Majority of competitive soccer players return to soccer following hip arthroscopy for femoroacetabular impingement: female and older aged players are less likely to return to soccer.

PURPOSE: To determine return to soccer rates and soccer performance in a large cohort of competitive soccer players after hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) and to identify possible risk factors associated with not returning to soccer. METHODS: An institutional hip preservation registry was retrospectively reviewed for patients identified as competitive soccer players who underwent primary hip arthroscopy for FAI performed between 2010 and 2017. Patient demographics and injury characteristics as well as clinical and radiographic findings were recorded. All patients were contacted for return to soccer information using a soccer-specific return to play questionnaire. Multivariable logistic regression analysis was used to identify potential risk factors for not returning to soccer. RESULTS: Eighty-seven competitive soccer players (119 hips) were included. 32 players (37%) underwent simultaneous or staged bilateral hip arthroscopy. The mean age at surgery was 21.6 ± 7.0 years. Overall, 65 players (74.7%) returned to soccer, of which 43 players (49% of all included players) returned to pre-injury level of play or better. Most common reasons for not returning to soccer were pain or discomfort (50%) followed by fear of re-injury (31.8%). The mean time to return to soccer was 33.1 ± 26.3 weeks. Among 22 players who did not return to soccer, 14 (63.6%) reported satisfaction from surgery. Multivariable logistic regression analysis revealed female players (odds ratio [OR] = 0.27; confidence interval [CI] = 0.083 to 0.872; p = 0.029) and older aged players (OR = 0.895; 95% CI = 0.832 to 0.963; p = 0.003) were less likely to return to soccer. Bilateral surgery was not found to be a risk factor. CONCLUSION: Hip arthroscopic treatment for FAI in symptomatic competitive soccer players allowed three-quarters of them to return to soccer. Despite not returning to soccer, two-thirds of players who did not return to soccer were satisfied with their outcome. Female and older aged players were less likely to return to soccer. These data can better guide clinicians and soccer players with realistic expectations related to the arthroscopic management of symptomatic FAI. LEVEL OF EVIDENCE: III.

Carboplasty, a Simple Tibial Marrow Technique for Knee Osteoarthritis: A Placebo-Controlled Randomized Trial.

Background: Carboplasty is a new minimally invasive technique for knee osteoarthritis (OA) that consists of injecting tibial marrow aspirate into the bone-cartilage interface as well as intra-articularly. Purpose: To compare the clinical and imaging outcomes, as well as the safety, of carboplasty for symptomatic knee OA in a placebo-controlled trial. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: The authors conducted a randomized controlled trial to compare carboplasty with placebo for the treatment of symptomatic knee OA. Patients who had failed medical treatment and had bone edema on magnetic resonance imaging (MRI) were randomized in a 1:1 ratio to carboplasty or placebo. The primary outcome of the study was the Numeric Pain Rating Scale (NPRS) for the knee at 1 year (scores range from 0 to 10, with a higher score indicating worse pain). Secondary outcomes were the Knee injury and Osteoarthritis Outcome Score (KOOS), treatment responder rate (based on achieving the minimal clinically important difference of the NPRS), MRI bone edema reduction, and treatment safety. Results: In total, 50 patients (25 carboplasty vs 25 placebo) were enrolled and followed up with for an average of 18 months (range, 14-24 months). The average NPRS at baseline decreased from 7.1 ± 0.9 to 2.9 ± 2.1 (P < .001) at 1 year in the carboplasty group and from 7.7 ± 0.9 to 4.9 ± 2.2 (P < .001) in the placebo group. On average, patients after carboplasty improved 60% from their initial NPRS, and patients after placebo improved 37% (P = .003). Patients had a statistically significantly greater improvement from baseline in all KOOS subscales in the carboplasty group compared with the placebo group (P < .001). The responder rates were 96% for carboplasty and 76% for placebo (P = .098). Bone edema was reduced in 72% of patients in the carboplasty group and 44% of patients in the placebo group (P = .045). Neither group had adverse events related to treatment. Conclusion: Carboplasty resulted in greater pain reduction, a significantly greater improvement in all KOOS subscales, and a similar safety profile compared with placebo in patients with symptomatic knee OA and bone edema. Registration: ISRCTN69838191 (ISRCT Registry).

Anterior Quadratus Lumborum Block Does Not Provide Superior Pain Control after Hip Arthroscopy: A Double-blinded Randomized Controlled Trial.

