JOURNAL CLUB

The Youth Throwing Score: Validating Injury Assessment in Young Baseball Players

Christopher S. Ahmad, MD, Ajay S. Padaki, MD, Manish S. Noticewala, MD, Eric C. Makhni, MD, MBA, Charles A. Popkin, MD: Am J Sports Med 2017: 45(2):317-324.
Epidemic levels of shoulder and elbow injuries have been reported recently in youth and adolescent baseball players. Despite the concerning frequency of these injuries, no instrument has been validated to assess upper extremity injury in this patient population.
Purpose/Hypothesis:
The purpose of this study was to validate an upper extremity assessment tool specifically designed for young baseball players. We hypothesized that this tool will be both reliable and valid.
Study Design:
Cohort study (diagnosis); Level of evidence, 2.
Methods:
The Youth Throwing Score (YTS) was constructed by an interdisciplinary team of providers and coaches as a tool to assess upper extremity injury in youth and adolescent baseball players (age range, 10-18 years). The psychometric properties of the test were then determined.
Results:
A total of 223 players completed the final survey. The players’ mean age was 14.3 ± 2.7 years. Pilot analysis showed that none of the 14 questions received a mean athlete importance rating less than 3 of 5, and the final survey read at a Flesch-Kincaid level of 4.1, which is appropriate for patients aged 9 years and older. The players self-assigned their injury status, resulting in a mean instrument score of 59.7 ± 8.4 for the 148 players “playing without pain,” 42.0 ± 11.5 for the 60 players “playing with pain,” and 40.4 ± 10.5 for the 15 players “not playing due to pain.” Players playing without pain scored significantly higher than those playing with pain and those not playing due to pain (P < .001). Psychometric analysis showed a test-retest intraclass correlation coefficient of 0.90 and a Cronbach alpha intra-item reliability coefficient of 0.93, indicating excellent reliability and internal consistency. Pearson correlation coefficients of 0.65, 0.62, and 0.31 were calculated between the YTS and the Pediatric Outcomes Data Collection Instrument sports/physical functioning module, the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, respectively. Injured players scored a mean of 9.4 points higher after treatment (P < .001), and players who improved in their self-assigned pain categorization scored 16.5 points higher (P < .001).
Conclusion:
The YTS is the first valid and reliable instrument for assessing young baseball players’ upper extremity health.

Hip Capsular Closure: A Biomechanical Analysis of Failure Torque

Jorge Chahla, MD, Jacob D. Mikula, BS, Jason M. Schon, BS, Chase S. Dean, MD, Kimi D. Dahl, MS, Travis J. Menge, MD, Eduardo Soares, MD, Travis Lee Turnbull, PhD, Robert F. LaPrade, MD, PhD, Marc J. Philippon, MD‡: Am J Sports Med 2017;45(2):434-439.

Background:

Hip capsulotomy is routinely performed during arthroscopic surgery to achieve adequate exposure of the joint. Iatrogenic instability can result after hip arthroscopic surgery because of capsular insufficiency, which can be avoided with effective closure of the hip capsule. There is currently no consensus in the literature regarding the optimal quantity of sutures upon capsular closure to achieve maximal stability postoperatively.

Purpose/Hypothesis:

The purpose of this study was to determine the failure torques of 1-, 2-, and 3-suture constructs for hip capsular closure to resist external rotation and extension after standard anterosuperior interportal capsulotomy (12 to 3 o’clock). Additionally, the degree of external rotation at which the suture constructs failed was recorded. The null hypothesis of this study was that no significant differences with respect to the failure torque would be found between the 3 repair constructs.

Study Design:

Controlled laboratory study.

Methods:

Nine pairs (n = 18) of fresh-frozen human cadaveric hemipelvises underwent anterosuperior interportal capsulotomy, which were repaired with 1, 2, or 3 side-to-side sutures. Each hip was secured in a dynamic biaxial testing machine and underwent a cyclic external rotation preconditioning protocol, followed by external rotation to failure.

