Forearm Flexor Injuries Among Major League Baseball Players: Epidemiology, Performance, and Associated Injuries.

BACKGROUND: Despite evidence highlighting the importance of the forearm flexor muscles of elite baseball players, no studies have reported on the epidemiology of flexor strains and their associated outcomes. PURPOSE: To examine the incidence, associated injuries, and outcomes associated with forearm flexor injuries among major and minor league baseball players. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Injury data attributed to forearm flexor injuries among Major League Baseball (MLB) and minor league teams between 2010 and 2014 were obtained from the professional baseball Health and Injury Tracking System. This analysis included the number of players injured, seasonal timing of injury, days spent on the disabled list (DL), preinjury performance data, and subsequent injuries. RESULTS: A total of 134 and 629 forearm flexor injuries occurred in MLB and the minor leagues, respectively. The mean player age was 28.6 and 22.8 years in the MLB and minor leagues, respectively. The mean time spent on the DL for MLB players was 117.0 days, as opposed to 93.9 days in the minor leagues ( P = .272). Interestingly, pitcher performance declined in all categories examined leading up to the season of injury, with significant differences in walks plus hits per inning pitched ( P = .04) and strike percentage ( P = .036). Of MLB players with a forearm injury, subsequent injuries included 50 (37.3%) shoulder, 48 (35.8%) elbow, and 24 (17.9%) forearm injuries. Among injured minor league players, subsequent injuries included 170 (27.0%) shoulder, 156 (24.8%) elbow, and 83 (13.2%) forearm injuries. These rates of subsequent injuries were significantly higher compared with the rates of injuries sustained among players without forearm injuries in both leagues ( P < .001). Finally, 26 (19.4%) MLB and 56 (8.9%) minor league players required an ulnar collateral ligament reconstruction, rates that were significantly higher compared with players without a flexor strain ( P < .001). CONCLUSION: Flexor-pronator injuries are responsible for considerable time spent on the DL for elite players in MLB and the minor leagues. The most significant findings of this investigation illustrate that a flexor strain may be a significant risk factor for subsequent upper extremity injuries, including an ulnar collateral ligament tear.

Pectoralis Minor Contracture in Throwing Shoulders of Asymptomatic Adolescent Baseball Players.

BACKGROUND: Although scapular malpositioning is commonly associated with rotational deficits and risk of injury, modifiable causes of such malpositioning in overhead athletes are not well described. PURPOSE/HYPOTHESIS: The purpose of this study was to examine the scapulothoracic profile of adolescent baseball players, specifically, pectoralis minor (PM) length. We hypothesized that PM would be shorter in throwing shoulders compared with nonthrowing shoulders. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Forty-nine healthy adolescent baseball players underwent clinical screening of PM lengths in throwing and nonthrowing shoulders by means of previously described, validated techniques. PM measurements were conducted while players were supine with arms at rest, sitting with arms at rest, and sitting with shoulders in maximal external rotation; measurements were made with a digital caliper and by assessment of table-to-acromion distance. Static scapular position and range of motion measurements were recorded. Demographic information and playing history were documented. RESULTS: All players were male, they had a mean ± SD age of 16.2 ± 1.16 years, and they predominantly threw right-handed (83.7%). Sixty-nine percent of players were pitchers, 61.2% had played baseball for 9 or more months per year, and 67.3% had played in excess of 30 games in the previous year. Significant differences were noted during side-to-side comparisons within participants. Absolute PM length was significantly shorter in throwing compared with nonthrowing shoulders when measured with players sitting with arms at rest (by 3.7 ± 11.8 mm) and with their shoulders in maximal external rotation (by 4.8 ± 15.1 mm) (P < .004 for both). The PM index was significantly reduced in throwing compared with nonthrowing shoulders while players were supine with arms at rest (P = .007), sitting with arms at rest (P = .006), and sitting with shoulders in maximal external rotation (P < .001). Mean table-to-acromion distance was increased 7.7 ± 1.26 mm in throwing versus nonthrowing arms (P < .001). The scapular index was significantly reduced in throwing compared with nonthrowing shoulders (P < .005). CONCLUSION: Asymptomatic adolescent baseball players have significant differences in PM length and static scapular measurements in throwing compared with nonthrowing shoulders. The clinical significance requires further investigation, but emphasis on PM stretching routines is encouraged.

