Camp, Christopher L.

Background: The limb symmetry index (LSI) is a measure comparing strength and functional movement between the surgical and nonsurgical limbs, used after anterior cruciate ligament reconstruction (ACLR) to guide rehabilitation and assess return-to-sport readiness. With increasing use of the quadriceps tendon autograft (QT-ACLR), limited data exist on whether the LSI score correlates with patient-reported outcome measures (PROMs). Hypothesis/Purpose: To evaluate the predictive value of postoperative strength and functional LSI tests at 3, 6, and 9 months for short-term PROMs, determine Patient Acceptable Symptom State (PASS) thresholds, and assess differences based on PASS achievement. It was hypothesized that quadriceps strength LSI score would more strongly predict 2-year PROMs than hamstring strength LSI score, and that higher 9-month isokinetic quadriceps LSI scores would be associated with higher International Knee Documentation Committee (IKDC) and Lysholm scores. Study Design: Case series; Level of evidence, 4. Methods: Patients undergoing primary QT-ACLR from 2021 to 2024 with LSI testing during rehabilitation (isometric and isokinetic lower extremity strength, Y-Balance, hop testing) and no revision or additional knee surgery were included. The LSI score was assessed at 3, 6, and 9 months, and PROMs, including Lysholm and IKDC scores, were collected at a mean follow-up of 2.0 ± 0.7 years. Multivariable linear regression was used to evaluate associations between LSI measures and PROMs after adjusting for age, sex, and body mass index (BMI). Receiver operating characteristic analysis was used to determine PASS thresholds. Results: A total of 100 knees in 100 patients (mean age, 25.3 ± 11.2 years; BMI, 25.9 ± 6.5 kg/m 2 ; 52% male) were included. Quadriceps and hamstring strength and functional performance progressively improved from 3 to 9 months, with the LSI score reaching 77% to 81% for quadriceps strength and 98% to 100% for hamstring strength by 9 months postoperatively. At a mean follow-up of 2.0 ± 0.7 years, the mean satisfaction score was 8.4 of 10, the Lysholm score was 90.7, and the IKDC score was 77.8. Linear regression, adjusted for age, sex, and BMI, demonstrated that 3-month isometric quadriceps LSI score had a strong effect on IKDC score, explaining substantial variance (β = 3.9; adjusted R 2 [Adj R 2 ] = 0.36; P < .03); 6-month isokinetic quadriceps and hamstrings showed moderate but significant effects (β = 2.9-3.7; Adj R 2 = 0.13-0.17; P < .05) on IKDC score; and 9-month fast quadriceps had a strong effect explaining substantial variance in Lysholm and IKDC scores (β = 3.9-4.7; Adj R 2 = 0.34-0.35; P ≤ .003). Lysholm and IKDC scores correlated with satisfaction and accurately discriminated PASS thresholds (area under the curve, 0.927-0.937; P < .001). Patients achieving the IKDC PASS demonstrated higher LSI scores across time points and all PROMs. Conclusion: After QT-ACLR, strength-associated LSIs were independently associated with PROMs at a mean 2-year follow-up, after adjusting for age, sex, and BMI. Early isometric quadriceps strength at 3 months predicted higher 2-year IKDC scores, with PASS achievers generally attaining a 60% to 70% LSI score by 3 months. Isokinetic quadriceps strength at 9 months predicted both IKDC and Lysholm scores. These findings highlight the importance of early quadriceps strength recovery and the value of LSI measures in predicting PROMs and informing early rehabilitation.

