All right, let's go ahead and get started. Want to welcome everybody to virtual didactics today, but I might mix it up so you can see my face and recognize who you've been talking to for the past, what, month now. Want to welcome everybody to AAP virtual didactics. As always, we want to recognize and appreciate those of you who have been especially hard hit by the COVID-19 pandemic, recognize that that burden has not been borne equitably, and we appreciate those of you who have kind of been on the front lines dealing with most of this, whether it be personally or professionally. We appreciate you. If there's anything we can do to further support you, please let us know. So as always, the goals of this didactic series are to augment didactic curricula that are ongoing at your home institutions, to offload overstretched faculty due to some of the logistical challenges associated with this pandemic, to provide additional learning opportunities for off-schedule residents. Again, we know that some of the scheduling changes that have occurred due to COVID-19 have impacted many of us in training. So we want to provide additional learning opportunities there to develop further digital learning resources and to further support physiatrists during this COVID-19 pandemic. As always, we're going to keep everybody's video and audio muted. If you have any questions, again, my name is Sterling Herring. I'm a PGY3 at Vanderbilt. If you click on your participants button, you should see me up near the top somewhere. If you don't click my name, you can send me messages related to the content. If you have a question for our presenter, you can send that over to me, and that will kind of allow us to maintain some semblance of order and help us kind of keep things appropriate. So if you can send those questions to me, we can ask them at appropriate times. If you have any general questions related to the lecture series or any concerns, please email. Feel free to reach out to me, but you can also email Candice directly at the email there on the screen, or you can find us on Twitter. So without further ado, we're excited for today's presenter, Dr. Zaremski from the University of Florida. Welcome, Dr. Zaremski. Thanks. Thank you very much. Appreciate it. So let's see here. I'm going to un-video myself. Let me do my share screen. And let's get back to the… Perfect. We see you and hear you. All right. You guys see, or can someone let me know you can see the slides okay? We can see it just fine. It looks great. All right. Well, thank you to the AAP and this really dynamic thing that has been set up. Something's been set up around the country, not only for AAP, but other memberships, organizations, academic setups from undergrad on upwards. So hopefully this is going to be helpful. For those of you who may not know me or some of my research, my sort of niche area that I focus on is the throwing athlete. I was fortunate enough to go to Tufts for my PMR residency, but then I did a sports medicine fellowship at Geisinger, and I've been at University of Florida since 2012. And as a former collegiate baseball player, I focused on the elbow and the shoulder. So I'm going to go over, it's kind of a 10,000-foot view of pitching and really elbow injuries. So any good resident physiatrist, if you're seeing any of these student athletes or athletes elbow pain, you should have a really broad differential of what's going on and how to diagnose it and what you're looking for based on the age group. If there's questions, as we just mentioned, feel free to use the chat button. I have my email at the end. For those of you who don't know me or have my email, more than welcome to share the slides. And I think we'll get started. So I have no disclosures relevant to this talk. So really what we're going to try to do is talk about, like, why do we care about this? Outside of the fact, maybe, like, baseball or, like, elbow. But so we'll talk about the epidemiology. Very brief background on anatomy and biomechanics. We do not need to be MD, PhDs or biomechanists, but you do have to understand some of the very basic biomechanics when you're dealing with an overhead athlete and a throwing athlete. A couple of slides on why we get injured, and this would pertain not just to a thrower, but in anything, which I think is extremely important in physiatry. Understanding the mechanics of gaits, the mechanics of throwing, mechanics of prosthetics and orthotics. So all of this is important, and I have a couple slides on that. We'll then really start to take a little deeper dive into really the majority of nearly all elbow injuries related to throwing that I can think of. And then very briefly, we'll talk about some basic concepts of treatment and rehabilitation pertinent to these type of athletes, these types of patients. And obviously talk about the kinetic chain and some prevention. So in general, depending on which data set you look at, there are a ton of baseball players. There's more than 10,000 baseball players just at the NCAA D1 level, more than half a million high school age baseball players. There's a million little leaguers. And remember, we're not even taking into account Division II, Division III, junior college, and I'm not even mentioning softball. And just with baseball alone, if you look at some of the research all the way back from the 60s up until just a couple of years ago, there's a lot of shoulder and a lot of elbow pain. And in just one season, pain can range anywhere from about 20 to almost 50%. So this is really common. If you start looking at rates as opposed to just absolute numbers, you can see that high school baseball players' elbow injury rate is just under one per 10,000 athlete exposures. Now an athlete exposure, for those of you who aren't aware or haven't done the research on this, you have to define what that is. But typically, that means you're exposed to the event. So it could be exposure to one game or exposure to one practice. So for example, in one high school season, which is usually three months, that's six days a week times 12 weeks. So your exposure would be of that magnitude per player. So when you see 10,000 athlete exposures, that really is not that much. That can only be just a couple of high school baseball teams. There we go. From an anatomy standpoint, it is important to understand that when you're in full extension, when your elbow is fully extended, you have a normal valgus carrying angle, somewhere around 11 to 16 degrees is sort of the netter answer. But there is variability. You'd also have to understand that there's a lot of torque, a lot of force. There's a lot of angular velocity when you're throwing a ball, particularly as fast as with folks that we may see on TV. So your valgus torque can be as high as 65 newton meters. Your angular velocity can be as high as 5,000 degrees per second. And while you don't necessarily have to memorize the numbers from a physiatric residency standpoint, what you have to understand is it's a lot. There's a lot of force. There's a lot of speed. And what you should know is when do you typically get injuries? It's typically in what's called the late cocking and early acceleration phases of throwing. Again, this is pertinent to the overhead thrower. What happens is there's basically three major forces that are placed on the elbow, and they all kind of work synergistically together. There's the tensile stress, the compression force, and the shearing stress. Now, the tensile stress, that's the one that we may hear about more often without even knowing about it. That is the medial aspect of the elbow, where you have the