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Background: Interval throwing programs (ITP) have been used for decades to enable baseball pitchers to return to competition after injury or surgery by gradually applying load to the throwing arm. Past programs have been based on personal experience; however, advances in our understanding of the biomechanics and workloads of throwing allow for a more modern data-based program to be developed. Hypothesis/Purpose: To 1) develop a updated ITP for rehabilitation of modern baseball pitchers based upon biomechanical and throwing workload data, and 2) compare the updated program with a past program to determine differences in chronic workload and acute:chronic workload ratios (ACWR). Study Design: Cross-sectional study. Methods: Workloads (i.e. daily, acute, chronic, and ACWR) for the original ITP were built from the prescribed throwing schedule. Elbow varus torque per throw was calculated based upon a relationship between elbow varus torque and throwing distance. Throw counts, daily/chronic/acute workloads, and ACWR were calculated and plotted over time. A new ITP was built to model current pitcher's throwing schedules and gradually increased ACWR over time. Results: The original ITP had a throwing schedule of 136 days, final chronic workload 15.0, and the ACWR above or below the "safe" range (i.e. 0.7 - 1.3) for 18% of the program with a peak of 1.61. The updated ITP was built to consist of a 217-day schedule, final chronic workload of 10.8, and deviated from the safe range for 9% of the program, with a peak of 1.33. Conclusion: The newly created ITP is more familiar to modern baseball pitchers while exhibiting a more gradual buildup of chronic workload than traditional ITP programs. This ITP may be used to return baseball pitchers back to competition as safely and efficiently as possible, and potentially with less risk of setbacks or reinjury. The ITP may be used following common injuries or surgeries to the throwing shoulder and elbow, such as Tommy John surgery, while also serving as a basis for future development of shorter duration ITPs. Level of Evidence: 2c.

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Shoulder and elbow injuries during athletic participation are very common and may require operative intervention if refractory to conservative care. In recovering from these upper extremity injuries, proper postoperative rehabilitation and setting reasonable expectations regarding return to play are very important. This review article focuses on the most common surgically treated shoulder and elbow injuries, including rotator cuff tears, SLAP tears, anterior and posterior shoulder instability, and elbow ulnar collateral ligament tears. Rates of return to play after surgical intervention are encouraging in most professional and recreational athletes but are highly dependent on the severity of injury, as well as the demands and position in sport. Real-world strategies for staged successful rehabilitation are presented and discussed.

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One of the most common methods of training to enhance pitching velocity is the use of weighted baseballs. As with anything else, the excitement and popularity often proceed our scientific understanding. While there is still a lot to learn, our understanding of the science and efficacy of weighted baseball training has grown in recent years. The purpose of this clinical viewpoint is to summarize our current scientific understanding.

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BACKGROUND: Baseball pitching injuries are increasing at an alarming rate. While weighted ball throwing programs may be effective at increasing pitching velocity, previous research has identified a 24% injury rate and a 3.3° increase in shoulder external rotation (ER) range of motion (ROM) after performing a 6-week program. However, previous research has not investigated, separately, the immediate effects of throwing underloaded and overloaded balls on ROM. The purpose of this study was to examine the acute effects of throwing differently weighted baseballs on shoulder ROM. By analyzing these differences, it may be possible to determine the specific weight range that may lead to the greatest increase in ROM and potential injury risk. HYPOTHESIS: Throwing with weighted balls will result in an increase in shoulder ER ROM. STUDY DESIGN: Randomized controlled trial. LEVEL OF EVIDENCE: Level 2. METHODS: A total of 16 male high school baseball pitchers agreed to participate in this study. The participants were (mean ± SD) 17.1 ± 1.0 years of age, 1.81 ± 0.09 m tall, and had a mass of 79.2 ± 11.1 kg. Each participant was tested on 3 different days, 1 week apart, with 3 different conditions in random order: (1) underload throwing, using regulation 5-oz baseballs and 4- and 2-oz balls; (2) overload throwing, using 5-, 6-, and 9-oz balls; and (3) extreme overload throwing, using 5-, 16-, and 32-oz balls. Each testing session began by measuring passive shoulder ROM (external rotation and internal rotation) using standard goniometric measurements. Participants then performed 3 throws with each weighted ball from 3 different positions (kneeling, rocker, and run-and-gun) for a total of 27 throws each test session. ROM measurements were repeated at the end of each test session. The effect of each throwing condition on ROM was compared from pre- to posttraining using a paired t test (P ≤ 0.05). RESULTS: There was no significant difference in ER after throwing at underloaded weights. The overload condition showed a statistically significant increase of 3.3° in external rotation (P = 0.05). The extreme overload condition showed a statistically significant increase in ER of 8.4° (P < 0.001). There were no differences in internal rotation for any group. CONCLUSION: A significant increase in shoulder ER was observed immediately after throwing overload weighted balls. This effect increased as the weights of the balls increased. CLINICAL RELEVANCE: Throwing with overload weighted baseballs causes an immediate increase in shoulder ER ROM. It is unknown why these changes occur; however, the results may explain both the increase in velocity and injury rates previously observed from throwing weighted balls. The current study results may be used to develop more scientifically validated weighted ball programs. Heavier balls should be used with caution, and ROM should be monitored during implementation of these programs.

