Batter's Shoulder: Diagnosis, Management, and Outcomes.

Batter's shoulder is characterized by posterior shoulder instability in the lead (front) shoulder of a batting athlete. This most commonly occurs as a discrete event, particularly a swing and miss at an outside pitch, which leads to an episode of shoulder subluxation. A thorough history and physical examination is key to diagnosis, with patients feeling pain and instability of the lead shoulder when attempting the baseball swing or during pushing-type activities, as well as positive posterior labral signs in tests such as the Kim, jerk, and modified dynamic labral shear tests. Magnetic resonance imaging can confirm the diagnosis of posterior labral tear and may show concomitant pathologies such as a reverse Hill-Sachs lesion. Nonsurgical treatment is directed at rotator cuff and scapular strengthening; however, arthroscopic posterior labral repair is often required for definitive stabilization. Overall, this is a relatively rare diagnosis, but outcomes of surgical repair are favorable with high satisfaction and rates of return to competition.

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball.

PURPOSE: To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature. METHODS: We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles. RESULTS: A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play. CONCLUSIONS: Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement. LEVEL OF EVIDENCE: Level IV, systematic review of level II-IV studies.

Increased Accuracy in Templating for Total Knee Arthroplasty Using 3D Models Generated from Radiographs.

Templating prior to total hip arthroplasty is a widely adopted practice that aims to improve operative efficiency and reduce clinical outliers. Predicting implant size before total knee arthroplasty (TKA), although less common, could increase operating room efficiency by reducing necessary equipment needed for the procedure. This study compared templating accuracy in TKA using two-dimensional (2D) digital radiographs to a novel imaging technology that generates a three-dimensional (3D) model from these 2D radiographs. Two hundred and two robotic-assisted primary TKA surgical cases using Persona Knee System (Zimmer Biomet, Warsaw, IN) were retrospectively analyzed. For all cases, 3D templating was completed preoperatively using a novel radiographic image acquisition protocol. Using the same radiographs, the knee was templated using a 2D digital templating program. All surgeons were blinded to the final implant sizes, and all templating was done independently. The accuracy of predictions within ± 1 from the final implant size was determined for the femoral and tibial components. The accuracy (within 1 size) of tibial size predictions was comparable between attending surgeons and residents (87 vs. 82%, p = 0.08), but attending surgeons more accurately predicted the femoral size (77 vs. 60%, p < 0.05). The 2D to 3D imaging technology more accurately predicted both tibial and femoral sizes compared with the attending surgeons (99.5 vs. 87%, p < 0.05; 84% vs. 77%, p < 0.05). However, the imaging technology, attending surgeons, and residents were all more likely to overestimate femur size (p < 0.05). Moreover, the 3D imaging technology predicted the exact tibial component size in 93.1% of cases, which was significantly greater compared with residents (40%, p < 0.01) and attending surgeons (53%, p < 0.01). The 2D to 3D imaging technology more accurately predicted tibial and femoral component sizes compared with 2D digital templating done by surgeons. All templating predictions were more accurate for the tibial implant size than for the femoral size. The increased accuracy of implant size predictions from this 3D templating technology has the potential to improve intraoperative efficiency and minimize costs and surgical time.

Athletes Perceive Weighted Baseballs to Carry a Notable Injury Risk, yet Still Use Them Frequently: A Multicenter Survey Study.

INTRODUCTION: Weighted baseball use in throwing programs is widespread; however, their use remains controversial. Prior research shows that weighted baseball programs can increase ball velocity but potentially increase throwing arm injuries. This study aims to ascertain perceptions of weighted baseballs among elite baseball players. METHODS: A created online survey questioned common practices, throwing regimens, injury risk factors, and weighted baseball program use. The questions were modeled to ascertain the perceptions of elite baseball players to understand their experience with weighted baseballs. Descriptive statistical analysis was conducted. RESULTS: Three hundred seventy-six baseball players with a mean age of 20 ± 2 years completed the survey; 64% of the players (239/376) were pitchers. 71% (267/376) reported the use of weighted baseballs. Of those, 75% (199/267) thought it made them a better player. Overall, 73% (275/377) thought weighted baseballs are a risk for injury. 17% (46/267) attributed their injury to using weighted baseballs. Overall, participants reported a mean 72% ± 30% likelihood of future weighted baseball use. CONCLUSION: Most of the participating elite adult baseball players reported prior weighted baseball use with a corresponding improvement in pitching performance despite a perceived increased injury risk. Nearly 20% of the players attributed pain or injury to weighted baseball use. Moreover, the players surveyed intend to continue using weighted baseballs because of the perceived performance benefit.