UCL, the ulnar collateral ligament, or what we sometimes hear about the Tommy John ligament, your flexor pronator mass, and the medial epicondyle. So that's the medial aspect. You have a synergistic compressive force. So you have a, you know, a coup, counter coup, bicep, tricep, medial, lateral. All these concepts apply. So if your tensile is medial, then your compressive is lateral. So your compressive force is the lateral aspect of the elbow. That's the radial capitellar joint. Then in this case with the elbow, you also have a shearing stress. That's the posterior compartment. That's the olecranon and the olecranon fossa. So if you can sort of visualize this, or for anyone who may be playing around with some anatomy pictures right now, that is the concept. And they're all working together. And if something is injured in one of these areas, you're not gonna be able to throw or throw hard without pain. You also have to understand at least two basic biomechanic terms. You have to understand the difference between kinematics versus kinetics. Kinematics is basically motion. Displacement, rotation, velocity. That's kinematics. Kinetics is motion plus forces. There's a picture of one of our pitchers in our Sports Performance Center in the first floor of our building here. And that's when you're looking at the forces and torque on top of the motion. Another way you can remember this, if you just want to try to remember it, is kinetics has an N and has the motion and the forces. Well, kinematics is the M and that's motion. But these two terms are really important when communicating and doing research, communicating with an athletic trainer, doing research with the sports performance expert, et cetera. So I think biomechanics is cool, but is this actually useful clinically? Well, it is important for those of you that may have worked or covered games before or worked with an athletic trainer or may have been an athletic trainer. You can see changes with biomechanics that may change if you have a change in velocity, maybe location is off by pitchers, the frequency, how many pitches one throws, joint loads change if your efficiency and your mechanics are not good, and pitch types. There's the old adage of, you know, don't throw a curveball while you're young. We're not going to discuss that today, but that can change the biomechanics as well. There's also biomechanical risk factors for medial elbow injury. As an example, if someone is rotating their trunk late, you have to sort of, and this is tough to do right now because we're not in person, you have to sort of get around your trunk. Well, that means the inside part of your elbow experiences a greater force. Same thing with reduced maximum shoulder external rotation. So you can see right now the shoulder, if you can see my cursor, it's going backwards, that's shoulder external rotation. If you can't get enough external rotation, the force has to go someplace. If it's not the shoulder, it's going to be dispersed in other parts of the body. In this case, you're going to feel it in that medial elbow. We also know that increased elbow flexion. Now, elbow flexion, you can think of it as if your arm is abducted to 90, and you're trying to make a biceps muscle while you're trying to flex. That's increased elbow flexion. So if you do that at ball release, that also places a greater strain and hence increase the risk for a medial elbow injury. So, but the question ultimately, why do we get injured? Yeah, maybe biomechanics aren't good. Yeah, maybe you threw too much, but there has to be a basic concept. And this is actually one of my favorite cartoons, if you will. And this is applies to anything in medicine. It could be sports. It could be being active. It could be a couch potato to 5K runs. It could be running. It could be throwing. It could be swimming. It applies to anything and everything. It applies to anything and everything. We have intrinsic risk factors. How old are we? How flexible are we? Have we had a previous injury in the same location? There is some genetic component to it. All of these play into what's called a predisposed athlete. The athlete's predisposed because they had an injury or because they have open growth plates. You then expose them to extrinsic risk factors. An extrinsic risk factor may be playing baseball when it's 25 degrees outside. Or maybe playing baseball when it's 105 degrees outside. Or as we all know, maybe returning to sports after COVID and all you've done is sit on the couch for eight weeks. These are extrinsic risk factors. Now what you have is a susceptible athlete. And then a susceptible athlete is then now exposed to an inside event. What's the inside event? Pitching, throwing, running, wherever the case may be. And therefore, an injury develops. So if we're talking about skeletally immature baseball players, that could be someone who's got open growth plates, maybe a previous shoulder or elbow injury. Maybe there's poor biomechanics or overuse. And now you're pitching in pain. So the concept makes sense. And really, I put the reference below. But this is something that is a really simple concept that sometimes medical students and residents kind of get lost in trying to figure out, well, how can we prevent these injuries? This one graph is actually very straightforward. It's more complicated than that in real life, but it's pretty straightforward. Well, because of that, some colleagues and I were asked to write a manuscript and we developed an algorithm, basically looking at a model for injury causality in adolescent throwing athletes. So this is based on that very last study that was done. But it's geared towards the adolescent thrower. So here we have our natural risk factors that are intrinsic. Our age, skeletal age, our height. Sometimes psychologically, things are different. Some people are built different ways. So intrinsically, maybe you're a little more type A. Maybe you're a little more relaxed. Maybe you're more anxious, whatever that may be. We also have a whole section on just developmental risk factors. How strong are you at age 12 is not going to be the same as how strong are you at age 14. What about your throwing velocity? What's your skill level? And so on and so forth. All of these predispose you as an adolescent throwing athlete to injury. Then here are the extrinsic risk factors. And you can read all of them, but it's nothing that we don't know. It's sport specialization, pitch volume, etc. So now the athlete is susceptible and then signed events the same. Throwing while already injured, maybe fatigued or unprepared for the rigors of the season, which is something we're all, particularly those of us in musculoskeletal medicine, are really going to have to be prepared for as patients and athletes become coming back to clinic and back to sport at some point in the near future. So based on all that as a background, these are the injuries I'm going to go over. Now there's a really nice summary in the journal. Here is a current sports medicine report. So it's written by Ben Oeschlag and Tracy Ray. Tracy is the current president of the American Society for Sports Medicine. Dr. Oeschlag is an emergency room physician who does sports medicine training at Duke. He's now on the front lines up at, I think it's Mount Sinai in New York. This was written a couple years ago, but this is a really nice manuscript for just kind of to keep around in case you like this stuff or you end up really wanting to study injuries and throwing athletes with respect to the elbow. So Panner's disease. Now this is important. The next couple cases, depending what rotations