Sciascia, Aaron D.

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.

Context : A common component within rehabilitation recommendations for baseball pitchers is employment of an interval throwing program. However, there is a lack of a consistent set of advocated guidelines for program content and implementation for athletes at the professional and collegiate levels. Design : Cross-sectional study. Methods : A survey was developed to obtain clinician views regarding the composition and implementation of interval throwing programs for baseball pitchers. The survey was divided into demographic information and sections on criteria to begin throwing programs, frequency of throwing, soreness management, warm-up components, program components and regulation of a program, and criteria to achieve permitting live throwing. Clinicians including physicians, physical therapists, and certified athletic trainers who evaluate and treat musculoskeletal injuries among baseball pitchers at the professional-level and/or collegiate-level clinician received the survey. Responses were tabulated and compared between the professional-level clinician and collegiate-level clinician groups using chi-square analyses with statistical significance set at P ≤ .05. Results : The survey was completed by 166 clinicians (collegiate level = 81, professional-level clinician = 85). There were no statistical differences between groups for allowing warm-up throws, program regulation, maximum distance allowed, managing soreness, or criteria to achieve before permitting live throwing. Between-group differences included criteria to begin a program (≤.03), warm-up distance ( P ≤ .02), nonthrowing warm-up methods ( P ≤ .04), non-warm-up distance ( P ≤ .01), using ratings of perceived exertion ( P < .01), throwing frequency ( P < .01), and program components ( P ≤ .04). Conclusions : Responses appear to mirror interval throwing program designs previously reported in the literature but there are modifications and additions utilized by clinicians at different playing levels.

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.