The Predictors of Surgery for Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears Change Over Time: Ten-Year Outcomes of the MOON Shoulder Prospective Cohort.

BACKGROUND: A prospective cohort study was conducted to assess the predictors of failure of nonoperative treatment, defined as the patient undergoing surgery for symptomatic, atraumatic full-thickness rotator cuff tears. We present the 10-year follow-up data of this population to determine if predictors for surgery change over time, and secondarily we report the outcomes of the cohort. METHODS: At the time of enrollment, demographic, symptom, rotator cuff anatomy, and patient-reported outcome data were collected in patients with symptomatic, atraumatic full-thickness rotator cuff tears. Patients underwent a standard physical therapy protocol for 6 to 12 weeks. Patient data were then collected at 1, 2, 5, 7, and 10 years. Failure of nonoperative treatment was defined as the patient electing to undergo surgery. RESULTS: Of the 452 patients in the original cohort, 20 patients (5%) withdrew from the study, 37 (9%) died before 10 years, and 40 (9%) were otherwise lost to follow-up. A total of 115 patients (27.0%) underwent a surgical procedure at some point during the 10-year follow-up period. Of these patients, 56.5% underwent surgery within 6 months of enrollment and 43.5%, between 6 months and 10 years. Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery. Workers' Compensation status and activity level were more important predictors of later surgery. Patient-reported outcome measures all improved following physical therapy. For patients who did not undergo a surgical procedure, patient-reported outcome measures did not decline over the 10-year follow-up period. CONCLUSIONS: Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery, whereas Workers' Compensation status and activity level were predictors of later surgery. Physical therapy was successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears at 10 years. Outcome measures improved with physical therapy and did not decline over the 10-year follow-up period. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Obesity is associated with muscle atrophy in rotator cuff tear.

Objective: The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears. Methods: This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis. Results: A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear. Conclusions: Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients. Level of Evidence: III.

High variability among surgeons in evaluation, treatment, and rehabilitation of medial ulnar collateral ligament injuries.

Hypothesis and/or Background: The incidence of elbow medial ulnar collateral ligament (MUCL) injuries has been increasing, leading to advances in surgical treatments. However, it is not clear that there is consensus among surgeons regarding diagnostic imaging, the indications for acute surgery and postoperative rehabilitation. The purpose of this study is evaluate surgeon variability in the presurgical, surgical, and postsurgical treatment of MUCL injuries regarding the imaging modalities used for diagnosis, indications for acute surgical treatment, and postoperative treatment recommendations for rehabilitation and return to play (RTP). Our hypothesis is that indications for acute surgical treatment will be highly variable based on MUCL tear patterns and that agreement on the time to RTP will be consistent for throwing athletes and inconsistent for nonthrowing athletes. Methods: A survey developed by 6 orthopedic surgeons with expertise in throwing athlete elbow injuries was distributed to 31 orthopedic surgeons who routinely treat MUCL injuries. The survey evaluated diagnostic and treatment topics related to MUCL injuries, and responses reaching 75% agreement were considered as high-level agreement. Results: Twenty-four surgeons responded to the survey, resulting in a 77% response rate. There is 75% or better agreement among surveyed surgeons regarding acute surgical treatment for distal full thickness tears, ulnar nerve transposition in symptomatic patients or with ulnar nerve subluxation, postoperative splinting for 1-2 weeks with initiation of rehabilitation within 2 weeks, the use of bracing after surgery and the initiation of a throwing program at 3 months after MUCL repair with internal brace by surgeons performing 20 or more MUCL surgeries per year. There were a considerable number of survey topics without high-level agreement, particularly regarding the indications for acute surgical treatment, the time to return to throwing and time RTP in both throwing and nonthrowing athletes. Discussion and/or Conclusion: The study reveals that there is agreement for the indication of acute surgical treatment of distal MUCL tears, duration of bracing after surgery, and the time to initiate physical therapy after surgery. There is not clear agreement on indications for surgical treatment for every MUCL tear pattern, RTP time for throwing, hitting and participation in nonthrowing sports.

Most Anterior Cruciate Ligament Injuries in Professional Athletes Occur Without Contact to the Injured Knee: A Systematic Review of Video Analysis Studies.