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BACKGROUND: Emphasis on enhancing baseball pitch velocity has become popular, especially through weighted-ball throwing. However, little is known about the physical effects or safety of these programs. The purpose of this study was to examine the effects of training with weighted baseballs on pitch velocity, passive range of motion (PROM), muscle strength, elbow torque, and injury rates. HYPOTHESIS: A 6-week weighted ball training program would result in a change in pitching biomechanical and physical characteristics. STUDY DESIGN: Randomized controlled trial. LEVEL OF EVIDENCE: Level 1. METHODS: During the baseball offseason, 38 healthy baseball pitchers were randomized into a control group and an experimental group. Pitch velocity, shoulder and elbow PROM, shoulder strength, elbow varus torque, and shoulder internal rotation velocity were measured in both groups. The experimental group then performed a 6-week weighted ball throwing program 3 times per week using balls ranging from 2 to 32 ounces while the control group only used a 5-ounce regulation baseball. Both groups performed a strength training program. Measurements were then repeated after the 6-week period. Injuries were tracked over the 6-week training program and the subsequent baseball season. The effect of training with a weighted ball program was assessed using 2-way repeated-measures analysis of variance at an a priori significance level of P < 0.05. RESULTS: Mean age, height, mass, and pretesting throwing velocity were 15.3 ± 1.2 years (range, 13-18 years), 1.73 ± 0.28 m, 68.3 ± 11 kg, and 30.3 ± 0.7 m/s, respectively. Pitch velocity showed a statistically significant increase (3.3%) in the experimental group ( P < 0.001). There was a statistically significant increase of 4.3° of shoulder external rotation in the experimental group. The overall injury rate was 24% in the experimental group. Four participants in the experimental group suffered elbow injuries, 2 during the training program and 2 in the season after training. No pitchers in the control group were injured at any time during the study. CONCLUSION: Performing a 6-week weighted ball throwing program increased pitch velocity. However, the program resulted in increased shoulder external rotation PROM and increased injury rate. CLINICAL RELEVANCE: Although weighted-ball training may increase pitch velocity, caution is warranted because of the notable increase in injuries and physical changes observed in this cohort.

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The overhead throwing athlete is an extremely challenging patient in sports medicine. The repetitive microtraumatic stresses and extreme ranges of motion observed within the athlete's shoulder joint complex during the throwing motion constantly place the athlete at risk for injury. While gross instability of the shoulder is possible, microinstability is seen far more frequently and is associated with a variety of different pathologies, including rotator cuff tendonitis, internal impingement, and labral lesions. Treatment of the overhead athlete requires the understanding of several principles based on the unique physical characteristics of this type of athlete and the demands placed upon the static stabilizing structures during the act of throwing. The purpose of this paper is to describe these principles and incorporate them into in a multi-phase progressive rehabilitation program designed to prevent injuries and rehabilitate the injured athlete, both non-operatively and postoperatively.

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The overhead-throwing athlete is a challenging sports medicine patient. The repetitive microtraumatic stresses imposed on the athlete's shoulder joint complex during the throwing motion constantly places the athlete at risk for injury. These stresses may effect several adaptations to normal shoulder range of motion, strength, and scapula position. The clinician should therefore appreciate the unique physical characteristics of the overhead-throwing athlete to accurately evaluate and treat throwing-related injuries.

