROM), medial elbow instability, and weakness of the involved shoulder and forearm musculature. A three staged criterion-based rehabilitation protocol was developed for this subject based on specific criteria, including pain, elbow ROM, arm strength, and functional outcomes.

Outcomes

The subject was treated for nine visits over six weeks, and demonstrated improvements in all strength tests of the involved upper extremity, with elbow flexion strength improving the most by 58%. Return to sport (RTS) tests were used to assess the subject's ability to return to practice. At approximately eight weeks after initial injury, the subject was able to return to full participation in competitive wrestling with no reports of elbow pain or instability.

Discussion

Through the utilization of a criterion-based rehabilitation protocol for the nonoperative management of an UCL injury, this high school wrestler was able to safely progress back to wrestling without pain or instability in an accelerated time frame. Previously, no detailed rehabilitation guidelines for nonoperative management of UCL injuries in contact sports have been described. Additionally, few studies exist which report on the inclusion of RTS testing following an injury to the UCL of the elbow, as RTS testing is optimal for determining readiness for sport.

Level of Evidence

4, Case Report.

Isokinetic Testing: Sensitivity of the Force-Velocity Relationship Assessed through the Two-Point Method to Discriminate between Muscle Groups and Participants' Physical Activity Levels

BACKGROUND

Isokinetic testing has been routinely used to assess the capacities of individual muscle groups. In this study we aimed to evaluate the sensitivity of the force-point (F-v) relationship assessed through the two-point method to discriminate between antagonist muscle groups and males with different physical activity levels.

METHODS

The concentric force output of the knee, hip, elbow, and shoulder flexors and extensors of 27 active and 13 non-active men was recorded at 60 and 180°/s to determine the F-v relationship parameters (maximum force [F₀], maximum velocity [v₀], and maximum power [P_max]).

RESULTS

F₀ and P_max were higher for knee extensors (effect size [ES] = 1.97 and 0.57, respectively), hip extensors (ES = 2.52 and 0.77, respectively), and shoulder flexors (ES = 1.67 and 0.83, respectively) compared to their antagonist muscles, while v₀ was higher for knee flexors compared to knee extensors (ES = 0.59). Active males revealed higher F₀ for knee extensors (ES = 0.72) and knee flexors (ES = 0.83) and higher P_max for knee flexors (ES = 0.70), elbow extensors (ES = 0.83) and shoulder extensors (ES = 0.36).

CONCLUSIONS

The sensitivity of the two-point method for testing the maximal mechanical capacities was high for the knee, moderate for the hip and shoulder, and low for the elbow joint.

Early Rehabilitation after Surgical Repair of Medial and Lateral Collateral Elbow Ligaments: A Report of Three Cases

Elbow ligament injuries are commonly caused by overuse; degeneration; and trauma; such as from a fall or collision. The purpose of this study was to present the results of three cases involving patients undergoing early rehabilitation after surgical treatment for complex injury of the elbow medial collateral ligament (MCL) and lateral collateral ligament (LCL). Two patients were non-athlete middle-aged women and one was a recreational judo player. Surgery was performed through open incision or arthroscopically. Rehabilitation consisted of range of motion (ROM) exercise; muscle strength restoration; and neuromuscular training. Passive ROM exercise and isometric strength exercise began at 7 days; isotonic strength training at 6 weeks; and neuromuscular training at 3 months after operation. Center- and home-based methods of exercise participation were combined. Center-based exercises were performed 1–2 times per week for the first 6 months and 1–2 times per month for the next 6 months. Patients also performed home-based and self-monitoring exercise. Examinations included ROM using a goniometer; muscle strength test using isokinetic equipment; and Oxford elbow score. In the six months after surgery; flexion ROM was 130° for Case A (health side 145°), 110° for Case B (health side 145°), and 135° for Case C (health side 135°); grip strength was restored to 13 kg (health side 28 kg), 16 kg (health side 25 kg), and 38 kg (health side 52 kg); and isokinetic flexion strength was improved to 30 Nm (health side 58 Nm), 21 Nm (health side 50 Nm), and 72 Nm (health side 80 Nm), respectively. In conclusion; patients who underwent early rehabilitation recovered ROM and muscle strength and returned to daily activity without any side effects. This study showed that patients with elbow MCL and LCL injuries took approximately 3 months to recover meaningful ROM; approximately 6 months to recover muscle strength; and 4–8 months to play light recreational sports. In addition; it took patients 6 weeks to return to their daily activities and 6 months to improve questionnaire scores in their function and pain during daily activity. In follow-up two years after surgery; all three patients had full ROM and muscle strength within 10% of the healthy side