Editorial Commentary: Baseball Catchers Who Throw From a Squatted Position May Reduce Medial Elbow Torque by Stretching Exercise to Increase Passive Internal Rotation of the Throwing-Side Hip.

Youth baseball pitchers who also play catcher are at nearly 3-fold increased risk of developing a shoulder or elbow injury throughout the course of a season. The risk of injury has been largely attributed to the increased workload from a greater overall number of throws. In addition, throws performed by catchers are often performed in the squatting or kneeling position, which is radically different from all other positions. Fortunately, recent research shows no difference in medial elbow torque between squatting and standing throws a standard distance from home plate to the pitcher and also shows that greater passive internal rotation of the hip on the throwing side is protective against loads on the medial elbow when throwing from the squatting position. Improving passive hip range of motion through stretching exercises may prevent injury in young baseball catchers.

Characterizing preoperative expectations for patients undergoing reverse total shoulder arthroplasty.

BACKGROUND: There remains a paucity of information analyzing which factors most influence preoperative expectations for patients undergoing reverse total shoulder arthroplasty (RTSA). The purposes of our study were to characterize preoperative patient expectations for those scheduled to undergo RTSA and to determine the impact of demographic factors, shoulder function, and shoulder pain on these preoperative expectations. METHODS: Patients were prospectively recruited into the study if they were scheduled to undergo an elective unilateral primary RTSA for a diagnosis of glenohumeral arthritis. Preoperative patient expectations were evaluated using the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Patients also completed the American Shoulder and Elbow Surgeons shoulder score, the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function-Upper Extremity computer adaptive test (version 2.0), the PROMIS Pain Interference (PI) computer adaptive test (version 1.1), the PROMIS Depression computer adaptive test (version 1.0), visual analog scores, and an itemized satisfaction questionnaire, which paralleled the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Demographic data and preoperative shoulder range of motion (ROM) were also recorded. RESULTS: A total of 107 patients scheduled to undergo RTSA were included in the study. Relief of daytime pain (n = 91, 85%), improvement in self-care (n = 86, 80%), and improvement in shoulder ROM (n = 85, 79%) were most commonly cited as "very important" expectations. In the item-specific analysis, lower PROMIS Upper Extremity scores were correlated with greater expectations for the ability to reach sideways (P = .015) and the ability to perform daily activities (P = .018). Patients with lower shoulder ROM had greater expectations for improved shoulder ROM (internal rotation with arm at 90°, P = .004) and an improved ability to perform daily activities (forward elevation, P = .038; abduction, P = .009). In the cumulative analysis, a greater number of very important expectations was associated with African American race (P = .013), higher PROMIS PI score (r = 0.351, P = .004), and lower overall preoperative satisfaction (r = 0.334, P < .001). CONCLUSION: Patients scheduled to undergo RTSA have the greatest expectations for relief of daytime pain, improvement in self-care, and improvement in shoulder ROM. Patients with limited preoperative ROM have greater expectations for improvement in self-care and the ability to perform daily activities in addition to expectations for improvement in shoulder ROM. Greater overall expectations for surgery were not associated with preoperative physical function but were instead associated with lower preoperative satisfaction and higher PROMIS PI scores.

The Effect of the Crow Hop on Elbow Stress During an Interval Throwing Program.

