Disclosures. Pitch 22. Pitch 22. Pitch 22 12/11/2015. Ulnar Collateral Ligament Reconstruction. The Hardball Times:

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12/11/2015 Disclosures Ulnar Collateral Ligament

considerations Drew Jenk PT, DPT CSM 2016 Anaheim,

from 2013-2014 Josh Johnson: 2 nd surgery April

surgery March 2015 Bronson Arroyo: surgery July

points: Ligament is not muscle it cannot be

s Law does not apply Rick Peterson: Orioles

kind of force for 60 seconds would die Pitch 22 The

1 12/11/2015 Disclosures Ulnar Collateral Ligament Reconstruction Nothing to Disclose and no financial considerations Drew Jenk PT, DPT CSM 2016 Anaheim, CA Pitch 22 Tommy John Surgery has increased 50% from Josh Johnson: 2 nd surgery April 2014 Matt Moore: surgery April 2014 Zack Wheeler: surgery March 2015 Bronson Arroyo: surgery July 2014 Ivan Nova: surgery April 2014 Pitch 22 Good points: Ligament is not muscle it cannot be strengthening like muscle Ligament is not bone Wolf s Law does not apply Rick Peterson: Orioles Director of Pitching Development Approached by a physicist O.03 seconds of acceleration A human exposed to that kind of force for 60 seconds would die Pitch 22 The Hardball Times: Recorded 101 professionals including 31 major leaguers who underwent the knife for Tommy John in

2 12/11/2015 Pitch 22 Could Tommy John be the end of the shoulder injury epidemic? Is the elbow the new weakest link? Shoulder injuries (Days on the DL) 2008: 7, : 3,000 Elbow injuries (Days on the DL) 2008: 5, : 8,000 2

3 Orr Limpisvasti MD - Orr Limpisvasti, M.D., is a Sports Medicine Surgeon and is member of the Kerlan-Jobe Orthopaedic Clinic board of directors. - His clinical practice specializes in sports medicine and arthroscopy, with an emphasis on shoulder, elbow, and knee surgery. - Dr. Limpisvasti is active in the training of orthopaedic surgeons at the Kerlan-Jobe Sports Medicine Fellowship Program. After completing his studies at the University of California, Irvine, he earned his medical doctorate at the University of Rochester. He went on to complete his orthopaedic surgery residency at the University of Hawaii and his sports medicine fellowship training at Kerlan- Jobe. - Dr. Limpisvasti is the team physician for Anaheim Ducks Hockey and is an orthopaedic consultant to the Los Angeles Dodgers, Los Angeles Lakers, and several other professional sports and collegiate teams. He also serves as a consultant for US Tennis and the PGA tour. - He is active in a number of professional organizations, including the American Academy of Orthopaedic Surgeons and the American Orthopaedic Society for Sports Medicine. - Dr. Limpisvasti reviews for several journals to include the American Journal of Sports Medicine and the Journal of Shoulder and Elbow Surgery. He has authored extensively in the professional literature and remains active in orthopaedic research. - He currently serves as clinical faculty at the Orthopaedic Biomechanics Laboratory at the Long Beach VA Healthcare System. - Due to copyright laws, Dr. Limpisvasti will provide links for citations for any pertinent guidelines or tables from his presentation, but there will be no handouts available. Thank you.

4 Rehabilitation following UCL Reconstruction in the Overhead Throwing Athlete Kevin E. Wilk, PT, DPT,FAPTA American Sports Medicine Institute Birmingham, Alabama asmi.org J Sports Health 12 1

$dislocation / fractures / tears$

5 J Sports Health 12 UCL Rehabilitation Rehab Plan Lower Extremity Strengthening Lower Extremity Strengthening Linking UE & LE Elbow Injuries in Sports Introduction Number of elbow injuries appear to be increasing Repetitive high forces overhead athlete 22% of all baseball injuries Macrotraumatic forces dislocation / fractures / tears Thrower s not all or none Rehabilitation must be specific for each type of athlete 2

AJSM 2010 UCL Surgeries on Pitchers at ASMOC 100% 1281 UCL procedures,

players ( 89% pitchers) Average follow-up: 49.

same level competition Return to competition: 11.