you've been in thus far, if you're a resident or med student on the call right now, you really don't have to know things from a pediatric standpoint. So Panner's disease is a form of articular osteochondrosis. Typically it's of the radial head or the capitellum. Usually it's little boys. The board answer is four to eight years old, but typically it's young boys. Typically the presentation is kind of several weeks of pain, some stiffness, maybe some mild trauma or overuse. Now normally we don't have, you know, if that was our own kids, we probably wouldn't send them in for an x-ray. But what happens is it doesn't improve with rest. So typically they come in, we get some x-rays. And what you can see, and you can see on this radiograph, you see some fissuring or regularity or fragmentation. That's sort of the buzzword. In this case, it's the capitellum on this radiograph. Why does this happen? Some valgus compressive micro trauma forces. Remember we talked about those three forces to the medial, the lateral, and the shearing or the posterior. Well, this is on the lateral side. There's valgus compressive forces to the radial capitellar joint. That's right there. On the exam, they're going to hurt right where there's Panner's disease. In this case, the capitellum. There might be some limited range of motion, most commonly in extension. Treatment for this, this does very well with non-operative management. Basically, we reduce symptoms. You're not going to throw, not going to hit. If they're that young, they're probably not lifting weights. Maybe take some NSAIDs. But the prognosis really is excellent with rest. So that's Panner's. On the opposite side is you're going to have OCD, osteochondritis dissecans. Now, typically, we may see this in the knee or in the talus bone in the ankle, but you can also see this in the capitellum. This is an inflammatory disorder of the osteochondral articular surface. So what happens here? The biomechanics are sort of similar. There's abnormal valgus stresses on an immature articular surface as you accelerate and then follow through. What happens is you actually have weakening of the subchondral bone due to repeated microtrauma. So the concept is very similar to Panner's. But in this case, typically, your patient is going to be a little bit older. So instead of 4 to 8 years old, it might be that 8 to 12-year-old athlete who is a little bit older, has a little bit more strength, can generate a little more power. And then there's some failure of the subchondral osteous elements, in this case, the bone. And you actually need an x-ray. If you have a displaced fragment, that's something you might need to talk to a surgeon about because that's now a loose body. You can see right here on advanced imaging, the image a little bit better. So typically, like I said, the presentation is typically it's insidious. You know, the big thing is looking for mechanical symptoms because then you're worried about loose bodies. And really, an x-ray is going to show you a lucency with that subchondral bone, as I just showed. But if you have any concerns, you really want to get an MRI. MRI is really the most sensitive study to assess for stability or instability of an OCD lesion. And really, they're more common in the capitellum due to its tenuous blood supply. The treatment really depends on the stage of the OCD. And that's where the MRI comes into play. Typically, if you have a non-displaced stable OCD in someone with open growth plates, these can be treated nonoperatively. But if these lesions are either unstable or become loose, like a loose body, they really need to go see a surgeon. Lily gullible. This is probably the thing that we know about the most. Many of us probably sustain lily gullible in one way or another. Typically, what happens is there's an injury to the medial epiphyseal plate. Again, this is from valgus stress or medial epicondyle apophysitis, okay? So this is with someone who's got open growth plates still. And typically, the pain basically just results from overuse, likely throwing. They may have had a previous injury history saying, oh, I had this three months ago. I had this a year ago. And the pain is very focal. It's right over the medial epicondyle. You might lose a little bit of elbow extension. There's a little bit of pain of valgus stress. Now, the thing I always tell folks is not everyone suffers a Tommy John injury, even though the UCL ligament is right there. And if you see enough of these, you understand that. But if you don't see a lot of these, or if you're doing any rotations with any of your faculty or with any of your orthopedic colleagues, is you really have to see enough of these to understand, differentiate when you're doing a really good physical exam if you think something is more of a little elbow versus a UCL injury. The treatment for this is non-operative. Again, it's simply rest, modification of activities, rest from throwing. could be anywhere up to three months, but the key is we have to work on doing really good job, and this is kind of redundant when I'm giving this to talk of future physiatrists, for a good rehabilitation program. That means an internal throwing program. I always say, if you're going to train for the Boston Marathon, do you just show up and run 26 miles? No, you've got to train for it. Well, for throwing, it's the same thing. You need to go through a rehab program if you are coming off an injury, or if it's the off-season, you need to build your arm strength up to prepare for the rigors of the season. So, on the flip side of Lily Goebel, this is the same concept, but this is a true avulsion. So, meal epicondyle avulsion fractures. Now, one thing to notice, if you look at the x-ray here, is the growth plates are closed. So, understand that when you are skeletally immature, the ligaments might be a little bit stronger, and when you're skeletally mature, the bone is going to be stronger. So, you have to be aware that you could sustain more of a ligamentous injury once your growth plates are closed, but in this case, if you rupture, I'm sorry, if you avulse off a piece of bone, such as we can see right here, that is very easy to detect on an x-ray. This is an acute injury. This injury is typically the story is, hey doc, what's going on? I was throwing a ball, and I just felt a pop in my elbow with one pitch. That's very different than my elbow is just continuously sore when I throw. Now, the treatment depends on the extent of the avulsion or fracture. If it's a small fragment, and there's less than three to five millimeters of displacement, that can be treated non-operatively with a hinged elbow brace, but if there is more than three to five millimeters of displacement, or you are not comfortable managing a patient like this, then you definitely should get a surgical consultation with either an elbow surgeon or a sports medicine surgeon. The reason this affects throwing athletes, or those athletes who place a lot of distraction force on the medial elbow, is because of the forces. This can include javelineers, gymnasts, wrestlers. In fact, the most sorry case of sustaining an injury like this is a quarterback who is right-handed, I saw, handed the ball off to his right back with his left arm, and one of the linemen broke through and hit his elbow from the outside and create a huge valgus force, and he actually suffered a medial epicondyle avulsion with a UCL tear on his non-throwing side when he wasn't even throwing the ball. So these can happen even when you're not throwing, but the key is to understand why they happen, and when to recognize when we can treat this