Scapular muscles strength in college baseball players with and without a history of UCL injury

BACKGROUND

Ulnar collateral ligament (UCL) injuries are common in overhead athletes and have increased in prevalence among baseball pitchers of all ages. The purpose of this study was to examine the difference between the strength of five scapular stabilizing muscles in college baseball pitchers with and without a history of UCL surgery. Data on a pitcher with a recent diagnosis of a Grade I UCL sprain was also included as a case study.

METHODS

Thirty-nine college baseball pitchers, eight pitchers with a history of UCL surgery, volunteered to participate. Each participant completed a self-guided warm-up and then the strength of five scapular stabilizing muscles were assessed using a hand-held dynamometer. Station one tested latissimus dorsi and serratus anterior while the middle trapezius, lower trapezius, and rhomboids were assessed at station two. To determine the difference between groups Mann-Whitney U tests were performed with a significance level of P≤0.05.

RESULTS

The results showed no significant difference in muscle strength for all five muscle strength tests between the two groups. Although not statistically significant, the injured group averaged greater strength than the non-injured group for all five muscles tested.

CONCLUSIONS

The results of this study indicated there was no difference is scapular stabilizing muscle strength between college baseball pitchers with and without a history of UCL surgery. This may be due to proper rehabilitation and rest following the UCL injury. More research is needed to determine the role of scapular stabilizing muscle strength on elbow and UCL injury in college baseball players.

Importance of radar gun inclusion during return-to-throwing rehabilitation following ulnar collateral ligament reconstruction in baseball pitchers: a simulation study

BACKGROUND

Rehabilitation following elbow ulnar collateral ligament reconstruction in baseball pitchers relies on a progression of pitching activities to ensure protection and gradual strengthening of the reconstructed ligament. The purpose of this study was to determine the medial elbow torque associated with pitches at various effort levels and determine whether radar gun assistance improves players' abilities to accurately match partial-effort pitches with true references based on maximum pitch velocity.

METHODS

Thirty-seven healthy high school and collegiate baseball pitchers were included in this study. Participants were excluded if they were injured, recovering from injury, or otherwise not currently pitching at full effort. Pitch parameters were collected using a validated wearable sensor. Participants threw 5 pitches at 50%, 75%, and 100% subjective effort. Pitchers then threw 5 pitches at 50% maximum velocity and 75% maximum velocity, as measured by a radar gun.

RESULTS

Thirty-seven pitchers completed this study. Pitches thrown at 50% and 75% partial effort were significantly faster and generated higher elbow torque than did pitches thrown at 50% and 75% velocity, respectively (P < .001). A 10% decrease in percentage of maximum velocity was associated with a 13% decrease in percentage of maximum elbow torque (β coefficient = 1.3, R² = 0.81, P < .001).

CONCLUSION

Pitchers generate higher-than-intended forces when throwing at 50% and 75% effort during a subjective partial-effort throwing protocol. Use of a radar gun to guide partial-effort throwing during throwing rehabilitation programs may protect the reconstructed elbow from excess medial torque.

Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review

Objective

Several studies have been published regarding the treatment of medial ulnar collateral ligament (MUCL) injuries for professional overhead athletes. However, there is a paucity of data regarding non‐professional athletes. The aim of this systematic review was to compare the rate of outcome scores and complications of conservative versus operative treatments both in non‐professional athletes and in non‐sport‐related trauma patients with MUCL lesions.