BACKGROUND: Postoperative rehabilitation protocols after ulnar collateral ligament (UCL) reconstruction typically involve a structured interval throwing program. In an effort to minimize torque placed on the UCL, athletes are often instructed to throw with a crow hop, even at short throwing distances. However, the effect of the crow hop on medial elbow stress is unknown. PURPOSE/HYPOTHESIS: The purpose was to determine whether elbow stress differs with and without a crow hop across the throwing distances of a typical interval throwing program. We hypothesized that crow hop throws would generate lower torque on the elbow than standing throws at each distance of the interval throwing program. STUDY DESIGN: Controlled laboratory study. METHODS: Healthy high school and collegiate pitchers and position players were recruited from the surrounding area. Each player was outfitted with a wearable athletic sleeve and device that recorded elbow torque (Newton-meters), arm slot (degrees), arm speed (revolutions per minute), and shoulder rotation (degrees). Ball velocity (miles per hour) was measured using a radar gun. Players were instructed to perform 3 crow hop throws and 3 standing throws at distances of 30, 45, 60, 90, 120, 150, and 180 feet. A repeated measures analysis of variance was used to compare ball velocity, elbow torque, arm slot, arm speed, and shoulder rotation between crow hop and standing throws at each throwing distance. RESULTS: Twenty athletes participated in this study (average age, 17.8 years; range, 15-25 years). The average medial elbow torque increased at each distance for both crow hop and standing throws at distances of 30, 45, 60, and 90 feet (P < .05), after which there were no significant increases in elbow torque (P > .05). The average torque was higher for crow hop throws than standing throws at distances of 30 feet (13.9 N·m vs 12.0 N·m; P = .002), 45 feet (21.8 N·m vs 19.3 N·m; P = .005), and 60 feet (28.0 N·m vs 24.5 N·m; P = .02). CONCLUSION: Crow hop throws generated greater medial elbow torque than standing throws at distances up to 60 feet; however, there were no differences in elbow torque at distances greater than 60 feet between the 2 throw types. For both crow hop and standing throws, elbow stress increased at each distance interval up to 90 feet before plateauing at distances greater than 90 feet. The crow hop throwing technique does not reduce medial elbow stress during a simulated interval throwing program, and it may actually increase torque at shorter throwing distances. CLINICAL RELEVANCE: The results of our study indicate that it would be prudent for players to initially perform standing throws at shorter distances and only later be allowed to employ a natural crow hop at greater distances to minimize torque placed on the medial elbow during UCL rehabilitation protocols.

Using Wearable Technology to Evaluate the Kinetics and Kinematics of the Overhead Throwing Motion in Baseball Players.

Recent advancements in wearable technology have made kinetic and kinematic analysis of the throwing motion more accessible to recreational and professional baseball pitchers. Utilization of wearable technology to monitor the pitching motion has several potential applications for injury prevention and postinjury rehabilitation. However, the device must be properly applied to collect meaningful data. Erratic or inconsistent measurements can be caused by inadequate battery charge, incorrect sensor placement, and inadvertent motion capture of fielding maneuvers or other nonpitching throws. These problems can be overcome with a protocol that includes collecting biomechanical data in real time and routinely checking the sensor position throughout the duration of the throwing session. In this article, we outline our protocol for collecting biomechanical data and troubleshooting suboptimal device function during pitching sessions.

What Are the Floor and Ceiling Effects of Patient-Reported Outcomes Measurement Information System Computer Adaptive Test Domains in Orthopaedic Patients? A Systematic Review.

PURPOSE: To perform a systematic review to answer the following: (1) What are the floor and ceiling (F/C) effects of the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) domains of physical function (PF), upper extremity physical function (UE), pain interference (PI), and depression (D) in adult orthopaedic patients? (2) Do the PROMIS-PF and PROMIS-PI domains have differing F/C effects depending on use in upper extremity, lower extremity, spine, neck, and back, or trauma patients?. METHODS: (Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed, the review was registered on PROSPERO, and the methodological index for non-randomized studies was used for this systematic review. Studies reporting the F/C effects of at least 1 of 4 PROMIS CAT domains in orthopaedic patient cohorts accessed through PubMed and Embase on October 30, 2018, were included. F/C effects for each study were reported within forest plots. RESULTS: Forty-three studies were included. Generally, varying cohorts demonstrated no F/C effects for PROMIS-PF (0%-9.0%), variable ceiling effects for PROMIS-UE (lower in v2.0; 0%-28.2%), variable floor effects for PROMIS-PI (0%-19.0%), and significant floor effects for PROMIS-D (0.4%-23.4%). CONCLUSIONS: The orthopaedic literature demonstrated generally favorable floor and ceiling effects for PROMIS CAT domains, with the exception of variable ceiling effects for PROMIS-UE (the newer version exhibits only minor effects), variable floor effects for PROMIS-PI, and significant floor effects for PROMIS-D. In addition, the F/C effects of PROMIS-PF did not vary based on patient population. Although the floor effects of PROMIS-PI did vary based on patient population, the variability does not appear to be based solely on anatomic location. The PROMIS-PF and PROMIS-UE v2.0 demonstrate consistently low floor and ceiling effects. However, the PROMIS-PI and PROMIS-D may need modification before widespread adoption for clinical and research purposes. LEVEL OF EVIDENCE: III; systematic review of Level I-III studies.

