Management of High Ankle Sprains Utilizing the Tightrope Surgical Procedure - A Novel Approach for a Rapid Return to Play

The distal tibiofibular joint is described as a syndesmosis. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Syndesmotic or high ankle sprains, involving the syndesmotic ligaments, pose a significant rehabilitative challenge due to their intricate anatomy, prolonged recovery periods following injury, and high susceptibility to persistent disability. Traditional management strategies have often been conservative, marked by lengthy periods of immobilization and a gradual return to activity. Severe syndesmotic injuries with diastasis have been treated surgically with screw fixation which may require a second intervention to remove the hardware and carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. The accelerated rehabilitation protocol promotes early weight-bearing and has been shown to expedite the return to sport. This emerging strategy has shown promise in reducing recovery time as it is now possible to return to sport in less than 2 months after a tightrope repair and accelerated rehabilitation, compared with 3-6 months post screw fixation. This clinical commentary delves into this novel approach, highlighting the procedure, rehabilitation protocols, and the implications for physical therapy practice.

Level of Evidence

V.

Isokinetic Testing: Why it is More Important Today than Ever

Isokinetics is a proven method to train and objectively assess the capability of muscle groups, particularly at the knee. The current re-injury rates and less than optimal return to sport percentages seen following anterior cruciate ligament surgery highlights the need for greater focus on what tests and methods are used to make these critical decisions. Isokinetics remains the best single method to objectively determine dynamic muscle strength, power, rate of force development and endurance. These factors make it well-suited to play a crucial role in influencing the appropriate patient progression through a rehabilitation program and assisting in determining return to play readiness following injury or surgery. In this article we will discuss why we believe isokinetics is a useful and necessary testing method, and elucidate testing parameters and goals used during knee extension/flexion assessment.

An Interval Throwing Program for Baseball Pitchers Based upon Workload Data

Background

Interval throwing programs (ITP) have been used for decades to enable baseball pitchers to return to competition after injury or surgery by gradually applying load to the throwing arm. Past programs have been based on personal experience; however, advances in our understanding of the biomechanics and workloads of throwing allow for a more modern data-based program to be developed.

Hypothesis/Purpose

To 1) develop a updated ITP for rehabilitation of modern baseball pitchers based upon biomechanical and throwing workload data, and 2) compare the updated program with a past program to determine differences in chronic workload and acute:chronic workload ratios (ACWR).

Study Design

Cross-sectional study.

Methods

Workloads (i.e. daily, acute, chronic, and ACWR) for the original ITP were built from the prescribed throwing schedule. Elbow varus torque per throw was calculated based upon a relationship between elbow varus torque and throwing distance. Throw counts, daily/chronic/acute workloads, and ACWR were calculated and plotted over time. A new ITP was built to model current pitcher's throwing schedules and gradually increased ACWR over time.

Results

The original ITP had a throwing schedule of 136 days, final chronic workload 15.0, and the ACWR above or below the "safe" range (i.e. 0.7 - 1.3) for 18% of the program with a peak of 1.61. The updated ITP was built to consist of a 217-day schedule, final chronic workload of 10.8, and deviated from the safe range for 9% of the program, with a peak of 1.33.

Conclusion

The newly created ITP is more familiar to modern baseball pitchers while exhibiting a more gradual buildup of chronic workload than traditional ITP programs. This ITP may be used to return baseball pitchers back to competition as safely and efficiently as possible, and potentially with less risk of setbacks or reinjury. The ITP may be used following common injuries or surgeries to the throwing shoulder and elbow, such as Tommy John surgery, while also serving as a basis for future development of shorter duration ITPs.

Level of Evidence

2c.

Neurocognitive and Reactive Return to Play Testing Protocol in Overhead Athletes Following Upper Extremity Injury

The incidence of upper extremity (UE) injuries in sport, particularly with the shoulder and elbow in baseball/softball players, appears to be increasing yearly, especially in younger age athletes. Improving the objective criteria and testing methods used to determine return to play (RTP) readiness following non-operative or post-operative management of UE injuries is one aspect of the rehabilitation process that may significantly help in reducing reinjury rates. Currently, the majority of clinicians are still using post operative time frame and/or strength/range of motion as their main criteria for clearance to RTP following UE injury. This demonstrates an inadequate reflection of the actual unpredictable, dynamic environment athletes are returning to participate in. In our clinical experiences, objective testing to allow for clearance to sport participation should incorporate neurocognitive and reactive testing to promote improvements in the athlete's ability to dual task and focus/concentrate on the multi-dimensional tasks at hand. We know that neuroplastic changes occur following UE injury resulting in decreased proprioception and increased motor activation with simple UE tasks. Currently the research on UE return to play testing is limited. The purpose of this clinical commentary was to describe the utilization and provide reference values for a series of reactive neurocognitive UE tests, to assist with RTP, in high school and collegiate overhead athletes (baseball and softball) utilizing the Blaze Pod light system. The use of a more dynamic reactive testing battery may decrease the reinjury rates when an athlete is cleared for participation by measuring readiness in chaotic circumstances that are more reflective of the sporting environment the athlete is working to return to resulting in a greater sense of confidence, performance and prevention of reinjuries.

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.

Patellofemoral Joint Loading during the Performance of the Wall Squat and Ball Squat with Heel-to-Wall-Distance Variations

INTRODUCTION

Although bodyweight wall and ball squats are commonly used during patellofemoral rehabilitation, patellofemoral loading while performing these exercises is unknown, which makes it difficult for clinicians to know how to use these exercises in progressing a patient with patellofemoral pathology. Therefore, the purpose was to quantify patellofemoral force and stress between two bodyweight squat variations (ball squat vs wall squat) and between two heel-to-wall-distance (HTWD) variations (long HTWD vs short HTWD).

