CHRONIC UCL INJURY: A MULTIMODAL APPROACH TO CORRECTING ALTERED MECHANICS AND IMPROVING HEALING IN A COLLEGE ATHLETE- A CASE REPORT.

BACKGROUND: Ulnar collateral ligament (UCL) tears and associated Tommy Johns surgical intervention from excessive and poor quality pitching has increased immensely-with more college and professional pitchers undergoing the surgery in 2014 alone than in the 1990s as a whole.(1) Faulty mechanics developed at young ages are often well-engrained by the late adolescent years and the minimal healing ability of the largely avascular UCL often leads to delayed safe return to sport.(2). PURPOSE: The purpose of this case study was to describe an innovative, multimodal approach to conservative management of a chronic UCL injury in a college-aged baseball pitcher. This innovative approach utilizes both contractile and non-contractile dry needling to enhance soft tissue healing combined with standard conservative treatment to decrease pain and improve sport performance as measured by the Disabilities of Arm, Shoulder and Hand (DASH), Numeric Pain Report Scale (NPRS), and return to sport. STUDY DESIGN: Retrospective Case Report. CASE DESCRIPTION: A collegiate athlete presented to an outpatient orthopedic physical therapy clinic for treatment of UCL sprain approximately six weeks post-injury and platelet-rich plasma injection. Diagnostic testing revealed chronic ligamentous microtrauma. Impairments at evaluation included proximal stabilizing strength deficits, myofascial trigger points throughout the dominant upper extremity, improper pitching form, and inability to pitch in game conditions due to severe pain. Interventions included addressing strength deficits throughout the body, dry needling, and sport-specific biomechanical training with pitching form analysis and correction. OUTCOMES: Conventional DASH and Sport-Specific scale on the DASH and the numeric pain rating scale improved beyond both the minimally clinically important difference and minimal detectable change over the 12 week treatment(3,4) At 24-week follow up, conventional DASH scores decreased from 34.20% disability to 3.33% disability while sport-specific DASH scores decreased from 100% disability to 31.25% disability. Although initially unable to compete due to high pain levels, the subject is currently completing his pitching role full-time with 1/10 max pain. DISCUSSION: The approach used in this case study provides an innovative approach to conservative UCL partial tear treatment. Dry needling of both contractile and non-contractile tissue in combination with retraining of faulty mechanics may encourage chronically injured ligamentous tissue healing and encourage safe return to sport. LEVEL OF EVIDENCE: Level 4.

Infection parameters in the sand fly vector that predict transmission of Leishmania major.

To identify parameters of Leishmania infection within a population of infected sand flies that reliably predict subsequent transmission to the mammalian host, we sampled groups of infected flies and compared infection intensity and degree of metacyclogenesis with the frequency of transmission. The percentage of parasites within the midgut that were metacyclic promastigotes had the highest correlation with the frequency of transmission. Meta-analysis of multiple transmission experiments allowed us to establish a percent-metacyclic "cutoff" value that predicted transmission competence. Sand fly infections initiated with variable doses of parasites resulted in correspondingly altered percentages of metacyclic promastigotes, resulting in altered transmission frequency and disease severity. Lastly, alteration of sand fly oviposition status and environmental conditions at the time of transmission also influenced transmission frequency. These observations have implications for transmission of Leishmania by the sand fly vector in both the laboratory and in nature, including how the number of organisms acquired by the sand fly from an infection reservoir may influence the clinical outcome of infection following transmission by bite.

Demonstration of genetic exchange during cyclical development of Leishmania in the sand fly vector.

Genetic exchange has not been shown to be a mechanism underlying the extensive diversity of Leishmania parasites. We report here evidence that the invertebrate stages of Leishmania are capable of having a sexual cycle consistent with a meiotic process like that described for African trypanosomes. Hybrid progeny were generated that bore full genomic complements from both parents, but kinetoplast DNA maxicircles from one parent. Mating occurred only in the sand fly vector, and hybrids were transmitted to the mammalian host by sand fly bite. Genetic exchange likely contributes to phenotypic diversity in natural populations, and analysis of hybrid progeny will be useful for positional cloning of the genes controlling traits such as virulence, tissue tropism, and drug resistance.