PURPOSE: To systematically review studies using video analyses to evaluate anterior cruciate ligament (ACL) injury mechanisms in athletes during sport to better understand risk factors and the potential for injury prevention. METHODS: A literature search was conducted in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines statement using SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials from database inception through June 2023. Inclusion criteria included studies reporting on ACL injury mechanisms occurring in athletes based on video analysis. Athlete demographics, injury mechanisms, position of the lower extremity, and activity at the time of injury were recorded. RESULTS: A total of 13 studies, consisting of 542 athletes, met inclusion criteria. Most athletes competed at the professional level (91%, n = 495/542), with 79% (n = 422/536) of athletes being male. The most common sports were soccer (33%, n = 178/542) and American football (26%, n = 140/542). The most common injury mechanism was noncontact in 42.9% (n = 230/536) of athletes, followed by indirect contact (32.6%, n = 175/536) and direct contact (22.4%, n = 120/536). The most common position of injury was with a planted foot (91.7%, n = 110/120), full or near-full knee extension (84.4%, n = 49/58), and axial loading (81.3%, n = 87/107). Injuries commonly involved a deceleration/shift in momentum (50.4%, n = 123/244) or pivoting maneuver (36.1%, n = 77/213). At the time of injury, the knee commonly fell into valgus (76.8%, n = 225/293) with associated internal (53.5%, n = 46/86) or external tibiofemoral rotation (57.7%, n = 101/175). CONCLUSIONS: Most ACL injuries, when evaluated by video analysis, involve professional athletes participating in soccer and American football. The most common injury mechanism occurred without contact with the knee in extension during a deceleration or momentum shift, with resultant valgus and rotational force across the knee. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Isolated, Proximal Tibiofibular Injuries in Athletic Patients: A Critical Analysis Review.

While infrequently reported, isolated injuries to the proximal tibiofibular (TF) joint primarily occur in young, athletic patients participating in sporting activities requiring explosive, high-impact movements, increasing the risk for potential twisting injuries, especially across a hyperflexed knee. The proximal TF joint is stabilized by bony, muscular and ligamentous structures, including both the anterior and posterior proximal TF complexes, with the anterior complex providing more robust stability. Proximal TF injuries frequently involve anterior and lateral displacement of the proximal fibula relative to its native articulation with the tibia. Proper diagnosis is dependent on careful and meticulous history and physical examination, as missed injuries are common, leading to the potential for continued pain, weakness and disability, especially in athletic patients. While spontaneous joint reduction has been reported, injuries may require formal closed reduction, with irreducible and chronic injuries requiring open reduction and stabilization, with recent investigations reporting satisfactory outcomes following anatomic reconstruction of the proximal TF ligament.

Relationship between Kinesiophobia and Dynamic Postural Stability after Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study.

INTRODUCTION: Anterior cruciate ligament (ACL) injuries in young, active patients generally require ACL reconstruction (ACLR) to restore mechanical and postural stability. The fear of movement or reinjury (kinesiophobia) has become increasingly recognized in the post-ACLR population; however, the association between restoration of postural stability and kinesiophobia remains largely unknown. The purpose of this study was to investigate changes in mean Tampa Scale of Kinesiophobia-11 (TSK-11), dynamic motion analysis (DMA) scores, and time on the testing platform, as well as any correlation between TSK-11 and mean overall and individual translational and rotational DMA scores during the first 12 months following ACLR. DESIGN: Cohort study. METHODS: Patients undergoing ACLR were prospectively enrolled and dynamic postural stability and kinesiophobia based on the TSK-11 were collected within 2 days prior to surgery and at 6 and 12 months following ACLR. Dynamic postural stability was quantified by calculating a DMA score, with score calculated in three translational (anterior/posterior [AP], up/down [UD], medial/lateral [ML]) and three rotational (left/right [LR], flexion/extension, and internal/external rotation) independent planes of motions. Correlations between DMA and TSK-11 scores at each time point were analyzed. RESULTS: A total of 25 patients meeting inclusion criteria were analyzed. Mean overall DMA and TSK-11 scores increased with each successive testing interval. At 6-month follow-up, a weakly positive association between TSK-11 and DMA scores was appreciated based on overall DMA, AP, UD, ML, and LR. At 12 months, a moderately positive correlation was appreciated between TSK-11 and the translational, but not rotational, planes of motion. CONCLUSIONS: Following ACLR, lower level of kinesiophobia were found to be moderately associated with improved dynamic stability, especially in the translation planes of motion.