non-operatively, and then with rehabilitation, versus getting them to our surgical colleagues. A look around stress fractures. I've seen a couple of these most recently, and this is one of those I think they're going to start presenting itself more, because there's something called weighted ball programs. I'm sure those of you who are into this stuff as much as I am, but if you watch baseball or softball, you've noticed the last couple years, man, the velocities are getting up there. If you look at any closer on a major league team, they're throwing over 100 miles per hour. It used to be just one person or all this Chapman, and now nearly every closer is thrown close to 100. There's a lot of starters that can hit 100. You have many starters thrown over 97. You have Justin Verlander who is in his upper 30s still throwing that speed. Well, what's happening is as you're throwing more and throwing harder with greater velocity, there's increased stress, and remember we talked about that shearing stress in the posterior compartment of the elbow. What happens is this increased stress and load is now seen and appreciated by the lecron due to this valgus extension load. There's then pain and painful pain, I'm sorry, painful extension when you extend, and it's right posterior. It's pretty much right in the area where there could be a stress fracture. You definitely need to test your triceps and do all the other stuff you usually do for this sort of a concern for an injury, but in the end the most significant finding on exam is pain with palpation over a bony landmark, in this case the lecron. So imaging you definitely want to start with some x-rays, but if they hurt and x-ray looks okay, you really should consider some advanced imaging. This is what happens if you miss one. An athlete played through it and unfortunately popped his lecron, and you can see very clearly a fracture here. This is just about a skeletally mature athlete. See the growth plate of the radial head is just about closed? That's a fracture there, and that's what happens when you fracture through it. Unfortunately, I have to go to surgical colleagues. I've seen three of these in Florida. I'm in Florida, so we had baseball until about mid-March. I had three of these age 11, age 12, and age 14 come into my clinic and was diagnosed with these. Fortunately, we caught them early. There was one last year where it was an athlete that basically tried to keep throwing through it and required surgery, and they took him out of all of last year. So these are really important. When my colleagues say they'll see you before you see it, you really have to be aware of it, and that's where a good exam and palpating your bony landmarks is very helpful. So you can also see osteophytes. Now, I'm sure many of us, if not all of us, particularly the senior level residents, have seen plenty of knee radiographs, plenty of shoulder radiographs, and see tons of osteoarthritis. Well, if you don't see enough in the elbow, you're not sure where you're looking at, and you could have some osteophytes, and that's due to something called valgus extension overload syndrome. It doesn't get nearly the publicity, I think, that Tommy John does or Little League Elbow does, but you definitely have to be aware of it. So the reason these osteophytes occur is because the repetitive motion through valgus extension, then you overload the joint. So again, this is that shearing stress, the posterior compartment of the olecranon-olecranon fossa creates these osteophytes, and then the compression, particularly the radiocapitellar compression laterally, may cause some chondral or osteochondral fractures or loose bodies in the posterior compartment. You should be able to pick these up on x-ray. Occasionally, you might need an MRI to see if there's cartilage, if the cartilage doesn't show up on x-ray, but this is something to keep in mind of. Now, they're not as frequent as the other injuries I've talked about so far, but something you should definitely be aware of. The last one I had was a third baseman that we caught. We actually required an MRI, and he had a elbow scope, was actually able to play about six to eight weeks later, because it was basically just removing the loose bodies that were causing pain. Typically, the presentation is you have some pain locking or catching, very similar to a bucket handle tear of the meniscus in the knee, except this is an elbow. So you have pain with forced elbow extension and limited range of motion, and you also have pain with something called the valgus extension overload test. Obviously, through the computer, I'm not able to do this right now. You guys can google it on YouTube. It's pretty simple test where you extend and basically create a force with valgus and see if there's any pain or not. Like I talked about, radiographs could CT it. A CAT scan, as I hope all of us know, is going to be a lot of radiation. My personal slant is if I'm going to get advanced imaging and I'm going to look for a loose body, I may get the MRI, because I'll look for the cartilage as well, but the key is getting radiographs first. It can be associated with cubital tunnel syndrome, so that's also something to be aware of if they're having ulnar nerve type symptoms. And again, like I talked about, really it depends. We may be able to treat this non-operatively, but if there's any concern of a loose body or loose body developing, they need to go to arthroscopic surgery. Humoral stress fractures. These are pretty rare. I've caught a couple in my career. Actually, myself and a couple colleagues have published on this, and it's important to understand how to detect them. Typically, you can have spiral and transverse stress fractures of your humerus. The presentation is a little bit different. It's simply your arm feels fatigued. There might be some aching after the sensation of active throwing. It's the same concept if you're developing an early bony stress reaction as a runner in your shin or your foot, but then eventually, if an athlete tries to go too far, they'll eventually have a severe pain, and they'll crack through it. For those of you who may be old enough, I may be the only one. If not, if you want to Google Dave Drevecky and the San Francisco Giants, I remember watching this game. I think this was 1987 or so. Unfortunately, he had cancer and had to have his arm amputated, but he was pitching in a major league game through one pitch, and he broke his arm in half. If they have the tape up on YouTube, he basically had a brewing stress fracture. Now, that wasn't due to overuse. It was unfortunately due to cancer, but the concept holds that it's this nagging fatigue and aching associated with throwing. There's usually tenderness at the side of the stress fracture. Now, I remember as a resident, even med students, when I was taught to palpate and examine my elbow and my upper arm and shoulder, I rarely palpated the arm. I would palpate, I mean, the upper arm. I would palpate the elbow, and I would palpate the shoulder, and I would do all my strength tests and reflexes and neurovascular exam, check my brachial pulse, etc. This is different. You have to really be aware. I have a picture in a moment, but really, if you suspect that there might be a stress fracture and the x-rays are normal, get an MRI. The worst thing that can happen is it'll be a normal MRI. The best thing that can happen is you're going to catch something. This is me with one of our physician assistants, and I just kind of came up with this. It sort of makes sense, but basically, I am squeezing his humerus from lateral to medial, and I'm going in between