4 months 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 18% 18% 18% 21% 11%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 AJSM

PROM, radar gun ball velocity, & biomechanics were analyzed

et al: AJSM 13 UCL reconstruction in throwing athletes a minimal 10

6 AJSM 2010 UCL Surgeries on Pitchers at ASMOC 100% 1281 UCL procedures, 1265 reconstructions Follow-up on 79% (743 patients) 95% baseball players ( 89% pitchers) Average follow-up: 49.1 months 83% returned to same level (recon) 63% of repairs returned to same level competition Return to competition: 11.6 months ITP initiated 4.4 months 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 18% 18% 18% 21% 11% Adult 28% 44% 40% 38% 38% 29% 32% 31% Adolescent AJSM active minor league pitchers 40 UCLr compared to 40 normal PROM, radar gun ball velocity, & biomechanics were analyzed Conclusions: no sign stat diff in any area tested Oshbar, Cain, Dugas et al: AJSM 13 UCL reconstruction in throwing athletes a minimal 10 year follow-up 256 of 313 (82%) available for F/U Average follow up 12.6 yrs yrs 90% were pitchers 85% of overhead throwers still playing Longevity of career after UCLr 3.6 yrs for all levels 3

UCL Reconstruction Return to Play & Performance Vitale & Ahmad: AJSM 08 Systematic review of UCLr in overhead athletes 83% excellent result 10% complication

did not return to MLB play No sign change in velocity following UCL No sign diff in innings pitched, ERA, walks, SO etc No sign diff in UCL group AJSM 2014

competition: 20 months Length of career 3.

within 2 full seasons Relief pitchers were able to resume 50% workload & starters reached 35% workload Relievers demonstrated better pitching stats compared

29/30 teams responded 100% responses in 29 teams 331 players had UCLr (8%) Pitchers: 300/2145 (14%) Position players: 31/1907 (2%) Avg age at time of

7 UCL Reconstruction Return to Play & Performance Vitale & Ahmad: AJSM 08 Systematic review of UCLr in overhead athletes 83% excellent result 10% complication rate Muscle splitting,decrhandling UN, & docking improved outcomes Jiang & Leland: AJSM MLB pitchers underwent UCL reconstruction pair matched group 8 did not return to MLB play No sign change in velocity following UCL No sign diff in innings pitched, ERA, walks, SO etc No sign diff in UCL group AJSM UCL reconstructions included in study 148 returned to play 83% returned to same level Only 5 pitchers were not able to return to play Return to competition: 20 months Length of career 3.9 months Pitchers performance improved after surgery JSES 2013 Utilizing MLB player performance statistics Overall 78% (14/18) pitchers returned to MLB play within 2 full seasons Relief pitchers were able to resume 50% workload & starters reached 35% workload Relievers demonstrated better pitching stats compared to the starters Elbow Injuries in Baseball UCL Surgeries Conte, Wilk: AJSM 15 Surveyed all Minor League Baseball Players 4,052 respondents (2,145 pitchers) 29/30 teams responded 100% responses in 29 teams 331 players had UCLr (8%) Pitchers: 300/2145 (14%) Position players: 31/1907 (2%) Avg age at time of surgery 21 Elbow Injuries in Baseball UCL Surgeries: Conte, Wilk: AJSM 15 Surveyed all Major League Baseball Players 1,036 respondents 30/30 teams responded 100% responses in 30 teams 166 players had UCLr (16%) Pitchers: 25% Position players: 5% 49% UCLr received concomitant surgery 4

Glenohumeral Passive Range of Motion & the Correlation to Elbow Injuries in Professional Baseball Players: An 8 year Prospective Study (AJSM 2014) Kevin E. Wilk, DPT Leonard C.

Fleisig, PhD Kyle Aune, MPH Ronald Porterfield, ATC Paul Harker, ATC James Andrews, MD 1 Methods & Materials 505 pitcher-seasons were included in this study 6,060 total PROM measurements

right-handed & 76 left-handed All subjects were asymptomatic when tested and had no surgeries within two years prior to testing Same two examiners performed PROM assessment each year 6

8% Surgery 6 352 14.0% Stress Reaction 4 309 12.2% Neuritis 3 203 8.3% Contusion 1 19 0.