Predictors of elbow torque among professional baseball pitchers.

BACKGROUND: Overuse injuries of the shoulder and elbow continue to be prevalent in elite baseball pitchers. Pitch velocity has been shown to impact medial elbow torque in adolescent baseball pitchers. However, the determinants of medial elbow torque in professional baseball pitchers are not known. PURPOSE: To determine the influence of pitch type, velocity, and player characteristics on medial elbow torque in professional baseball pitchers. METHODS: Professional baseball pitchers were recruited for participation. Height, weight, body mass index (BMI), and throwing arm measurements were obtained for all study participants. While wearing a gyroscopic sensor equipped with an accelerometer, participants were instructed to throw a standard, randomized sequence of fastballs, changeups, and curveballs. Elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity were recorded for each pitch. A linear mixed model was used to evaluate the association of pitch type with each pitch parameter, adjusting for pitchers' demographics. RESULTS: A total of 12 professional baseball pitchers were included in this study. Among the pitch types, medial elbow torque was significantly higher in fastballs than in curveballs (P = .001). An increased BMI value was independently associated with decreased elbow torque in pitchers (P = .035). CONCLUSION: Fastballs place significantly higher torque on the medial elbow than do curveballs, which is consistent with previous studies done on high school and collegiate populations. Pitchers with a higher BMI experience significantly less torque across the medial elbow.

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 (ß 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.

Fatigue Increases Dynamic Knee Valgus in Youth Athletes: Results From a Field-Based Drop-Jump Test.

PURPOSE: To determine whether fatigue increases dynamic knee valgus in adolescent athletes, as measured after a standardized exercise protocol and video-based drop-jump test. A secondary aim was to determine whether individual risk factors place certain athletes at increased risk for dynamic knee valgus. METHODS: Athletes aged 14 to 18 years were recruited for this video analysis study. Athletes were recorded performing a standard drop-jump to assess dynamic valgus. Participants then completed a standardized exercise protocol. Fatigue was quantified using a maximum vertical jump, which was compared with pre-exercise values. The drop-jump was repeated postexercise. All drop-jump recordings were randomized and scored for dynamic valgus by 11 blinded reviewers. Univariate analysis was performed to identify characteristics that predisposed athletes to increased dynamic valgus. RESULTS: Eighty-five (47 female, 38 male) athletes with an average age of 15.4 years were included in this study. Forty-nine percent of athletes demonstrated an increase in dynamic valgus determined by drop-jump assessment after exercise. A significantly greater percentage of athletes were graded "medium or high risk" in jumps recorded after the exercise protocol (68%) as compared with before the exercise protocol (44%; P < .01). Female athletes (P < .01) and those older than 15 years of age (P < .01) were the most affected by fatigue. CONCLUSIONS: In conclusion, our study found that exercise increases dynamic knee valgus in youth athletes. Female athletes and those older than 15 years of age were most significantly affected by exercise. Greater fatigue levels were found to correlate with an increase in dynamic knee valgus, which may place athletes at greater anterior cruciate ligament injury risk. The field-based exercise drop-jump test is a low-cost and reproducible screening tool to identify at-risk athletes who could possibly benefit from anterior cruciate ligament injury-prevention strategies. LEVEL OF EVIDENCE: III, Comparative trial.

Relationship Between Glenohumeral Internal Rotation Deficit and Medial Elbow Torque in High School Baseball Pitchers.