Methods

A systematic review of the published literature was performed by applying the PRISMA guidelines. A search was conducted using three databases: Medline, Science Direct, and Web of Science. The keywords used were “ulnar collateral ligament injury,” “elbow,” “surgery,” and “conservative treatment”. Patients were divided into three groups: patients who underwent conservative treatment (C‐group), surgical treatment (S‐group), and surgery after a failed conservative treatment (C&S‐group). Clinical outcomes were analyzed: Disability of Arm, Shoulder and Hand (DASH), Conway scale, Carson score, and Kerlan–Jobe Orthopaedic Clinic score (KJOC).

Results

A total of 15 studies were included, evaluating 513 patients. Although good and excellent outcomes were found for most patients during daily and/or sport activities, independently of the type of treatment, the C‐group had better results. Excellent results were found in 98.8% of the C‐group, in 88.1% of the S‐group, and in 87.7% of the C&S‐group. The complication rate in the C‐group was statistically higher compared to the S and C&S groups (P < 0.001). However, its complication rate was higher with lower patient satisfaction.

Conclusions

There is insufficient evidence to establish statistically significant differences in the effects of conservative versus surgical treatments on the functional outcomes of patients with MUCL lesions. However, a period of rehabilitation therapy and the functional request of the single injured subject are useful to discern which patients genuinely require MUCL surgical repair.

The Effectiveness of a Hinged Elbow Orthosis in Medial Collateral Ligament Injuries: An In Vitro Biomechanical Study

BACKGROUND

Medial collateral ligament (MCL) injuries are common after elbow trauma and in overhead throwing athletes. A hinged elbow orthosis (HEO) is often used to protect the elbow from valgus stress early after injury and during early return to play. However, there is minimal evidence regarding the efficacy of these orthoses in controlling instability and their influence on long-term clinical outcomes.

PURPOSE

(1) To quantify the effect of an HEO on elbow stability after simulated MCL injury. (2) To determine whether arm position, forearm rotation, and muscle activation influence the effectiveness of an HEO.

STUDY DESIGN

Controlled laboratory study.

METHODS

Seven cadaveric upper extremity specimens were tested in a custom simulator that enabled elbow motion via computer-controlled actuators and motors attached to relevant tendons. Specimens were examined in 2 arm positions (dependent, valgus) and 2 forearm positions (pronation, supination) during passive and simulated active elbow flexion while unbraced and then while braced with an HEO. Testing was performed in intact elbows and repeated after simulated MCL injury. An electromagnetic tracking device measured valgus angulation as an indicator of elbow stability.

RESULTS

When the arm was dependent, the HEO increased valgus angle with the forearm in pronation (+1.0°± 0.2°, P = .003) and supination (+1.5°± 0.0°, P = .006) during active motion. It had no significant effect on elbow stability during passive motion. In the valgus position, the HEO had no effect on elbow stability during passive or active motion in pronation and supination. With the arm in the valgus position with the HEO, muscle activation reduced instability during pronation (-10.3°± 2.5°, P = .006) but not supination (P = .61).

CONCLUSION

In this in vitro study, this HEO did not enhance mechanical stability when the arm was in the valgus and dependent positions after MCL injury.

CLINICAL RELEVANCE

After MCL injury, an HEO likely does not provide mechanical elbow stability during rehabilitative exercises or when the elbow is subjected to valgus stress such as occurs during throwing.

An Overview of the Pathogenesis and Treatment of Elbow Osteoarthritis

The elbow joint could be associated with degenerative processes of primary and post-traumatic aetiology. Among these, osteoarthritis may also be secondary to repeated use as well as trauma. Pain, discomfort and progressive loss of functionality are common signs of this condition. The evaluation of elbow osteoarthritis should comprise an in-depth study to detect the primary cause of the illness and to facilitate the decision-making process regarding personalized treatment. Discordance between clinical manifestations and radiological findings is common. Conservative approaches may provide symptomatic relief in the early stages of disease for most patients. The goal of the treatment is to reduce pain and ensure an adequate range of motion and proper functioning of the joint while preserving the anatomical structure, to postpone elbow arthroplasty interventions for as long as possible. According to treatment guidelines, surgery should be considered depending on aetiology and severity, patient age, and functional demands. This narrative review aims to investigate the current literature regarding the pathogenesis and treatment of primary and post-traumatic arthritis of the elbow.