BACKGROUND: Hip arthroscopy is associated with moderate to severe postoperative pain. This prospective, randomized, double-blinded study investigates the clinically analgesic effect of anterior quadratus lumborum block with multimodal analgesia compared to multimodal analgesia alone. The authors hypothesized that an anterior quadratus lumborum block with multimodal analgesia would be superior for pain control. METHODS: Ninety-six adult patients undergoing ambulatory hip arthroscopy were enrolled. Patients were randomized to either a single-shot anterior quadratus lumborum block (30 ml bupivacaine 0.5% with 2 mg preservative-free dexamethasone) or no block. All patients received neuraxial anesthesia, IV sedation, and multimodal analgesia (IV acetaminophen and ketorolac). The primary outcome was numerical rating scale pain scores at rest and movement at 30 min and 1, 2, 3, and 24 h. RESULTS: Ninety-six patients were enrolled and included in the analysis. Anterior quadratus lumborum block with multimodal analgesia (overall treatment effect, marginal mean [standard error]: 4.4 [0.3]) was not superior to multimodal analgesia alone (overall treatment effect, marginal mean [standard error]: 3.7 [0.3]) in pain scores over the study period (treatment differences between no block and anterior quadratus lumborum block, 0.7 [95% CI, -0.1 to 1.5]; P = 0.059). Postanesthesia care unit antiemetic use, patient satisfaction, and opioid consumption for 0 to 24 h were not significantly different. There was no difference in quadriceps strength on the operative side between groups (differences in means, 1.9 [95% CI, -1.5 to 5.3]; P = 0.268). CONCLUSIONS: Anterior quadratus lumborum block may not add to the benefits provided by multimodal analgesia alone after hip arthroscopy. Anterior quadratus lumborum block did not cause a motor deficit. The lack of treatment effect in this study demonstrates a surgical procedure without benefit from this novel block.

Characteristics of Soccer Players Undergoing Primary Hip Arthroscopy for Femoroacetabular Impingement: A Sex- and Competitive Level-Specific Analysis.

BACKGROUND: Radiographic features of femoroacetabular impingement (FAI) are prevalent in kicking athletes, especially soccer players. However, there remains a paucity of data on the characteristics of symptomatic soccer players with an established diagnosis of FAI. PURPOSE: To report on patient demographics, injury, and clinical and radiographic characteristics in a large cohort of soccer players who underwent primary hip arthroscopy for FAI and to perform a sex- and competition level-specific analysis of these data. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An institutional hip preservation registry containing 3318 consecutive primary hip arthroscopies for FAI performed between March 2010 and January 2016 was retrospectively reviewed for patients identified as soccer players. Patient demographics, injury characteristics, and clinical and radiographic findings were recorded, and sex- and competition level-specific differences were analyzed. RESULTS: A total of 421 hips (336 soccer players) were identified, including 257 (61.0%) men and 164 (39.0%) women. Of these, 105 (24.9%) were reported as highly competitive, 194 (46.1%) as competitive, 75 (17.8%) as recreational, and 47 (11.2%) did not report a level. The majority of the 336 soccer players (231 hips; 55%) reported chronic hip pain lasting >6 months with no acute injury at the initial visit. Alpha angle, coronal center-edge angle, and femoral version on computed tomography scan measured 64.5°± 12°, 32.3°± 9°, and 13.7°± 10° (mean ± SD), respectively. There were 230 (55%) hips with a type 2 anterior inferior iliac spine (AIIS), 78 (18.5%) with a type 1 AIIS, and 19 (4.5%) with a type 3 AIIS. When compared with male athletes, female athletes had more hip internal rotation on physical examination (14.9° vs 8°; P < .001), lower alpha angles (57.5° vs 68.5°; P < .001), and lower-grade AIIS morphology (P = .003). Acute injury as the reason for hip symptoms was most likely in the highly competitive group (P < .001). CONCLUSION: Female soccer players were more likely to have less severe clinical and radiographic findings than were male soccer players. Acute injury as the cause of hip symptoms was more common in highly competitive players. CLINICAL RELEVANCE: Focusing on soccer players with an established FAI diagnosis, the findings of this study suggest that there are sex- and competition level-based differences in the presentation, physical examination, and imaging characteristics among the players. These findings can better guide clinicians in the diagnostic evaluation of symptomatic soccer players with FAI and in tailoring treatment recommendations to specific cohorts.

Upper Extremity and Hip Range of Motion Changes Throughout a Season in Professional Baseball Players.

BACKGROUND: Loss of upper and lower extremity range of motion (ROM) is a significant risk factor for injuries in professional baseball players. PURPOSE/HYPOTHESIS: The purpose was to determine changes in ROM in professional baseball players over the course of a single season and their careers. We hypothesized that pitchers and position players would lose ROM, specifically total shoulder motion (total ROM [TROM]) and hip internal rotation (IR), over the course of a season and their careers. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Upper and lower extremity ROM measurements were recorded during pre-, mid-, and postseason on all professional baseball players for a single organization between 2011 and 2018. ROM measurements were compared for pitchers and position players over the course of the season and their careers. Also, ROM measurements over the pre-, mid-, and postseason were compared between pitchers and position players. RESULTS: A total of 166 professional baseball players (98 pitchers, 68 position players) were included. Pitcher hip external rotation (ER; P < .001), IR (P = .010), and TROM (P < .001) for lead and trail legs decreased over the course of the season. Pitcher shoulder ER (P = .005), TROM (P = .042), and horizontal adduction (P < .001) significantly increased over the course of the season. Position player shoulder flexion (P = .046), hip ER (P < .001, lead leg; P < .001, trail leg), and hip TROM (P = .001; P = .002) decreased over the course of the season. Position player shoulder ER (P = .031) and humeral adduction (P < .001) significantly increased over the course of the season. Over the course of pitchers' careers, there was decreased shoulder IR (P = .014), increased shoulder horizontal adduction (P < .001), and hip IR (P = .042) and hip TROM (P = .027) for the lead leg. Position players experienced loss of hip TROM (P = .010, lead leg; P = .018, trail leg) over the course of their careers. Pitchers started with and maintained more shoulder ER and gained more shoulder TROM over a season as compared with position players. CONCLUSION: Pitchers and position players saw overall decreases in hip ROM but increases in shoulder ROM over the course of the season and career.