METHODS

Sixteen participants performed a dynamic ball squat and wall squat with long HTWD and short HTWD. Ground reaction force and kinematic data were used to measure resultant knee force and torque from inverse dynamics, whereas electromyographic data were used in a knee muscle model to predict resultant knee force and torque, and subsequently, all these data were inputted into a biomechanical computer optimization model to output patellofemoral joint force and stress at select knee angles. A repeated-measures two- and three-way ANOVA ( P < 0.01) was used for statistical analyses.

RESULTS

Collapsed across long HTWD and short HTWD, patellofemoral joint force and stress were greater in ball squat than wall squat at 30° ( P = 0.009), 40° ( P = 0.008), 90° ( P = 0.003), and 100° ( P = 0.005) knee angles during the squat descent, and greater in wall squat than ball squat at 100° ( P < 0.001), 90° ( P < 0.001), 80° ( P = 0.004), and 70° ( P = 0.009) knee angles during squat ascent. Collapsed across ball and wall squats, patellofemoral joint force and stress were greater with a short HTWD than a long HTWD at 100° ( P = 0.007) and 90° ( P = 0.008) knee angles during squat ascent.

CONCLUSIONS

Patellofemoral joint loading changed according to both squat type and HTWD variations. These differences occurred in part due to differences in forces the wall or ball exerted on the trunk, including friction forces. Overall, patellofemoral force and stress were greater performing the bodyweight wall squat compared with the bodyweight ball squat. Moreover, squatting with short HTWD produced anterior knee displacement beyond the toes at higher knee angles, resulting in greater patellofemoral force and stress compared with squatting with long HTWD.

The Golfer's Fore, Fore +, and Advanced Fore + Exercise Program: An Exercise Series and Injury Prevention Program for the Golfer

Golf is increasing in popularity with 24.8 million golfers in the U.S. in 2020, a 2% increase from the previous year. This number increased to 37.5 million in 2021 which can be further broken down to 25.1 million on course and 12.4 million participating in off course activities. Playing golf does not come without risk of injury, with an annual incidence between 15.8% and 40.9% in amateurs and 31% in professional golfers. Most injuries in golf occur due to overuse (82.6%) and only a small percentage occur from a single traumatic event (17.4%). Injuries most commonly occur at the low back followed by the wrist. Injury prevention programs have shown to be successful in other sports however to date there are no studies assessing a golfer's specific program. The purpose of this clinical commentary is to describe three individualized and unsupervised golf exercise programs (The Golfer's Fore, Fore+, and Advanced Fore+), of varying difficultly, designed to reduce the risk of injury, improve strength/mobility, and optimize performance.

Level of Evidence

5.

Reliability of Upper Extremity Functional Performance Tests for Overhead Sports Activities

Background

There is lack of consensus on which tests, particularly upper extremity functional performance tests (FPT) that should be used for clinical decision making to progress a patient through a rehabilitation program or criteria for return to sport (RTS). Consequently, there is a need for tests with good psychometric properties that can be administered with minimal equipment and time.

Purpose

(1) To establish the intersession reliability of several open kinetic chain FPT in healthy young adults with a history of overhead sport participation. (2) To examine the intersession reliability of the limb symmetry indices (LSI) from each test.

Study Design

Test-retest reliability, single cohort study.

Methods

Forty adults (20 males, 20 females) completed four upper extremity FPT during two data collection sessions three to seven days apart: 1) prone medicine ball drop test 90°shoulder abduction (PMBDT 90°), 2) prone medicine ball drop test 90°shoulder abduction/90° elbow flexion (PMBDT 90°-90°), 3) half-kneeling medicine ball rebound test (HKMBRT), 4) seated single arm shot put test (SSASPT). Measures of systematic bias, absolute reliability and relative reliability were computed between the sessions for both the original test scores and LSI.

Results

Except for the SSASPT, all tests demonstrated significant (p ≤ 0.030) improvements in performance during the second session. Generally, for the medicine ball drop/rebound tests, the absolute reliability was the highest (less random error) for the HKMBRT, next the PMBDT 90°followed by PMBDT 90°-90°. Excellent relative reliability existed for the PMBDT 90°, HKMBRT, and SSASPT, whereas fair to excellent relative reliability for the PMBDT 90°-90°. The SSASPT LSI revealed the highest relative and absolute reliability.

Conclusion

Two tests, HKMBRT and SSASPT demonstrated sufficient reliability; therefore, the authors' recommend those tests can be used for serial assessments to advance a patient through a rehabilitation program as well as criteria for progression to RTS.

Level of Evidence

3.

Active range of motion of the shoulder: a cross-sectional study of 6635 subjects

Background

Normative data for passive range of motion are well established, but daily living is comprised of active motion. The purpose of this study was to establish normative values for active range of motion of the shoulder across age, sex, and arm. Our hypotheses were that active range of motion of the shoulder (1) decreases with age group, (2) differs between males and females, and (3) differs between the right arm and left arm.

Methods

Shoulder active range of motion was captured with an eight-camera markerless motion capture system. Data were collected for a heterogenous sample of 6635 males and females of all ages. For each subject, 6 shoulder motions were collected with maximum values measured: external rotation, internal rotation, flexion, extension, abduction, and horizontal abduction. Three-way repeated measures analyses were performed, with 2 between-subject factors (age group and sex) and 1 within-subject factor (arm). The unadjusted threshold for statistical significance was α = 0.05.

Results

External rotation decreased with age (approximately 10° decrease from below 30 years to above 60 years). External rotation was approximately 5° greater in the right arm, whereas internal rotation was approximately 5° greater in the left arm. Flexion decreased with age (approximately 15° decrease from below 20 years to above 60 years). For age groups from 10 to 59 years, extension and horizontal abduction were approximately 5° to 10° greater in females than males. Abduction was greater for females than males. Abduction was also greater in younger people (aged 10-29 years) than older people.

Conclusion

In general, active range of motion of the shoulder decreases with age. Sex (male/female) and arm side (right/left) also influence shoulder range of motion.