the biceps and triceps muscle bellies, and then I do it again from the anterior to posterior plane. I then do it on the other side, and compare the difference. A lot of people hurt. If you squeeze your arm, it's going to hurt, but if it feels the same on both sides, I'm not too worried about it. If someone is in significant pain on the affected side, you should now really be considering, is there a stress fracture or bony stress injury developing in the humerus? As I mentioned here, what's the treatment for this? I actually just got an email from a former sports fellow who's practicing in Minnesota who asked about this. You really got to be careful with these. You don't want them to say, all right, just rest for four weeks, go back to throwing. No. This is a bony stress injury, and as we talked about already, there's a significant amount of forces and angular velocity that you don't want to expose the arm to. Basically, the way that I treat it and the way it's written in some of the literature, you're going to basically be shut down for four to six weeks. You don't necessarily have to use a sling, but you can for comfort, but you really need to just make sure you maintain a range of motion or tell your patient to, because elbows notoriously will get stiff very quickly. So gentle range of motion is fine, but there is to be no physical therapy. There's no lifting. There's no swinging. They're shut down for four to six weeks, and then you should see them back. Then you see them back. If they are better at rest, then you start a non-throwing, non-valgus PT program. Come on back in six weeks. So now you're about 12 weeks out, three months. Check them again clinically. Now is when you start a throwing program, and you start slow. So the way I typically do this is it's six weeks, six weeks, six weeks. This is a four and a half month deal. Some folks ask about re-imaging. I don't think you need to reorder the MRI or reorder x-rays as long as the patients are continuing to heal, and if patients are not continuing to heal, that's when you want to get a second opinion. But I've had three of these. I caught two in one year and one about two years ago, and they've all done fine. They were all, ironically enough, high school baseball catchers. Two were 15 and one was 16 years old. I do think, though I can't prove it, this is also associated with a good growth spurt. So it's always important in your history to ask or ask the parent, has it been a growth spurt in the last three to six months? This is the picture of one of my patients. Obviously, it's anonymized, but you can see this is a T2-weighted image. It's a coronal view. Here's the radial head. Here's the ulna. This is the humerus, and you can see that all this is lighting up right here. I have it circling in red. Hopefully, everyone can see, but you can see the edema there. So this was a grade one versus grade two, supracondylar stress, bony stress injury in a high school baseball catcher. I think I might have presented this at AAPMNR actually a couple years ago, but this is something that you really need to be aware of. They don't happen that frequently, but you don't want to miss it. I think this is pretty straightforward. I think most of us know this, but ulnar nerve, aka cubital tunnel syndrome. I know there was a really good lecture just given by Dr. Bowers out of Emory. I think it was a week or two ago where he reviewed all peripheral neuropathies in the upper extremity. I would just briefly say in the context with throwers, this can be associated due to the extreme valgus throwing. You can have kind of a traction neuritis due to this valgus stress. Maybe there's a compression of an osteophyte. Maybe there is a secondary muscle. There can be subluxation. You should know it's the second most common entrapment neuropathy of the upper extremity, the number one being carpal tunnel. And obviously, we can diagnose this with the EMG, maybe consider an MRI if we think there's an accessory anconious muscle or hypertrophic muscle compressing the nerve. And the treatment really depends on how significant the symptoms are. I've had a couple patients where they are completely asymptomatic with hitting, with lifting weights. It's only with throwing. And in that case, even though they're fine, we still sent them over for a surgical consult. We have tried a couple of times with one of my colleagues, with Dan Herman, to almost do like a stress EMG, so have them play catch, and then go do the EMG right away. It doesn't really work great, similar to when you're doing like a compartment test. But it is important to understand, is there any additional factor that's causing the ulnar nerve dysfunction? Is it the extra muscle? Is it a pathological issue? Is it a fascial issue? Is it something from the creative struthers? Whatever the case may be. But ultimately, we need to correct biomechanics, plus or minus if they had surgery or not, and then a return to throw program. Okay, I'm gonna take a minute to have a sip of my Powerade. Does anybody have any questions so far? Yeah, we did have a brief question. Can I just say it's appropriate that you're drinking Powerade? I mean, this being a sport. Yeah, you know, what's really funny is I'm from Chicago and did most of my training in Boston and Pennsylvania. I like Powerade better than Gatorade, but I'm not really supposed to say that publicly. But to me, it tastes better, which is kind of funny. Even though it was invented here. I know, right? I think the powers that be are on their way to your office right now. Yeah, I got locked down. All right, well, what we got so far? A quick question about OCD at the capitella. So, longest stress as a mechanism. Is that because of secondary compressive force on lateral elbow? Yeah. Okay. Yeah, it's basically you can think of it in terms of a micro shearing and micro repetitive microtrauma. For those of you who are residents and particularly probably I'm guessing PGI threes and fours who may be on the call. If you've seen OCDs, and this is a usually a path and mark for a board type question. It's the lateral aspect of the medial femoral condyle in the knee. That's because there's a micro, there's repeated microtrauma. It's the same thing of the medial aspects of the tail or dome. It's the same thing, the elbow. The concept is the same. It's just in a different location. So, you can have OCD of the elbow, OCD of the knee, OCD of the ankle. But the concept, as was just asked, is the same. It's a microtrauma due to repetitive overuse. So, that's basically what the deal is, the way that occurs. Perfect. Thank you. Sure. All right. So, this is a way to get in a Star Wars slide and then we'll move on to the UCL since I know a lot of folks always have questions about Tommy John and the ulnar clavicle ligament. So, let's talk about the ulnar clavicle ligament. This is, you know, I see a lot of guys try to get this tattoo sometimes. Sometimes it works. Unfortunately, when you get older, the baseball seems sort of sag when we get 50s or 60s. So, the first thing to understand is what is the purpose of the UCL? Why is this one ligament such a big deal? Outside of the ACL, this is probably the next most important ligament that we hear about in all, you know, sports, it seems like, at least with the media. Well, the purpose of the UCL is it's a resistor of valgus loads. It provides elbow joint stability by slowing the elbow extension during the deceleration phase of throwing. Essentially, and this goes back to we talked about those three stressors and forcers before, you generate a various counterbalance torque to the induced valgus