Results:

The failure torque of the 1-suture hip capsular closure construct was significantly less than that of the 3-suture construct. The median failure torque for the 1-suture construct was 67.4 N·m (range, 47.4-73.6 N·m). The median failure torque was 85.7 N·m (range, 56.9-99.1 N·m) for the 2-suture construct and 91.7 N·m (range, 74.7-99.0 N·m) for the 3-suture construct. All 3 repair constructs exhibited a median 36° (range, 22°-64°) of external rotation at the failure torque.

Conclusion:

The most important finding of this study was that the 2- and 3-suture constructs resulted in comparable biomechanical failure torques when external rotation forces were applied to conventional hip capsulotomy in a cadaveric model. The 3-suture construct was significantly stronger than the 1-suture construct; however, there was not a significant difference between the 2- and 3-suture constructs. Additionally, all constructs failed at approximately 36° of external rotation.

Clinical Relevance:

Re-establishing the native anatomy of the hip capsule after hip arthroscopic surgery has been reported to result in improved outcomes and reduce the risk of iatrogenic instability. Therefore, adequate capsular closure is important to restore proper hip biomechanics, and postoperative precautions limiting external rotation should be utilized to protect the repair.

 

Medial Patellofemoral Ligament Reconstruction Combined With Distal Realignment for Recurrent Dislocations of the Patella: 5-Year Results of a Randomized Controlled Trial

Iswadi Damasena, MBBS*, Murray Blythe, FRACS(Orth), David Wysocki, FRACS(Orth), David Kelly, MBBS, Peter Annear, FRACS(Orth): Am J Sports Med 2017; 45(2):369-376.

Background:

Tibial tubercle transfer (TTT) and medial patellofemoral ligament (MPFL) reconstruction have both shown, either in isolation or in combination, to provide improved patellofemoral joint (PFJ) stability. There are few studies that provide evidence that this remains true in the long term.

Purpose:

To compare the long-term results of patellar instability after TTT with and without MPFL reconstruction in 2 randomized groups.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 34 patients (36 knees) were randomized to 2 groups. The first group underwent lateral release (LR) and TTT for confirmed maltracking of the patella (control group). The second group underwent MPFL reconstruction in addition to TTT and LR (reconstruction group). Patients were followed up with validated questionnaires (Kujala score, Tegner activity score), a visual analog scale (VAS) assessing their insecurity, and a clinical assessment at a minimum of 5 years postoperatively. Participants also underwent quantitative computed tomography (CT) at 1 year for comparison. Two patients in the control group and 1 patient in the reconstruction group were lost to follow-up at 5 years.

Results:

There were no significant differences in the Kujala (P = .75), Tegner (P = .36), or VAS (P = .75) scores at any time period. One patient in the control group sustained a patellar redislocation at 3 years. Five patients in the control group and 2 in the reconstruction group had functional failures and required reoperations; however, this was not statistically significant (P = .30). There were no significant differences between groups in the time to return to school or work (P = .65) or sports (P = .38) after surgery. Overall patient satisfaction was higher in the reconstruction group compared with the control group (P = .04), and quantitative CT scans showed that the reconstruction group had a statistically significant improvement in the mean patellar tilt (6° vs −8°, respectively; P = .03) and mean congruence angle (13° vs −11°, respectively; P = .03) in the quadriceps-contracted state compared with the control group.

Conclusion:

Reconstruction of the MPFL in addition to TTT and LR resulted in improved alignment parameters (congruence angle, patellar tilt angle) as well as patient satisfaction. The Kujala and Tegner scores were no different between the 2 groups at any time period. There was insufficient evidence to conclude that the addition of MPFL reconstruction to TTT results in fewer redislocations or reoperations. This study concludes that MPFL reconstruction improves PFJ alignment and patient satisfaction; however, further studies with larger patient numbers are required to satisfy its significance with respect to redislocation rates and functional scores in the long term.

Humeral Retrotorsion and Glenohumeral Motion in Youth Baseball Players Compared With Age-Matched Nonthrowing Athletes

Elliot M. Greenberg, PT, DPT, PhD, OCS*, J. Todd R. Lawrence, MD, PhD, Alicia Fernandez-Fernandez, PT, DPT, PhD, Philip McClure, PT, PhD, FAPTA: Am J Sports Med 2017; 45(2):454-461.