8 Glenohumeral Passive Range of Motion & the Correlation to Elbow Injuries in Professional Baseball Players: An 8 year Prospective Study (AJSM 2014) Kevin E. Wilk, DPT Leonard C. Macrina, MSPT Glenn S. Fleisig, PhD Kyle Aune, MPH Ronald Porterfield, ATC Paul Harker, ATC James Andrews, MD 1 Methods & Materials 505 pitcher-seasons were included in this study 6,060 total PROM measurements taken 296 individual pitchers were included 46 pitchers were assessed in three or more consecutive seasons 80 were assessed in two seasons 170 were assessed only once 220 pitched right-handed & 76 left-handed All subjects were asymptomatic when tested and had no surgeries within two years prior to testing Same two examiners performed PROM assessment each year 6 Results Conclusions & Clinical Relevance Specific Type of Injuries: Injury # of Injuries Days on DL % Days on DL Elbow Strains: % UCL % Inflammation % Surgery % Stress Reaction % Neuritis % Contusion % Based on the results of this study: Pitchers with a throwing shoulder deficit in TRM had a 2.3x risk of sustaining an elbow injury Pitchers with a dominant shoulder loss of Flexion exhibited a greater risk (2.8x) risk of an elbow inj GIRD did not correlate with elbow injuries Clinicians need to be aware of this and plan a preventative & rehabilitation program that addresses these findings this to prevent &/or treat elbow injuries in the overhead pitcher 17 OJSM 14 5

9 Elbow Injuries in Sports UCL Injuries Traumatic UCL Injuries Repetitive Overhead Stresses Elbow Dislocation 6

10 Flexor/Pronator Avulsion UCL Avulsion (10 yr old) 10 wks post-op 7

11 Elbow Injuries Overhead Thrower Tremendous forces & stress Acceleration phase: 64 NM valgus stress Increase stress with specific pitches (slider, split-finger) Pitchers are bigger & stronger & able to generate Tremendous torques generated Better recognition of injuries Pathomechanics Two critical instants UCL Pathomechanics Maximum External Rotation 40 Elbow Varus Torque = 64 Nm (40#) Max. ER Ball Release Fleisig GS: AJSM 07 8

Prevention Programs for the Throwing Athlete Throw

the increase in injuries at all levels of baseball?

Technique & Skill level Size of players Number of

years throwing Type of pitches Lyman, Fleisig, et al:

Olsen, Fleisig, et al: AJSM 06 Injury Prevention

allowed per game 17-18 yrs 105 pitches 13-16 yrs 95

pitches Days rest after pitching (14 and under) 66 or

12 Prevention Programs for the Throwing Athlete Throw Like A Pro App The Overhead Thrower Introduction Why the increase in injuries at all levels of baseball??? Factors that influence injury rates: Arm fatigue Technique & Skill level Size of players Number of pitches per game Number of games per year Number of years throwing Type of pitches Lyman, Fleisig, et al: AJSM 02 Lyman, Fleisig, et al: Med Sci Spts Ex 01 Olsen, Fleisig, et al: AJSM 06 Injury Prevention Little League Pitch Count Rule (since 2007)»Pitches allowed per game yrs 105 pitches yrs 95 pitches yrs 85 pitches pitches pitches Days rest after pitching (14 and under) 66 or more pitches 4 days pitches 3 days pitches 2 days pitches 1 day 9

Olsen, Fleisig, Dun, Loftice, Andrews: Am J

had surgery to 45 pitchers who never had a

Pitched more often & when fatigued» Used

Characteristics of the Thrower s Elbow The

13 Olsen, Fleisig, Dun, Loftice, Andrews: Am J Sports Med 06 Risk factors for developing shoulder & elbow injuries in adolescent baseball pitchers Compared 95 pitchers who had surgery to 45 pitchers who never had a significant injury Risk factors:» Pitched more months per year» Games per year» Innings per game» Pitches per game» More starting pitchers» Participated in showcases» Pitched at higher velocity» Pitched more often & when fatigued» Used NSAIDs & ice» Injured group was taller & heavier Biomechanics of the Elbow Joint Complex During Throwing Physical Characteristics of the Thrower s Elbow The Elbow Joint in Throwers Range of Motion Wilk, Macrina, Reinold, Porterfield Unpublished: 15 Extension: 7 ± 7 0 Flexion: 147 ± 4 0 Pronation: 98 ± 4 0 Supination: 93 ±4 0 n =