The Effects on Knee Swelling, Range of Motion and Pain using a Commercially Available Hot/Cold Contrast Device in a Rehabilitation and Sports Medicine Setting

Background and Purpose

Contrast therapy consists of alternating thermotherapy and cryotherapy repeatedly to assist in the management of acute, subacute, and chronic musculoskeletal conditions. This has been utilized for several decades with good to excellent subjective and objective results reported for patients with swelling (acute to chronic), pain, and loss of motion. Typically, the intervention is performed by either the use of a hot and cold whirlpool or by applying hot and cold packs which can be very time consuming and labor intensive. The purpose of this study was to determine the efficacy of a single treatment of the Hyperice X system in reducing knee joint pain, swelling and stiffness in active patients and young injured athletes. A secondary purpose was to measure patient satisfaction with the use of the device.

Subjects

Fifty subjects (34 males and 16 females) with a mean age of 22.2 +/- 4.9 yrs (ranging from 17 to 45 yrs of age) were recruited. Subjects presented with various types of knee pain, both non-operative and operative, secondary to ligamentous, tendinous, cartilage, muscle, and/or meniscus pathology. The subjects were in various stages of rehabilitation with six in the acute stage, 24 in subacute stage, and 20 in the chronic stage. The subjects participated in a variety of different sports at various levels of competition ranging from recreational to professional.

Methods

Subjects were recruited from one of two centers: an athletic training room or an outpatient sports medicine rehabilitation center. They were evaluated for baseline pain using the visual analog scale (VAS),verbal patient satisfaction on a scale of 1-10, verbal assessment of knee tightness, knee circumference, and knee flexion range of motion. The Hyperice X was applied to the knee utilizing the contrast setting for a total of 18 minutes with three six-minute cycles, each consisting of three minutes of heat therapy and three minutes of cold therapy. The contrast therapy was applied at the initiation of the physical therapy session and all subjective and objective measures were repeated immediately post contrast treatment.

Results

The VAS scores significantly improved following the treatment session with the mean score pretreatment of 2.59 and following the treatment of 1.68. Knee circumference improved for mid patella and 5 cm below mid patella, but no significant improvement was noted at the 5 cm above the patella region. Knee flexion improved from 130 degrees pre-treatment to 134 degrees post treatment. Knee extension improved from 2.72 degrees of hyperextension to 3.44 degrees, both of which were statistically significant(p<.001).

Conclusion

Contrast therapy utilizing the Hyperice X device demonstrated effectiveness in affecting pain reduction, swelling, and knee ROM. A commercially available device providing contrast therapy, may enhance outcomes in athletes after even a single treatment. In addition, the device was found to be easy to use, clinically practical, and demonstrated very high subjective patient satisfaction.

Level of Evidence

Level 3.

The Clinician's Guide to Baseball Pitching Biomechanics

CONTEXT

Improper baseball pitching biomechanics are associated with increased stresses on the throwing elbow and shoulder as well as an increased risk of injury.

EVIDENCE ACQUISITION

Previous studies quantifying pitching kinematics and kinetics were reviewed.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

At the instant of lead foot contact, the elbow should be flexed approximately 90° with the shoulder at about 90° abduction, 20° horizontal abduction, and 45° external rotation. The stride length should be about 85% of the pitcher's height with the lead foot in a slightly closed position. The pelvis should be rotated slightly open toward home plate with the upper torso in line with the pitching direction. Improper shoulder external rotation at foot contact is associated with increased elbow and shoulder torques and forces and may be corrected by changing the stride length and/or arm path. From foot contact to maximum shoulder external rotation to ball release, the pitcher should demonstrate a kinematic chain of lead knee extension, pelvis rotation, upper trunk rotation, elbow extension, and shoulder internal rotation. The lead knee should be flexed about 45° at foot contact and 30° at ball release. Corrective strategies for insufficient knee extension may involve technical issues (stride length, lead foot position, lead foot orientation) and/or strength and conditioning of the lower body. Improper pelvis and upper trunk rotation often indicate the need for core strength and flexibility. Maximum shoulder external rotation should be about 170°. Insufficient external rotation leads to low shoulder internal rotation velocity and low ball velocity. Deviation from 90° abduction decreases the ability to achieve maximum external rotation, increases elbow torque, and decreases the dynamic stability in the glenohumeral joint.

CONCLUSION

Improved pitching biomechanics can increase performance and reduce risk of injury.

SORT

Level C.

Patellofemoral Joint Loading During the Performance of the Forward and Side Lunge with Step Height Variations

BACKGROUND

Forward and side lunge exercises strengthen hip and thigh musculature, enhance patellofemoral joint stability, and are commonly used during patellofemoral rehabilitation and training for sport.

HYPOTHESIS/PURPOSE

The purpose was to quantify, via calculated estimates, patellofemoral force and stress between two lunge type variations (forward lunge versus side lunge) and between two step height variations (ground level versus 10 cm platform). The hypotheses were that patellofemoral force and stress would be greater at all knee angles performing the bodyweight side lunge compared to the bodyweight forward lunge, and greater when performing the forward and side lunge at ground level compared to up a 10cm platform.

STUDY DESIGN

Controlled laboratory biomechanics repeated measures, counterbalanced design.

METHODS

Sixteen participants performed a forward and side lunge at ground level and up a 10cm platform. Electromyographic, ground reaction force, and kinematic variables were collected and input into a biomechanical optimization model, and patellofemoral joint force and stress were calculated as a function of knee angle during the lunge descent and ascent and assessed with a repeated measures 2-way ANOVA (p<0.05).