Quantifying Parental Influence on Youth Athlete Specialization: A Survey of Athletes' Parents.

BACKGROUND: Youth athlete specialization has been linked to decreased enjoyment, burnout, and increased injury risk, although the impact of specialization on athletic success is unknown. The extent to which parents exert extrinsic influence on this phenomenon remains unclear. PURPOSE/HYPOTHESIS: The goal of this study was to assess parental influences placed on young athletes to specialize. It was hypothesized that parents generate both direct and indirect pressures on specialized athletes. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A survey tool was designed by an interdisciplinary medical team to evaluate parental influence on youth specialization. Surveys were administered to parents of the senior author's orthopaedic pediatric patients. RESULTS: Of the 211 parents approached, 201 (95.3%) completed the assessment tool. One-third of parents stated that their children played a single sport only, 53.2% had children who played multiple sports but had a favorite sport, and 13.4% had children who balanced their multiple sports equally. Overall, 115 (57.2%) parents hoped for their children to play collegiately or professionally, and 100 (49.7%) parents encouraged their children to specialize in a single sport. Parents of highly specialized and moderately specialized athletes were more likely to report directly influencing their children's specialization (P = .038) and to expect their children to play collegiately or professionally (P = .014). Finally, parents who hired personal trainers for their children were more likely to believe that their children held collegiate or professional aspirations (P = .009). CONCLUSION: Parents influence youth athlete specialization both directly and by investment in elite coaching and personal instruction. Parents of more specialized athletes exert more influence than parents of unspecialized athletes.

Factors That Drive Youth Specialization.

BACKGROUND: Specialization in young athletes has been linked to overuse injuries, burnout, and decreased satisfaction. Despite continued opposition from the medical community, epidemiological studies suggest the frequency is increasing. HYPOTHESIS: Extrinsic pressures in addition to individual aspirations drive this national trend in sports specialization. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 3. METHODS: A novel instrument assessing the driving factors behind youth specialization was generated by an interdisciplinary team of medical professionals. Surveys were administered to patients and athletes in the department's sports medicine clinic. RESULTS: The survey was completed by 235 athletes between 7 and 18 years of age, with a mean age of 13.8 ± 3.0 years. Athletes specialized at a mean age of 8.1 years, and 31% of athletes played a single sport while 58% played multiple sports but had a preferred sport. More than 70% of athletes had collegiate or professional ambitions, and 60% played their primary sport for 9 or more months per year, with players who had an injury history more likely to play year-round ( P < 0.01). Approximately one-third of players reported being told by a coach not to participate in other sports, with specialized athletes reporting this significantly more often ( P = 0.04). Half of the athletes reported that sports interfered with their academic performance, with older players stating this more frequently ( P < 0.01). CONCLUSION: Young athletes are increasingly specializing in a single sport before starting high school. While intrinsic drive may identify healthy aspirations, extrinsic influences are prevalent in specialized athletes. CLINICAL RELEVANCE: Extrinsic factors contributing to youth specialization were identified and compounded the deleterious sequelae of youth athlete specialization.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: Radiographic Characteristics.

PURPOSE: To provide a detailed account of the location of the long head of the biceps (LHB) tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis patients of similar characteristics. METHODS: Postoperative radiographs from a prospective group of all-arthroscopic suprapectoral LHB tenodeses were compared with a retrospective group of open subpectoral tenodeses. Digital anteroposterior images were used to measure distances from clinically pertinent radiographic landmarks to tenodesis tunnel sites. RESULTS: Forty patients (20 all-arthroscopic, 20 open) met the inclusion criteria. The inferior border of the bicipital groove was located a mean distance of 33.7 ± 6.9 mm from the top of the humeral head. The mean distance measured in the open group was approximately 28 mm (P < .001) distal compared with the arthroscopic group. The humeral diameter was 7.5 ± 5.4 mm narrower at the subpectoral tenodesis site (P < .001). All 20 patients in the open subpectoral group had tenodesis tunnels placed distal to the bicipital groove compared with 17 of 20 patients (85%) in the all-arthroscopic group. There were 2 cases of lateral wall cortical reaming during subpectoral tenodesis but no periprosthetic humeral fractures. There were 2 cases of bicortical reaming during the all-arthroscopic tenodesis with no known complications. CONCLUSIONS: The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Epidemiology of Medial Ulnar Collateral Ligament Reconstruction: A 10-Year Study in New York State.