The Elbow Joint in Throwers Range of Motion Wright,O Neal,Paletta:AJSM 05 Tested 33 pitchers

extension overload Flexor/pronator tendonitis Extensor tendonitis Ulnar collateral ligament

neuritis Medial Elbow Pathologies UCL Sprains UCL is the main medial stabilizer of the elbow

Thickness UCL Tears in Throwers Rehab Program Jobe: Clin Spts Med 86 Yocum: Clin Spts Med 89

96 Wilk & Andrews: JOSPT 93 Rettig: AJSM 01* Podesta et al: AJSM 13 Effective Treatment Plan

14 The Elbow Joint in Throwers Range of Motion Wright,O Neal,Paletta:AJSM 05 Tested 33 pitchers Bilateral difference in ROM Elbow extension 7 degrees Elbow flexion 5.5 degrees Total ROM difference 13 deg. Elbow Injuries in Sports Overview Common elbow injuries in the overhead athletes Vaglus extension overload Flexor/pronator tendonitis Extensor tendonitis Ulnar collateral ligament sprains Degeneration of elbow joint Ulnar neuritis Elbow Injuries in Sports Overview Common elbow injuries in the overhead athletes Vaglus extension overload Flexor/pronator tendonitis Extensor tendonitis Ulnar collateral ligament sprains Degeneration of elbow joint Ulnar neuritis Medial Elbow Pathologies UCL Sprains UCL is the main medial stabilizer of the elbow Anterior bundle is the primary structure involved in throwing Non-Operative Rehab Partial Thickness UCL Tears in Throwers Rehab Program Jobe: Clin Spts Med 86 Yocum: Clin Spts Med 89 Jobe: Instr Course Lect 91 Wilk & Andrews: Spts Med Arth Rev 95 Azar & Wilk Op Tech Spts Med 96 Wilk & Andrews: JOSPT 93 Rettig: AJSM 01* Podesta et al: AJSM 13 Effective Treatment Plan What % of Patients 11

Non-Operative Rehab UCL Sprains Typical Program - Literature No throwing for 8 weeks to 4

Esp. of wrist flexors/pronators» Emphasize shoulder program Initiate throwing program at

Mixed clinical results how many return to play Rettig, Sherill, et al: AJSM 01 31 overhead

views Treated non-operatively»no throwing 2-3 months»rom exercise & ice»strengthening

24.5 weeks (13-54 weeks) Podesta, Best, Yocum: AJSM 13 34 overhead athletes with confirmed

injection IA PRP injection & specific rehabilitation program 30/34 (88%) returned to same

15 Non-Operative Rehab UCL Sprains Typical Program - Literature No throwing for 8 weeks to 4 months (severity) Restricted motion; caution with valgus stress Progressive strengthening» Esp. of wrist flexors/pronators» Emphasize shoulder program Initiate throwing program at timeframe: 6-8 weeks to 3-4 months from time of initial injury? Mixed clinical results how many return to play Rettig, Sherill, et al: AJSM overhead athletes suspected UCL sprains»(20 pitchers, 2 javelin throwers) Some had MRI or stress views Treated non-operatively»no throwing 2-3 months»rom exercise & ice»strengthening program»begin throwing at 2-3 months 42% were able to return to play *Average time to return 24.5 weeks (13-54 weeks) Podesta, Best, Yocum: AJSM overhead athletes with confirmed (MRI) partial thickness UCL tear All players failed non-op Rx previously All Rx with 1 injection IA PRP injection & specific rehabilitation program 30/34 (88%) returned to same level of play without any complications (1 had UCLr) Average return to play 12 weeks Joint opening reduced from 7 to 2.5 mm PRP Platelet-rich Plasma 12

Platelet Rich Plasma Overview - PRP Autologous blood therapy Uses patient s own blood components to

factors Used to treat injured tissues Rehab UCL Sprains in Throwers Immediate restricted motion

? Control valgus stress Brace for 3-4 weeks Muscle training Isometric for UE/ shoulder Emphasize

Injuries Dislocated Elbow Hyperextended elbow- often UCL injury & capsular tear Immobilize in posterior

program Functional brace Rehabilitation Following UCL Reconstruction Our Current Program (2015) Recent