Repair of the Ulnar Collateral Ligament of the Elbow: Rehabilitation Following Internal Brace Surgery

Injuries to the elbow in athletes who play overhead sports, especially in baseball pitchers, continue to increase in frequency. The anterior band of the ulnar collateral ligament (UCL), the primary restraint to valgus stress, is commonly injured from throwing. Historically, such injuries have been treated with surgical reconstruction techniques, using a tendon autograft. A recently developed UCL repair procedure with an internal brace, utilizing collagen tape, is gaining popularity. The primary goal of this surgery is to enhance elbow joint stability while the ligament is healing and to allow earlier return to sport after UCL reconstruction. The rehabilitation program following UCL repair with internal brace progresses through a different time frame than after UCL reconstruction. The purpose of this commentary, based on our experience with more than 350 cases, including 79 patients with at least a 1-year postsurgical follow-up, was to describe and provide the rationale for the rehabilitation process following UCL repair with internal brace. J Orthop Sports Phys Ther 2019;49(4):253-261. doi:10.2519/jospt.2019.8215.

[Research progress of posteromedial rotatory instability of the elbow]

Objective

To summarize the research progress in posteromedial rotatory instability (PMRI) of the elbow joint.

Methods

The recent researches about the management of PMRI of the elbow joint from the aspects of pathological anatomy, biomechanics, diagnosis, and therapy were analyzed and summarized.

Results

The most important factors related to PMRI of the elbow joint are lateral collateral ligament complex (LCLC) lesion, posterior bundle of the medial collateral ligament complex (MCLC) lesion, and anteromedial coronoid fracture. Clinical physical examination include varus and valgus stress test of the elbow joint. X-ray examination, computed tomography, particularly three-dimensional reconstruction, are particularly useful to diagnose the fracture. Also MRI, arthroscopy, and dynamic ultrasound can assistantly evaluate the affiliated injury of the parenchyma. It is important to repair and reconstruct LCLC and MCLC and fix coronoid process fracture for recovering stability of the elbow joint. There are such ways to repair ligament injury as in situ repairation and functional reconstruction, which include direct suturation, borehole repairation, wire anchor repairation, and transplantation repairation etc. The methods for fixation of coronal fracture include screw fixation, plate fixation, unabsorbable suture fixation, and arthroscopy technology.

Conclusion

It is crucial that recovering the stability of the elbow joint and early functional exercise for the treatment of PMRI. Individual treatment is favorable to protect soft tissue, reduce surgical complications, and improve the functional recovery and the quality of life.

Rehabilitation: Common Problems and Solutions

There are numerous complications that can occur following a musculoskeletal injury or surgery in the sporting population. Prevention of the most frequent complications is the key in any successful rehabilitation program, but occasionally problems do occur. A thorough well-designed postoperative or postinjury rehabilitation program may prevent these problems. However, if complications do arise, a team approach among the parties involved in the process to develop an evidenced-based treatment program designed for the underlying complication can successfully treat these issues. The authors discuss the complications seen in sports injuries to the knee, shoulder, elbow, and foot/ankle joints of the body.

Ulnar Collateral Ligament Reconstruction Versus Repair With Internal Bracing: Comparison of Cyclic Fatigue Mechanics

Background:

Ulnar collateral ligament (UCL) injuries have increased significantly in recent years, and reconstruction has become the preferred treatment for UCL injury over ligament repair. In a recent study, UCL repair with internal bracing demonstrated significantly greater resistance to gap formation in biomechanical tests, even at low cycles of valgus loading.