BACKGROUND: Despite an increase in the prevalence of medial ulnar collateral ligament (UCL) reconstruction of the elbow in professional baseball and popularity within the media, there are no population-based studies examining the incidence of UCL reconstruction. PURPOSE: To examine the epidemiological trends of UCL reconstruction on a statewide level over a 10-year period. The primary endpoint was the yearly rate of UCL reconstruction over time; secondary endpoints included patient demographics, institution volumes, and concomitant procedures on the ulnar nerve. STUDY DESIGN: Descriptive epidemiology study. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) database contains records for each ambulatory discharge in New York State. This database was used to identify all UCL reconstructions in New York State from 2002 to 2011 using the outpatient CPT-4 (Current Procedural Terminology, 4th Revision) code. Assessed were patient age, sex, ethnicity, insurance status, and associated procedures, as well as hospital volume. RESULTS: There was a significant yearly increase in the number of UCL reconstructions (P < .001) performed in New York State from 2002 to 2011. The volume of UCL reconstructions increased by 193%, and the rate per 100,000 population tripled from 0.15 to 0.45. The mean ± SD age was 21.6 ± 8.89 years, and there was a significant trend for an increased frequency in UCL reconstruction in patients aged 17 to 18 and 19 to 20 years (P < .001). Male patients were 11.8 times more likely to have a UCL reconstruction than female patients (P < .001), and individuals with private insurance were 25 times more likely to have a UCL reconstruction than those with Medicaid (P = .0014). There was a 400% increase in concomitant ulnar nerve release/transposition performed over time in the study period, representing a significant increase in the frequency of ulnar nerve procedures at the time of UCL reconstruction (P < .001). CONCLUSION: The frequency of UCL reconstruction is steadily rising in New York State and becoming more common in adolescent athletes. Emphasis on public education on the risks of overuse throwing injuries and the importance of adhering to preventative guidelines is essential in youth baseball today.

Media perceptions of Tommy John surgery.

OBJECTIVES: The prevalence of medial ulnar collateral ligament (UCL) reconstruction is increasing in professional athletes and the delivery of baseball news by the media exerts a powerful influence on public opinion of the injury and surgery. The purpose of this investigation was to examine the media's perception regarding the causes of UCL injury as well as the indications, risks, benefits, and rehabilitation related to UCL reconstruction. STUDY DESIGN: Cross-sectional survey study, Level 3. METHODS: This study utilized an online thirty-question survey designed to assess an individual's perception of UCL reconstruction with regard to risk factors for injury, indications, benefits, surgical details, and rehabilitation. Eligible study participants were members of the media including print, internet, radio and/or television directly involved in the coverage of Major League Baseball (MLB). RESULTS: A total of 516 members of the media with a mean age of 43.6 years completed the survey. In nearly half (47.8%), professional baseball represented 76-100% of their total sports coverage responsibility. INDICATIONS: although the majority answered correctly, 45% did not know if an athlete needed an elbow injury as a prerequisite for UCL reconstruction and 25% believed the primary indication was performance enhancement. As percentage of baseball coverage increased, media members were less likely to believe that an elbow injury was not required (p = 0.038). BENEFITS: eighty percent recognized that pitching speed is typically reduced following surgery, but the remaining 20% felt that velocities actually increased compared with pre-injury velocities. Return to play: fifty-two percent overestimated the ability of pitchers to return to back to professional baseball and 51.2% believed return would occur in 12 or less months. Estimates were higher in those of older age (p = 0.032) and increased percentage of baseball coverage (p < 0.001). Overuse injuries: less than half (48.4%) believed the use of pitch counts to be important in the prevention of UCL injury and 33.2% felt that throwing injuries were not preventable in adolescent baseball. CONCLUSION: Common misconceptions exist regarding UCL reconstruction within the professional baseball media. Efforts for physicians to educate the media on the risks of overuse throwing injuries with emphasis on accurate indications, outcomes, and recovery of Tommy John Surgery are encouraged.