RESULTS

At 10° (p=0.003) knee angle (0° = full knee extension) during lunge descent and 10° and 30° (p<0.001) knee angles during lunge ascent patellofemoral joint force and stress were greater in forward lunge than side lunge. At 40°(p=0.005), 50°(p=0.002), 60°(p<0.001), 70°(p=0.006), 80°(p=0.005), 90°(p=0.002), and 100°(p<0.001) knee angles during lunge descent and 50°(p=0.002), 60°(p<0.001), 70°(p<0.001), 80°(p<0.001), and 90°(p<0.001) knee angles during lunge ascent patellofemoral joint force and stress were greater in side lunge than forward lunge. At 60°(p=0.009) knee angle during lunge descent and 40°(p=0.008), 50°(p=0.009), and 60°(p=0.007) knee angles during lunge ascent patellofemoral joint force and stress were greater lunging at ground level than up a 10cm platform.

CONCLUSIONS

Patellofemoral joint loading changed according to lunge type, step height, and knee angle. Patellofemoral compressive force and stress were greater while lunging at ground level compared to lunging up to a 10 cm platform between 40° - 60° knee angles, and greater while performing the side lunge compared to the forward lunge between 40° - 100° knee angles.

LEVEL OF EVIDENCE

II.

The Youth Throwers Ten Exercise Program: A variation of an exercise series for enhanced dynamic shoulder control in the youth overhead throwing athlete

The overhead throwing motion is an extremely stressful athletic movement. The high velocity and repetitive nature of this activity places immense pressure on the entire body, which can frequently result in injury to the throwing arm. Extensive literature exists with regards to the management of these injuries in the collegiate and professional level athlete; and it is well understood that a multiphasic approach is required to return an individual to prior level of play. However, there is a gap in the literature which fails to address the management of youth individuals. This article presents a new and innovative approach to the rehabilitation, training and management of the youth overhead throwing athlete, The Youth Throwers Ten Exercise Program. This program addresses principles of: coactivation, coordination, dynamic stabilization, neuromuscular control, proprioception, muscle strength, endurance and scapular rhythm all of which are vital for successful performance. This exercise series utilizes bodyweight and Theraband exercises that cater to the unique characteristics of the youth athlete making it a safe way to prepare for the demands of overhead throwing activities.

Effect of Forearm Position on Glenohumeral External Rotation Measurements in Baseball Players

BACKGROUND

Alterations in glenohumeral internal rotation (GIR), glenohumeral external rotation (GER), and the total arc of motion (TAM) have been linked with increased injury risk in the shoulder and elbow. These motions have been routinely measured with the forearm in neutral rotation (GIRN, GERN, TAMN). GER capacity appears to be especially important. The throwing motion, however, requires forearm pronation as GER occurs to achieve optimal cocking (GERP). No previous studies have evaluated GERP to determine GER capacity or pronated TAM (TAMP) values.

HYPOTHESIS

There would be significant differences between GERN and TAMN and between GERP and TAMP.

STUDY DESIGN

Cross-sectional.

LEVEL OF EVIDENCE

Level 3.

METHODS

Sixty asymptomatic male Minor League Baseball players (32 pitchers, 28 position players) participated in the study and were tested on the first day of spring training. Passive range of motion measurements were recorded using a long-arm bubble goniometer for GIRN, GERN, and GERP on both arms. TAM was calculated separately as the sum of internal and external rotational measurements under neutral and pronated conditions.

RESULTS

Within pitchers and position players, all measurements were statistically reduced for the throwing arm (P ≤ 0.03) except for GERN of the pitchers. GERP measures were significantly less than GERN for both arms of each group (P < 0.01): pitchers throwing arm +11.8°/nonthrowing arm +4.8°, position players throwing arm = +8.6°/nonthrowing arm +4.0°.

CONCLUSION

The forearm position of pronation, which appears to be mediated by tightness of the biceps, decreases GER capacity and TAM. GER and TAM should be calculated in neutral and pronated positions, considering that 80% of the players have a demonstrated difference between 8° and 12°.

CLINICAL RELEVANCE

Measurement of GERP more accurately reflects the GER required in throwing, allows better quantification of the motion capacity necessary to withstand the loads in throwing, and may suggest interventions for at risk athletes.

Clinical Outcomes and Return to Play in Youth Overhead Athletes After Medial Epicondyle Fractures Treated With Open Reduction and Internal Fixation

Background:

There is limited literature regarding outcomes after operative treatment of displaced medial epicondyle avulsion fractures in adolescent athletes. Most studies have had a relatively small sample size and have not assessed return to play of the overhead athlete.

Purpose:

To examine return to play and outcomes of youth overhead athletes who underwent open reduction and internal fixation (ORIF) with screw fixation.

Study Design:

Case series; Level of evidence, 4.

Methods:

Charts and radiographs were queried between January 2003 and June 2018 for young overhead athletes (age, <17 years) who underwent ORIF for displaced medial epicondyle fracture. Patients with open fracture or concomitant injury were excluded. Radiographs from postoperative follow-up visits were examined for radiographic union. Eligible patients were asked to provide responses to the American Shoulder and Elbow Surgeons Standardized Assessment Elbow questionnaire and Kerlan-Jobe Orthopaedic Clinic questionnaires as well as questions regarding return to play.

Results:

Overall, 29 patients were included in the study; the mean age at surgery was 14.7 years (range, 12.9-16.5 years). There were 25 baseball players, 3 football quarterbacks, and 1 tennis player. Of the 23 patients with available images at least 3 months after surgery, 96% demonstrated radiographic union at last follow-up. Imaging for the 1 patient with nonunion was taken 3 months after ORIF, and it is unknown if he eventually had union. All patients (100%) were successfully contacted to complete questionnaires at a mean follow-up of 4.8 years (range, 1.0-13.5 years). The mean KJOC score was 93.0, and the mean scores for the American Shoulder and Elbow Surgeons Elbow questionnaire were 8.9, 35.6, and 9.8 for pain, function, and satisfaction, respectively. One overhead athlete did not return to play, while the other 28 returned at a mean 7 months after surgery. No patient underwent revision ORIF, 1 underwent hardware removal, and 1 underwent ulnar nerve transposition. No players underwent ulnar collateral ligament reconstruction after primary ORIF of the medial epicondyle.