Degenerative Meniscus Tears Treated Nonoperatively With Platelet-Rich Plasma Yield Variable Clinical and Imaging Outcomes: A Systematic Review.

Purpose: To perform a systematic review on clinical and radiologic outcomes for meniscus tears treated nonoperatively with platelet-rich plasma (PRP). Methods: A literature search was performed according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using keywords and Boolean operators in SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials in April 2023. Inclusion criteria were limited to Level I to IV human studies reporting on outcomes of meniscus tears treated nonoperatively with PRP. Results: A total of 6 studies, consisting of 184 patients, were identified. There was 1 Level I study and 5 Level IV studies. Mean patient age was 47.8 ± 7.9 years, with 62% (n = 114/184) being female. The medial meniscus was treated in 95.7% (n = 157/164) of patients. Mean follow-up ranged from 75.9 days to 31.9 months. Meniscus tears were generally described as chronic, degenerative, or intrasubstance. In 4 studies, magnetic resonance imaging revealed variable improvement in meniscus grade with complete healing in 0% to 44% of patients and partial healing in 0% to 40% of patients. Four of 5 studies reported significant statistical improvement in pain from baseline to final follow-up. Studies reporting on clinical outcomes showed significant improvements Lysholm score (2 studies), Knee injury and Osteoarthritis Outcome Score total score (2 studies), and Tegner score (1 study). Successful return to sport occurred in 60% to 100% of patients. Two studies reported that most patients were either very satisfied or satisfied following treatment. Conclusions: The use of PRP injections for the treatment of meniscus tears led to variable results based on postoperative magnetic resonance evaluation and improvements in clinical outcomes, although the clinical significance remains unclear. The heterogeneity of PRP protocols, short-term follow-up, and lack of comparative studies limit findings. Level of Evidence: Level IV, systematic review of Level I to IV studies.

Interval Throwing Programs for Baseball Players: Methodological Assessment of the Quality and Construct of Publicly Available Programs.

CONTEXT: The quality and interprogram variability of publicly available throwing programs have not been assessed. OBJECTIVE: To (1) identify publicly available interval throwing programs, (2) describe their components and structure, and (3) evaluate their quality, variability, and completeness. DATA SOURCES: Google, Bing, Yahoo; keyword: "interval throwing program." STUDY SELECTION: Baseball-specific publicly available programs. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Independent evaluation by 2 authors using a novel 21-item Quality Assessment Rubric (QAR). RESULTS: Of the 99 included programs, 54% were designed for return from injury/surgery; 42% explicitly stated no expected timeline for completion, and approximately 40% did not provide criteria to initiate the program. Program construction was highly variable. There were broad-ranging shortest (mean: 40±8 ft, range: 20-45 ft) and longest (mean: 150±33 ft, range: 90-250 ft) long toss distances, and variable maximum numbers of mound pitches thrown before returning to game play (range: 40-120, mean: 85). Only 63% of programs provided guidelines for handling setbacks, and standardized warm-ups, arm care, and concomitant training were absent in 32%, 63%, and 47% of programs, respectively. Mean QAR completion rate and QAR item response rate were low (62 ± 4% [range, 24-91%], 62 ± 24% [range, 7-99%], respectively). Finally, only 20 (20%) programs provided at least 1 peer-reviewed reference, most of which were published >10 years ago. CONCLUSION: Publicly available interval throwing programs are readily available but demonstrate significant interprogram heterogeneity across multiple areas including target audience, program construction, progression, and execution. The quality and consistency of publicly available interval throwing programs is poor at this time, which may limit their utility and effectiveness for baseball players attempting to return to competition. This work identifies a multitude of deficiencies in currently available throwing programs that should be targets of future improvement efforts.

Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review.