Do Professional Baseball Players With a Higher Valgus Carrying Angle Have an Increased Risk of Shoulder and Elbow Injuries?

BACKGROUND: There are many risk factors for shoulder and elbow injuries in professional baseball pitchers. The elbow carrying angle has not been studied as a potential risk factor. PURPOSE/HYPOTHESIS: The aim of this study was to determine whether elbow carrying angle is a risk factor for shoulder or elbow injuries in professional baseball pitchers. We hypothesized that pitchers with a higher elbow carrying angle would be less likely to sustain an injury during the season than pitchers with a lower elbow carrying angle. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: All professional pitchers for a single baseball club during the 2018 season had the carrying angle of both elbows measured at spring training by a single examiner. The pitchers were followed prospectively throughout the season. Shoulder and elbow injuries were recorded prospectively. RESULTS: A total of 52 pitchers (21 [40%] Major League Baseball and 31 [60%] Minor League Baseball) were included. During the season, 23 (44%) pitchers became injured. The mean carrying angle in the throwing arm was 12.5° ± 4.2° versus 9.9° ± 2.8° in the nonthrowing arm (P < .001). Comparing the injured and noninjured groups, there were no differences in level of play (P = .870), throwing hand dominance (P = .683), batting hand dominance (P = .554), throwing-side carrying angle (P = .373), nonthrowing-side carrying angle (P = .773), or side-to-side difference in carrying angle (P = .481). CONCLUSION: The elbow carrying angle was not associated with an injury risk during a single season in professional baseball pitchers.

Surface Mapping of the Musculotendinous Attachments at the Pubic Symphysis in Cadaveric Specimens: Implications for the Treatment of Core Muscle Injury.

PURPOSE: To characterize the 3-dimensional muscular, musculotendinous, and neurovascular anatomy about the pubic symphysis relevant to core muscle injury (CMI). METHODS: Ten cadaveric hips were dissected to characterize the musculotendinous insertion of the rectus abdominis and inguinal ligament, origins of the adductor longus and adductor brevis, and the pubic cartilage plate. A 3-dimensional coordinate measuring system and data acquisition software were used to calculate structure cross-sectional area, and the landmark anatomical relationships to 1 another and relevant neurovascular structures. RESULTS: All specimens were male with an average age of 62 ± 2 years. The mean footprints of the rectus abdominis, inguinal ligament, adductor longus, and adductor brevis were 8.4 ± 3.1, 1.2 ± 0.5, 3.8 ± 1.6, and 2.9 ± 1.3 cm2, respectively. The mean pectineus and gracilis footprints were 6.3 ± 2.4 and 3.4 ± 0.9 cm2, respectively. The mean cross-sectional area of the cartilage plate was 24.8 ± 5.6 cm2. The adductor longus was an average 1.5 ± 0.25 cm from the adductor brevis and 0.69 ± 0.52 cm from the rectus abdominis. The genital branch of the genitofemoral nerve was an average of 4.3 cm (range, 2.8-6.4) lateral to the insertion of the inguinal ligament. The femoral vein and artery were 3.0 cm (range, 2.5-3.6) and 3.7 cm (range, 2.5-5.9) lateral to the inguinal ligament footprint. The obturator nerve was 2.5 cm (range, 1.6-3.4) lateral to the adductor longus. CONCLUSIONS: Familiarity with the anatomy of the pubic symphysis is essential for surgeons treating patients with CMI. We have shown that this relatively small area is the site of many muscular, musculotendinous, and neurovascular structures with various sized footprints and described the 3-dimensional anatomy of the anterior pubic symphysis. The origin of the adductor longus lies in close proximity to other structures, such as the adductor brevis, the insertion of the rectus abdominis, and the obturator nerve. These findings should be considered when operating in this region and treating patients with chronic groin pain. CLINICAL RELEVANCE: The anatomy of the pelvic region and pubic symphysis has not been well characterized. Intimate knowledge of relevant anatomy is essential to treating CMI, also known as athletic pubalgia or sports hernia.

Editorial Commentary: "Dancing the Hip Away"-Does Joint Laxity Correlate With Worse Outcome in Dancers Undergoing Hip Arthroscopy for Femoral Acetabular Impingement?