BACKGROUND: Alterations in throwing mechanics have been identified as a risk factor for overuse injuries in baseball players. Glenohumeral internal rotation deficit (GIRD) has been found to adversely affect throwing mechanics, but the effect of GIRD on medial elbow torque is unclear. PURPOSE: To investigate the relationship between GIRD and medial elbow torque in high school-aged baseball pitchers. STUDY DESIGN: Descriptive laboratory study. METHODS: High school baseball pitchers (14-18 years old) were recruited for participation in this study. Players' height, weight, body mass index, and arm measurements were recorded as well as shoulder and elbow range of motion measurements. GIRD was calculated from the difference between dominant and nondominant shoulder internal rotation. Participants then pitched 5 fastballs at maximum effort while wearing a wireless sensor that recorded elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity. Principal component analysis was performed to determine which variables were associated with elbow torque or ball velocity. RESULTS: Twenty-three high school pitchers participated in this study; 35% (n = 8) of participants exhibited GIRD of at least 20°. The mean GIRD was 15.3°± 11.2° and was not a predictor of medial elbow torque (P = .205) or ball velocity (P = .333). Ball velocity, age, and height were predictors of medial elbow torque (P = .012, P = .003, and P = .024, respectively). CONCLUSION: In high school baseball pitchers, GIRD was not associated with medial elbow torque during the pitching motion. Instead, ball velocity, player age, and player height carried greater significance. CLINICAL RELEVANCE: This study suggests that high school pitchers with GIRD do not have an inherently greater risk for increased medial elbow torque during the throwing motion. It is recommended that pitchers instead assess their ball velocity to evaluate for relative differences in medial elbow torque.

Hamstring Injury Trends in Major and Minor League Baseball: Epidemiological Findings From the Major League Baseball Health and Injury Tracking System.

BACKGROUND: Hamstring strains are the most common injury for professional baseball players and can result in significant time on the disabled list. To date, no study has reported the current trends in hamstring strains in professional baseball. HYPOTHESIS: Professional baseball players would have an increased incidence of hamstring strains from 2011 through 2016. STUDY DESIGN: Descriptive epidemiology study. METHODS: Injury data were prospectively collected from 2011 through 2016 for every Major League Baseball (MLB) and Minor League Baseball (MiLB) team and was recorded in the MLB Health and Injury Tracking System. Data collected for this study included date of injury, activity during injury, time lost, primary injury or reinjury status, and imaging findings as well as player demographic information related to level of play, age, and position for all hamstring injury events. Injury rates were reported as hamstring injuries per number of games. RESULTS: From 2011 to 2016, there were 2633 hamstring strains in professional baseball players. The rate of hamstring strains increased in MLB from a low of 1 injury every 39 games in 2011 to a high of 1 injury every 30 games in 2016. In MiLB, there were 2192 hamstring strains, with 1 injury every 35 games in 2011 compared with 1 injury every 30 games in 2016. The majority of injuries occurred in the infielder positions (37.5%) and resulted from base running (>50%), most commonly from home to first base. The most common hamstring injury was a grade 2 injury to the distal biceps femoris. The mean time missed after a hamstring injury was 14.5 days. Grade 3 and grade 2 hamstring strains resulted in significantly more days missed compared with grade 1 injuries (P = .005 and P = .002, respectively). The rate of recurrent hamstring injuries was 16.3% for MLB and 14.2% for MiLB. Recurrent hamstring injuries resulted in more time lost than primary injuries (mean, 16.4 vs 14.5 days, respectively; P = .02). A total of 42 injuries were treated with platelet-rich plasma, and 19 were treated with surgery. The number of injuries treated with platelet-rich plasma increased in successive years. CONCLUSION: The rate of hamstring strains in professional baseball players has increased over the past 6 years and has resulted in a significant loss of playing time. Study results indicated that these injuries are affected by injury characteristics, position played, running to first base, seasonal timing, and history of hamstring injuries.

Using a Web-Based Data Collection Platform to Implement an Effective Electronic Patient-Reported Outcome Registry.

Modern health care places significant emphasis on patient-centered care. As a result, many orthopaedic providers are incorporating routine patient-reported outcome measure (PROM) collection into their practice. However, routine PROM collection often disrupts clinical workflow and can place a burden on both the patient and the provider. Electronic PROM collection systems, if implemented deliberately to maximize convenience and efficiency, have the potential to mitigate these obstacles. This technique guide presents an overview of designing and implementing a PROM-based clinical registry for the ambulatory orthopaedic clinic using Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, TN). We outline the basic steps of creating a simple but effective patient registry using this accessible data collection platform.