PURPOSE: To systematically review (1) biomechanical properties of augmented elbow ulnar collateral ligament (UCL) repair compared with reconstruction and (2) clinical efficacy and complication rates of UCL repair with and without augmentation. METHODS: A systematic review was completed August 15, 2023, identifying articles that (1) biomechanically compared suture augmented UCL repair and reconstruction and (2) clinically evaluated medial elbow UCL repairs. Search terms included: "UCL repair" OR "internal brace" OR "suture augmentation" AND "UCL reconstruction." For inclusion, biomechanical studies compared augmented repair with reconstruction; clinical studies required clinical outcomes with minimum 6-month follow-up. Biomechanical data included torsional stiffness, gap formation, peak torque, and failure torque. Clinical data included return to previous level of play, time to return, functional outcomes, and complications. RESULTS: In total, 8 biomechanical and 9 clinical studies were included (5 with and 4 without augmentation). In most biomechanical studies, augmented repairs demonstrated less gap formation, with equivalent torsional stiffness, failure load, and peak torque compared with reconstruction. Clinical outcomes in 104 patients without augmentation demonstrated return to previous level of 50% to 94% for nonprofessional athletes and 29% for professional baseball pitchers. Suture augmented repairs in 554 patients demonstrated return to previous level from 92% to 96%, at 3.8 to 7.4 months, with Kerlan Jobe Orthopaedic Clinic scores of 86 to 95. The overall complication rate for augmented UCL repair was 8.7%; most commonly ulnar neuropraxia (6%). CONCLUSIONS: Biomechanically, UCL repair with augmentation provided less gapping with equivalent torsional stiffness and failure compared with reconstruction. Clinically, augmented UCL repair demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return. Augmented UCL repair is biomechanically equivalent to reconstruction and may be a viable alternative to reconstruction in indicated athletes. CLINICAL RELEVANCE: UCL repair with suture augmentation is biomechanically equivalent to reconstruction and clinically demonstrates excellent outcomes.

Elbow Ulnar Collateral Ligament Tears in 2023: Evaluation and Management.

The ulnar collateral ligament, also called the medial collateral ligament of the elbow, is the primary stabilizer against valgus loads. This ligament can be traumatically torn, such as in an elbow dislocation, or can tear through attritional damage with overhead sports. Although baseball pitching is the most common contributor, these injuries also occur with volleyball, gymnastics, and javelin throwing. Patients most commonly report a history of medial elbow pain with associated loss of command, control, and throw velocity. The ulnar nerve lies directly superficial to the posterior band of the ulnar collateral ligament and ulnar neuritis is commonly associated with ulnar collateral ligament pathology. Nonsurgical treatment, including rest from activity, flexor-pronator strengthening, and possible platelet-rich plasma injections, can be considered for partial-thickness tears. Surgical treatment can be considered for patients in whom nonsurgical treatment fails and full-thickness tears. Historically, surgical treatment involved reconstruction of the ligament with a tendon graft. Ipsilateral palmaris longus autograft has been the most commonly used graft, but contralateral palmaris, autograft hamstring tendons, and allograft tendon have also been used. This procedure has a high rate of return to play and a low complication rate, but most athletes require 12 to 18 months to fully return. More recently, repair of the ligament, with the addition of a biologic ingrowth ligament augmentation suture, has demonstrated similarly high rates of return to play and low complication rates, with a full return to play in 6 months.

Global variations in treatment and outcomes reported for anterior shoulder instability: a systematic review of the literature.