More present: Full ext ASAP * Acute Injury Chronic Injury Emphasis on wrist flexors, shoulder strength

16 Platelet Rich Plasma Overview - PRP Autologous blood therapy Uses patient s own blood components to stimulate healing response PRP enhance body s own healing response Uses platelets which have growth factors Used to treat injured tissues Rehab UCL Sprains in Throwers Immediate restricted motion Non-painful ROM* Usually almost full ROM* Gradually establish full ROM Consider ROM brace?? Control valgus stress Brace for 3-4 weeks Muscle training Isometric for UE/ shoulder Emphasize flexor/pronators Control applied forces No throwing 2-3 months Throwing mound (12-16 wks) UCL Sprains Injuries Dislocated Elbow Hyperextended elbow- often UCL injury & capsular tear Immobilize in posterior splint for 1-2 weeks Begin easy ROM program Control elbow extension Gradual restore ROM Strengthening program Functional brace Rehabilitation Following UCL Reconstruction Our Current Program (2015) Recent Adaptations in Our Program Earlier restoration of motion Previous: 7-8 wks FROM Present: 4-6 wks FROM More present: Full ext ASAP * Acute Injury Chronic Injury Emphasis on wrist flexors, shoulder strength Preparation phase of throwing plyometrics longer Throwing programs long toss (more time) delay hard throwing for longer return to games delayed 13

Rehabilitation Following UCLr in Throwers Rehabilitation 4 Phases Program

Phase: Phase IV: Return to Activity Phase: Rehabilitation UCLr Throwers

the healing tissue (UCL) Gradually restore motion Decrease inflammation &

Subacute Phase (weeks 9-12 Continue ROM & stretching Isotonic strengthening

Core & Leg program Rehabilitation UCLr Throwers Rehabilitation 4 Phases

Strength, power, & endurance Advanced thrower s ten program Plyometrics

Thrower s ten program Plyometrics Interval throwing program (ITP) Light

of Jobe procedure Jobe: JBJS 86 Andrews: Op Tech Spts Med 96 Andrews et al:

source Palmaris longus Gracilis Reconstruction of the UCL Surgical Technique

17 Rehabilitation Following UCLr in Throwers Rehabilitation 4 Phases Program Phase I: Acute Post-Op Phase: Phase II: Subacute Phase: Phase III: Advanced Phase: Phase IV: Return to Activity Phase: Rehabilitation UCLr Throwers Rehabilitation 4 Phases Program Phase I: Post-Op Phase (weeks 0-8): Protect the healing tissue (UCL) Gradually restore motion Decrease inflammation & pain Prevent muscular atrophy Scapular, GH joint, leg, core program Phase II: Subacute Phase (weeks 9-12 Continue ROM & stretching Isotonic strengthening program (Throw 10 Scapular & Glenohumeral joint Fine tune muscular ratios Core & Leg program Rehabilitation UCLr Throwers Rehabilitation 4 Phases Program Phase III: Advanced Phase(weeks Advanced isotonic program Strength, power, & endurance Advanced thrower s ten program Plyometrics Continue stretching & ROM program Phase IV: Return to Activity Phase: 4 mos Thrower s ten program Plyometrics Interval throwing program (ITP) Light stretching program Reconstruction of the UCL Surgical Overview Modification of Jobe procedure Jobe: JBJS 86 Andrews: Op Tech Spts Med 96 Andrews et al: Am J Sports Med 10 Subcutaneous ulnar nerve transposition fascial sling Graft source Palmaris longus Gracilis Reconstruction of the UCL Surgical Technique Update Graft location: UCL reconstruction Palmaris longus 62% ipsilateral:(78%) contralateral: (22%) Gracilis 38% 14

18 Reconstruction of the UCL Surgical Technique Docking Procedure Altchek DW: HSS Muscle split Single huneral tunnel No ulnar nerve transposition Rohrbough & Altchek: AJSM 02 Dodson: AJSM 06 UCL RECONSTRUCTION REHAB Range of Motion Progression Week one: splint at 90 degrees Week two: brace degrees Week three: brace degrees Progress program 5 degrees of extension and 10 degrees of flexion per week Full ROM at week 5-6 More Aggressive with ROM UCL Strain with PROM Bernas: AJSM 09 15

