Differences in Shoulder Internal Rotation Strength Between Baseball Players With Ulnar Collateral Ligament Reconstruction and Healthy Controls

The ulnar collateral ligament (UCL) is the primary restraint to valgus force at the elbow during the baseball throwing motion.¹⁴ Throughout the last 3 decades, there has been a documented and steep rise in primary and revision UCL reconstruction (UCLR).⁷^,⁹^,²⁵^,⁴⁵ Up to 25% of major league pitchers and 15% of minor league pitchers have reported a history of primary UCLR.⁹ Revision rates of 15% to 37% for baseball pitchers²⁵^,⁴⁵ and 3.4% to 8.2% for position players⁷ have been reported after primary UCLR in professional baseball. While revision rates may vary among positions in baseball, it is well-established that decreased performance and career longevity are significantly diminished after surgery, making the focus of clinical outcomes after primary UCLR of paramount impact.³^,²⁶

A number of risk factors for excessive UCL stress and potential UCL injury or reinjury have been identified in the literature: glenohumeral range of motion measures,¹⁶^,⁴⁰ measures of throwing volume,¹^,³⁴ kinetic chain deficits,¹⁵^,¹⁸ and parameters of pitching performance.²^,⁴^,¹³^,²⁹^,³¹^,³⁹ Decreases in rotator cuff strength have also been linked to risk for elbow injury.⁶^,¹⁷^,³⁸ Tyler et al³⁸ noted a relationship between decreased supraspinatus strength and increased relative internal rotation (IR) strength and its association to elbow pain during overhand throwing. Preseason external rotation (ER) weakness has been associated with throwing-related, time loss injuries that required surgery in a cohort of professional baseball pitchers.⁶ More specific to a UCL-injured cohort, baseball players with confirmed UCL injury have demonstrated decreased rotator cuff strength at the time of injury.¹⁷ These studies identified a potential association between rotator cuff strength and elbow injury risk but did not address the relationship of rotator cuff strength after UCL injury and its relationship to secondary injury or return to prior level of competition.

The rotator cuff is one component of the kinetic chain that transfers the forces necessary to obtain high-velocity throws while controlling the stresses placed across the medial elbow, especially in the late cocking and acceleration phases.⁸ Therefore, baseball players looking to return to preinjury throwing performance after UCLR must demonstrate adequate muscular force before the initiation of a return-to-throwing program. However, to date, no studies have examined rotator cuff strength at the time of return to throwing after UCLR.

The purpose of this study was to compare isometric IR and ER strength of the throwing and nonthrowing shoulders in male baseball players diagnosed with UCL tears with that of healthy age-matched baseball players at the time of return to throwing. It was hypothesized that baseball players who underwent UCLR would demonstrate significant decreases in IR and ER strength in the throwing arm as compared with that of healthy players.

Methods

Participants

This was a cohort study with institutional review board approval. Competitive high school and collegiate baseball players from across the United States were recruited to participate in this study. Male athletes who underwent UCLR were compared with healthy controls without a UCL tear matched by age, height, weight, and position. Assent and/or consent was collected before enrollment in the study.

Participants were considered for the study if they were a baseball athlete between the ages of 15 and 25 years. Inclusion criteria for the UCLR group were (1) an inability to throw as the result of an injury, (2) an inability to continue pitching or throwing in baseball at the level before the UCL injury, (3) clinical examination results positive for a UCL tear, (4) confirmation of a UCL tear via magnetic resonance imaging, and (5) intent to return to prior level of competition after UCLR and subsequent postoperative rehabilitation. Exclusion criteria were revision of primary UCLR, any full-thickness chondral defects >1 cm², and previous shoulder surgery for labral or rotator cuff pathology. Participants in the healthy group were included in this study if the baseball athlete (1) was between 15 and 25 years old, (2) had no history of UCLR or UCL repair, (3) had no history of shoulder surgery for labral or rotator cuff pathology in the past year, and (4) had no complaints of elbow or shoulder pain that limited or restricted recent participation. An investigator within our outpatient sports medicine clinic screened eligible participants and subsequently enrolled each individual who met the study criteria.

