Michael G. Ciccotti

Objectives: Injury of the ulnar collateral ligament (UCL) has become increasingly common, particularly in overhead athletes. There is no consensus on management of the ulnar nerve in UCL reconstruction (UCLR) in patients with pre-operative ulnar nerve symptoms, as literature supports both not decompressing the nerve as well as ulnar nerve transposition (UNT). The purpose of this study is to compare subjective clinical outcomes and return to play metrics between patients who received UNT during UCLR and a matched cohort who underwent UCLR alone. We hypothesized that there would be no significant difference in patient outcomes or return to sport (RTS) metrics between the cohorts. Methods: Using an institutional database, patients who underwent UCLR with UNT between 2007 and 2017 were retrospectively identified. These patients were matched based on sex, age at surgery (± 3 years), and BMI (± 2) to a comparison group that underwent UCLR alone. Patients completed the Kerlan Jobe Orthopaedic Clinic Shoulder & Elbow score (KJOC), the Timmerman and Andrews elbow score, the Conway-Jobe scale, and custom patient satisfaction and return to play questionnaires. Results: Thirty patients who underwent UCLR with concomitant UNT and 30 matched patients who underwent UCLR without UNT were available for follow up at a mean of 6.9 and 8.1 years respectively. The UNT group reported similar KJOC (78.4 in UNT vs 76.8; P=0.780), Conway-Jobe (60% excellent in UNT vs 77% excellent; P=0.504), Timmerman and Andrews (86.2 in UNT vs. 88.8; P=0.496), and satisfaction scores (85.3% in UNT vs. 89.3%; P=0.512) compared to UCLR group. In terms of RTS rate (84% in UNT vs 93%; P=0.289) and duration required to RTS (11.1 months in UNT vs 12.5 months; P=0.176), the two groups did not significantly differ. Finally, despite significant differences in preoperative ulnar nerve symptoms (100% in UNT vs 7% in UCLR; P<0.001), the two groups did not statistically differ in the proportion of patients that experienced post-operative ulnar nerve symptoms (13% in UNT vs 0%; P=0.112) Conclusions: This matched cohort analysis showed no statistically significant differences in patient reported outcomes and return to sport between patients undergoing UCLR with and without UNT. [Table: see text]

Objectives: The presence of ulnar neuropathy in baseball pitchers is a poor prognostic factor of successful return to play and may adversely impact outcomes after ulnar collateral ligament reconstruction (UCLR). Screening programs to identify negative ulnar nerve adaptations in throwing athletes can help minimize injury risk, individualize treatment programs, and optimize rehabilitation. Ultrasound provides the advantage of viewing structural adaptations prior to the onset of symptoms, an important factor in identifying potential injuries in advance. However, it is currently unclear how the ulnar nerve adapts chronically in professional baseball pitchers. Therefore, the primary purpose of this study was to compare ulnar nerve ultrasound characteristics between the throwing (dominant) and non- throwing control (non-dominant) elbows in professional pitchers, with a secondary purpose of comparing ultrasound characteristics between subluxing and non-subluxing ulnar nerves. The authors hypothesized that ulnar nerve area and echogenicity (i.e. brightness) would be increased in the throwing elbow. Methods: All healthy professional baseball pitchers from a single organization underwent bilateral ultrasound examination at the beginning of the 2022 Minor League Baseball spring training. Ultrasound examination was done by a musculoskeletal radiologist (**) for imaging and subsequent quantification of the ulnar nerve properties, as well as to identify ulnar nerve subluxation. ImageJ software was utilized to measure ulnar nerve area, echogenicity (i.e. brightness), and circularity by one investigator (**) who was blinded to subluxation findings and arm dominance. Comparison of ulnar nerve ultrasound characteristics were performed between: dominant vs. non-dominant elbows, subluxing vs. non- subluxing dominant elbows, and between all (dominant and non-dominant) subluxing vs. non-subluxing elbows. Results: Overall, 74 male professional baseball pitchers (age: 22.5 ± 2.4 years; professional experience: 1.7 ± 1.5 years) were enrolled. There was a trend toward statistical significance for echogenicity bilaterally (dominant: 137 optical density vs. non-dominant: 128 optical density, p=0.053), while area (0.2 mm² vs. 0.2 mm², p=0.767) and circularity (0.67 vs. 0.69, p=0.165) did not differ bilaterally (Table 1). There were no demographic differences between pitchers with subluxing vs. non-subluxing dominant ulnar nerves, including similar years of professional experience and similar Beighton hypermobility scores between groups (Table 2). Echogenicity was significantly lower in subluxing dominant ulnar nerves compared to non-subluxing dominant ulnar nerves (128 optical density vs. 142 optical density, p=0.020). Echogenicity remained significantly lower in subluxing ulnar nerves after evaluating all subluxing vs. non-subluxing elbows (121 optical density vs. 138 optical density, p=0.001) (Table 3). Ulnar nerve area and circularity did not differ based on ulnar nerve subluxation. Conclusions: There was a trend towards the ulnar nerve of the throwing elbow having increased echogenicity relative to the non-throwing elbow, suggesting that echogenicity may play a role in the chronic adaptations of the ulnar nerve. Nerve echogenicity also differed based on ulnar nerve subluxation, however further research is necessary to determine why this difference exists and the potential direction of causality. [Table: see text][Table: see text][Table: see text]