Conclusion:

ORIF of displaced medial epicondyle fractures is a reliable and successful procedure in adolescent overhead athletes with high demands, with relatively low risk of major complications, reinjury, or reoperation.

Outcomes After Ulnar Collateral Ligament Revision Reconstruction in Baseball Players

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.

RETURN TO SPORT PARTICIPATION CRITERIA FOLLOWING SHOULDER INJURY: A CLINICAL COMMENTARY

CONTEXT

The shoulder complex is frequently injured during sports. The tremendous mobility of the shoulder makes returning to sport participation following shoulder injury a challenging task for both the clinician and athlete. The purpose of this clinical commentary is to review the current literature on return to sport criteria and provide evidence-informed and clinically useful guidelines and recommendations to aid in clinical decision making for return to sports after shoulder micro- and macro-traumatic injuries.

EVIDENCE ACQUISITION

A search of the PubMed database using the terms functional tests, upper extremity testing, return to play, and shoulder injury was performed. Further evaluation of the bibliographies of the identified articles expanded the evidence. This evidence was used to inform the clinical commentary.

RESULTS

Return to sport decision making is a sequential, criterion-based process. Assessment of patient reported outcomes, range of motion, strength, and functional performance must all be considered. Numerous tests are available for the clinician to determine whether a patient is ready to return to sports following a shoulder injury or surgery. A different set of tests should be utilized for the overhead athlete (microtrauma injury) compared to the patient with a macrotraumatic shoulder injury because of the differing demands and sports requirements.

CONCLUSION

Use of pre-determined criteria, available in the literature, minimizes the reliance on the subjective element alone during takes athlete progression and provides everyone involved in the process with known, pre-established, measurable markers and goals that must be achieved prior to progressing to practice and returning to competition. This type of performance progression assessment testing provides the clinician with a useful set of tools to objectively assist and guide the determination regarding when an athlete can safely progress back to practice and then return to unrestricted athletic activities.

LEVEL OF EVIDENCE

5.

Treatment After Anterior Cruciate Ligament Injury: Panther Symposium ACL Treatment Consensus Group

Treatment strategies for anterior cruciate ligament (ACL) injuries continue to evolve. Evidence supporting best-practice guidelines for the management of ACL injury is to a large extent based on studies with low-level evidence. An international consensus group of experts was convened to collaboratively advance toward consensus opinions regarding the best available evidence on operative versus nonoperative treatment for ACL injury. The purpose of this study was to report the consensus statements on operative versus nonoperative treatment of ACL injuries developed at the ACL Consensus Meeting Panther Symposium 2019. There were 66 international experts on the management of ACL injuries, representing 18 countries, who were convened and participated in a process based on the Delphi method of achieving consensus. Proposed consensus statements were drafted by the scientific organizing committee and session chairs for the 3 working groups. Panel participants reviewed preliminary statements before the meeting and provided initial agreement and comments on the statement via online survey. During the meeting, discussion and debate occurred for each statement, after which a final vote was then held. Ultimately, 80% agreement was defined a priori as consensus. A total of 11 of 13 statements on operative versus nonoperative treatment of ACL injury reached consensus during the symposium. Overall, 9 statements achieved unanimous support, 2 reached strong consensus, 1 did not achieve consensus, and 1 was removed because of redundancy in the information provided. In highly active patients engaged in jumping, cutting, and pivoting sports, early anatomic ACL reconstruction is recommended because of the high risk of secondary meniscal and cartilage injuries with delayed surgery, although a period of progressive rehabilitation to resolve impairments and improve neuromuscular function is recommended. For patients who seek to return to straight-plane activities, nonoperative treatment with structured, progressive rehabilitation is an acceptable treatment option. However, with persistent functional instability, or when episodes of giving way occur, anatomic ACL reconstruction is indicated. The consensus statements derived from international leaders in the field will assist clinicians in deciding between operative and nonoperative treatment with patients after an ACL injury.

Rehabilitation of Elbow Injuries: Nonoperative and Operative

Athletes are subject to traumatic and repetitive stress injuries at the elbow joint as a result of high levels of forces imparted across the elbow. Injuries can be acute to the point of tissue failure, or chronic as a result of repetitive overuse. Complete restoration of elbow function must be achieved to allow the athlete to return to their prior level of function. Systematic and progressive rehabilitation programs can help avoid overstressing healing tissues. Treatment programs are designed to restore full motion, muscular strength, endurance, and neuromuscular control. Multiphased rehabilitation programs are designed to restore function in the athlete's elbow.

A Comparison of Physical Therapy Protocols Between Open Latarjet Coracoid Transfer and Arthroscopic Bankart Repair

CONTEXT

Recent studies examining return to sport after traumatic shoulder instability suggest faster return-to-sport time lines after bony stabilization when compared with soft tissue stabilization. The purpose of the current study was to define variability across online Latarjet rehabilitation protocols and to compare Latarjet with Bankart repair rehabilitation time lines.

EVIDENCE ACQUISITION

Online searches were utilized to identify publicly available rehabilitation protocols from Accreditation Council for Graduate Medical Education (ACGME)-accredited academic orthopaedic surgery programs.

STUDY DESIGN

Descriptive epidemiology study.

LEVEL OF EVIDENCE

Level 3.

RESULTS

Of the 183 ACGME-accredited orthopaedic programs reviewed, 14 institutions (7.65%) had publicly available rehabilitation protocols. A web-based search yielded 17 additional protocols from private sports medicine practices. Of the 31 protocols included, 31 (100%) recommended postoperative sling use and 26 (84%) recommended elbow, wrist, and hand range of motion exercises. Full passive forward flexion goals averaged 3.22 ± 2.38 weeks postoperatively, active range of motion began on average at 5.22 ± 1.28 weeks, and normal scapulothoracic motion by 9.26 ± 4.8 weeks postoperatively. Twenty (65%) protocols provided specific recommendations for return to nonoverhead sport-specific activities, beginning at an average of 17 ± 2.8 weeks postoperatively. This was compared with overhead sports or throwing activities, for which 18 (58%) of protocols recommended beginning at a similar average of 17.1 ± 3.3 weeks.