Surgical Procedure and Rehabilitation

The diagnosis of an elbow UCL tear was made by a fellowship-trained, board-certified orthopaedic surgeon (J.E.C.) and confirmed via magnetic resonance imaging. Participants who sustained a UCL tear were recruited during the initial evaluation by the participating physician (J.E.C.) and physical therapist (J.C.G.). All athletes in the UCLR group had surgery performed by the participating physician (J.E.C.) using the contralateral palmaris longus tendon graft; if the palmaris longus was absent in the contralateral extremity, the gracilis tendon graft was used.²³ If the athlete’s contralateral palmaris longus tendon was available for a graft choice, a modified docked figure-of-8 procedure was performed³⁰; if absent, the ipsilateral gracilis tendon graft was used via a docking method.³³

Athletes in the UCLR group attended formal physical therapy with a standardized rehabilitation protocal at the outpatient sports medicine clinic if they lived within a commutable distance. Those in the UCLR group who were unable to be seen at the outpatient sports medicine clinic participated in formal physical therapy in closer proximity to their homes with the same standardized rehabilitation protocol. Each patient attending formal physical therapy outside of the sports medicine clinic was evaluated by a board-certified, residency-trained sports physical therapist at each physician follow-up (every 4-6 weeks). During the follow-up visit, the participants were provided with written recommendations to improve their standardization of care based on input from the treating surgeon and objective clinical data as measured by the sports physical therapist. The participants of the healthy group were recruited from local high schools and colleges, and all were healthy at the time of data collection.

Ankle Fractures: How Much Are We Really Seeing?

Ankle fractures remain a common orthopaedic injury requiring surgical repair. Surgical management of displaced ankle fractures has been the standard of care secondary to tibiotalar incongruence or displacement predisposing to the development of early posttraumatic osteoarthritis. However, despite appropriate treatment and restoration of alignment after ankle fracture surgical fixation, a certain subset of this population experiences poor long-term clinical outcomes. Several studies examining chronic ankle pain and osteoarthritis in patients have shown posttraumatic injury as a prevalent historical element. This subset of patients who experience poor clinical outcomes after repair of acute ankle fracture have often been described as containing occult intra-articular pathologies occurring at the time of acute ankle fracture. Additionally, concomitant chondral lesions have been shown to be an independent predictor of the development of posttraumatic osteoarthritis and are common after an acute ankle fracture. This pathology can be difficult to detect by conventional methods, including physical examination and imaging.

Ankle arthroscopy during the repair of acute ankle fractures has the potential to increase the detection of occult intra-articular pathologies, ligamentous damage, and syndesmotic disruptions. However, arthroscopy after ankle fracture is not routinely performed, and there is a paucity of literature comparing outcomes of acute ankle fracture repair by arthroscopically assisted open reduction and internal fixation (ORIF) versus ORIF alone. Various studiessuggest that arthroscopy may be valuable in improving outcomes after ankle fracture by reducing the rate of posttraumatic osteoarthritis development; however, long-term outcomes are still pending. The authors are not aware of any current literature comparing the degree of visualization arthroscopically versus open surgical visualization at the time of fixation. The purpose of this study was to quantify the degree of tibiotalar articular surface visible through a standard combined medial and lateral approach to an ankle fracture. We hypothesized that open visualization alone through the fracture fragments would be insufficient to rule out the presence of associated intra-articular pathology.