Dancers have a disproportionately high prevalence of hip issues compared with other types of athletes. Many of these hip issues are complex: a cam and/or pincer impingement combined with a seemingly paradoxical borderline dysplasia, capsular laxity, and subsequent instability. Our experience as nonarthritic hip surgeons tells us that careful patient selection is critical for a successful outcome after the arthroscopic treatment of a dancer. But, there is little guidance in the literature on the management of this specific group of patients. We have studies that advise us to repair the labrum when possible versus performing labral debridement in female patients with predominantly pincer-type impingement and studies that support capsular plication and careful capsule closure in patients, predominantly female patients, with combined hip impingement and dysplasia or borderline dysplasia. However, few studies have examined predictors of outcomes after hip arthroscopy in dancers.

Shoulder and Elbow Range of Motion Can Be Maintained in Major League Baseball Pitchers Over the Course of the Season, Regardless of Pitching Workload.

BACKGROUND: Studies examining the evolution of shoulder and elbow range of motion (ROM) in baseball pitchers over a single season have yielded inconsistent results. PURPOSE: To evaluate shoulder and elbow ROM in Major League Baseball (MLB) pitchers over a single season and to assess for correlations between these changes and measures of a pitcher's workload. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Bilateral shoulder ROM (internal rotation [IR], external rotation [ER], and total range of motion [TROM]) was assessed in 92 MLB pitchers pre- and postseason. Shoulder forward flexion (FF) was measured in 64 pitchers, horizontal adduction (HA) was measured in 87 pitchers, and elbow ROM was measured in 86 pitchers. Data collected included demographics (age, height, weight, and body mass index) and measures of workload for pitchers (pitches thrown, innings pitched, and mean fastball velocity). Pitchers were not specifically excluded if they had an injury during the season but had recovered and were actively pitching at the time of postseason measurements. The change in motion from pre- to postseason was measured and the associations with player demographics and workload were calculated by use of the Pearson correlation coefficient. RESULTS: On average, pitchers demonstrated an increase in dominant shoulder ER from 118.8° to 125.4° (P < .001) and TROM from 173.1° to 181.7° (P < .001). HA was increased by an average of 15.7° (P < .001). The average shoulder IR (P = .189), FF (P = .432), and elbow ROM (flexion, P = .549; extension, P = .185) remained similar over the span of the season. Average glenohumeral IR deficit did not increase. Pitcher demographics and measures of throwing workload (total pitches thrown, innings pitched, mean fastball velocity) were not significantly correlated with changes in shoulder or elbow ROM. CONCLUSION: Significant increases in dominant shoulder ER, TROM, and HA were identified in MLB pitchers over the course of a single baseball season. These ROM changes were not correlated with measures of pitching workload.

The Middle and Distal Aspects of the Ulnar Footprint of the Medial Ulnar Collateral Ligament of the Elbow Do Not Provide Significant Resistance to Valgus Stress: A Biomechanical Study.

BACKGROUND: The medial ulnar collateral ligament (UCL) insertion of the elbow has been shown to extend distally beyond the sublime tubercle. The contribution to valgus stability of the distal aspect of the footprint is unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the contribution of each part of the UCL footprint to the elbow valgus stability provided by the UCL. It was hypothesized that the distal two-thirds of the ulnar UCL footprint would not contribute significantly to valgus stability provided by the UCL. STUDY DESIGN: Descriptive laboratory study. METHODS: Fifteen cadaveric arms were dissected to the capsuloligamentous elbow structures and potted. A servohydraulic load frame was used to place 5 N·m of valgus stress on the intact elbow at 30°, 60°, 90°, and 120° of flexion. The UCL insertional footprint was measured and divided into thirds (proximal, middle, and distal). One-third of the UCL footprint was elevated off the bone (leaving the ligament in continuity), and the elbow was retested at the same degrees of flexion. This was repeated until the entire UCL footprint on the ulna was sectioned. Each elbow was randomized for how the UCL would be sectioned (sectioning the proximal, then middle, and then distal third or sectioning the distal, then middle, and then proximal third). Ulnohumeral joint gapping (millimeters) was recorded with a 3-dimensional motion capture system using physical and virtual markers. Two-group comparisons were made between each sectioned status versus the intact condition for each flexion angle. RESULTS: When the UCL was sectioned from distal to proximal, none of the ligaments failed prior to complete sectioning. When the UCL was sectioned from proximal to distal, 3 of the 6 ligaments failed after sectioning of the proximal third, while 2 more failed after the proximal and middle thirds were sectioned. Of the specimens with the distal third of the ligament sectioned first, no significant differences were found between intact, distal third cut, and distal plus middle thirds cut at all flexion angles. CONCLUSION: The middle and distal thirds of the insertional footprint of the UCL on the ulna did not significantly contribute to gap resistance at 5 N·m of valgus load. The proximal third of the footprint is the primary resistor of valgus load. CLINICAL RELEVANCE: This cadaveric biomechanical study demonstrated that the middle and distal thirds of the native UCL insertion onto the ulna did not significantly contribute to valgus resistance at the elbow. When a UCL reconstruction is performed, the proximal third of the UCL insertion may be the most clinically important portion of the ligament to reconstruct.