Purpose/Hypothesis:

The purpose of this study was to compare the fatigue and failure mechanics of traditional UCL reconstruction with UCL repair and internal bracing. We hypothesized that repaired specimens would have less gap formation, closer return to native gap formation, and greater maximum torque to failure versus traditionally reconstructed specimens.

Study Design:

Controlled laboratory study.

Methods:

Ten matched pairs of cadaveric elbows were positioned at 90° of flexion and the native UCL subjected to 500 cycles of subfailure valgus loading. A simulated tear was created, and the 10 cycles were repeated. Each pair of specimens was next given repair with internal bracing on 1 side and a modified Jobe reconstruction on the contralateral side, followed by 100 manual cycles of flexion-extension, 500 cycles of valgus rotation, and, finally, rotation to failure.

Results:

The specimens that received the repair unexpectedly experienced significantly less gapping in the torn state than did those in the reconstruction group. At the 10th cycle, repaired UCL injuries had significantly less gap formation than the reconstructed UCLs. At the 100th and 500th cycles, repaired UCL injuries continued to experience significantly less gap formation as compared with the reconstructed injuries.

Conclusion:

When compared with the gold standard reconstruction technique, UCL repair with internal bracing is more resistant to gap formation under fatigue loading. However, the unexpected early difference between the torn states may have confounded this finding. Time-zero failure properties of this repair technique are on par with those of traditional reconstruction, even after 500 cycles of valgus loading.

Clinical Relevance:

UCL reconstruction has become a common procedure among adolescent and elite-level throwers. Recent data suggest that UCL repair may be a viable option for younger athletes with acute proximal or distal UCL tears, allowing a faster return to play.

Arthroscopic treatment successfully treats posterior elbow impingement in an athletic population

PURPOSE

Posterior elbow impingement can cause disabling pain and limited motion during activities involving elbow extension. Less understood is whether arthroscopic treatment, compared to open surgery, can result in effective management of pain, loss of range of motion, and return athletes to previous levels of activity. This study determined whether arthroscopic debridement is a safe and effective treatment for posterior elbow impingement and whether it enables athletes to return to a previous level of function.

METHODS

A retrospective review of 36 consecutive patients that underwent arthroscopic debridement of the posterior elbow was performed. There were 34 male and 2 female patients, with a median age of 32 years (17-54 years). There were 7 professional athletes, 6 college athletes, and 23 high school or recreational athletes. All patients had a positive posterior impingement test for posterior pain with extension and limitations of activity. Arthroscopic debridement and additional surgical procedures were performed, and patients underwent follow-up visits at a median 51 months (range 14-81).

RESULTS

Significant improvements were seen in pain, motion, and function. No neurovascular complications were seen related to the arthroscopic debridement. The mean Andrews and Timmerman elbow score improved from 159 ± 27 to 193 ± 11 (p < 0.01). Thirty-five of thirty-six (97%) patients returned to their previous level of activity, including all professional athletes.

CONCLUSIONS

Arthroscopic management of posterior elbow impingement is safe and effective and can return patients, including professional athletes, to high-level athletic activity. Athletes with symptomatic posterior elbow impingement can be successfully and safely treated with arthroscopic debridement and typically will return to preinjury levels of activity.

LEVEL OF EVIDENCE

IV.

Avoiding Tommy John Surgery: What Are the Alternatives?

The number of ulnar collateral ligament (UCL) reconstructions being performed has risen sharply in recent years, most notably in the young amateur athlete. While successful outcomes have been reported with reconstruction, the surgery and the associated rehabilitation timeline may be difficult for the nonelite athlete to incur. Return-to-play expectations, along with level of competition, should help guide surgeons in exploring management options. While reconstruction remains a mainstay, focused research exploring nonreconstructive options has expanded. This review discusses the clinical approach to those with UCL injury, including current support for rehabilitation, biologic strategies, and available repair or augmentation alternatives.