Baseball players exhibit a more posteriorly oriented humeral head in their throwing arm. This is termed humeral retrotorsion (HRT) and likely represents a response to the stress of throwing. This adaptation is thought to occur while the athlete is skeletally immature, however currently there is limited research detailing how throwing activity in younger players influences the development of HRT. In addition, it is presently unclear how this changing osseous orientation may influence shoulder motion within young athletes.

Purpose:

To determine the influence of throwing activity and age on the development of side-to-side asymmetry in HRT and shoulder range of motion (ROM).

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Healthy athletes (age range, 8-14 years) were categorized into 2 groups based upon sports participation; throwers (n = 85) and nonthrowers (n = 68). Bilateral measurements of HRT, shoulder external rotation (ER), internal rotation (IR), and total range of motion (TROM) at 90° were performed using diagnostic ultrasound and a digital inclinometer. Side-to-side asymmetry (dominant minus nondominant side) in HRT and in shoulder ER, IR, and TROM were assessed. Statistical analysis was performed with 2-way analysis of variance and Pearson correlation coefficients.

Results:

Throwers demonstrated a larger degree of HRT on the dominant side, resulting in greater asymmetry compared with nonthrowers (8.7° vs 4.8°). Throwers demonstrated a gain of ER (5.1°), a loss of IR (6.0°), and no change in TROM when compared with the nondominant shoulder. Pairwise comparisons identified altered HRT and shoulder ROM in all age groups, including the youngest throwers (age range, 8-10.5 years). A positive correlation existed between HRT and ER ROM that was stronger in nonthrowers (r = 0.63) than in throwers (r = 0.23), while a negative correlation existed with IR that was stronger in throwers (r = −0.40) than in nonthrowers (r = −0.27).

Conclusion:

Throwing activity causes adaptive changes in HRT and shoulder ROM in youth baseball players at an early age. Other factors in addition to HRT influence shoulder motion within this population.

A Prospective Randomized Study Comparing the Interference Screw and Suture Anchor Techniques for Biceps Tenodesis

Ji Soon Park, MD, Sae Hoon Kim, MD, PhD, Ho Jin Jung, MD, Ye Hyun Lee, MD, Joo Han Oh, MD, PhD¶: Am J Sports Med 2017; 45(2):440-447.

Several methods are used to perform biceps tenodesis in patients with superior labrum-biceps complex (SLBC) lesions accompanied by a rotator cuff tear. However, limited clinical data are available regarding the best technique in terms of clinical and anatomic outcomes.

Purpose:

To compare the clinical and anatomic outcomes of the interference screw (IS) and suture anchor (SA) fixation techniques for biceps tenodesis performed along with arthroscopic rotator cuff repair.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 80 patients who underwent arthroscopic rotator cuff repair with SLBC lesions were prospectively enrolled and randomly divided according to the tenodesis method: the IS and SA groups. Functional outcomes were evaluated with the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), Constant score, Korean Shoulder Score (KSS), and long head of the biceps (LHB) score at least 2 years after surgery. The anatomic status of tenodesis was estimated using magnetic resonance imaging or ultrasonography, and the anatomic failure of tenodesis was determined when the biceps tendon was not traced in the intertubercular groove directly from the insertion site of the IS or SA.

Results:

Thirty-three patients in the IS group and 34 in the SA group were monitored for more than 2 years. All postoperative functional scores improved significantly compared with the preoperative scores (all P < .001) and were not significantly different between the groups, including the LHB score (all P > .05). Nine anatomic failures of tenodesis were observed: 7 in the IS group and 2 in the SA group (P= .083). In a multivariate analysis using logistic regression, IS fixation (P = .003) and a higher (ie, more physically demanding) work level (P = .022) were factors associated with the anatomic failure of tenodesis significantly. In patients with tenodesis failure, the LHB score (P = .049) and the degree of Popeye deformity by the patient and examiner (P = .004 and .018, respectively) were statistically different compared with patients with intact tenodeses.

Conclusion:

Care must be taken while performing biceps tenodesis in patients with a higher work level; IS fixation appears to pose a higher risk in terms of the anatomic failure of tenodesis than SA fixation, although functional outcomes were not different.