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The overhead throwing athlete is an extremely challenging patient in sports medicine. The repetitive microtraumatic stresses imposed on the athlete's shoulder joint complex during the throwing motion constantly place the athlete at risk for injury. Treatment of the overhead athlete requires the understanding of several principles based on the unique physical characteristics of the overhead athlete and the demands endured during the act of throwing. These principles are described and incorporated in a multiphase progressive rehabilitation program designed to prevent injuries and rehabilitate the injured athlete, both nonoperatively and postoperatively.

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Postoperative rehabilitation programs following articular cartilage repair procedures will vary greatly among patients and need to be individualized based on the nature of the lesion, the unique characteristics of the patient, and the type and detail of each surgical procedure. These programs are based on knowledge of the basic science, anatomy, and biomechanics of articular cartilage as well as the biological course of healing following surgery. The goal is to restore full function in each patient as quickly as possible by facilitating a healing response without overloading the healing articular cartilage. The purpose of this article is to overview the principles of rehabilitation following microfracture procedures of the knee.

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BACKGROUND: Iliotibial band friction syndrome (ITBFS) is an overuse injury causing lateral knee pain. There is evidence that the pathological lesion is in fact an inflamed bursa underlying the iliotibial band (ITB) rather than an inflamed ITB itself. HYPOTHESIS: Resection of the bursa underlying the ITB in ITBFS patients will relieve their pain and allow them to return to their preinjury activity level. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We describe the technique of ITB bursectomy and report a minimal 20-month follow-up of patients who had ITB bursectomies performed by a single surgeon. The patients completed a survey detailing their preoperative and postoperative symptoms and activities. RESULTS: The senior author performed 12 consecutive cases of ITB bursectomies (12 patients). One was excluded from the study (previous microfracture). The average age at surgery was 32 years (standard deviation, 5; range, 24-41). There were 7 men and 4 women. Postoperatively, patients were able to return to their preinjury Tegner activity levels, and the visual analog pain scores decreased by an average of 6 points (P < .001). Six patients were completely satisfied with the surgical outcome, 3 were mostly satisfied, 2 were somewhat satisfied, and none were dissatisfied. Nine of 11 patients said that knowing what they know now, they would have the surgery performed again for the same problem. CONCLUSION: Iliotibial band bursectomy successfully reduces knee pain in patients with ITBFS and allows them to return to their preinjury level of activity. The great majority of patients were satisfied with the results of the procedure.

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SYNOPSIS: The biomechanical analysis of rehabilitation exercises has led to more scientifically based rehabilitation programs. Several investigators have sought to quantify the biomechanics and electromyographic data of common rehabilitation exercises in an attempt to fully understand their clinical indications and usefulness. Furthermore, the effect of pathology on normal shoulder biomechanics has been documented. It is important to consider the anatomical, biomechanical, and clinical implications when designing exercise programs. The purpose of this paper is to provide the clinician with a thorough overview of the availableliterature relevant to develop safe, effective, and appropriate exercise programs for injury rehabilitation and prevention of the glenohumeral and scapulothoracic joints. LEVEL OF EVIDENCE: Level 5.

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BACKGROUND: The loss of glenohumeral internal rotation range of motion in overhead athletes has been well documented in the literature. Several different methods of assessing this measurement have been described, making comparison between the results of studies difficult. HYPOTHESIS: Significant differences in the amount of internal rotation range of motion exist when using different methods of stabilization. STUDY DESIGN: Descriptive laboratory study. METHODS: THREE TECHNIQUES WERE USED BILATERALLY IN RANDOM FASHION TO MEASURE GLENOHUMERAL INTERNAL ROTATION RANGE OF MOTION: stabilization of the humeral head, stabilization of the scapula, and visual inspection without stabilization. An initial study on 20 asymptomatic participants was performed to determine the intrarater and interrater reliability for each measurement technique. Once complete, measurements were performed on 39 asymptomatic professional baseball players to determine if a difference existed in measurement techniques and if there was a significant side-to-side difference. A 2-way repeated-measures analysis of variance was used. RESULTS: While interrater reliability was fair between all 3 methods, scapular stabilization provided the best intrarater reliability. A statistically significant difference was observed between all 3 methods (P < .001). Internal rotation was significantly less in the dominant shoulder than in the nondominant shoulder (P < .001). CONCLUSION: Differences in internal rotation range of motion measurements exist when using different methods. The scapula stabilization method displayed the highest intrarater reproducibility and should be considered when evaluating internal rotation passive range of motion of the glenohumeral joint. CLINICAL RELEVANCE: A standardized method of measuring internal rotation range of motion is required to accurately compare physical examinations of patients. The authors recommend the use of the scapula stabilization method to assess internal rotation range of motion by allowing normal glenohumeral arthrokinematics while stabilizing the scapulothoracic articulation.

