Bowman, Eric N.

Background: Several special tests for detecting medial ulnar collateral ligament (MUCL) injuries of the elbow have been described, but data on the clinical utility of these tests are limited. Purpose: To determine the clinical utility of selected elbow special tests to detect MUCL injuries in an athletic population. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 84 consecutive patients with sports-related elbow pain underwent a standardized clinical examination. Overall, 6 special tests (moving valgus stress test, static valgus stress test, modified valgus stress test, milking maneuver, pronation flexion resistance test, and temple/cheek press test) were performed. Sensitivity, specificity, accuracy, positive/negative predictive value, and positive/negative likelihood ratio (LR+ and LR–, respectively) were calculated for individual tests and combinations of tests to detect MUCL injuries. Higher values for the LR+ and lower values for the LR– represent stronger clinical utility. Results: For detecting MUCL injuries, the moving valgus stress test resulted in the highest sensitivity (98%) and accuracy (93%) with the lowest LR– (2%). The milking maneuver had the highest LR+ (5.1) with the second highest sensitivity (77%) and accuracy (79%). The pronation flexion resistance test and the temple/cheek press test had the lowest LR+ (1.5 and 1.8, respectively) and highest LR– (94% and 95%, respectively) in addition to the lowest sensitivity (16% and 9%, respectively) and accuracy (33% and 30%, respectively). No combination of tests resulted in increased clinical utility. Conclusion: The moving valgus stress test and milking maneuver demonstrated acceptable clinical utility in which the moving valgus stress test was better for ruling out MUCL injuries and the milking maneuver was better at ruling in MUCL injuries. There was no added value when combining the 2 tests together or with other maneuvers.

Purpose To use publicly available injured list (IL) data to 1) describe Major League Baseball injury trends from 2010 to 2024; 2) analyze injury types and body regions affected to report the highest impact injuries; and 3) report the financial implications of time lost due to injury over this 15‐year period. Methods IL data for every Major League Baseball player (pitchers and position players) from the 2010 to 2024 regular seasons were collected using publicly available sources, including player demographics, IL placements, body part injured, and length of each IL stay. Player salaries were compiled to determine the “financial loss” per injury. Results Across 15 seasons, 8078 players were placed on the IL, totaling 478,085 days. The mean IL placements/year was 634, and the annual number increased by an additional 27 injuries/year ( P < .001). Mean total IL days/season was 31,872, and this increased year‐over‐year ( P = .008). Shoulder injuries represented the most IL placements (n = 1555), followed by elbow (n = 1344) and upper leg (n = 769). Elbow injuries averaged the most days missed/IL placement (mean: 93, median: 74) and the greatest total days missed (129,610), followed by shoulder (95,189). Pitchers comprised 55% of IL placements and most commonly injured their shoulder or elbow. Infielders and outfielders accounted for 21% and 16% of IL placements, respectively. A total financial loss of $9,636,753,291 was accumulated over 15 seasons. Financial loss increased season‐to‐season (+$32,309,178/year, P = .002). Elbow injuries accounted for the highest financial loss at $1,932,048,168 ($1,379,049 lost/injury). In 2024, $2,220,432 was lost/elbow injury, $1,110,573/shoulder injury, $1,397,322/any injury, and $952,973,760 total for the season. Conclusions This study observed that the number of players, IL placements, days spent on the IL, and financial loss due to injury increased steadily each year. Pitchers were the most frequently injured players with shoulder and elbow injuries being most common. Over the 15‐season study period, there was a total financial loss of nearly $9.7 billion due to salary paid to injured players, with elbow injuries contributing the highest loss at just under $2 billion. Clinical Relevance Injury trends and financial data from Major League Baseball highlight the growing burden of shoulder and elbow injuries, particularly in pitchers. These findings underscore the need for orthopaedic surgeons to focus on prevention, early intervention, and optimized surgical management of high‐impact injuries to reduce long‐term morbidity and associated financial costs at the elite level.

Context: The quality and interprogram variability of publicly available throwing programs have not been assessed. Objective: To (1) identify publicly available interval throwing programs, (2) describe their components and structure, and (3) evaluate their quality, variability, and completeness. Data Sources: Google, Bing, Yahoo; keyword: “interval throwing program.” Study Selection: Baseball-specific publicly available programs. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Independent evaluation by 2 authors using a novel 21-item Quality Assessment Rubric (QAR). Results: Of the 99 included programs, 54% were designed for return from injury/surgery; 42% explicitly stated no expected timeline for completion, and approximately 40% did not provide criteria to initiate the program. Program construction was highly variable. There were broad-ranging shortest (mean: 40±8 ft, range: 20-45 ft) and longest (mean: 150±33 ft, range: 90-250 ft) long toss distances, and variable maximum numbers of mound pitches thrown before returning to game play (range: 40-120, mean: 85). Only 63% of programs provided guidelines for handling setbacks, and standardized warm-ups, arm care, and concomitant training were absent in 32%, 63%, and 47% of programs, respectively. Mean QAR completion rate and QAR item response rate were low (62 ± 4% [range, 24-91%], 62 ± 24% [range, 7-99%], respectively). Finally, only 20 (20%) programs provided at least 1 peer-reviewed reference, most of which were published >10 years ago. Conclusion: Publicly available interval throwing programs are readily available but demonstrate significant interprogram heterogeneity across multiple areas including target audience, program construction, progression, and execution. The quality and consistency of publicly available interval throwing programs is poor at this time, which may limit their utility and effectiveness for baseball players attempting to return to competition. This work identifies a multitude of deficiencies in currently available throwing programs that should be targets of future improvement efforts.