Methods

Ethics approval was obtained through our institution to utilize 2 fresh-frozen cadaveric specimens (Center for Procedural Innovation), allowing for the analysis of a total of 4 ankles. Cadavers were excluded if they contained any visible deformity through the lower extremity or surgical scars evidencing prior surgical intervention. Both specimens had minimal tibiotalar osteoarthritis. Dissection was carried out by a single researcher (K.A.P.), who made standard bimalleolar ankle fracture incisions both medially and laterally. For the lateral approach, the distal fibula was outlined and an incision was extended from 1 cm distal to the tip of the lateral malleolus to 11 cm proximal to the tip of the lateral malleolus midline along the fibula .Dissection was carried to the bone, and the periosteal envelope was dissected anteriorly and posteriorly around the distal fibula and syndesmosis. For the medial approach, the medial malleolus was outlined and an incision was made contouring from 1 cm distal to the tip of the medial malleolus to 5 cm proximal along the border of the tibia. Subperiosteal dissection was then carried out proximally while preserving the deltoid ligament distally.

Kevin Durant’s Promising Return from Achilles Tear

Dr. Raymond Reiter is an associate physician with Atlas Spine and Interventional Medicine in North Nergen, NJ. Dr. Raymond Reiter also serves as a physician at the North Jersey Orthopedic and Sports Medicine Institute, a role that involves the evaluation of orthopedic and athletic injuries.

The Achilles tear has long been viewed as the most devastating injury for athletes in stop-and-go sports, such as basketball. In the NBA, athletes who suffer an Achilles tear usually see their playing careers cut in half. Former All Stars Demarcus Cousins and John Wall have experienced significant drops in athleticism and productivity after the injury. Other athletes, however, offer hope for improved recoveries.

Kevin Durant tore his Achilles during the 2019 NBA Finals and missed the entirety of the 2019-2020 season. A tall, wiry player, Durant’s ability to shoot over defenses was unlikely to diminish as the result of the injury, but it remained to be seen whether his athleticism would hold up at age 32.

While Durant was limited to 35 games in his 2020-2021 campaign with the Brooklyn Nets, he matched his career high by shooting 53.7 percent, including a career best 35 percent from three. His 60.8 effective field goal percentage made him one of the most efficient scorers in the league.

Durant’s injury did not hamper his athleticism. He continued to attack the basket, getting to the free throw line 6.8 times per game for his best mark in 7 years. He finished the season averaging 26.9 points, his highest average in several seasons, despite sharing the floor with high-volume scorers James Harden and Kyrie Irving.

Injuries to Harden and Irving put a halt to Durant and the Net’s championship aspirations, but Durant played about 40 minutes per game and averaged over 30 points in the playoffs. A few weeks later, he traveled to Tokyo and led the US men’s basketball team to a gold medal at the summer Olympics, where he was named tournament MVP.

A Look at the Themes in Death of a Salesman Play

A Dean’s list student, Dr. Raymond Reiter studied biology at Hobart College in Geneva, NY and graduated in 1976. Now, he is an experienced physician in Clifton, NJ. Dr. Raymond Reiter enjoys watching plays and going to the theater.

Death of a Salesman is one of the most iconic plays in American history. It is often cited as a working-class Oedipus Rex. It criticizes fundamental American values and the American Dream. The themes in this play border abandonment, betrayal, and the American Dream.

The main character, Willy, is a firm believer in what he sees as the American Dream’s promise. A “well-liked” and “attractive” businessman would undoubtedly make it and enjoy the material pleasures of a modern American life. However, he fails to see the reality, and the reality is that hard labor without complaint is the key to success. This inability to grasp reality is at the crux of his mental breakdown, which leads to his death.

Throughout Willy’s life, he moves from one abandonment to the other. Each abandonment takes a bit out of him. Willy and Ben are abandoned by their father. Ben then abandons Willy and goes to Alaska. These events cause Willy to develop a fear of abandonment.

Throughout the play, Willy’s major focus is what he perceives to be Biff’s betrayal of the dreams he has for him. Willy feels Biff ought to follow through on his commitment. Biff’s rejection of Willy’s dreams of him is something Willy sees as a personal assault on him. And Willy, being the salesman he is, suffers serious despair for his failure to sell him the American Dream.