Magnetic Resonance Imaging Predictors of Failure in the Nonoperative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers

BACKGROUND

A medial ulnar collateral ligament (UCL) injury of the elbow is an increasingly common injury in professional baseball pitchers. Predictors of success and failure are not well defined for the nonoperative management of these injuries.

PURPOSE

To evaluate the efficacy of objective measures to predict failure of the nonoperative management of UCL injuries.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Thirty-two professional pitchers (82%) met inclusion criteria and underwent an initial trial of nonoperative treatment for UCL tears based on clinical and radiological findings. Age, preseason physical examination results, magnetic resonance imaging (MRI) characteristics, and performance metrics were analyzed for these pitchers. Successful nonoperative management was defined as a return to the same level of play or higher for >1 year. Failure was defined as recurrent pain or weakness requiring a surgical intervention after a minimum of 3 months' rest when attempting a return to a throwing rehabilitation program.

RESULTS

Thirty-two pitchers (mean age, 22.3 years) who underwent initial nonoperative treatment of UCL injuries were evaluated. Thirty-four percent (11/32) failed and required subsequent ligament reconstruction. Sixty-six percent (21/32) successfully returned to the same level of play for 1 year without a surgical intervention. There was no significant difference seen in physical examination findings or performance metrics between these patients. When comparing MRI findings between the groups, 82% (9/11) ( P < .001) who failed nonoperative management had distal tears, and 81% (17/21) who did not fail had proximal tears ( P < .001). When adjusting for age, location, and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 12.40 times greater ( P = .020) with a distal tear. No other variable alone or in combination reached significance. When combining the parameters of a high-grade tear and distal location, 88% (7/8) failed nonoperative management.

CONCLUSION

In professional pitchers, distal UCL tears showed significantly higher odds of failure with nonoperative management compared with proximal tears. Thus, tear location should be considered when deciding between operative and nonoperative management.

Rehabilitation, clinical outcome and return to sporting activities after posterolateral elbow instability: a systematic review

INTRODUCTION

The aim of this study was to systematically review the literature for rehabilitation concepts, clinical outcome and sporting performance after surgical or non-surgical treatment of Posterolateral Rotatory Instability of the elbow (PLRI).

EVIDENCE ACQUISITION

In order to identify any published clinical study reporting on rehabilitation concepts and sporting performance following surgical or non-surgical treatment of PLRI a systematic search in literature was conducted. Rehabilitation protocols were reviewed according to main rehabilitation protocol categories (bracing, range of motion [ROM], strengthening and return to sport [RTS]).

EVIDENCE SYNTHESIS

Seven articles, including 148 patients met the inclusion criteria. Lateral ulnar collateral ligament (LUCL) repair with sutures or suture anchors was reported in two studies. In four studies, treatment was an isolated graft reconstruction and in one study a repair or graft reconstruction was performed. No study reporting on conservative treatment was found. Bracing with initially limiting ROM was declared in all studies. Duration of immobilization varied from one day to six weeks postoperative. Limitation of ROM to 30° of elbow extension was reported in the majority of studies. Strengthening was allowed from six to eight weeks postoperative. Postoperative improvement in elbow range of motion was noted in all studies.

CONCLUSIONS

Although there is agreement concerning bracing and limiting ROM following PLRI surgery there is currently no consensus in the rehabilitative- and conservative treatment modalities for patients with symptomatic PLRI. The majority of surgically treated patients with PLRI regain high acceptable results but further research is needed to determine the postoperative level of performance of these athletes.

Optimal management of ulnar collateral ligament injury in baseball pitchers

The ulnar collateral ligament stabilizes the elbow joint from valgus stress associated with the throwing motion. During baseball pitching, this ligament is subjected to tremendous stress and injury if the force on the ulnar collateral ligament during pitching exceeds the physiological limits of the ligament. Injuries to the throwing elbow in baseball pitchers result in significant time loss and typically surgical intervention. The purpose of this paper is to provide a review of current information to sports medicine clinicians on injury epidemiology, injury mechanics, injury risk factors, injury prevention, surgical interventions, nonsurgical interventions, rehabilitation, and return to play outcomes in baseball pitchers of all levels.