Getting Hit by Pitch in Professional Baseball: Analysis of Injury Patterns, Risk Factors, Concussions, and Days Missed for Batters.

BACKGROUND: Although batters are frequently hit by pitch (HBP) in baseball, the effect of HBP injuries remains undefined in the literature. PURPOSE: To determine the effect of HBP injuries in terms of time out of play, injury patterns resulting in the greatest time out of play, and the value of protective gear such as helmets and elbow pads. STUDY DESIGN: Descriptive laboratory study. METHODS: Based on the Major League Baseball (MLB) Health and Injury Tracking System, all injuries to batters HBP during the 2011-2015 MLB and Minor League Baseball (MiLB) seasons were identified and analyzed. Video analysis was performed on all HBP events from the 2015 MLB season. Multivariate stepwise regression analysis was utilized to determine the predictive capacity of multiple variables (velocity, pitch type, location, etc) on injury status and severity. RESULTS: A total of 2920 HBP injuries resulted in 24,624 days missed (DM) over the 5 seasons. MLB HBP injuries occurred at a rate of 1 per 2554 plate appearances (1 per 9780 pitches thrown). Mean DM per injury were 8.4 (11.7 for MLB vs 8.0 for MiLB, P < .001). Surgery was required for 3.1% of MLB injuries and 1.2% of MiLB injuries ( P = .005). The most common body regions injured were the hand/fingers (n = 638, 21.8%), head/face (n = 497, 17.0%), and elbow (n = 440, 15.7%), and there were 146 (5.0%) concussions. Injury rates and mean DM correlated with velocity in a near linear fashion. Players hit in the head/face (odds ratio, 28.7) or distal upper extremity (odds ratio, 6.4) were more likely to be injured than players HBP in other locations. Players with an unprotected elbow missed 1.7 more days (95% CI, -4.1 to 7.6) than those with an elbow protector ( P = .554) when injured after being HBP. CONCLUSION/CLINICAL RELEVANCE: Although HBP injuries occur infrequently in the course of normal play, they collectively represent a significant source of time out of play. The most common body regions injured include the hands/fingers and head/face, and batters hit in these locations are significantly more likely to be injured. After contusions, concussions were the most common injury diagnosis.

Summative Report on Time Out of Play for Major and Minor League Baseball: An Analysis of 49,955 Injuries From 2011 Through 2016.

BACKGROUND: Recent epidemiologic reports have demonstrated rising injury rates in Major League Baseball (MLB) and Minor League Baseball (MiLB). Although several studies have recently been published on specific injuries, the majority of injuries have not yet been formally studied. PURPOSE: The purpose of this study is to (1) generate a summative analysis of all injuries that occur in MLB and MiLB, (2) identify the 50 most common injuries, and (3) generate focused reports and fact sheets on the characteristics of each of those diagnoses. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The MLB Health and Injury Tracking System was used to identify injuries occurring in MLB and MiLB players from 2011 to 2016. Injuries were defined as those that occurred during normal baseball activity and resulted in at least 1 day out of play. A multitude of player and injury characteristics were analyzed, and detailed reports of the 50 most commonly occurring injuries were generated. RESULTS: A total of 49,955 injuries occurred during the study period; 45,123 were non-season ending, and they resulted in 722,176 days out of play. The mean (median) days missed per injury was 16 (6) days. Overall, 39.1% of all injuries occurred in pitchers. The upper extremity was involved in 39% of injuries, while 35% occurred in the hip/groin/lower extremity. Surgery was required in 6.5% of cases, and 9.7% of injuries were season ending. Hamstring strains were the most common injury (n = 3337), followed by rotator cuff strain/tear (n = 1874), paralumbar muscle strain (n = 1313), biceps tendinitis (n = 1264), oblique strain (n = 1249), and elbow ulnar collateral ligament injury (n = 1191). The diagnoses that were most likely to end a player's season were elbow ulnar collateral ligament injury (60% season ending) and superior labrum anterior and posterior tear (50.9% season ending). CONCLUSION: Contrary to prior reports relying on disabled list data, the annual number of injuries in professional baseball remained steady from 2011 to 2016. Similar trends were noted for the annual number of days missed and mean days missed per injury. Although the mean days missed per injury was high (16), the median was much lower at 6 days.

Decreased Hip Internal Rotation Increases the Risk of Back and Abdominal Muscle Injuries in Professional Baseball Players: Analysis of 258 Player-seasons.

INTRODUCTION: The relationship of hip range of motion (ROM) to shoulder, elbow, abdominal, and back injuries remains undefined. METHODS: We assessed hip ROM on players reporting to Major League Spring Training for an organization over six seasons (2010 to 2015). Hip ROM was correlated with player abdominal, back, shoulder, and elbow injury status for those seasons using multivariate binomial logistic regression analysis. RESULTS: A total of 258 player-seasons (129 pitchers and 129 position players) resulted in 20 back and 35 abdominal injuries across all players and 28 elbow and 25 shoulder injuries in pitchers. Hip ROM did not correlate with shoulder or elbow injuries. Hip internal rotation deficit of 5° correlated with core injury (odds ratio [OR], 1.40; P = 0.024 for pitchers; OR, 1.35; P = 0.026 for position players) and back injury (OR, 1.160; P = 0.022 for pitchers). DISCUSSION: Hip internal rotation deficits were predictive of back and abdominal injuries but not shoulder or elbow injury.