The knee arthroscopy learning curve: quantitative assessment of surgical skills.

PURPOSE: To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumulative Summation Test for Learning Curve (LC-CUSUM). METHODS: Twenty orthopaedic trainees in postgraduate year (PGY) 1 through 5 performed diagnostic knee arthroscopy and were evaluated intraoperatively with a validated 10-point knee task-specific checklist (TSCL) and 50-point global rating scale (GRS). A score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the knee TSCL was considered to indicate a successful procedure. For the LC-CUSUM analysis, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. A limit h equal to 1.6 was selected to give a true-discovery rate of 90% and a false-discovery rate of 10% over 50 procedures. RESULTS: A total of 340 consecutive procedures were performed by 20 trainees during the 12-month study period. The cumulative number of arthroscopic procedures performed by trainees before study start increased with increasing PGY. The median number of arthroscopic procedures performed per trainee was 16.5 (interquartile range, 14 to 21.75). Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13 to 20), and for the GRS by only a single trainee (5%), after 14 procedures. Threshold-adjusted curves stratified by PGY level enabled multiple trainees to achieve competency for both the TSCL and GRS. CONCLUSIONS: The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks. CLINICAL RELEVANCE: The LC-CUSUM is an effective method to evaluate procedure competence in arthroscopic training and can provide objective feedback and benchmarks in the learning phase.

Arthroscopic proficiency: methods in evaluating competency.

BACKGROUND: The current paradigm of arthroscopic training lacks objective evaluation of technical ability and its adequacy is concerning given the accelerating complexity of the field. To combat insufficiencies, emphasis is shifting towards skill acquisition outside the operating room and sophisticated assessment tools. We reviewed (1) the validity of cadaver and surgical simulation in arthroscopic training, (2) the role of psychomotor analysis and arthroscopic technical ability, (3) what validated assessment tools are available to evaluate technical competency, and (4) the quantification of arthroscopic proficiency. METHODS: The Medline and Embase databases were searched for published articles in the English literature pertaining to arthroscopic competence, arthroscopic assessment and evaluation and objective measures of arthroscopic technical skill. Abstracts were independently evaluated and exclusion criteria included articles outside the scope of knee and shoulder arthroscopy as well as original articles about specific therapies, outcomes and diagnoses leaving 52 articles cited in this review. RESULTS: Simulated arthroscopic environments exhibit high levels of internal validity and consistency for simple arthroscopic tasks, however the ability to transfer complex skills to the operating room has not yet been established. Instrument and force trajectory data can discriminate between technical ability for basic arthroscopic parameters and may serve as useful adjuncts to more comprehensive techniques. There is a need for arthroscopic assessment tools for standardized evaluation and objective feedback of technical skills, yet few comprehensive instruments exist, especially for the shoulder. Opinion on the required arthroscopic experience to obtain proficiency remains guarded and few governing bodies specify absolute quantities. CONCLUSIONS: Further validation is required to demonstrate the transfer of complex arthroscopic skills from simulated environments to the operating room and provide objective parameters to base evaluation. There is a deficiency of validated assessment tools for technical competencies and little consensus of what constitutes a sufficient case volume within the arthroscopy community.

The language of evidence based medicine: answers to common questions?

Evidence based medicine (EBM) is an expanding field that combines clinical intuition with the best available evidence in clinical decision making. The shift to evidence based rationale encourages educating future physicians to formulate appropriate research questions and develop critical appraisal skills that are needed to practice EBM. This article identifies areas where clinicians may struggle with epidemiological terminology when critically appraising the literature. A review of the relevant terminology encountered in studies that focus on therapy, harm, diagnosis and prognosis can be beneficial to the clinician and are explained within this article.