Purpose To assess the reliability, predictability, and discriminative capacity of 3 anatomic measurements, tibial tubercle‐trochlear groove (TT‐TG), tibial tubercle‐posterior cruciate ligament, and patellar tendon‐lateral trochlear ridge (PT‐LTR), where PT‐LTR may offer a complementary approach to assessing recurrent patellofemoral instability (PFI) risk. Methods Patients diagnosed with PFI before primary patellofemoral stabilization surgery at a single institution between 2022 and 2024 were included. A control group without PFI was propensity matched 1:1 for age, sex, and laterality. Magnetic resonance images were evaluated to measure TT‐TG, tibial tubercle‐posterior cruciate ligament, and PT‐LTR. A priori power analysis determined the cohort size. Statistical analyses compared differences between the PFI and control groups with Student t‐tests, receiver operating characteristic analyses, and area under the curve with resultant sensitivity, specificity, and an optimal cutoff. Results Patients included 50 knees with PFI (28 women, 22 men; mean age 18 ± 5 years). The control group included 50 knees (27 women, 23 men; mean age 18 ± 4 years). Excellent inter‐ and intra‐rater reliability (intraclass correlation coefficient > 0.7) was shown for TT‐TG and PT‐LTR in the PFI and control groups. The distances for TT‐TG, tibial tubercle‐posterior cruciate ligament, and PT‐LTR were significant predictors ( P ≤ .025) of PFI. The average PT‐LTR distance difference for the PFI and control groups was 7.0 mm ( P < .001). PT‐LTR showed an area under the curve of 0.80 and, when ≥4.6 mm, was 66% sensitive and 92% specific for PFI. Conclusions The PT‐LTR distance is a reliable and discriminative metric for identifying PFI in both pediatric and adult populations. A PT‐LTR cutoff value of 4.6 mm showed diagnostic discrimination and substantially high specificity for recurrent PFI, indicating strong ability to identify patients with instability. Level of Evidence Level III, retrospective case control study.

Medial ulnar collateral ligament (MUCL) injuries of the elbow have increased over the past 2 decades, particularly among adolescent and young adult overhead throwing athletes. Over time, operative techniques for MUCL injuries have evolved, with the goals of improving time to return and rates of return to sport and meeting athlete-specific demands. The purpose of this review is to evaluate the state of surgical management of MUCL injuries, assessing indications, techniques, and outcomes. Surgical techniques reviewed included MUCL-augmented repair with internal bracing, traditional reconstruction, reconstruction augmented with internal bracing, and revision MUCL reconstruction. While MUCL reconstruction has been the gold standard of treatment, augmented reconstruction and repair techniques have shown promising outcomes; these strategies emphasize anatomic restoration, preservation of native tissue, and individualized patient selection.

This article introduces a novel, single‐operator stress ultrasound technique for evaluating medial ulnar collateral ligament (MUCL) integrity by assessing medial ulnohumeral joint (MUHJ) widening under valgus stress. Unlike prior methods requiring dual operators, specialized equipment, or the use of hand/wrist weights, this approach was designed for clinical efficiency, reproducibility, and patient comfort. By positioning the patient comfortably in a side‐lying position with the elbow flexed to 50°, MUHJ width is measured at baseline (maximally apposed) and manually stressed positions, in a manner that may reduce muscular compensation, avoid viscoelastic creep, and facilitate consistency. While additional research is needed to evaluate clinical feasibility, assess reliability, and compare our technique with previously published methods of dynamic MUCL assessment, the aim of this manuscript is to describe our technique and provide a rationale for its potential utility in musculoskeletal ultrasound practice and research.

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.

Background: Recent reports suggest increasing trends in injuries, primarily among pitchers and upper extremity injuries, among Major League Baseball (MLB) and Minor League Baseball (MiLB) players. Accordingly, an updated comprehensive report on injury epidemiology in professional baseball is needed. Purpose: To (1) update the literature with a comprehensive epidemiological report of all injuries in MLB and MiLB; (2) provide a detailed breakdown of characteristics of the top 50 injuries; and (3) analyze long-term trends in injuries and days missed (DM) over time. Study Design: Case Series; Level of evidence, 4. Methods: The MLB Health and Injury Tracking System was used to identify injuries in MLB and MiLB players from 2011 to 2023. The inclusion criteria consisted of injuries occurring during spring training, regular season, or postseason activities that resulted in ≥1 DM from play. Basic and advanced player and injury characteristics were analyzed—including a list of the top 50 most common injuries. Results: From 2011 to 2023, a total of 83,215 musculoskeletal injuries occurred among MLB and MiLB players, resulting in 1,280,887 total DM, with a mean (median) DM per injury of 18 (11). The upper extremity accounted for 46% of injuries, and the lower extremity for 30%. The most common injury was hamstring strains (n = 6603; 7.9%); hamate fractures had the highest rate of surgery (81%); and elbow medial ulnar collateral ligament injury resulted in the highest DM (583,070 days). From 2011 to 2023, a significant increase was observed in the number of annual injuries (excluding 2020) ( P = .028) and injuries per game ( P = .003). However, 2018 and 2019 saw the highest number of injuries, and injuries did not rise after 2020. Conclusion: The annual number of injuries and rate of injuries per game increased significantly from 2011 to 2023; however, injuries did not increase over the final 3 years of the study (2021 to 2023). The percentage of overall injuries was dominated by upper extremity injuries among pitchers, although hamstring strains were the most common injury type overall.