Background: Although pitch count and rest guidelines have been promoted for youth and adolescent baseball players for nearly 2 decades, compliance with guidelines remains poorly understood. Purpose/Hypothesis: The purpose of this study was to determine the frequency of compliance with Major League Baseball (MLB) Pitch Smart guidelines as well as the association between compliance and range of motion (ROM), strength, velocity, injury, and pitcher utilization. It was hypothesized that pitchers in violation of current recommendations would have increased strength, velocity, and injury. Study Design: Case-control study; Level of evidence, 3. Methods: This was a prospective, multicenter study of 115 high school pitchers throughout the United States. Pitchers were surveyed about their compliance with current off-season, rest-related guidelines, and history of injury. During the preseason, pitchers underwent standardized physical examinations, and pitch velocity was measured. Pitch counts were collected during the baseball season that followed. Dynamometer strength testing of shoulder forward flexion, and external rotation as well as grip strength was recorded. We compared pitchers who were compliant with recommendations with those who were noncompliant using Student t and Mann-Whitney U tests. Results: Based on preseason data, 84% of pitchers had violated current Pitch Smart guidelines. During the season, 14% had at least 1 violation of the Pitch Smart guidelines. Across both the preseason survey and in-season pitch counts, 89% of players had at least 1 violation of the Pitch Smart guidelines. While there were no significant differences in ROM or strength, the noncompliant group had higher maximum pitch velocity than the compliant group (74 ± 8 vs 69 ± 5 mph [119 ± 13 vs 111 ± 8 kph], respectively; P = .009). Players’ self-reported velocity differed significantly from the direct measurement, for both peak velocity (80 ± 6 vs 73 ± 8 mph [129 ± 9 vs 117 ± 13 kph], respectively; P < .001) and mean velocity (73 ± 8 vs 53 ± 27 mph [117 ± 13 vs 85 ± 43 kph], respectively; P < .001). Conclusion: Most high school pitchers were not fully compliant with current Pitch Smart guidelines, and they tended to overestimate their peak velocity by 7 mph (11 kph). Pitchers who threw with greater velocity were at higher risk for violating Pitch Smart recommendations.

Objectives: Ulnar Collateral Ligament (UCL) tears are common in baseball players. When non-operative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics, or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs reconstruction. Methods: Twenty-six orthopaedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intra-operatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (peri-ligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, mid-substance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95%CI) helped identify significant predictors for both queries. Results: The odds of recommending surgical treatment compared to non-operative treatment were 2.4x more likely for a proximal partial-thickness tear, 3.2x for distal partial-thickness tear, 5.1x for distal full- thickness tear, and 7.0x for proximal full-thickness tear (p<0.001). Significant indications for repair included distal partial (OR=1.6, 95%CI 1.0, 2.1, p<0.001) and full-thickness tears (OR=1.7, 95%CI 1.1, 2.3, p<0.001). Repair was 3x less likely recommended for mid-substance full-thickness tears (OR=3.0, 95%CI - 5.0, -1.0, p=0.004). Ultrasound stress testing was requested in 78% of partial tears. Conclusions: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial- thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete mid-substance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes. [Table: see text]

Objectives: While pitch count and rest guidelines have been promoted for youth and adolescent baseball players for nearly two decades, compliance with guidelines remains poorly understood. The purpose of this study was to determine the frequency of compliance with Pitch Smart guidelines, as well as the association between compliance and range of motion, strength, velocity, injury, and pitcher utilization. Methods: This study was a prospective, multi-center study of high school pitchers, encompassing each region of the United States. Pre-season pitchers were surveyed about their compliance with current off- season rest-related guidelines and history of injury. Pre-season, pitchers underwent standardized physical examinations and pitch velocity was measured. During the high school season that followed, both pitch counts and injury incidence were collected. Results: One hundred and fifteen pitchers participated. Based upon pre-season data, 84% of pitchers had previously violated current pitch recommendation guidelines. During the season, 14% had at least one instance of a violation of the current pitch counts guidelines. Across both the pre-season survey and in-season pitch counts, 89% of players had at least one violation of the current Pitch Smart guidelines. While there were no significant differences in range of motion or strength, those pitchers who were non-compliant with guidelines in the pre-season had higher max pitch velocity (mean±standard deviation 74±8 miles per hour vs. 69±5 miles per hour, p=0.009). Pitchers self-reported their peak velocity at 7 MPH greater than the actual measured velocity. Only a single injury occurred during the season, precluding a comparison between groups. There were no significant differences in the incidence of a history of injury between those pitchers who were noncompliant with between-season rest guidelines (p=0.285). Conclusions: Most high school pitchers are non-compliant with current Pitch Smart guidelines, and they tend to overestimate their peak velocity by 7 MPH. Pitchers with greater velocity were at the highest risk for violating current pitch count recommendations. Since both increased throwing volume and pitch velocity are known risk factors for injury, these athletes may be at particular risk for subsequent injury. research is necessary to understand whether taking three consecutive month rest between seasons prevents pitching-related injury.