Feasibility of PROMIS CAT Administration in the Ambulatory Sports Medicine Clinic With Respect to Cost and Patient Compliance: A Single-Surgeon Experience.

BACKGROUND: Pay-for-performance reimbursement models are becoming increasingly popular, but the implementation of a routine patient-reported outcome (PRO) collection system places additional burden on both the patient and the provider. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed in an effort to make PRO collection more practical and efficient, but providers may be reluctant to embrace a transition to a PROMIS-based clinical outcome registry. HYPOTHESIS: PROMIS can be successfully incorporated into daily clinical practice, with an overall patient compliance rate of 80%. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: As part of routine practice, all patients presenting to a single surgeon's sports medicine clinic for an appointment were asked to complete a series of PROMIS computerized adaptive tests (CATs), including PROMIS Physical Function, Physical Function-Upper Extremity, Pain Interference, and Depression subscales. Overall compliance was calculated by dividing the number of survey sets completed by the number of eligible clinic visits. Compliance rates were further assessed by patient age, type of clinic visit, and location of injury. Costs associated with this system of routine PRO collection were categorized as start-up or maintenance costs. RESULTS: From August 7, 2017, to December 8, 2017, there were 581 patients (1109 clinic encounters) who met inclusion criteria for the study. Of the 1109 clinic encounters, there was an overall compliance rate of 91.3% (1013/1109 visits during which the patient completed the entire PROMIS survey set). Overall, the full survey set consisted of a mean 15.3 questions and took a mean of 2.6 minutes to complete. Patients who were aged ≥62 years had a significantly lower compliance rate (81.8%; P < .0001) than each of the younger patient quartiles. When analyzing patients by the most common locations of injury (elbow, shoulder, hip, knee), the compliance rate for completing PROMIS was significantly higher for the hip than for the shoulder (95.1% vs 88.9%, respectively; P = .02). The cost of establishing a PROMIS-based registry using our project design and workflow was estimated at $2045, whereas the monthly maintenance cost was $1000. CONCLUSION: The routine electronic collection of PROMIS scores in the ambulatory orthopaedic clinic resulted in a compliance rate of over 90%, although older patients were generally less compliant than younger patients. Our system of data collection is practical and efficient in a high-volume orthopaedic clinic and places minimal financial burden on the provider.

The Correlation Between PROMIS Pain Interference and VAS Pain in Ambulatory Orthopedic Patients.

The purpose of this study was to investigate the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) score with traditionally collected visual analog scale (VAS) scores and to determine the influence of patient demographics on PROMIS PI and VAS scores. Patient demographics were collected, and PROMIS PI, PROMIS Physical Function (PF), and VAS questionnaires were distributed to 215 patients in orthopedic ambulatory clinics. The primary outcome was correlation between PROMIS PI and VAS questionnaires. The statistical method of seemingly unrelated regressions was used to identify significant predictors and strengths of correlation between PROMIS PI and conventional forms. The PROMIS PI score was highly correlated to conventional pain and functional scores, with each standard deviation increase in PROMIS PI score predicting a 16-point increase for pain-related VAS scores (current pain, pain at rest, pain during activity, pain at night), an 18-point decrease in satisfaction of function score, and a 6-point decrease in general health score. Each standard deviation increase in PROMIS PF score for black patients predicted a reduction of 11 points for current pain, 10 points for pain at rest, 10 points for pain during activity, and 12 points for pain at night scores. The PROMIS PI score consistently predicts changes in VAS pain scores and can be considered a useful, standardized tool for measuring pain for clinical and research purposes. [Orthopedics. 2018; 41(6):e813-e819.].

Effect of Fatigue on Medial Elbow Torque in Baseball Pitchers: A Simulated Game Analysis.