Background: Anterior shoulder instability is a common problem around the world, with a high risk for recurrence following the index dislocation. Surgical stabilization is commonly indicated for persistent instability, particularly in patients at high risk for recurrence, to minimize the risk of further labral injury and glenoid bone loss. However, there is little known about global geographic differences in the surgical management of anterior shoulder instability. As such, the purpose of this study was to evaluate and systematically review regional differences in the surgical treatment of anterior shoulder instability, particularly the indications for and outcomes from bony stabilization procedures compared to soft tissue procedures. Methods: A systematic review, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was performed. Inclusion criteria consisted of level I and II evidence studies evaluating indications, techniques, and outcomes following operative management of anterior shoulder instability published from January 2000 to September 2021. Studies meeting inclusion criteria were grouped into four global regions (Asia, Europe, North America, South America) based on primary study location. Patient demographics, procedural details, patient reported outcomes, and complications (recurrence and reoperation rates) were compared between regions. Results: Sixty (n = 60) studies (5480 patients) were identified. Eighty-six percent of all patients were male, with a mean age of 26.7 years. There was no difference in mean patient age, though patients undergoing bony stabilization procedures were older than those undergoing soft-tissue stabilization procedures (P = .0002) in all regions. The proportion of bony versus soft-tissue procedure groups did not differ significantly among regions. The indications for bony stabilization procedures varied significantly. Mean final follow-up was 3.5 years. Recurrent instability was 5.0% and did not vary across regions. However, recurrent instability occurred more frequently following soft-tissue compared to bony stabilization procedures (P = .017). South American studies utilized fewer anchors during soft tissue stabilization (P < .0001) and reported a higher reoperation rate compared to other regions (P = .009). Conclusion: There is global variation in the reporting of outcomes following surgery for anterior shoulder instability. The proportion of bony and soft-tissue procedures is similar, irrespective of geographic region. Recurrent instability does not vary by region but occurs more frequently following soft-tissue compared to bony stabilization procedures. There are a number of potential medical and nonmedical factors that may affect global variation in the surgical treatment of anterior shoulder instability.

Early single sport specialization does not improve pitching velocity, motion, strength, or utilization in high school baseball pitchers.

Background: The impact of single-sport specialization on performance and injury risk in youth and adolescent athletes remains debated. The purpose of this study was to determine the incidence of single-sport specialization and its association with pitch velocity, pitcher utilization, range of motion, strength, and injury history. Methods: High school pitchers in the Northeastern, Southeastern, Midwestern, and Western Regions of the United States were prospectively recruited. Prior to the season, pitchers were surveyed about their basic demographics, sport participation history, and injury history. At this timepoint, a standardized physical examination was performed and max pitch velocity was measured. They were then prospectively followed over the ensuing high school season, where pitch utilization and counts were followed and injuries were tracked. Results: Across the study, 115 pitchers were recruited, of whom 53% played baseball as their only sport and 47% played other sports. Single- position specialization within baseball was uncommon as 90% of athletes played positions other than pitcher. There were no differences in range of motion, strength, or pitch velocity between multisport athletes and single-sport specialists. Within the multisport group, 26% reported a history of injury, while 38% of the single-sport specialists reported a history of injury (P = .179). There were no significant differences in pitcher utilization between multisport athletes and single-sport specialists. Only a single prospective injury occurred in the 115 players. Conclusion: Although single-sport specialization is common, nearly half of all high school pitchers in this study were multisport athletes. While injury history was generally similar between the two groups, single-sport baseball players did not have the following: improved motion, increased strength, higher ball velocity, or greater pitching volumes during the high school baseball season compared to multisport athletes. Accordingly, single-sport specialization did not have a competitive advantage for these high school pitchers based on the performance factors studied. Further prospective studies are necessary to understand the association between single-sport specialization and injury risk in high school baseball players.

Factors Associated With Humeral Avulsion of Glenohumeral Ligament Lesions in Patients With Anterior Shoulder Instability: An Analysis of the MOON Shoulder Instability Cohort.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability. Purpose: To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups. Results: A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001). Conclusion: Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions.

Characteristics Associated With Noncompliance of Current Pitch Smart Guidelines in High School Baseball Pitchers Throughout the United States.