force. So, basically, you have a dynamic joint stability system going on, and the UCL helps create that stability. If you don't have the UCL intact, you don't have stability. Understanding the very basics of the anatomy is there's three main bands, and the one that's most common, the one that's simply ruptured that you hear about is the anterior band. You also have the oblique, which connects the A to P, and then even the posterior. You also have to understand its relationship to the ulnar nerve and its origin insertion. This is a question I love to test residents on, because honestly, you all have no idea, because it's usually not tested, is where does the UCL insert? And I always kind of get the finger to the inside of the elbow. I'm like, no, no, no, I actually want to know where. It's called the sublime tubercle of the ulna, okay? So, understanding inserts into the ulna is very important to know, because I've had people say, oh, it inserts into the meal placanda. I'm like, no, that's where it starts. So, if you understand the origin insertion and why you're doing these valgus tests, this milking maneuver and valgus loads, it sort of makes sense why this one ligament is so important for throwing or for creating this valgus joint stability. So, the anterior band is the chief restraint of valgus up to about 90 degrees of flexion, whereas the posterior band's function is to resist valgus stress between 60 degrees and full flexion. So, if you remember that one slide I put up, it was in black and white. If you have increased elbow flexion, that's a risk of increased elbow injury. You can see why. Here, the posterior band, which is now as robust as the anterior band, is going to have more of a, take more of the valgus load if your elbow is bent more. So, this is a lot of biomechanical data, and I'm just presenting to kind of show you the concept. The UCL, based on some cadaveric studies, presents more than half of all the stability of valgus stress generated while throwing. It's kind of a cool cadaveric study done, gosh, Dr. Fleisig, I think, did in 95, so 30 years ago or 25 years ago. But when you test a live, healthy patient who can throw more than 80, 85 miles per hour, The mean valgus torque is around 67 newton meters. And when you throw even harder, so these are probably collegiate pitch above, you can get above 70 newton meters. So again, you don't need to memorize those numbers. What's important to understand is the mean torque on a pitch-to-pitch basis is greater than the torque to failure in cadavers by about 250%. So that doesn't make a lot of sense, does it? This is why it's so important to maintain strength and stability around the UCL. When you are lifting weights and you're doing the bench press, you're not just working out your pec muscles. It's your anterior deltoid. It's your tricep muscle. When you're doing lat pulldowns, it's not just your latissimus dorsi. It's going to be your flexor form and your bicep muscles. When your UCL is being trained, if you have strong flexor forearm muscles, it's going to support it and prevent injury. And if you don't, it's going to get injured. So like I said, the flexor pronus is around the UCL bundle. It absorbs the highest amount of valgus force across the elbow during throwing activities. It is a dynamic or they are dynamic stabilizers and they help prevent these injuries through repetitive contraction. Again, you've heard this before during the acceleration phase and with wrist flexion. Because when you flex your wrist, obviously you're activating those flexor forearm muscles. So the flexor pronator is not something that's talked about a lot in non-operative pregnancies, family medicine, PM&R. But it's very important to understand the synergy that flexor pronator mass has with the UCL. Remember, if the UCL is compromised, what is next up? Next up is the flexor pronator mass. So if you have, let's say, a sprain or a low-grade partial tear of the UCL and you have a very strong flexor pronator mass, your patient may be fine. And if they're weak or their forearm is weak, they may not be fine. So how do we know about this? Well, a lot of this makes the media, for whatever reason, sports medicine, probably because of professional athletes and Division I athletes, seem to be in the news more than any other area of medicine, short of the COVID pandemic right now. And you can see why. This is a really nice study. Chris Amad is the head team physician for New York Yankees and he was the senior author on this. This was a 10-year study in the state of New York. And you can see that the volume of UCL reconstructions increased by nearly 200 percent and the rate tripled in the first decade of this century. And you can see it's typically men, typically college age, maybe a little bit younger. It's also important to understand, private insurance were 25 times more likely to have this injury. I don't know what to make of that other than possibly baseball players and their families and where the study was done, they might have had more access. But that doesn't mean if your student athlete or your patient has Medicaid that there's not a chance they can have a UCL injury. What the take-home is these injuries are going up. This is a really nice slide I took from some data site that basically shows the increase in UCL reconstructions at the professional level. This went through 2014. There's newer data that has, I think, through 2018 that's continued to go back up again. You see there's one injury in 1974. That was Tommy John himself. And you see that the numbers really started to go up in the mid to late 90s. It's kind of apropos. I played high school ball. I graduated in 94 and I played college ball and graduated in 98. So I was kind of in that group of folks that was part of the first real generation of this going up. What happened in the 90s? What happened was there was an increase in showcases. There's an increase in travel ball. There was the starting of creatine. There was a starting of velocity programs. All this stuff really got going in the 1990s. And what happens then, you're bigger, faster, stronger. But what comes with that, if you don't train right or you're throwing harder, you've increased forces, you can sustain injuries. This is taken from the American Sports Medicine Institute in Birmingham, Alabama, where Dr. Andrews used to practice. And these are UCL reconstructions for youth athletes. That's high school and younger. So if you look in 1995, hardly any of their patients that required reconstructions were these ages. By the time you got to about 2011-12, between a quarter and a third of all their patients, and they're one of the leading centers in the country that does this surgery, were having UCL reconstructions. So actually something has changed. Well, we need to fill in the gaps. What about high school and college? Well, this was done out of Chicago at the time these physicians were at Rush. They're in New York now, but Brandon Erickson, Anthony Romeo was the senior author. They looked at the UCL reconstructions of the high school and college. You can see, again, over an entire decade, nearly a six times increase in the number of UCL reconstructions. So now we have data from the youth to the high school, to the collegiate, to the professional. So this goes across all walks of life and throwers. So therefore it's important to understand where some misconceptions versus realities of UCL reconstruction. Yes, we are not surgeons, but you have to be able to speak intelligently about the basics of this, particularly if you ever going to want to be a team physician or care for these type of athletes. The