19 Rehab of Graft Site Wrist & hand ROM / gripping Palmaris tendon graft:»ice & compression first 5-7 days»immediate wrist motion, no aggressive stretching 2 weeks»immediate hand gripping exercises» Soft tissue (scar) mobilization at 2 wks» If scars: US, stretch, tissue tissue»begin strengthening program for wrist flexors Isometrics immediate Isotonicsat 3 weeks» Progress to stretch with open hand & digits extended Rehab of Graft Site Gracilis tendon graft»ice & compression first 5-7 days»no stretching of hamstrings for 2-3 weeks»soft tissue (scar) mobilization on day 15»No isolated hamstrings for 3-4 wks»may bicycle at 2-4 weeks»begin strengthening program for hamstrings & calf Isometrics at 4 weeks Isotonics at 6 weeks UCL RECONSTRUCTION REHAB Muscular Strength Training Wrist & hand isometrics day 1 Isometrics UE week 1-2 Active ROM week 2-3 Isotonics program week 3-4 Thrower s Ten program week 4/5 Weight lifting week Sports (golf) week 11 Plyometrics» Two hand drills week 12» One hand drills week 14 Thrower s Ten Program 16

20 Rotator Cuff Strengthening Rotator Cuff Strengthening Advanced Strengthening Phase: Week Progress strengthening program Initiate isotonic strengthening program Bench press (seated) Pull-downs Seated Rows Biceps/Triceps Advanced Throwers 10 Strengthening Drills- MR Elbow/Wrist Flex C/E Manual Resistance Techniques 17

21 Elbow Rehabilitation in Athletes Dynamic Stabilization Strengthening Drills Davidson et al: AJSM 95 Advanced Thrower s Ten Program Advanced Thrower s Ten Advanced Thrower s Ten 18

22 19

23 Scapular NM Control Drills Dynamic Stabilization Exercises Dynamic Stabilization Exercises Strengthening Drills Lower Extremity Strengthening Lower Extremity Strengthening 20

24 Advanced Strengthening Phase (Week 12-16) Plyometric Progression:» Week 12: 2 hand drills» Week 14: 1 hand drills» Week 15: plyoball throws Gradual Progression!!! Escamilla, Ionno, Wilk, et al: MMSE Compared 3 baseball specific training programs on maximum throwing velocity 68 high school players (aged 14-17) Randomly assigned to 1 of 4 groups:»thrower s Ten Program»Kaiser cable system»plyometrics»control group»3 x week for 6 weeks Throwing velocity assessed pre & post training Compared to pre-test throwing sign increase in throwing velocity (p<0.05) Throwers ten (1.7%) Plyometrics (2.0%) Kaiser (1.2 %) 21

CRITERIA TO RETURN TO THROWING Full non-painful ROM Elbow stability Satisfactory isokinetic test Satisfactory

CRITERIA TO RETURN TO COMPETITIVE THROWING ER strength > opposite side Full can strength > opposite side Ball

Activity ITP (I): long toss week 16 ITP (II): mound - week 26 Competitive throwing 8-9 mos (simulated game) RTP:

25 CRITERIA TO RETURN TO THROWING Full non-painful ROM Elbow stability Satisfactory isokinetic test Satisfactory clinical exam moving valgus stress test (-) Adequate healing time How long is that? 6, 9 or 12 mos. CRITERIA TO RETURN TO COMPETITIVE THROWING ER strength > opposite side Full can strength > opposite side Ball drops at 90 prone with 1 Ib ball 20 throws against wall with RS at every 5 reps w/o pain or difficulty 30 throws into plyoback with #1.5 ball without pain & proper mechanics Completed ITP w/o difficulty Intra-squad game w/o problems Return to Activity ITP (I): long toss week 16 ITP (II): mound - week 26 Competitive throwing 8-9 mos (simulated game) RTP: mos Thrower s Ten program» Strengthening & Stretching Functional Drills Thrower s ten program Plyometric drills Stretching Core & leg program Interval throwing program:» long toss» interval mound throwing» Gradual return to competition 22

Fleisig, Bolt, Fortenbaugh, Wilk: JOSPT 11 17 healthy college pitchers Biomechanical analysis of long & short throwing Threw 18.