Biomechanical Effects of an Injury Prevention Program in Preadolescent Female Soccer Athletes

 

Julie A. Thompson, PhD, Andrew A. Tran, MD, Corey T. Gatewood, BS, Rebecca Shultz, PhD, Amy Silder, PhD, Scott L. Delp, PhD, Jason L. Dragoo, MD‖: Am J Sports Med 2017; 45(2):294-301.

Background:

Anterior cruciate ligament (ACL) injuries are common, and children as young as 10 years of age exhibit movement patterns associated with an ACL injury risk. Prevention programs have been shown to reduce injury rates, but the mechanisms behind these programs are largely unknown. Few studies have investigated biomechanical changes after injury prevention programs in children.

Purpose/Hypothesis:

To investigate the effects of the F-MARC 11+ injury prevention warm-up program on changes to biomechanical risk factors for an ACL injury in preadolescent female soccer players. We hypothesized that the primary ACL injury risk factor of peak knee valgus moment would improve after training. In addition, we explored other kinematic and kinetic variables associated with ACL injuries.

Study Design:

Controlled laboratory study.

Methods:

A total of 51 female athletes aged 10 to 12 years were recruited from soccer clubs and were placed into an intervention group (n = 28; mean [±SD] age, 11.8 ± 0.8 years) and a control group (n = 23; mean age, 11.2 ± 0.6 years). The intervention group participated in 15 in-season sessions of the F-MARC 11+ program (2 times/wk). Pre- and postseason motion capture data were collected during preplanned cutting, unanticipated cutting, double-leg jump, and single-leg jump tasks. Lower extremity joint angles and moments were estimated using OpenSim, a biomechanical modeling system.

Results:

Athletes in the intervention group reduced their peak knee valgus moment compared with the control group during the double-leg jump (mean [±standard error of the mean] pre- to posttest change, –0.57 ± 0.27 %BW×HT vs 0.25 ± 0.25 %BW×HT, respectively; P = .034). No significant differences in the change in peak knee valgus moment were found between the groups for any other activity; however, the intervention group displayed a significant pre- to posttest increase in peak knee valgus moment during unanticipated cutting (P = .044). Additional analyses revealed an improvement in peak ankle eversion moment after training during preplanned cutting (P = .015), unanticipated cutting (P = .004), and the double-leg jump (P = .016) compared with the control group. Other secondary risk factors did not significantly improve after training, although the peak knee valgus angle improved in the control group compared with the intervention group during unanticipated cutting (P = .018).

Conclusion:

The F-MARC 11+ program may be effective in improving some risk factors for an ACL injury during a double-leg jump in preadolescent athletes, most notably by reducing peak knee valgus moment.

Clinical Relevance:

This study provides motivation for enhancing injury prevention programs to produce improvement in other ACL risk factors, particularly during cutting and single-leg tasks.


Cole BJ, Karas V, Hussey K, Pilz K, Fortier LA: Hyaluronic Acid Versus Platelet-Rich Plasma: A Prospective, Double-Blind Randomized Controlled Trial Comparing Clinical Outcomes and Effects on Intra-articular Biology for the Treatment of Knee Osteoarthritis. Am. J. Sports Med. 2017;45(2)339-346

  • Prospective, randomized, double-blind, controlled trial; Level of Evidence 1
  • HA is a synthetically derived product, PRP is an autologous blood product providing a biological alternative to HA and also addresses the underlying inflammation via growth factor stimulation and inflammatory cytokine suppression
  • Aim of the study was to compare the clinical and biological effects of intra-articular Platelet Rich Plasma (PRP) Injections vs Hyaluronic Acid (HA) Injections in the treatment of mild to moderate knee osteoarthritis (OA)
  • A total of 111 patients with symptomatic cartilage lesions or OA were enrolled between 2011-2014

o   Final randomized allocation: PRP n=49 HA n=50

o   Outcome measures:

§  Primary: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

§  Secondary: Visual Analog Scale (VAS) 0-100, Lysholm Knee Score, International Knee Documentation Committee (IKDC)

§  Tertiary: Tumor Necrosing Factor- Alpha (TNF-α) at 12 and 24 weeks within the knee