first is UCL reconstruction will improve performance and is 100% effective. No, UCL reconstruction UCL reconstruction is a very successful surgery and the success is actually improving. I think a newer study came out that has the upper nineties now, but it's not perfect. The other thing is, and this may sound silly, is prophylactic UCL reconstruction should not be performed to enhance performance. There was a really nice survey study done by Chris Amam, 2012, that asked patients, parents of baseball players, if they would want their kid to have a prophylactic UCL surgery. And 33% said, yes, because they just don't have the knowledge. UCL reconstruction does not mean you're going to go from throwing 80 miles an hour to 90 is not going to prevent a re-injury. That's something that everyone who treats these athletes should be aware of. The second is UCL reconstruction is less than a year. Now, for those of you who are already seeing patients in the musculoskeletal clinic, what's, what's the biggest question, doc, when can I return to play? Well, if you're taking care of a team or you're taking care of an athlete and they've had surgery, or maybe they had surgery in the off season and they moved to your city or your state for college, and you need to know how to care for them. Well, the first thing is you're not going to be pitching in a game in less than a year. If you're at the high school age, that's just not going to happen. The evidence is really quite mixed. There's lots of studies out there and the average return time to competition ranges anywhere from about a year to 55 months. Though I think those are a little bit outliers, the ones that took that long. What is important to note is if you look at all the data is on average return to competition will likely take more than a year in our younger pitchers. Another thing to understand is our high school pitchers or adolescent pitchers, they don't have access to the same facilities that, you know, big time division one pitchers do or professional pitchers do. They have obligations such as going to school. Their parents may not have the funds. They may not have the car bill to get to physical therapy. They might have an athletic trainer depending on what high school they're at. So all these are important to understand. UCL reconstruction is a one-time procedure. This is not true also. There is unfortunately a growing trend of UCL reconstruction failure and a requirement for revision. Now you can read the two bullet points below, but it's important to understand that originally back in 1974 and up into the 90s, most of these were being done on professional major league pitchers who are already in their 20s and 30s. Tommy John was halfway through his major league career when this happened. What's going on now? Well as I showed you before, you have all these youth pitchers and high school pitchers having this surgery and unfortunately what happens is the reconstruction, excuse me, is very good. Unfortunately it's not designed to last for 20 or 30 years. So that's something to be aware of, that there is a risk of rupture. And the last thing, particularly for the audience today, it's really important to understand that UCL injuries are not a one-time acute injury. They're what I like to call an acutely chronic injury. Over time you have wear and tear. You play through pain. You pitch through pain. You pitch through injury and you don't tell any, you don't tell your team physician. You don't tell your athletic trainer. You don't tell your parents. By the time they get to you, they already have a high grade partial tear. They have a rupture. So our job, particularly as non-operative musculoskeletal and sports medicine physiatrists, is to prevent these injuries from occurring in the very first place. So there's a couple slides I have. This is more just interesting stuff. I'm going to skip it in the abundance of time, but a lot of folks do want to know about velocity and do velocity lead to increased UCL tears. The short answer is we think so because more velocity means increased forces across the elbow. So I'm going to skip these slides, but if you're interested, I'm more than happy to send it to you, but just in the interest of time. So the last kind of section, the last couple slides I want to mention is injury prevention. It's really important, and this goes with any athlete in any sport. You have proper mechanics. You have, you implement prevention of mechanisms. Understand what the injury mechanisms are and appropriate strength programs. You want to have fall appropriate rest guidelines in the offseason. Train your arm before the start of the season, and obviously you want to make sure you have in-season conditioning. You want to use common sense. You know, following safety rules, following pitch restriction guidelines makes the most sense, particularly our youth athletes. From a physiatric standpoint, you really got to understand you've got to restore full range of motion. You've got to restore full strength. You want to have static and dynamic stability and neuromuscular control. Only then, when all these are satisfied, is someone potentially ready to go back into competition. So we also want to do pelvic and core strengthening, scapular control, as I mentioned a lot already, flexor forearm strengthening, rotator cuff activation, and we need to have good flexibility throughout the entire kinetic chain. That means not just the shoulder elbow. That means the hamstrings, the thoracic lumbar spine. There's actually some folks who talked about dorsiflexion of the ankles. So when you're pitching, you have a greater hyperflexion of your ankles so that you reduce the stress that kind of travels up your spine. This is a really nice manuscript. The journal of Pimenaro, the purple, I guess it's the white journal now, but to me it was the purple journal from Kevin Wilk. This talks about the phaser habilitation and overhead throwing athlete. I'll let you all read it, but I summarized it, but it's a really nice way to think about your aims and your treatment as someone progresses in rehabilitation through the acute, intermediate, advanced strengthening, and then return to activity phases. Also understand the importance of the kinetic chain. So you want to have good core and hip strength, lower extremity balance, and the timing of biomechanical phase events is very important. That's where working with sport performance professionals is very paramount here. There's these are different tests that we can do. Some of you probably know them already, but doing simple single leg squats or Trendelenburg sign or inline lunges or hip drops. These are things to test if someone has good proximal leg strength, which is very important in throwing athletes. The other thing is from the core strength standpoint, there are actually some data out there that says improving core strength can actually enhance shoulder strength and throwing velocity. We don't really have data yet with the elbow, however, that I'm aware of. We do know that core strength programs are improving velocity in handballs, and for those of you who know, handball is a really big sport in the Scandinavian countries. And here's some more balance. But in the end, what's important is we have appropriate kinetic chain stability. You don't want to have any weak links in the chain. So from the ankle and cervical spine, you really want to make sure that everything is intact because one kink in the chain and something can be thrown off. Timing is also very important, and this is not a talk to focus on that, but this is where having someone who's really good