Ulnar Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes

Context:

Ulnar collateral ligament (UCL) injuries lead to pain and loss of performance in the thrower’s elbow. Ulnar collateral ligament reconstruction (UCLR) is a reliable treatment option for the symptomatic, deficient UCL. Injury to the UCL usually occurs because of chronic accumulation of microtrauma, although acute ruptures occur and an acute-on-chronic presentation is also common.

Evidence Acquisition:

Computerized databases, references from pertinent articles, and research institutions were searched for all studies using the search terms ulnar collateral ligament from 1970 until 2015.

Study Design:

Clinical review.

Level of Evidence:

Level 5.

Results:

All studies reporting outcomes for UCLR are level 4. Most modern fixation methodologies appear to be biomechanically and clinically equivalent. Viable graft choices include ipsilateral palmaris longus tendon autograft, gracilis or semitendinosus autograft, and allograft. Clinical studies report excellent outcomes of UCLR for both recreational and elite level athletes with regard to return to sport and postoperative performance. Complications, although rare, include graft rerupture or attenuation, ulnar nerve symptoms, stiffness, pain, and/or weakness leading to decreased performance.

Conclusion:

Injuries to the UCL have become commonplace among pitchers. Nonoperative treatment should be attempted, but the limited studies have not shown promising results. Operative treatment can be performed with several techniques, with retrospective studies showing promising results. Complications include ulnar neuropathy as well as failure to return to sport. Detailed preoperative planning, meticulous surgical technique, and a comprehensive rehabilitation program are essential components to achieving a satisfactory result.

The thrower's elbow

Overhead throwing activities expose the elbow to tremendous valgus stress, making athletes vulnerable to a specific constellation of injuries. Although baseball players, in particular pitchers, are the athletes affected most commonly, overhead throwing athletes in football, volleyball, tennis, and javelin tossing also are affected. The purpose of this review is to review the anatomy, biomechanics, pathophysiology, and treatment of elbow disorders related to overhead throwing athletes. Although focus is on management of ulnar collateral ligament injuries, all common pathologies are discussed.

Correlation of shoulder and elbow injuries with muscle tightness, core stability, and balance by longitudinal measurements in junior high school baseball players

[Purpose] The present study longitudinally investigated injury occurrences and the risk factors for muscle tightness, core stability, and dynamic standing balance among junior high school student baseball players. [Subjects] Thirty-nine male students, belonging to baseball clubs at 2 junior high schools, participated in this study. [Methods] Study measurements were obtained twice, once in the early stage of the baseball season (March) and once at the end of the season (July). All subjects underwent muscle tightness testing, the Star Excursion Balance Test (SEBT), and trunk endurance testing during each measurement session. [Results] Fifteen players experienced episodes of elbow or shoulder pain while throwing. Players in the pain group demonstrated a significant increase in the tightness of their shoulder internal rotators, axis-leg quadriceps, and axis-leg hamstrings. There was no clear evidence of differences of changes in core stability and dynamic standing balance between the groups. [Conclusion] The results of this study suggest that lower extremity muscle tightness early in a season and the subsequent decline in the flexibility of the axis-leg quadriceps and hamstrings during the season may be due to an increased upper extremity load while throwing, thus producing shoulder and elbow pain.

Nonoperative and postoperative rehabilitation for glenohumeral instability

The glenohumeral joint is an inherently unstable joint that relies on the interaction of the dynamic and static stabilizers to maintain stability. Disruption of this interplay or poor development of any of these factors may result in instability, pain, and a loss of function. Rehabilitation will vary based on the type of instability present and the key principles described. Whether a course of nonoperative rehabilitation is followed or the patient presents postoperatively, a comprehensive program designed to establish full ROM and balance capsular mobility, in addition to maximizing muscular strength, endurance, proprioception, dynamic stability, and neuromuscular control is essential. A functional approach to rehabilitation using movement patterns and sport-specific positions along with an interval sport program will allow a gradual return to athletics. The focus of the program should minimize the risk of recurrence and ensure that the patient can safely return to functional activities.