CONCLUSION

Similar to Bankart repair protocols, Latarjet rehabilitation protocols contain a high degree of variability with regard to exercises and motion goal recommendations. However, many milestones and start dates occur earlier in Latarjet protocols when compared with Bankart-specific protocols. Consequently, variability in the timing of rehabilitation goals may contribute to earlier return to play metrics identified in the broader literature for the Latarjet procedure when compared with arthroscopic Bankart repair.

STRENGTH OF RECOMMENDATION TAXONOMY (SORT)

Level C.

Prevalence of Medial Ulnar Collateral Ligament Surgery in 6135 Current Professional Baseball Players: A 2018 Update

Background:

As the incidence of ulnar collateral ligament (UCL) surgery continues to rise rapidly, an update on the current prevalence and demographics in professional baseball players is warranted.

Hypothesis:

The prevalence of UCL reconstruction in Major League Baseball (MLB) and Minor League Baseball (MiLB) players will be higher than that previously reported, and the increase in prevalence will be most notable in MiLB pitchers.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

During the 2018 baseball season, an online questionnaire regarding a history of UCL surgery was distributed to the certified athletic trainers of all 30 MLB organizations. These trainers then administered the survey to all players within their organizations, including MLB, MiLB (AAA, AA, High A, Low A, High Rookie, Low Rookie), and Dominican Summer League (DSL) players. Demographics were compared between MLB, MiLB, and DSL players. Results of this 2018 survey were compared with previously published data from the 2012 season to assess the change over time.

Results:

There were 6135 professional baseball players who completed the survey (66% response rate). The prevalence of UCL reconstruction in all MLB and MiLB players was 13% (637/4928), while the prevalence in DSL players was 2% (20/1207) (P < .001). The prevalence in all MLB and MiLB players (13%) and pitchers (20%) both increased significantly from 2012 (P < .001). MLB pitchers reported a higher prevalence of UCL reconstruction than did MiLB pitchers (26% vs 19%, respectively; P < .001). In 2018, the prevalence of UCL reconstruction has increased significantly in MiLB pitchers (19% vs 15%, respectively; P < .001) and pitchers aged 21 to 30 years (22% vs 17%, respectively; P < .001) compared with 2012. Additionally, United States–born pitchers were more likely to have undergone UCL reconstruction compared with Latin America–born pitchers (23% vs 13%, respectively; P < .001).

Conclusion:

The prevalence of UCL reconstruction has increased significantly in professional baseball players over the past 6 years from 10% to 13%. Ultimately, the prevalence of UCL reconstruction has increased most significantly since 2012 in MiLB pitchers, pitchers aged 21 to 30 years, and pitchers born in the United States.

Ulnar Collateral Ligament Repair With Collagen-Dipped FiberTape Augmentation in Overhead-Throwing Athletes

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.

THE USE OF SERIAL PLATELET RICH PLASMA INJECTIONS WITH EARLY REHABILITATION TO EXPEDITE GRADE III MEDIAL COLLATERAL LIGAMENT INJURY IN A PROFESSIONAL ATHLETE: A CASE REPORT

BACKGROUND

Medial collateral ligament (MCL) injuries are one of the most commonly treated knee pathologies in sports medicine. The MCL serves as the primary restraint to valgus force. The large majority of these injuries do not require surgical intervention.

CASE SUBJECT DESCRIPTION

A 30-year-old professional wrestling athlete presented to the clinic with acute complaints of right medial knee pain resulting from a traumatic valgus force. Physical exam revealed Grade 3 MCL injury. Magnetic resonance imaging confirmed clinical diagnosis of a Grade 3 proximal MCL tear. This athlete had sustained a prior grade 3 ACL injury with Grade 3 distal MCL injury which required surgery to reconstruct the ACL and repair the MCL 13 months prior, in November of 2015.

OUTCOMES

The subject was successfully treated with a series of three sequential Leukocyte Rich Platelet Rich Plasma (LR-PRP) Injections spaced evenly one week apart in addition to an early physical therapy regimen. The total treatment time was cut down from an expected 35-49 days to 31 days.

DISCUSSION

When paired with the appropriate rehabilitation treatment progression, the use of LR-PRP injections in the treatment of an isolated MCL tear was beneficial for this subject.

CONCLUSION

The results of this case report indicate that the use of LR-PRP and early rehabilitation shows promise in treating an acute grade 3 MCL injury. Future research utilizing randomized controlled trials are needed.

LEVEL OF EVIDENCE

Case Report, 4.

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.

Rehabilitation Principles of the Anterior Cruciate Ligament Reconstructed Knee: Twelve Steps for Successful Progression and Return to Play

The rehabilitation process begins immediately after injury to the anterior cruciate ligament (ACL). The goal of preoperative rehabilitation is to prepare the patient for surgery. Current rehabilitation programs focus on strengthening exercises and proprioceptive and neuromuscular control drills to provide a neurologic stimulus. It is also important to address preexisting factors, especially for the female athlete, that may predispose to future injury, such as hip and hamstring weakness. Our goal in the rehabilitation program is to restore full, unrestricted function and to assist the patient to return to 100% of the preinjury level while achieving excellent long-term outcomes.