Background: Although pitch count and rest guidelines have been promoted for youth and adolescent baseball players for nearly 2 decades, compliance with guidelines remains poorly understood. Purpose/Hypothesis: The purpose of this study was to determine the frequency of compliance with Major League Baseball (MLB) Pitch Smart guidelines as well as the association between compliance and range of motion (ROM), strength, velocity, injury, and pitcher utilization. It was hypothesized that pitchers in violation of current recommendations would have increased strength, velocity, and injury. Study Design: Case-control study; Level of evidence, 3. Methods: This was a prospective, multicenter study of 115 high school pitchers throughout the United States. Pitchers were surveyed about their compliance with current off-season, rest-related guidelines, and history of injury. During the preseason, pitchers underwent standardized physical examinations, and pitch velocity was measured. Pitch counts were collected during the baseball season that followed. Dynamometer strength testing of shoulder forward flexion, and external rotation as well as grip strength was recorded. We compared pitchers who were compliant with recommendations with those who were noncompliant using Student t and Mann-Whitney U tests. Results: Based on preseason data, 84% of pitchers had violated current Pitch Smart guidelines. During the season, 14% had at least 1 violation of the Pitch Smart guidelines. Across both the preseason survey and in-season pitch counts, 89% of players had at least 1 violation of the Pitch Smart guidelines. While there were no significant differences in ROM or strength, the noncompliant group had higher maximum pitch velocity than the compliant group (74 ± 8 vs 69 ± 5 mph [119 ± 13 vs 111 ± 8 kph], respectively; P = .009). Players' self-reported velocity differed significantly from the direct measurement, for both peak velocity (80 ± 6 vs 73 ± 8 mph [129 ± 9 vs 117 ± 13 kph], respectively; P < .001) and mean velocity (73 ± 8 vs 53 ± 27 mph [117 ± 13 vs 85 ± 43 kph], respectively; P < .001). Conclusion: Most high school pitchers were not fully compliant with current Pitch Smart guidelines, and they tended to overestimate their peak velocity by 7 mph (11 kph). Pitchers who threw with greater velocity were at higher risk for violating Pitch Smart recommendations.

Most high school baseball pitchers are using weighted ball throwing programs to increase ball velocity: crosssectional analysis of US high school pitchers.

Background: Weighted-ball velocity training programs are popular but may be associated with increased injury risk. The purpose of this study was to determine the current frequency of these programs, as well as their association with range of motion, strength, velocity, injury, and utilization in high school baseball pitchers. Methods: This was a multicenter, prospective, community-based study including high schools from the Northeastern, Southeastern, Midwestern, and Western regions of the United States. Preseason pitchers were surveyed about their use of weighted ball velocity programs and history of injury. Preseason pitchers underwent standardized physical examinations and pitch velocity was measured. During a single high school season, pitch counts and injury incidence were prospectively collected. Results: In total, 115 pitchers were recruited, of whom 63% had participated in a weighted ball program. There were no differences in range of motion or strength between groups who used weighted balls and those who did not. Pitchers that utilized weighted ball programs demonstrated a higher average fastball velocity (114.26 vs. 106.22 km/h [71 vs. 66 mph]; P < .001) as well as peak fastball velocity (115.87 vs. 109.44 km/h [72 vs. 68 mph]; P = .001) compared to those that did not use weighted ball programs. Pitchers that utilized weighted ball programs were no more likely to be single-sport athletes (44%) than those who were multisport athletes (49%, P = .667). Within the group who had used a weighted ball program 29% (13/45) reported a history of injury and within the group who had not used a weighted ball program 25% (10/40) reported a history of injury (P = .687). As only a single injury occurred in the entire cohort, comparison of injury rates could not be completed. Conclusion: In this prospective study, the majority of high school pitchers reported using weighted ball programs to increase velocity, and these programs were associated with increased average and peak velocity compared to pitchers who did not use weighted ball programs. There were no significant differences in injury history between the 2 groups. Further study is necessary to understand the injury risk associated with weighted ball programs.

Reliability of ulnar collateral ligament findings in magnetic resonance imaging.