Ulnar collateral ligament injuries in the throwing athlete

Repetitive valgus forces on the throwing elbow place significant stress on that joint. This stress can cause structural damage and injury to the ulnar collateral ligament. Many acute injuries of the throwing elbow are caused by repetitive chronic wear. Although much work has been done on injury prevention in youth who are pitchers, overuse injury in throwing sports constitutes an epidemic. Failing nonsurgical management, ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition.

Lower extremity balance is improved at time of return to throwing in baseball players after an ulnar collateral ligament reconstruction when compared to pre-operative measurements

BACKGROUND

/

PURPOSE

Lower extremity balance deficits have been shown to lead to altered kinematics and increased injury risk in lower extremity athletes. The purpose of this study was to compare lower extremity balance in baseball players with an ulnar collateral ligament (UCL) tear pre-operatively and post-operatively at the beginning of the pre-return to throwing program stage of rehabilitation (3 months).

METHODS

Thirty-three competitive high school and collegiate male baseball players (18.5 ± 3.2) with a diagnosed UCL tear volunteered for the study. Of the 33 baseball players 29 were pitchers, 1 was a catcher, and 3 were infielders. Participants were seen pre-operatively and at 3 months post operatively. This 3 month point was associated with a follow-up visit to the orthopedic surgeon and subsequent release to begin the pre-return to throwing mark for baseball players following their surgery. Following surgery, each participant followed a standard UCL protocol which included focused lower extremity balance and neuromuscular control exercises. Participants were tested for single leg balance using the Y-Balance Test™ - Lower Quadrant (YBT-LQ) on both their lead and stance limbs. YBT-LQ composite scores were calculated for the stance and lead limbs pre- and post-operatively and compared over time. Paired t-tests were used to calculate differences between time 1 and time 2 (p < 0.05).

RESULTS

Baseball players with diagnosed UCL tears demonstrated significant balance deficits on their stance (p < .001) and lead (p = .009) limbs prior to surgery compared to balance measures at the 3-month follow up (Stance Pre-Op = 89.4 ± 7.5%; Stance 3 Month = 94.9 ± 9.5%) (Lead Pre-Op = 90.2 ± 6.7%; Lead 3 Month = 93.6 ± 7.2%).

CONCLUSION

Based on the results of this study, lower extremity balance is altered in baseball players with UCL tears prior to surgery. Statistically significant improvements were seen and balance measures improved at the time of return to throwing.

LEVEL OF EVIDENCE

Level 2b.

Throwing injuries in the adolescent athlete

INTRODUCTION

Adolescents ranging in age from 11-15 (early-mid adolescence) comprise the largest percentage of baseball and softball athletes in the United States. Shoulder and elbow injuries are commonly experienced by these athletes with baseball pitchers and softball position players most likely to be injured.

COMMON INJURIES

Physeal injury often termed "Little League" shoulder or elbow is common and should be differentiated from soft tissue injuries such as biceps, rotator cuff, or UCL injuries. Regardless of diagnosis, rehabilitation of these athletes' shoulder and elbow injuries provide a unique challenge given their rapidly changing physical status.

TREATMENT

Common impairments include alterations in shoulder range of motion, decreased muscle performance, and poor neuromuscular control of the scapula, core, and lower extremity. A criterion based, progressive rehabilitation program is presented. Discharge from formal rehabilitation should occur only when the athlete has demonstrated a resolution of symptoms, acceptable ROM, muscle performance, and neuromuscular control while progressing through a symptom free return to sport.

PREVENTION OF REINJURY

Reintegration into the desired level of sport participation should be guided by the sports medicine professional with a focus on long-term durability in sport performance as well as injury prevention. A prevention program which includes parent, coach, and athlete education, regular screening to identify those athletes at the highest risk, and monitoring athletes for the development of risk factors or warning signs of injury over the course of participation is indicated.

LEVEL OF EVIDENCE

5.