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.

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback for throwing athletes, often requiring reconstruction with 12 to 18 months of rehabilitation. The authors previously described a more anatomic technique with improved mechanical strength as compared with the docking technique, which may allow for an accelerated return to sport. Purpose: To evaluate return-to-sport rates, time to return to sport, and the effect on the functional performance of amateur and professional throwing athletes who underwent anatomic MUCL reconstruction with suture tape augmentation. Study Design: Case series; Level of evidence, 4. Methods: A retrospective case series was performed including baseball players who underwent anatomic MUCL reconstruction with suture tape augmentation by a single surgeon from 2018 to 2022. Inclusion criteria consisted of a minimum 2-year follow-up, participation in baseball, and utilization of autograft (palmaris longus or gracilis). Patients who underwent previous MUCL reconstruction were excluded from the study. All patients initially followed an accelerated rehabilitation protocol. Outcome measures were collected, including Kerlan-Jobe Orthopaedic Clinic (KJOC), Single Assessment Numeric Evaluation (SANE), and Conway-Jobe scores, as well as throwing metrics such as ball velocity and spin rate. Results: Thirty-four baseball players (mean ± SD age, 21 ± 3 years) underwent primary MUCL reconstruction. Time of final follow-up was 36.1 ± 10.3 months. Of these, 16 were professional athletes and 18 were amateur. All throwers returned to live gameplay at a mean 10.1 ± 2.0 months after reconstruction (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8). Furthermore, 97% (94% professional, 100% amateur) advanced through the accelerated postoperative protocol without issues, and 91% (88% professional, 94% amateur) returned to the same role and 85% (75% professional, 94% amateur) to the same level of play. Professional postinjury KJOC scores improved from 42.6 ± 16 to 87.5 ± 8.3 and SANE scores from 25.0 ± 11.2 to 95.6 ± 4.2. Amateur postinjury KJOC scores improved from 35.6 ± 10.7 to 90.9 ± 8.6 and SANE scores from 57.5 ± 16.9 to 95.2 ± 7.2. No significant difference was identified in preinjury versus postreconstruction throwing velocity, ball spin rate, or horizontal/vertical ball movement. The overall failure rate was 2.9%, with 1 professional pitcher requiring revision for graft rupture at 3 years postoperatively. Conclusion: Anatomic reconstruction of the MUCL with suture tape is a viable option for MUCL injuries, allowing an expedited return to sport at 10.1 ± 2.0 months (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8) in baseball players, with a low failure rate.