at knowing the biomechanics, having a good athletic trainer, a sports performance professional, because checking about the timing of trunk rotation or checking about the appropriateness of your elbow flexion is really important. Checking on stride length, all these things come into play when you're assessing an overhead throwing athlete. And really, if you don't have good timing, it just can ruin a bad day. That's my one silly joke for this lecture. In the end, keep it simple. You want to have some good off-season, in-season training programs. You want to incorporate biomechanics, have good kinetic chain assessment. As physicians, we really need to have an open mind and be aware of all the possibilities of the injuries, which is what was two-thirds of this lecture. I will stop sharing and put myself on video. And then I'm welcome to take questions through Sterling, or Sterling, you can unmute folks, and folks are more than welcome to ask questions. Thank you so much. I'll jump on there with you. So you mentioned earlier that the ACL is kind of like the UCL of the upper extremity, right, in terms of media coverage, in terms of sensationalism, maybe, but also in terms of injury. So the FIFA 11 Plus, right, is designed to kind of prevent... Oh, we're on. Okay. Dr. Power's on. Just a second. The FIFA 11 Plus is designed to prevent ACL injuries. Is there something akin to that for UCL prevention, something like a prescribed set of exercises? It's a really good question. There's not necessarily one area. What it has right now is you've got something called, and I didn't go into this because there wasn't enough time, but something called Major League Baseball Pitch Smart. So whoever's on, if you want, Google it and go to that website through Major League Baseball. It talks about pitch count restriction based on age. It talks about preseason conditioning. It talks about connect chain. It talks about, I mean, it talks about a lot of things. What's challenging with an overhead throwing athlete, you have to deal with the arm and the legs. With an ACL, you're not really worrying about strengthening your arm if you're trying to prevent ACL injury. You've got your quads and your glutes and your flexibility and your hips. No one cares about your arm if you're worried about an ACL prevention program. With an overhead athlete, you've got to deal with both. So I still maintain overhead athletes. It's a little more challenging because you've got to deal with the whole body for the most part. I think what's most important is it's kind of a, what's the term, a bicycle where you have different spokes. You have your pitch count restrictions. You have your off-season conditioning. You have your connect chain. You have your strengthening. All these things come into play. The challenge also with baseball, particularly if anyone here is in a warm weather state such as myself, is the year-round play, particularly with little kids. I mean, it's tough. With COVID, obviously nothing's going on. We got half of our high school baseball season before it got canceled, and that was mid-March. I mean, our first games are in February. Practice starts in January. I grew up in Chicago. I never had that. So to me, this is great, but that comes with an overuse injury, as probably some of you who are in warm weather states can attest to. But there's not just one like a FIFA 11 for ACL where you go to that. Unfortunately, it's a lot of different things. Okay. Yeah, it sounds far more complicated. I know for my son, it's that balance, right? So I have an eight-year-old that's really, and some of the better players on his team are out doing travel ball and really pushing it in the off-season, and he does spring ball and fall ball. But beyond that, I'm hesitant to kind of expand that beyond that, even though some of these other kids are getting reps, which is nice. Yeah, and it's tough. I mean, you, for example, you were at an institution at Vanderbilt. You have a couple of folks there. They're very big into adolescent sports medicine. Alex Diamond and Andrew Gregory are at your institution, so you can go right to them if need be. There are some places, if you're in a rural area or, I think everyone on this call needs to be aware that if you're going to do something like this, that's great. You have to be proactive because it's not just treating the injury in the clinic, it's preventing that injury from coming back or preventing it potentially in the first place. And again, that depends on what your specialization ends up becoming. If you end up being an inpatient physiatrist, you're probably not going to really deal with this injury. Well, if you're an outpatient physiatrist, a musculoskeletal physiatrist, you're a team physician, such as I am, you have to be aware of this stuff, and that's things where you kind of have to go above and beyond. That makes a lot of sense. We have one more question coming in. Since the flexor pronator mask plays such a pivotal role in medial elbow stability, is there any focus on strengthening that? I mean, I know I see pitchers doing this where my ignorance comes in, the finger bench. So yes, that's a really good question. There's a really nice study, I've got to remember the name of it, but I think it came out of the American Journal of Sports Medicine in the last three years maybe, it was out of Japan, where they looked at, I think it was eight to 11-year-old, they had two arms, or two groups, two arms. One group did all these strengthening exercises for the arm, and the other did not, and they just looked at medial elbow injury after 12 weeks, and the group that did the strengthening had 50% less pain and injury. I'm actually leading a study right now, we're doing a retrospective review, since we can't really do prospective as none of us can right now, but looking back at all of our UCL injuries in the last 10 years through MRI, and seeing if there's an associated flexor injury, just no one ever comments on, because we talk about it a lot, but if you look through the literature, there's not a lot out there. There's a couple papers on it that actually look at if you strengthen the flexor program and ask how much does the stress go off the UCL, but there's not a ton out there, so that's an area where I think there can definitely be some good prospective studies. If anyone has questions, shoot me an email, happy to chat with you about it, but that's actually something we're even thinking about here. All right, well thank you very much, I appreciate it. Sorry, pop this up here, here we go. We don't have any further questions, but if any more come up, we have your information. I think you had your email on there, we've got your Twitter information right here as well. Anybody that has any questions, please feel free to reach out to him or to either of us, and we can put you in touch in terms of email, and if any of you did not get to see this whole lecture, any of your colleagues might want to see this, and we're busy doing other things as I'm hearing many of you are in some of the harder hit states. That website right there, physiatry.org slash webinars, is where you can find the recordings of this and other lectures, and as I mentioned before, they will be up at least through the end of this calendar year for those of you who are so inclined. Thank you again for joining us, we appreciate you so much. Thanks, good luck to everybody. Thank you. All right, let's go ahead.

UCL injuries

baseball players

Panner's disease

OCD

Little League elbow

flexor pronator injuries

stress fractures

ulnar nerve compression

biomechanics

injury prevention strategies