The Impact of Workload on the Evolution of Hip Internal and External Rotation in Professional Baseball Players Over the Course of the Season.

BACKGROUND: Although restricted hip range of motion (ROM) is associated with an increased risk for injuries in baseball players, the evolution of hip ROM over the season remains undefined. HYPOTHESIS: Hip ROM profiles would be symmetric between hips and positions (pitchers vs position players) but would decrease from preseason to postseason. Additionally, it was hypothesized that this decrease in motion would correlate with workload. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Bilateral hip ROM was assessed in 96 professional baseball players (54 pitchers, 42 position players) preseason and postseason. ROM comparisons were made between lead and trailing hips, pitchers and position players, and preseason and postseason measures. The change from preseason to postseason was correlated with player demographics and measures of workload for pitchers and position players. RESULTS: Preseason hip ROM was symmetric between hips; however, pitchers demonstrated increased preseason lead hip internal rotation (IR) (P = .018) and bilateral hip total ROM (TROM) (P < .020) compared with position players. From preseason to postseason, position players lost 7° of external rotation (ER) (P ≤ .005 ). In pitchers, the loss of IR correlated with increased pitches (P = .016) and innings (P = .037), while the loss of ER (P = .005 ) and TROM (P = .014) correlated with increasing mean fastball velocity. Workload for position players did not correlate with motion loss. CONCLUSION: Symmetric hip ROM profiles should be anticipated in baseball players; however, pitchers may have increased preseason IR and TROM and postseason ER and TROM relative to position players. Although loss of motion correlated with workload in pitchers, this was not the case for position players. Hip motion should be monitored over the course of the season. This is particularly true for pitchers who lose IR as workload increases, which may place them at a greater risk for injuries.

Hip and Groin Injuries in Baseball Players.

PURPOSE OF REVIEW: To discuss the clinical significance of the most common hip and groin injuries in baseball players, as well as an algorithmic approach to diagnosis and treatment of these injuries. RECENT FINDINGS: (a) Limitations in throwing velocity, pitch control, and bat swing speed may be secondary to decreased mobility and strength within the proximal kinetic chain, which must harness power from the lower extremities and core. (b) Approximately 5.5% of all baseball injuries per year involve the hip/groin and may lead to a significant amount of time spent on the disabled list. Injuries involving the hip and groin are relatively common in baseball players. Our knowledge of the mechanics of overhead throwing continues to evolve, as does our understanding of the contribution of power from the lower extremities and core. It is paramount that the team physician be able to accurately diagnose and treat injuries involving the hip/groin, as they may lead to significant disability and inability to return to elite levels of play. This review focuses on hip- and groin-related injuries in the baseball player, including femoroacetabular impingement, core muscle injury, and osteitis pubis.

Decreased Shoulder External Rotation and Flexion Are Greater Predictors of Injury Than Internal Rotation Deficits: Analysis of 132 Pitcher-Seasons in Professional Baseball.

PURPOSE: The primary aims of this work were to (1) describe normal range of motion (ROM) profiles for elite pitchers, (2) describe the characteristics of shoulder and elbow injuries in professional pitchers over a 6-year period in one Major League Baseball organization, and (3) identify ROM measures that were independently associated with a future shoulder or elbow injury. METHODS: Over 6 seasons (2010-2015), a preseason assessment was performed on all pitchers invited to Major League Baseball Spring Training for a single organization. ROM measures included shoulder flexion, horizontal adduction, external rotation (ER), internal rotation, as well as elbow flexion and extension, were measured for both the dominant and nondominant arm, and total range of motion and deficits were calculated. All noncontact shoulder and elbow injuries were identified. Using multivariate binomial logistic regression analysis to control for age, height, weight, and all other ROM measures, the factors associated with an increased risk of subsequent shoulder or elbow injury were identified. RESULTS: A total of 53 shoulder (n = 25) and elbow (n = 28) injuries occurred during 132 pitcher seasons (n = 81 pitchers). The most significant categorical risk factor associated with increased elbow injury rates was the presence of a shoulder flexion deficit >5° (odds ratio [OR] 2.83; P = .042). For continuous variables, the risk of elbow injury increased by 7% for each degree of increased shoulder ER deficit (OR 1.07; P = .030) and 9% for each degree of decreased shoulder flexion (OR 1.09; P = .017). None of the measures significantly correlated with shoulder injuries. CONCLUSIONS: Preseason shoulder ER and flexion deficits are independent risk factors for the development of elbow injuries during the upcoming season. Although prior work has supported the importance of reducing glenohumeral internal rotation deficits in pitchers, this study demonstrates that deficits in shoulder ER and flexion are more significant predictors of subsequent elbow injury. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Timing of Hip Arthroscopy After Intra-articular Hip Injection Affects Postoperative Infection Risk.