BACKGROUND: Ulnar collateral ligament (UCL) tears are common in baseball players. Although magnetic resonance imaging (MRI) is the most used imaging modality for UCL injuries, the inter-rater reliability of MRI analyzing specific characteristics of UCL pathology has not been defined. The purpose of this study was to define the inter-rater reliability of MRI for evaluating UCL characteristics. METHODS: Three surgeons analyzed 45 noncontrast MRIs: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with intraoperatively confirmed full-thickness tears. Findings evaluated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcifications, and partial- or full-thickness tearing) and location of the pathology (proximal, midsubstance, or distal). Fleiss' κ coefficients were used to assess interobserver reliability. RESULTS: There were high rates of agreement for midsubstance (κ: 0.50) and distal (κ: 0.69) ligament edema and proximal osseous edema (κ: 0.48). There were low rates of agreement for proximal ligament edema (κ: 0.08), ligament thickening (κ: -0.02 to 0.20), and proximal to midsubstance calcifications (κ: -0.04 to 0.10). Midsubstance (κ: 0.55) and distal full-thickness tears (κ: 0.63) demonstrated higher agreement than proximal (κ: 0.29). Proximal partial-thickness tears (κ: 0.45) had higher agreement than midsubstance (κ: -0.02) or distal (κ: -0.02). CONCLUSIONS: In our study, there was high inter-rater reliability regarding proximal osseous edema, midsubstance, and distal ligament edema and full-thickness tears. There was no agreement for midsubstance and distal partial-thickness UCL tears, but fair agreement for proximal tears. UCL tissue characteristics including ligament thickening and calcifications demonstrated low agreement. Challenges remain in effectively evaluating UCL tissue characteristics on noncontrast MRIs.

Predictors of Bone Loss in Anterior Glenohumeral Instability.

BACKGROUND: Anterior shoulder instability can result in bone loss of both the anterior glenoid and the posterior humerus. Bone loss has been shown to lead to increased failure postoperatively and may necessitate more complex surgical procedures, resulting in worse clinical outcomes and posttraumatic arthritis. HYPOTHESIS/PURPOSE: The purpose of this study was to investigate predictors of glenoid and humeral head bone loss in patients undergoing surgery for anterior shoulder instability. It was hypothesized that male sex, contact sport participation, traumatic dislocation, and higher number of instability events would be associated with greater bone loss. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 892 patients with anterior shoulder instability were prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort. The presence and amount of anterior glenoid bone loss and accompanying Hill-Sachs lesions were quantified. Descriptive information and injury history were used to construct proportional odds models for the presence of any bone defect, for defects >10% of the anterior glenoid or humeral head, and for combined bony defects. RESULTS: Anterior glenoid bone loss and Hill-Sachs lesions were present in 185 (20.7%) and 470 (52.7%) patients, respectively. Having an increased number of dislocations was associated with bone loss in all models. Increasing age, male sex, and non-White race were associated with anterior glenoid bone defects and Hill-Sachs lesions. Contact sport participation was associated with anterior glenoid bone loss, and Shoulder Actitvity Scale with glenoid bone loss >10%. A positive apprehension test was associated with Hill-Sachs lesions. Combined lesions were present in 19.4% of patients, and for every additional shoulder dislocation, the odds of having a combined lesion was 95% higher. CONCLUSION: An increasing number of preoperative shoulder dislocations is the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions, and combined lesions. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. Patients should be made aware of the expected course of shoulder instability, especially in athletes at high risk for recurrence and osseous defects, which may complicate care and worsen outcomes. REGISTRATION: NCT02075775 (ClinicalTrials.gov identifier).

Isolated, Full-Thickness Proximal Rectus Femoris Injury in Competitive Athletes: A Systematic Review of Injury Characteristics and Return to Play.