§  Evaluated at baseline treatment weeks 2 and 3, and post-treatment weeks 6,12,24, and 52

  • Injections: Three weekly injections with ultrasound guidance

o   PRP: 4 mL Leukocyte poor

o   HA:  2mL containing 16 mg of hylan G-F 20

o   Instructed to limit leg use for 24 hours minimum post-injection, rest or mild exertion activities were recommended immediately, followed by gradual return to sport/recreation

  • Results:

o   All outcome scores showed significant interaction between pre/post-treatment up to week 24 in both PRP and HA groups, both showed decline at week 52

o   WOMAC score was not significant in either group at any time

o   Patients with grade 1 OA had statistically significant improvement in IKDC score compared to grade 3; no significant differences between grade 1 vs grade 2 or grade 2 vs grade 3

ü  Significantly higher IKDC score in PRP group at 24 week follow up compared to HA, similar effect noted at 52 week follow-up

ü  Statistically lower VAS score at week 24 in PRP group

ü  PRP group demonstrated a statistically significant improvement over HA at 24 & 52 weeks after treatment

o   No statistical difference between groups in regards to pro-inflammatory or anti-inflammatory cytokines

o   Decreased IL-1β and TNF-α pro-inflammatory cytokines noted in the PRP group

  • Clinical Implications:

ü  Intra-articular Leukocyte-poorPRP injections are showing promise in the treatment of knee OA

o   No standardized number of PRP injections for optimal treatment effect has been established

ü  IKDC scores and VAS scores favored PRP injections over HA injections

ü  PRP appears to have anti-inflammatory properties

o   A period of decreased weight bearing activity with active rest should be incorporated into treatment plans immediately following HA and PRP injections with a gradual progression back to the desired level of recreational or sport activity

 

 


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Wilk KE, Macrina L, Fleisig G, Aune K, Porterfield R, Simpson C, Harker P, Evans T, Andrews JR: Deficits in Glenohumeral Passive Range of Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers a Prospective study. Am J Sports Med 2015 43(10) 2379-2385.

  • This prospective study is the largest to examine the relationship between shoulder range of motion and shoulder injuries in professional baseball pitchers. It especially attempted to answer if TROM &/or GIRD causes shoulder injuries.
     
  • Conducted over 8 competitive seasons from (2005-20012) 505 pitcher seasons (296 pitchers)

o   46 pitchers assessed for 3 consecutive seasons

o   80 pitchers assessed for 2 consecutive seasons

o   170 pitchers assessed only once

o   220 Right handed pitchers (368 pitcher seasons)

o   76 Left handed pitchers (137 pitcher seasons)

  • All participants pain free and asymptomatic at testing. Exclusion Criteria: any player who was unable to participate in daily spring training activities. Passive Range of Motion (PROM) assessed by same examiners

o   Internal Rotation (IR)/ External Rotation (ER) assessed at 90˚ abduction with bubble goniometer and scapular stabilization

  • Shoulder/Elbow injury defined by any placement on the Disabled List (DL) due to injury of either joint
  • Determined to have Glenohumeral Internal Rotation Deficit (GIRD) if throwing shoulder displayed > 20˚ loss of IR compared to their non-throwing side
  • Total Rotational Motion (TRM) deficit = > 5˚ for dominant shoulder in comparison with non-dominant
  • 46% of pitchers had TRM deficit (21% placed on DL for shoulder injury)
  • 18% of pitchers had flexion deficit,12% placed on DL for shoulder injury
  • 46% had insufficient ER, 23% placed on DL for shoulder injury

Conclusions:

1) Pitchers with insufficient ER 4.0x more likely to have surgery, 2.2x more likely to be on DL
2) GIRD did not correlate to shoulder injuries
3)  TROM was associated with a higher shoulder injury rate

Clinical implications:

  • Assess passive ER/IR, add the two together (ER+IR=TROM) this is an important value
  • Assess  ER ROM, if ER deficit are  present this has been shown to correlate to higher shoulder injuries and more likely to have surgery
  • Assess for GIRD; but the presence of GIRD in isolation does not equal increased risk of shoulder injury
  • Excessive ER ROM (which most throwers will have excessive retrotorsion)  may be protective for the shoulder in throwers