PURPOSE: To evaluate the association of preoperative intra-articular hip injection with surgical site infection after hip arthroscopy. METHODS: A large administrative database was used to identify all patients undergoing hip arthroscopy from 2007 to 2015 within a single private insurer and from 2005 to 2012 within Medicare in the United States. Those that received an ipsilateral preoperative intra-articular hip injection were identified. The patients were then divided into the following groups based on the interval between preoperative injection and ipsilateral hip arthroscopy: (1) <3 months, (2) 3 to 6 months, and (3) 6 to 12 months. These groups were compared to a control group composed of patients with no history or a remote history (>12 months) of preoperative hip injection. Patients developing a surgical site infection within 6 months following hip arthroscopy were identified using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes associated with infection. Groups were compared using a multivariate logistic regression analysis to control for age, gender, body mass index, smoking status, alcohol usage, and multiple medical comorbidities including diabetes mellitus, hemodialysis use, inflammatory arthritis, and peripheral vascular disease. RESULTS: In total, 19% of privately insured and 6% of Medicare patients received a hip injection within 12 months of hip arthroscopy. The overall infection rate in privately insured and Medicare patients was 1.19% and 1.10%, respectively. Preoperative hip injection within 3 months of surgery was associated with a significantly higher risk of postoperative infection versus controls (2.16%, odds ratio [OR] 6.1, P < .001, for privately insured group; 2.80%, OR 1.99, P = .037, for Medicare group). In contrast, preoperative hip injection given after more than 3 months of surgery was not associated with an increased risk of postoperative infection versus controls. CONCLUSIONS: Risk of infection after hip arthroscopy increased when preoperative intra-articular hip injections were given within 3 months of surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Epidemiology and Effect of Sliding Injuries in Major and Minor League Baseball Players.

BACKGROUND: Although sliding occurs frequently in professional baseball, little is known about the epidemiology and effect of injuries that occur during sliding in this population of elite athletes. PURPOSE: To describe the incidence and characteristics of sliding injuries, determine their effect in terms of time out of play, and identify common injury patterns that may represent appropriate targets for injury prevention programs in the future. STUDY DESIGN: Descriptive epidemiologic study. METHODS: All offensive sliding injuries occurring in Major League Baseball (MLB) and Minor League Baseball (MLB) that resulted in time out of play during a span of 5 seasons (2011-2015) were identified. In addition to player demographics, data extracted included time out of play, location on field where injury occurred, level of play, treatment (surgical vs nonsurgical), direction of slide (head vs feet first), body region injured, and diagnosis. Descriptive statistics were used to describe the distribution of these injuries, and injury rates were calculated per slide. RESULTS: From 2011 to 2015, 1633 injuries occurred as a result of a slide. The total number of days missed per season was 4263. Surgical intervention was required for 134 (8.2%) injuries, and the mean days missed was 66.5 for players treated surgically and 12.3 days for players treated nonoperatively ( P < .001). MLB players were more likely than MiLB players to require surgical intervention (12.3% vs 7.5%, P = .019). Injuries to the hands/fingers represented 25.3% of all injuries and 31.3% of those requiring surgery. Although the majority of injuries occurred at second base (57%), the per-slide injury rate was similar across all bases ( P = .991). The estimated overall frequency of injury in MLB was once per every 336 slides, and the rate of injury for head- and feet-first slides was 1 in 249 and 413 slides, respectively ( P = .119). CONCLUSION: Injuries occurring while sliding in professional baseball result in a significant amount of time out of play for these elite athletes. Injuries occurring at second base and those occurring to the hands and fingers were most prevalent and may be an appropriate target for future injury prevention programs.

Functional Outcomes and Cam Recurrence After Arthroscopic Treatment of Femoroacetabular Impingement in Adolescents.