BACKGROUND: The incidence of overuse injury to the elbow among baseball pitchers continues to rise, despite extensive efforts at pitch count regulations and emphasis on proper throwing mechanics. PURPOSE: To determine if the medial elbow experiences increased torque levels as a baseball pitcher fatigues through the course of a simulated game. STUDY DESIGN: Descriptive laboratory study. METHODS: High school and collegiate baseball pitchers were recruited for this simulated game study. Each pitcher completed a simulated game consisting of 6 innings and a standardized pitching scheme of fastballs, curveballs, and changeups. In total, each pitcher threw 90 pitches. Fatigue was reported per inning with a visual analog scale, and pitch velocity was captured per pitch with a radar gun. Outcome measures were assessed with a validated mobile sensor and included medial elbow torque, arm speed, arm rotation, and arm slot. Linear and quadratic regression modeling was used to evaluate the relationship between pitcher fatigue and pitching kinematics. RESULTS: A total of 11 pitchers (mean age, 17.6 years; range, 15-20 years) completed the study. Visual analog scale fatigue scores increased 0.72 points per inning pitched ( P < .01, effect size = 0.64). Medial elbow torque also increased beyond inning 3, with an increase of 0.84 N·m each inning ( P < .01, effect size = 0.08), while pitch velocity decreased (0.28 mph per inning, P < .01, effect size = 0.27). Fastballs generated the greatest amount of medial elbow torque (49.3 ± 1.4 N·m, P < .01, effect size = 0.24). There were no differences in arm rotation ( P = .42) or arm speed ( P = .80) as the game progressed. However, arm slot decreased with each successive inning (0.73° on average per inning, P = .03, effect size = 0.12). No adverse outcomes were noted with use of the mobile sensor. CONCLUSION: In this simulated game analysis, pitchers experienced increased fatigue after each successive inning. While the average pitch velocity declined with each successive inning, the torque on the medial elbow increased after inning 3. These findings signify a possible relationship between fatigue and injury risk.

Predictors of Elbow Torque Among Youth and Adolescent Baseball Pitchers.

BACKGROUND: There has been an increasing incidence of overuse elbow injuries among youth and adolescent pitchers. Pitch type has been implicated as a risk factor for excess torque at the medial elbow; however, this has not been definitively demonstrated. PURPOSE: To assess predictors of torque across the medial elbow in youth and adolescent pitchers with a mobile sensor. In addition, the authors aimed to determine the differences in elbow torque produced according to pitch type (fastball, curveball, changeup) and pitcher demographics. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty youth and adolescent pitchers were instructed to throw 8 fastballs, 8 curveballs, and 8 changeups in a standardized but randomized sequence over a 25-minute period. Five pitchers were evaluated each day. A sensor placed at the medial elbow reported elbow torque, arm speed, arm slot, and shoulder rotation for each pitch, while a radar gun measured peak ball velocity. The primary outcome was a determination of thrower and pitch characteristics associated with elevated torque across the medial elbow. Secondary outcomes included the evaluation of differences in throwing biomechanics among different pitch types. Outcomes were assessed via a multivariable model, which controlled for possible covariates. RESULTS: In total, 20 youth baseball pitchers with a mean age of 14.1 years (range, 12-17 years) were included in the study. On average, fastballs caused the greatest torque across the medial elbow (least squares mean ± SE, 47.3 ± 0.5 N·m) as compared with changeups (44.2 ± 0.5 N·m; P < .001) and curveballs (45.0 ± 0.5 N·m; P = .002). However, curveballs produced the greatest arm speed (917.8 rpm). Pitchers who started throwing curveballs at an older age experienced less elbow torque ( P < .001). A multivariable model demonstrated that increased ball velocity and body mass index and decreased arm slot were independent predictors of increased elbow torque. Conversely, increasing age, longer arm length, and greater elbow circumference were independent protectors against elbow torque. CONCLUSION: This study found that among youth and adolescent pitchers, fastballs generate the highest elbow torque while curveballs generated the greatest arm speed. Increased ball velocity and body mass index and decreased arm slot were predictors of elbow torque; however, increasing age and size of a pitcher's arm were protectors against elbow torque. These findings are important to better understand risk factors for overuse injury in this at-risk athletic population. CLINICAL RELEVANCE: These findings may inform future pitching recommendations with intentions of curtailing medial elbow injuries experienced by young pitchers, such as ulnar collateral ligament injuries.