26 Fleisig, Bolt, Fortenbaugh, Wilk: JOSPT healthy college pitchers Biomechanical analysis of long & short throwing Threw 18.4m, 37m, 55m & maximal distance on a line Shoulder line was horizontal for mound distance but gradually went uphill as distance increased Maximal throwing distance resulted in more ER, more Elb Flexion, more shoulder IR torque & more varus elbow torque Trunk tilt gradually increased with distance Azar, Andrews, Wilk: AJSM UCL reconstructions, 17 primary repairs 41% professional baseball, 45% collegiate Average follow-up 35.4 months 79% return to previous level Return to competitive throwing 9.8 months AJSM UCL procedures, 1265 reconstructions Follow-up on 79% (743 patients) 95% baseball players ( 89% pitchers) Average follow-up: 49.1 months 83% returned to same level (recon) 63% of repairs returned to same level competition Return to competition: 11.6 months ITP initiated 4.4 months Conclusions Elbow injuries common in the overhead thrower UCL injuries occur in several situations (throwers, macrotraumtic) Surgery often indicated for UCL injuries Rehab must match the surgery Gradual restoration through rehab Adequate tissue healing Stiffness occurs in less than 3% Predictable & Reproducible Results Rehabilitation Following UCL Repair with Augmentation UCL Surgery Repair 2 x 3.5 mm corkscrew PEEK anchors Collagen-coated Fiber Tape Size 0 supersuture(ticron)»one limb of FiberTapeand suture placed through the eyelet of the first anchor»first anchor placed at the site of avulsion»suture used to repair avulsed ligament»both limbs of tape placed through eyelet of the second anchor»second anchor placed at other insertion UCL Caution on tension of tape 23

UCL Repair Augmentation Rehab Week 1: Posterior splint 5-7 days» Shoulder isometric

isotonics» Initiate elbow & wrist exercises Week 3-4:»Thrower s Ten Program» Week 4-5

6:»Advanced Thrower s Ten Program» Plyometrics 2 hand drills Week 8:» Plyo 1 hand

Week 16>:» Return to play Conclusions Elbow injuries common in the overhead thrower UCL

for UCL injuries Rehab must match the surgery Gradual restoration through rehab

27 UCL Repair Augmentation Rehab Week 1: Posterior splint 5-7 days» Shoulder isometric exercises»scapular exercises Week 2: ROM Brace ( )»Continue shoulder exercises isotonics» Initiate elbow & wrist exercises Week 3-4:»Thrower s Ten Program» Week 4-5 full PROM Week 5-6:»Advanced Thrower s Ten Program UCL Repair Augmentation Rehab Week 6:»Advanced Thrower s Ten Program» Plyometrics 2 hand drills Week 8:» Plyo 1 hand drills» hitting week 10 Week 11-16:» ITP Phase I (week 10-11» ITP Phase II (wk Week 16>:» Return to play Conclusions Elbow injuries common in the overhead thrower UCL injuries occur in several situations (throwers, macrotraumtic) Surgery often indicated for UCL injuries Rehab must match the surgery Gradual restoration through rehab Excellent outcomes: 85% > return sport Stiffness occurs in less than 2% Predictable & Reproducible Results 24

28 12/11/2015 Return to Play Considerations for the Throwing Athlete Following an Upper Extremity Injury Sue Falsone PT, MS, SCS, ATC, CSCS, COMT, RYT Founder, S&F: Structure and Function Founder, Dr. Ma s Systemic Dry Needling ROM Strength Negative special tests MD clearance Athlete understanding Skill coach participation Prerequisites Strength and Conditioning Perspective Focus on transfer of force from lower body to upper body Consider Core stabilization vs core propulsion Resistance training load variables Time under tension Chops Lifts Downward facing dog Core Stability Rolling Propulsive chops Propulsive lifts Core Propulsion Resistance/ Load Intensity/ Time Under Tension Relative Strength 1 to 5 Reps 0-20s per set Relative Power Reps Depending on Specificity 0-10s per set Power Endurance Capacity of Wattage over time Applied/Functional Hypertrophy 6-8 Reps 20-40s per set Hypertrophy 9-15 Reps 40-70s per set 1