Background: Characteristics regarding mechanism of injury, management, and return-to-play (RTP) rate and timing are important when treating and counseling athletes with rectus femoris tears. Purpose: To systematically review the literature to better understand the prevalence, sporting activity, injury mechanisms, and treatment of patients with rectus femoris injury and to provide prognostic information regarding the rate and timing of RTP. Study Design: Systematic review; Level of evidence, 4. Methods: Following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we queried PubMed/MEDLINE, Cochrane, OVID, EMBASE, and Google Scholar in March 2022 for studies reporting on athletes sustaining isolated, full-thickness tearing, or bony avulsion injuries to the proximal rectus femoris during sporting activity. Excluded were studies without evidence of full-thickness tearing or avulsion, with athletes sustaining concomitant injuries, or with injuries occurring from nonsporting activities. The percentage of athletes sustaining injuries was calculated based on sport, injury mechanism, and management (nonoperative versus operative). Results: Of 132 studies initially identified, 18 were included, comprising 132 athletes (mean age, 24.0 ± 5.4 years; range, 12-43 years). The most common sporting activities were soccer (70.5%) and rugby (15.2%). The most reported mechanisms of injury were kicking (47.6%) and excessive knee flexion/forced hip extension (42.9%). Avulsion injuries were reported in 86% (n = 114) of athletes. Nonoperative management was reported in 19.7% of athletes, with operative management performed in 80.3%. The mean follow-up time was 21.4 ± 11.4 months (range, 1.5-48 months). The RTP rate was 93.3% (n = 14) in nonoperatively treated and 100% (n = 106) in operatively treated athletes, and the mean RTP time was 11.7 weeks (range, 5.5-15.2 weeks) in nonoperatively treated and 22.1 weeks (range, 14.0-37.6 weeks) in operatively treated athletes. Complications were reported in 7.7% (2/26) of nonoperatively treated and 18% (n = 19/106) of operatively treated athletes. Conclusion: Full-thickness proximal rectus femoris injuries occurred most frequently in athletes participating in soccer and rugby secondary to explosive, eccentric contractions involved in kicking and sprinting. Operative management was performed in the majority of cases. Athletes who underwent operative repair had a 100% RTP rate versus 93.3% in athletes treated nonoperatively.

What are the indications for medial ulnar collateral ligament surgery in baseball players? An MRI case-based study.

BACKGROUND: Ulnar collateral ligament (UCL) tears are common in baseball players. When nonoperative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs. reconstruction. METHODS: Twenty-six orthopedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, midsubstance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95% CI) helped identify significant predictors for both queries. RESULTS: The odds of recommending surgical treatment compared to nonoperative treatment were 2.4× more likely for a proximal partial-thickness tear, 3.2× for distal partial-thickness tear, 5.1× for distal full-thickness tear, and 7.0× for proximal full-thickness tear (P < .001). Significant indications for repair included distal partial (OR = 1.6, 95% CI 1.0, 2.1, P < .001) and full-thickness tears (OR = 1.7, 95% CI 1.1, 2.3, P < .001). Repair was 3× less likely recommended for midsubstance full-thickness tears (OR = 3.0, 95% CI -5.0, -1.0, P = .004). Ultrasound stress testing was requested in 78% of partial tears. CONCLUSIONS: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial-thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete midsubstance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes.

Magnetic Resonance Imaging Assessment of Cartilage Appearance Following Marrow Stimulation of Osteochondritis Dissecans of the Humeral Capitellum.

PURPOSE: Osteochondritis dissecans (OCD) of the capitellum is often treated by marrow stimulation techniques with good long-term outcomes. Magnetic resonance imaging (MRI) can be used to characterize the healing of cartilage repair tissue. However, no formal system exists for assessment of cartilage healing after marrow stimulation in capitellar OCD. The aims of this study were to describe the postoperative MRI appearance of capitellar repair cartilage after debridement and marrow stimulation for capitellar OCD and assess differences between symptomatic and asymptomatic patients. METHODS: This was a retrospective study of patients with capitellar OCD who underwent arthroscopic debridement and marrow stimulation and had a postoperative MRI to assess healing. The classification system developed by Marlovits and colleagues (Magnetic Resonance Observation of Cartilage Repair Tissue) was used to quantitatively profile the cartilage repair tissue in comparison to adjacent "normal" cartilage. Study participants completed an online survey to correlate outcomes with cartilage appearance. RESULTS: Eleven patients who underwent MRI for routine evaluation (asymptomatic), and 18 who underwent MRI for symptoms were identified. Overall, 59% of defects were completely filled, and in 83%, the cartilage surface had ulcerations or fibrillations. The cartilage variables were similar between symptomatic and asymptomatic patients. Capitellar subchondral bone edema was observed on the MRI of every patient who underwent a reoperation and was present in only 62% of those who did not. Clinical scores did not correlate with MRI cartilage findings, but the small sample size limited conclusions regarding clinical outcomes related to postoperative cartilage features seen on MRI. CONCLUSIONS: This detailed assessment of cartilage appearance by MRI after marrow stimulation for capitellar OCD demonstrated that incomplete cartilage fill was common in both symptomatic and asymptomatic patients. Those requiring a second surgery were more likely to demonstrate subchondral bone edema. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.