Esenting in a chronic fashion, operative management can involve graft reconstruction or primary repair. When there is adequate tendon excursion and quality, primary repair is preferred. The purpose of this systematic review was to investigate the literature regarding outcomes of direct surgical repair of chronic distal biceps tendon ruptures. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review and for the presentation of results. A search of the literature was performed on the electronic database Medline, Scopus, and the Cochrane Library. Included studies evaluated subjective and objective outcomes after delayed treatment (≥4 weeks postinjury) for chronic distal biceps tendon ruptures, without use of graft augmentation. Subjective and objective outcome metrics such as functional scores, range of motion, strength, pain level, and return to employment were collected. Results: Eight studies were reviewed. The studies included 124 patients with chronic distal biceps tendon tears, treated surgically after a mean delay to surgery of 121.8 days. Four studies included comparison of patients with acute and chronic tears, whereas the other 4 studies assessed chronic tears only. The findings of these 4 studies suggest that direct repair of chronic tears is correlated with a mildly higher rate of lateral antebrachial cutaneous nerve (LABCN) injury palsy (10/82 [12.1%] chronic vs. 3/38 [7.9%] acute, p = 0.753); however, this complication was overwhelmingly transient. There were only 3 reported reruptures (3.19%) across 5 studies reporting this complication. Overall, patients who had undergone direct repair of chronic distal biceps tears had good patient satisfaction, outcomes, and range of motion. Conclusion: Direct repair of chronic distal biceps tendon tears without the use of graft reconstruction is associated with acceptable patient satisfaction, range of motion, and functional outcome scores, although transient LABCN palsy rates may be slightly higher. When sufficient residual tendon is present in the setting of chronic distal biceps rupture, direct repair is a viable treatment option. However, the existing literature regarding direct repair of chronic distal biceps repair is limited, and further prospective assessment directly comparing primary repair vs. reconstruction of chronic distal biceps ruptures is warranted. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence....

The purpose of this article is to provide updated information for sports health care specialists regarding the Disabled Throwing Shoulder (DTS). A panel of experts, recognized for their experience and expertise in this field, was assembled to address and provide updated information on several topics that have been identified as key areas in creating the DTS spectrum. Each panel member submitted a concise presentation on one of the topics within these areas, each of which were then edited and sent back to the group for their comments and consensus agreement in each area. Part 1 presents the following consensus conclusions and summary findings regarding anatomy and mechanics, including: 1) The current understanding of the DTS identifies internal impingement, resulting from a combination of causative factors, as the final common pathway for the great majority of the labral pathoanatomy; 2) intact labral anatomy is pivotal for glenohumeral stability, but its structure does not control or adapt well to shear or translational loads; 3) the biceps plays an active role in dynamic glenohumeral stability by potentiating "concavity compression" of the glenohumeral joint; 4) the ultimate function of the kinetic chain is to optimize the launch window, the precise biomechanical time, and position for ball release to most effectively allow the ball to be thrown with maximum speed and accuracy, and kinetic chain function is most efficient when stride length is optimized; 5) overhead throwing athletes demonstrate adaptive bony, capsular, and muscular changes in the shoulder with repetitive throwing, and precise measurement of shoulder range of motion in internal rotation, external rotation, and external rotation with forearm pronation is essential to identify harmful and/or progressive deficits. LEVEL OF EVIDENCE: Level V, expert opinion.

The purpose of this paper is to provide updated information for sports healthcare specialists regarding the disabled throwing shoulder (DTS). A panel of experts, recognized for their experience and expertise in this field, was assembled to address and provide updated information on several topics that have been identified as key areas in creating the DTS spectrum. Each panel member submitted a concise presentation on one of the topics within these areas, each of which were then edited and sent back to the group for their comments and consensus agreement in each area. Part two presents the following consensus conclusions and summary findings regarding pathomechanics and treatment, including (1) internal impingement results from a combination of scapular protraction and humeral head translation; (2) the clinically significant labral injury that represents pathoanatomy can occur at any position around the glenoid, with posterior injuries most common; (3) meticulous history and physical examination, with a thorough kinetic chain assessment, is necessary to comprehensively identify all the factors in the DTS and clinically significant labral injury; (4) surgical treatment should be carefully performed, with specific indications and techniques incorporating low profile implants posterior to the biceps that avoid capsular constraint; (5) rehabilitation should correct all kinetic chain deficits while also developing high-functioning, throwing-specific motor patterns and proper distribution of loads and forces across all joints during throwing; and (6) injury risk modification must focus on individualized athlete workload to avoid overuse. LEVEL OF EVIDENCE: V, expert opinion.