PURPOSE: To compare the functional outcomes after arthroscopic treatment of femoroacetabular impingement (FAI) in adolescent patients and non-adolescent patients, and to report on the rate of cam recurrence within 2 years after femoral osteoplasty in a limited sample of the adolescent group. METHODS: From 2010 to 2014, patients younger than 18 years with symptomatic FAI (alpha angle >50°) who underwent hip arthroscopy with minimum 2-year follow-up or reoperation were identified. A group of non-adolescent patients with identical inclusion criteria, except age of 18 years or older, was also identified for comparison. In addition, a separate group of adolescent patients with 2-year postoperative radiographs was reviewed for cam recurrence. Demographic data, operative data, and radiographic and clinical outcomes (modified Harris Hip Score [mHHS], Hip Outcome Score-Activities of Daily Living [HOS-ADL], Hip Outcome Score-Sport-Specific Subscale [HOS-SSS], and International Hip Outcome Tool 33 [iHOT-33] score) were collected. RESULTS: We identified 34 adolescent patients (38 hips) with an average age of 16 years (range, 13-17 years). The mean clinical follow-up period was 36.1 ± 11.6 months (range, 24.1-71.7 months) and 29.6 ± 2.4 months (range, 27.9-31.3 months) without and with reoperation, respectively. A control group of 296 non-adolescent patients (306 hips), with a mean age of 31 years (range, 18-59 years), was identified as our non-adolescent group. The mean clinical follow-up period was 34.1 ± 11 months (range, 24.0-77.4 months) and 15.1 ± 9.1 months (range, 3.6-34.6 months) without and with reoperation, respectively. Significant improvement was noted in adolescents in the changes in outcome scores (mHHS, 22.2 [95% confidence interval (CI), 15.4-29.0]; HOS-ADL, 18.6 [95% CI, 11.9-25.2]; HOS-SSS, 33.5 [95% CI, 24.5-42.5]; and iHOT-33 score, 30.5 [95% CI, 21.8-39.2]; P < .001). Similar improvements were observed in non-adolescents (mHHS, 21.0 [95% CI, 19.0-23.0]; HOS-ADL, 16.6 [95% CI, 14.6-18.6]; HOS-SSS, 30.1 [95% CI, 26.6-33.6]; and iHOT-33 score, 34.9 [95% CI, 31.5-38.3]; P < .001). There was no evidence of a difference in follow-up survey scores between groups (P > .203). Revision surgery was required in 2 adolescent hips (5.3% [95% CI, 1.5%-17.3%]) and 19 non-adolescent hips (6.2% [95% CI, 4.0%-9.5%]). Minimum 2-year radiographs were available for review in 24 adolescent patients (30 hips). The alpha angle (mean ± standard deviation) was reduced from 55.4° ± 12.1° preoperatively to 38.7° ± 4.9° at 6 weeks postoperatively (mean difference, -16.4° [95% CI, -19.8° to -12.9°]; P < .001). At 2 years, the alpha angle remained at 39.2° ± 11.2°, which did not differ from 6-week measurements (mean difference, 0.5° [95% CI, -2.9° to 3.9°]; P = .784). There were no cases of cam recurrence (0% [95% CI, 0%-11.4%]). CONCLUSIONS: Significant improvement in clinical outcomes can be anticipated after arthroscopic treatment of FAI in adolescents. From a limited sample of our adolescent population, the risk of cam recurrence appears low; however, further follow-up is needed to ensure this does not represent a biased sample of the initial population. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Diagnosis of Intraabdominal Fluid Extravasation After Hip Arthroscopy With Point-of-Care Ultrasonography Can Identify Patients at an Increased Risk for Postoperative Pain.

BACKGROUND: Intraabdominal fluid extravasation (IAFE) after hip arthroscopy has historically been diagnosed in catastrophic circumstances with abdominal compartment syndrome requiring diuresis or surgical decompression. A previous retrospective study found the prevalence of symptomatic IAFE requiring diuresis or decompression to be 0.16%, with risk factors including surgical procedure and high pump pressures. IAFE can be diagnosed rapidly by using point-of-care ultrasound (POCUS) via the Focused Assessment With Sonography for Trauma (FAST) examination, which is a well-established means to detect free fluid with high specificity and sensitivity. In this study, we used POCUS to determine the incidence of IAFE in patients undergoing hip arthroscopy. We predicted a higher incidence and that patients with IAFE would have symptoms of peritoneal irritation such as pain and nausea. METHODS: One hundred patients undergoing ambulatory hip arthroscopy were prospectively enrolled. A FAST examination was performed after induction by a trained anesthesiologist to exclude the preoperative presence of intraperitoneal fluid. Postoperatively, the same anesthesiologist repeated the FAST examination, and patients with new fluid in the abdominal or pelvic peritoneum were diagnosed with IAFE. Patients were followed up in the postanesthesia care unit (PACU) for 6 hours assessing pain, antiemetic and opioid use, and length of stay. RESULTS: Sixteen of 100 patients were found to have IAFE (16.0%; 99% confidence interval [CI], 8.4-28.1). These patients had, on average, a greater increase in pain score from their baseline assessment throughout their entire PACU stay (adjusted difference in means [99% CI]: 2.1 points [0.4-3.9]; P = .002). Patients with IAFE used more opioids, but this difference did not meet statistical significance (adjusted difference in means [99% CI]: 7.8 mg oral morphine equivalents [-2.8 to 18.3]; P = .053). There were no differences in postoperative nausea interventions or length of stay. CONCLUSIONS: Our incidence of IAFE was 16%, showing that IAFE occurs quite commonly in hip arthroscopy. Patients with IAFE had a greater increase in pain scores from baseline throughout the PACU stay. None of our patients required interventions. These findings suggest that even a small amount of new fluid in the peritoneum may be associated with a worse postoperative experience. This study brings awareness to a common yet potentially life-threatening complication of hip arthroscopy and highlights a unique and meaningful way that anesthesiologists in the perioperative setting can use POCUS to rapidly identify and guide management of these patients. Further studies with a larger sample size are needed to identify surgical and patient risk factors.