Objectives: There is a paucity of research comparing the outcomes of medial ulnar collateral ligament (MUCL) repair with internal bracing to isolated MUCL reconstruction in professional baseball players. Further, the practice of supplementing a MUCL reconstruction with an internal brace, a "hybrid" reconstruction, has increased in the surgical treatment of MUCL injuries for professional baseball players, without any currently known published research defining the clinical outcomes of this modification. We sought to investigate the trends and outcomes of MUCL repair with internal bracing and "hybrid" MUCL reconstruction with internal bracing. Using a matched cohort analysis, we also sought to compare the clinical outcomes of both MUCL repair with internal bracing and "hybrid" MUCL reconstruction with internal bracing to isolated MUCL reconstructions, without internal bracing, in professional baseball players. Methods: The MLB Health and Injury Tracking System was used to identify all professional baseball players who underwent MUCL surgery, regardless of surgery technique, from 2010 to 2023. Professional players of all levels (MLB and MiLB) and players of all positions were included. Player demographics, injury characteristics, surgical details, and postoperative outcomes were obtained. Player demographics included age at surgery, position of play, professional level of play and surgical technique. Outcomes assessed were return to play (RTP) status, time to RTP, return to same level of play (RTSL), time to RTSL, revision MUCL surgery, and time to revision MUCL surgery, with a minimum of 2 years of follow up. Players were considered to have RTP if they participated in at least one game at any professional level. RTSL was defined as returning to the same league of professional play or higher. Patients undergoing MUCL repair and "hybrid" MUCL reconstruction with internal bracing were independently compared to propensity matched patients undergoing isolated MUCL reconstruction, without internal bracing, to assess for a difference in postoperative outcomes. Four subgroup analyses were conducted by further categorizing patients to MLB players, MiLB players, pitchers, and position players. Results: 76 patients underwent MUCL repair with internal bracing from 2016-2021 and were successfully propensity matched to 76 patients undergoing isolated MUCL reconstructions. Baseline patient demographic variables of MUCL repairs were statistically similar to those of controls except for age at time of surgery (24.5 vs 21.8; p<0.001). 81 patients underwent "hybrid" MUCL reconstructions with internal bracing from 2016-2021 and were successfully propensity matched to 81 patients undergoing isolated MUCL reconstructions. Baseline demographic variables of "hybrid" MUCL reconstructions were statistically similar to those of controls except for age at time of surgery (24.3 vs. 23.3; p=0.006). Compared to isolated MUCL reconstruction controls, all patients undergoing MUCL repair demonstrated significantly shorter time to RTP (mean 421.2 vs. 546.2 days; p<0.001), shorter time to RTSL (mean 436.2 vs. 558.8 days; p<0.001), and shorter time to revision (mean 465.2 vs.1648 days; p=0.036). The number of patients who RTP at any level, RTSL, and number of revision surgeries were not significantly different. Compared to isolated MUCL reconstruction controls, all patients undergoing "hybrid" MUCL reconstructions demonstrated no significant differences with respect to the number of patients who RTP, time to RTP, number of patients who RTSL, days to RTSL, number of revision surgeries, and time to revision surgery. In MLB players only, compared to isolated MUCL reconstruction controls, patients who underwent MUCL repairs demonstrated significantly shorter time to RTP (mean 282.8 vs 507.3 days; p=0.008) and shorter time to RTSL (mean 299.7 vs. 598.0 days; p = 0.024). No other outcomes were significant. In MLB players only, compared to isolated MUCL reconstruction controls, patients who underwent "hybrid" MUCL reconstructions demonstrated significantly shorter time to RTP (mean 436.2 vs. 525.3 days; p=0.026). No other outcomes were significant. In MiLB players only, compared to isolated MUCL reconstruction controls, patients who underwent MUCL repairs demonstrated significantly shorter time to RTP (mean 444.3 vs 550.7 days; p<0.001) and shorter time to RTSL (mean 451.7 vs. 556.5 days; p<0.001). No other outcomes were significant. In MiLB players only, compared to isolated MUCL reconstruction controls, patients who underwent "hybrid" MUCL reconstructions demonstrated no significant differences in outcomes. In evaluating pitchers only, compared to isolated MUCL reconstruction controls, patients undergoing MUCL repair demonstrated significantly shorter time to RTP (mean 421.7 vs. 578.6 days; p<0.001), shorter time to RTSL (mean 434.8 vs. 591.6 days; p <0.001), and shorter time to revision surgery (mean 465.2 vs.1648 days; p=0.036). No other outcomes were significant. In pitchers only, compared to isolated MUCL reconstruction controls, patients undergoing "hybrid" MUCL reconstructions demonstrated significantly shorter time to RTP (mean 488.1 vs. 549.0 days; p=0.013) and shorter time to RTSL (mean 505.7 days vs. 577.0 days, respectively; p=0.021). No other outcomes were significant. Notably, all revision surgeries in occurred in pitchers only. Conclusions: Based on a matched cohort anaylsis of professional baseball players undergoing MUCL surgery, when compared to an isolated MUCL reconstruction, MUCL repair with internal bracing may allow for a shorter time to RTP and RTSL, with a shorter time to revision surgery. For pitchers, "hybrid" MUCL reconstruction may allow for a shorter time to RTP and RTSL. For MLB players, "hybrid" MUCL reconstruction may allow for a shorter RTP.