29 12/11/2015 Sequential Phasic Individualized Fluid Progressive Axel et al, 2009, Sports Health Reinold et al, 2002, JOSPT Variables to consider Distance Volume (number of throws) Intensity Frequency Type of pitch thrown (if a pitcher) Flat ground progression Mound progression Simulated games Rehab games Return to competition Phases to consider Long Toss Controversy Hard, horizontal, flat-ground throws were biomechanically similar to pitching Maximum distance throws detrimentally altered pitching mechanics (Fleisig et al., 2011) Minimum and maximum throwing distances should be less for youth pitchers Axe et al., 2009, Sports Health Heavy resistance training to improve running mechanics during acceleration Zafeiridis et al, Journal of Sports Med and Physical Fitness Bottom line: we don t know Intensity/ Velocity Knowledge of the pitcher s pre-injury maximal throwing velocity can be used to calculate percent effort and throwing velocity throughout the program by using a radar gun Most programs begin with short tosses at no more than 50-60% effort When an appropriate base is established, intensity should progress to 70, 80, and 90% effort, throwing fastballs on flat ground Velocity/ Intensity The clinician must realize that the ability of the pitcher to estimate throwing effort is poor Pitchers were instructed to throw at 50% effort Radar gun measurements indicated that throws were an average of 83% of their maximum speed Slenker et al., 2014, AJSM 2

30 12/11/2015 Volume/ Number of Throws The type of player (e.g., starting or relief pitcher, position player, catcher) influences the number of throws completed on a routine basis and the level that must be attained to return to competition The time required to develop an acceptable endurance level can vary dependent upon the type of player or pitcher and the different types of pitches thrown (e.g., fast ball; breaking ball; curve; changeup) Frequency Every other day? Two days on, one day off? Daily? Progression? Determined by volume and intensity? Pitchers and Flat Ground Working out to X feet based on previous discussion then back in to 60 feet Ex: 5-15 throws at 45 feet feet Followed by 3-5 throws at 165 feet feet The above is done with all fastballs Pitchers and Flat Ground Once this happens and is symptom free, can begin throwing down with fastballs Breaking balls can be introduced after several sessions of symptom free fastball throwing down Mound Progression Mound sessions should be performed: Starters: two times simulating a five day rotation Relievers: every other day Rest or other training on off-days The pitcher should only throw fastballs for the first several outings Important to establish confidence and control with the fastball before introducing other pitches Mound Progression/ Volume Gradually increase volume On average, an inning is 15 pitches Can progress volume by pitches per outing Continue to consider starter vs. reliever when progression volume 3

31 12/11/2015 Mound Progression/ Intensity Use radar gun to monitor and progress Finish with a hitter standing in to track the ball One left handed and one right handed Simulated Games Game day intensity is difficult, if not impossible, to replicate Simulated games = the pitcher throws to live hitters, pitch count is monitored, game situations are called out by coach so pitcher can actively select appropriate pitches (mixing it up) The closest option to pitching in an actual game Rest should be scheduled after several hitters to mimic pitching an inning After 3 hitters, or approximately 15 pitchers, the pitcher will sit down, rest, and then return after 5 minutes or so Rehab games Return to competition Pitching in an actual game, but at a lower level (e.g., AAA or AA in professional baseball) The necessary number and frequency of rehab games is determined primarily by the type of pitcher (reliever vs. starter) and the length of time out of competition If starter, gradual increase in volume (typically by 15 pitches) on normal days rest In Summary Return to throwing programs should be individualized Progression should be based on a variety of factors Manipulate one variable at a time Maintain consistent communication with the athlete and pitching coach to facilitate a smooth progression through the program Stay in touch FB: Sue Falsone Pt Atc Twitter: suefalsone Instagram: suefalsone LinkedIn: Sue Falsone sue@suefalsone.com 4

Rehabilitation following UCL Surgery in the Overhead Throwing Athlete Kevin E. Wilk, PT, DPT,FAPTA. UCL Rehabilitation Rehab Plan

Rehabilitation following UCL Surgery in the Overhead Throwing Athlete Kevin E. Wilk, PT, DPT,FAPTA Elbow Injuries in Sports Introduction Number of elbow injuries appear are to be increasing Repetitive