Low Intensity Ultrasound for Promoting Soft Tissue Healing: A Systematic Review of the Literature and Medical Technology

Therapeutic ultrasound has been studied and used for the past seven decades to treat musculoskeletal injuries. Recently, a significant body of animal and human research has focused on the biomechanical effects of daily-applied, low intensity therapeutic ultrasound (LITUS) on soft tissue recovery. We performed a systematic review of the last two decades of LITUS literature to examine the effects on tendon, skeletal muscle, ligament, and tendon-bone junction injuries. LITUS facilitated tendon healing, with increased tensile strength and improved collagen alignment. For skeletal muscle and ligament injuries, LITUS increased cell proliferation during myoregeneration and improved tissue biomechanics (ultimate load, stiffness, energy absorption). LITUS aided tendon-bone junction healing through improved tissue function. Scientific evidence supports the use of LITUS to treat soft tissue injuries, and improve outcomes for musculoskeletal injuries and post-operative recovery. Lastly, we discuss the use of LITUS devices facilitating daily applied therapy in the home setting.

2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern

Deciding when to return to sport after injury is complex and multifactorial-an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups-each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athlete's return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.

Deficits in Glenohumeral Passive Range of Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers: A Prospective Study

BACKGROUND

Shoulder injuries from repetitive baseball pitching continue to be a serious, common problem.

PURPOSE

To determine whether passive range of motion of the glenohumeral joint was predictive of shoulder injury or shoulder surgery in professional baseball pitchers.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Passive range of motion of the glenohumeral joint was assessed with a bubble goniometer during spring training for all major and minor league pitchers of a single professional baseball organization over a period of 8 successive seasons (2005-2012). Investigators performed a total of 505 examinations on 296 professional pitchers. Glenohumeral external and internal rotation was assessed with the pitcher supine and the arm abducted to 90° in the scapular plane with the scapula stabilized anteriorly at the coracoid process. Total rotation was defined as the sum of internal and external glenohumeral rotation. Passive shoulder flexion was measured with the pitcher supine and the lateral border of the scapula manually stabilized. After examination, shoulder injuries and injury durations were recorded by each pitcher's respective baseball organization and reported to the league as an injury transaction as each player was placed on the disabled list.

RESULTS

Highly significant side-to-side differences were noted within subjects for each range of motion measurement. There were 75 shoulder injuries and 20 surgeries recorded among 51 pitchers, resulting in 5570 total days on the disabled list. Glenohumeral internal rotation deficit, total rotation deficit, and flexion deficit were not significantly related to shoulder injury or surgery. Pitchers with insufficient external rotation (<5° greater external rotation in the throwing shoulder) were 2.2 times more likely to be placed on the disabled list for a shoulder injury (P = .014; 95% CI, 1.2-4.1) and were 4.0 times more likely to require shoulder surgery (P = .009; 95% CI, 1.5-12.6).

CONCLUSION

Insufficient shoulder external rotation on the throwing side increased the likelihood of shoulder injury and shoulder surgery. Sports medicine clinicians should be aware of these findings and develop a preventive plan that addresses this study's findings to reduce pitchers' risk of shoulder injury and surgery.

Prevalence of Ulnar Collateral Ligament Surgery in Professional Baseball Players

BACKGROUND

While the high rate of ulnar collateral ligament (UCL) injuries in professional baseball is widely discussed in the media and medical literature, the actual prevalence of UCL reconstruction has not been documented.

HYPOTHESIS

The prevalence of UCL reconstruction will be higher among pitchers than nonpitchers, and Major League Baseball (MLB) pitchers will have a higher prevalence than will minor league pitchers.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

An online questionnaire was distributed to all 30 MLB organizations. Certified athletic trainers from each team administered the questionnaire to all players in the organization, including major league players and 6 levels of minor league players. Demographic data were compared between major and minor league players. Continuous variables (age, years of professional baseball, country of origin, etc) were compared with Student t tests (P < .05). Categorical variables (level, position, etc) were compared using chi-square analysis (P < .05).

RESULTS

A total of 5088 professional baseball players (722 major league and 4366 minor league) participated in the survey. Pitchers represented 53% of all players, and 497 players reported at least 1 UCL reconstruction, demonstrating a prevalence rate of 10% (497 of 5088). Pitchers reported a significantly higher prevalence of UCL reconstruction (16%; 437 of 2706) than nonpitchers (3%; 60 of 2382; P < .001). Among major league pitchers, 25% (96 of 382) had a history of UCL reconstruction, while minor league pitchers showed a 15% (341 of 2324) prevalence (P < .001). Major league pitchers were also significantly older (28.8 ± 3.9 years) than minor league pitchers (22.8 ± 3.0; P < .001). The majority of major leaguers (86%) had their UCL reconstruction as professional pitchers, whereas the majority of minor league pitchers (61%) underwent their UCL reconstruction during high school and college (P < .001). The rates of UCL revision, prior elbow surgery, prior shoulder surgery, and types of UCL graft were similar between the major league and minor league pitchers. No difference in prevalence was shown between pitchers born in the United States versus Latin American countries.

CONCLUSION

Pitchers have a high prevalence of UCL reconstruction in professional baseball, with 25% of major league pitchers and 15% of minor league pitchers having a history of the surgery.

Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: a prospective study

BACKGROUND

Injuries to the elbow joint in baseball pitchers appear common. There appears to be a correlation between shoulder range of motion and elbow injuries.

PURPOSE

To prospectively determine whether decreased ROM of the throwing shoulder is correlated with the onset of elbow injuries in professional baseball pitchers.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

For 8 consecutive years (2005-2012), passive range of motion of both the throwing and nonthrowing shoulders of all major and minor league pitchers within a single professional baseball organization were measured by using a bubble goniometer during spring training. In total, 505 examinations were conducted on 296 pitchers. Glenohumeral external rotation and internal rotation were assessed in the supine position with the arm at 90° of abduction and in the plane of the scapula. The scapula was stabilized per methods previously established. Total rotation was defined as the sum of external rotation and internal rotation. Passive shoulder flexion was assessed with the subject supine and the scapula stabilized per methods previously established. Elbow injuries and days missed because of elbow injuries were assessed and recorded by the medical staff of the team. Throwing and nonthrowing shoulder measurements were compared by using Student t tests; 1-tailed Fisher exact tests were performed to identify significant associations between shoulder motion and elbow injury. Nominal logistic regression was performed to determine the odds of elbow injury.

