Faculty Bibliography

The extreme range of motion at the shoulder, the high angular velocities and torques, and the repetitious nature of the pitching motion combine to make the shoulder vulnerable to injury during the baseball pitch. An understanding of the biomechanics that contribute to shoulder injuries during each phase of the pitching motion can facilitate the athlete's diagnosis, treatment, and rehabilitation. The athlete's symptoms and signs, as well as radiographic imaging, are key elements in arriving at a diagnosis of shoulder injuries. Nonoperative treatment consisting of an initial period of rest and NSAIDS, followed by physical therapy and a gradual return to activity, is usually successful. When this approach fails, surgical intervention, either arthroscopic or open, may be necessary. Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint, yet preserving the range of motion necessary for performance. Through rehabilitation, the dedicated athlete can often return to the pitching mound at his previous level of performance

The extreme range of motion at the shoulder, the high angular velocities and torques, and the repetitious nature of the pitching motion combine to make the shoulder vulnerable to injury during the baseball pitch. An understanding of the biomechanics that contribute to shoulder injuries during each phase of the pitching motion can facilitate the athlete's diagnosis, treatment, and rehabilitation. Common injuries that occur during the late cocking and acceleration phases of the pitch include anterior instability and impingement, bicipital tendinitis, and subacromial impingement. Nonoperative treatment consisting of an initial period of rest and NSAIDS, followed by physical therapy and a gradual return to activity, is usually successful. When this approach fails, surgical intervention, either arthroscopic or open, may be necessary. Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint, yet preserving the range of motion necessary for performance. Through rehabilitation, the dedicated athlete can often return to the pitching mound at his previous level of performance

A retrospective study was performed to compare nonoperative and operative treatments of Type II distal clavicle fractures. From a total of 30 diagnosed patients, 16 were identified as receiving nonoperative treatment and 14 open reduction and coracoclavicular stabilization. The average follow-up was 53.5 months for the nonoperative group and 59.8 months for the operative group. All patients were evaluated postoperatively for pain, range of motion, function, and fracture healing as well as for isokinetic strength. Fractures treated surgically achieved union within six to ten weeks. Nonoperative treatment resulted in seven nonunions. There were no significant differences between the two groups in the mean UCLA, Constant, and ASES scores. Nonunion had no significant effect on functional outcome or strength. This study suggests that Type II distal clavicle fractures can be successfully managed nonoperatively. The high incidence of nonunion does not impede a clinical outcome comparable to that achieved by surgical treatment

We report the case of an 'overhead' athlete (a collegiate tennis player) who developed severe ulnar neuropathy after anterior subcutaneous transposition and placement of a fasciodermal sling. Treatment consisted of opening the sling, excising suture material, releasing all other areas of potential compression, and performing anterior submuscular transposition of the ulnar nerve deep to the flexor muscle group. Two years after surgery, subjective symptoms were significantly improved, though the patient continued to experience mild medial-side elbow discomfort and intermittent paresthesia along the ulnar nerve distribution. Pain relief achieved without full sensory and motor recovery is consistent with results reported elsewhere. In short, extreme care must be taken when creating a fasciodermal sling during anterior subcutaneous transposition of the ulnar nerve

Recently, the use of thermal energy to shrink the redundant glenohumeral joint capsule in patients with instability has generated a great deal of interest. Proponents assert that the procedure avoids the need for an open stabilization and it may be used as an adjunct to an open or arthroscopic capsulolabral repair. The use of nonablative thermal energy to shrink soft-tissue collagen appears to induce ultra-structural and mechanical changes at or above 60 degrees C. The microscopic changes reflect the unwinding of the collagen triple helix and loss of the fiber orientation. The fibrils contract into a shortened state and reactive fibroblasts have been shown to grow into this treated area and synthesize the collagen matrix. The biomechanical properties of the tissue do not appear to be detrimentally altered if shrinkage is limited to less than 15% and if ablation or excess focal treatment is avoided. The endpoint of optimal shrinkage is not known and clinical estimations of tissue changes and volumetric reduction are used as guides to treatment. The first clinical follow-up study was only recently published in the peer-reviewed literature and prior preliminary reports were optimistic regarding the use of thermal energy for the treatment of glenohumeral instability. Thermal capsular shrinkage has been used as an adjunct to a capsulolabral repair, as well as an isolated treatment for the disorders of internal impingement and multidirectional instability. Additional evaluation is necessary to determine the optimal quantity of energy needed for tissue shrinkage without inadvertent tissue destruction. The long-term clinical effect, mechanical properties, and durability of the newly produced collagen need to be analyzed further. The basic science and clinical applications of this newly applied technology are reviewed in this article.

The elbow is subjected to enormous valgus stresses during the throwing motion, which places the overhead-throwing athlete at considerable risk for injury. Injuries involving the structures of the medial elbow occur in distinct patterns. Although acute injuries of the medial elbow can occur, the majority are overuse injuries as a result of the repetitive forces imparted to the elbow by throwing. Injury to the ulnar collateral ligament complex results in valgus instability. Valgus extension overload leads to diffuse osseous changes within the elbow joint and secondary posteromedial impingement. Overuse of the flexor-pronator musculature may result in medial epicondylitis and occasional muscle tears and ruptures. Ulnar neuropathy is a common finding that may be due to a variety of factors, including traction, friction, and compression of the ulnar nerve. Advances in nonoperative and operative treatment regimens specific to each injury pattern have resulted in the restoration of elbow function and the successful return of most injured overhead athletes to competitive activities. With further insight into the relevant anatomy, biomechanics, and pathophysiology involved in overhead activities and their associated injuries, significant contributions can continue to be made toward prevention and treatment of these injuries.

Isolated posterolateral rotatory instability of the knee is an uncommon injury pattern that may result in significant degrees of functional disability. This injury complex can be a challenging diagnostic and therapeutic problem for the orthopaedic surgeon. The presence of associated ligamentous and soft-tissue injuries, resulting in combined instability patterns, further complicates management. The results of recent research have enhanced our understanding of the complex anatomy and biomechanics of the posterolateral aspect of the knee. Numerous surgical techniques have been described for both repair and reconstruction of the injured posterolateral structures; however, long-term functional results have been only moderately successful.