RESULTS

Significant differences were noted during side-to-side comparisons within subjects. There were 49 elbow injuries and 8 surgeries in 38 players, accounting for a total of 2551 days missed. Neither glenohumeral internal rotation deficit nor external rotation insufficiency was correlated with elbow injuries. Pitchers with deficits of >5° in total rotation in their throwing shoulders had a 2.6 times greater risk for injury. Pitchers with deficit of ≥5° in flexion of the throwing shoulder had a 2.8 times greater risk for injury.

CONCLUSION

Bilateral differences in shoulder total rotation and flexion had a significant effect on the risk for elbow injuries in pitchers. Clinicians need to be aware of these findings and plan preventive programs that address these issues in hopes of reducing elbow injuries.

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.

Optimal management of shoulder impingement syndrome

Shoulder impingement is a progressive orthopedic condition that occurs as a result of altered biomechanics and/or structural abnormalities. An effective nonoperative treatment for impingement syndrome is aimed at addressing the underlying causative factor or factors that are identified after a complete and thorough evaluation. The clinician devises an effective rehabilitation program to regain full glenohumeral range of motion, reestablish dynamic rotator cuff stability, and implement a progression of resistive exercises to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers. The clinician can introduce stresses and forces via sport-specific drills and functional activities to allow a return to activity.

Disentangling Electronic and Vibrational Coherence in the Phycocyanin-645 Light-Harvesting Complex

Energy transfer between chromophores in photosynthesis proceeds with near-unity quantum efficiency. Understanding the precise mechanisms of these processes is made difficult by the complexity of the electronic structure and interactions with different vibrational modes. Two-dimensional spectroscopy has helped resolve some of the ambiguities and identified quantum effects that may be important for highly efficient energy transfer. Many questions remain, however, including whether the coherences observed are electronic and/or vibrational in nature and what role they play. We utilize a two-color, four-wave mixing experiment with control of the wavelength and polarization to selectively excite specific coherence pathways. For the light-harvesting complex PC645, from cryptophyte algae, we reveal and identify specific contributions from both electronic and vibrational coherences and determine an excited-state structure based on two strongly coupled electronic states and two vibrational modes. Separation of the coherence pathways also uncovers the complex evolution of these coherences and the states involved.

The recognition and treatment of superior labral (slap) lesions in the overhead athlete

The overhead athlete presents with a unique profile that may predispose them to specific pathology. Injury to the superior aspect of the glenoid labrum (SLAP lesions) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important in order to determine the most appropriate non-operative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure that has been performed, as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions in the overhead athlete. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

LEVEL OF EVIDENCE

5.

Glenohumeral motion deficits: friend or foe?

In most shoulder conditions a loss of glenohumeral motion results in shoulder performance impairments. However, in the overhead athlete loss of glenohumeral internal rotation, termed glenohumeral internal rotation deficiency (GIRD), is a normal phenomenon that should be expected. Without a loss of glenohumeral internal rotation the overhead athlete will not have the requisite glenohumeral external rotation needed to throw a baseball at nearly 100 miles per hour, or serve a tennis ball at velocities of 120 miles per hour or more. Not all GIRD is pathologic. The authors of this manuscript have defined two types of GIRD; one that is normal and one that is pathologic. Anatomical GIRD (aGIRD) is one that is normal in overhead athletes and is characterized by a loss of internal rotation of less than 18°-20° with symmetrical total rotational motion (TROM) bilaterally. Pathologic GIRD (pGIRD) is when there is a loss of glenohumeral internal rotation greater than 18°-20° with a corresponding loss of TROM greater than 5° when compared bilaterally. A more problematic motion restriction may be that of a loss of TROM in the glenohumeral joint. Recent evidence supports that a loss of TROM is predictive of future injury to the shoulder in professional athletes. Additionally, external rotation deficiency (ERD), the difference between external rotation (ER) of the throwing shoulder and the non-throwing shoulder of less than 5°, may be another predictor of future shoulder injury and disability.

LEVEL OF EVIDENCE

5.

Cannulated screw fixation of refractory olecranon stress fractures with and without associated injuries allows a return to baseball

BACKGROUND

An olecranon stress fracture is a rare injury associated with valgus extension overload in baseball players. No long-term outcomes studies have been published documenting the results of surgical fixation of olecranon stress fractures with or without concomitant injuries in baseball players.

HYPOTHESIS

Open reduction and internal fixation (ORIF) of an olecranon stress fracture will reliably produce bony union and allow a successful return to the previous level of activity in competitive baseball players.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-five patients treated with ORIF for an olecranon stress fracture at least 2 years earlier (range, 2-10.14 years) were retrospectively contacted to complete a telephone survey; 18 of 25 (72%) patients responded. Data were collected to determine the return to play rate, level of arm pain, and overall arm function.

RESULTS

All 18 stress fractures went on to successful union; 17 of 18 (94%) athletes returned to baseball at or above their previous level. Average return to play time was 29 weeks. The numeric analog pain score was 0.2 at rest and 0.3 when throwing at the time of follow-up, at an average 6.2 years (range, 2.0-10.14 years) after surgery. The average score at follow-up on the disabilities of the arm, shoulder and hand outcome measure-shortened version (QuickDASH) was 4.1 (range, 0-27.3). Ten (56%) patients required 13 additional future surgeries on their throwing arm; 7 surgeries in 6 (33%) patients were not related to the index surgery. Six of 18 (33%) patients underwent hardware removal, with 2 (11%) for infection.

CONCLUSION

Open reduction and internal fixation of olecranon stress fractures in competitive baseball players has a high rate of success in returning players to or above their former level of play and allows for good elbow function at an average of 6.2 years postoperatively. However, these patients are at high risk for additional future surgeries on their throwing arm.