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BACKGROUND: Muscle weakness, particularly of shoulder external rotation, is common after rotator cuff repair surgery. Neuromuscular electrical stimulation has been shown to be an effective adjunct in the enhancement of muscle recruitment. HYPOTHESIS: Shoulder external rotation peak force can be enhanced by neuromuscular electrical stimulation after rotator cuff repair surgery. STUDY DESIGN: Controlled laboratory study. METHODS: Thirty-nine patients (20 men, 19 women) who had undergone rotator cuff repair surgery were tested a mean of 10.5 days after surgery. Testing consisted of placing patients supine with the shoulder in 45 degrees of abduction, neutral rotation, and 15 degrees of horizontal adduction. Neuromuscular electrical stimulation was applied to the infraspinatus muscle belly and inferior to the spine of the scapula. Placement was confirmed by palpating the muscle during a resisted isometric contraction of the external rotators. Patients performed 3 isometric shoulder external rotation contractions with and without neuromuscular electrical stimulation, each with a 5-second hold against a handheld dynamometer. Neuromuscular electrical stimulation was applied at maximal intensity within comfort at 50 pulses per second, symmetrical waveform, and a 1-second ramp time. The 3 trials under each condition were recorded, and an average was taken. The order of testing was randomized for each patient tested. A paired samples t test was used to determine significant differences between conditions (P < .05). Each group was also divided based on age, rotator cuff tear size, number of days postoperative, and neuromuscular electrical stimulation intensity. Analysis of variance models were used to determine the influence of these variables on external rotation force production (P < .05). RESULTS: Peak force production was significantly greater (P < .001) when tested with neuromuscular electrical stimulation (3.75 kg) as opposed to without neuromuscular electrical stimulation (3.08 kg) for all groups tested. There was no significant difference based on the size of the tear, age of the patient, number of days after surgery, or level of neuromuscular electrical stimulation intensity. CONCLUSION: Peak shoulder external rotation force was significantly increased by 22% when tested with neuromuscular electrical stimulation after rotator cuff repair surgery. Neuromuscular electrical stimulation significantly increased force production regardless of the age of the patient, size of the tear, intensity of the current, or the number of days postoperative. CLINICAL RELEVANCE: Neuromuscular electrical stimulation may be used concomitantly with exercises to enhance the amount of force production and potentially minimize the inhibition of the rotator cuff after repair surgery.

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BACKGROUND: The overhead throwing athlete has unique range of motion characteristics of the shoulder and elbow. Numerous theories exist to explain these characteristics; however, the precise cause is not known. Although it is accepted that range of motion is altered, the acute effect of baseball pitching on shoulder and elbow range of motion has not been established. HYPOTHESIS: There will be a reduction in passive range of motion immediately after baseball pitching. STUDY DESIGN: Controlled laboratory study. METHODS: Sixty-seven asymptomatic male professional baseball pitchers participated in the study. Passive range of motion measurements were recorded using a customized bubble goniometer for shoulder external rotation, shoulder internal rotation, total shoulder rotational motion, elbow flexion, and elbow extension on the dominant and nondominant arms. Testing was performed on the first day of spring training. Measurements were taken before, immediately after, and 24 hours after pitching. RESULTS: A significant decrease in shoulder internal rotation (-9.5 degrees), total motion (-10.7 degrees), and elbow extension (-3.2 degrees) occurred immediately after baseball pitching in the dominant shoulder (P<.001). These changes continued to exist 24 hours after pitching. No differences were noted on the nondominant side. CONCLUSION: Passive range of motion is significantly decreased immediately after baseball pitching. This decrease in range of motion continues to be present 24 hours after throwing. High levels of eccentric muscle activity have previously been observed in the shoulder external rotators and elbow flexors during pitching. These eccentric muscle contractions may contribute to acute musculotendinous adaptations and altered range of motion. The results of this study may suggest a newly defined mechanism to range of motion adaptations in the overhead throwing athlete resulting from acute musculoskeletal adaptations, in addition to potential osseous and capsular adaptations.

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CONTEXT: Investigators have observed electromyographic (EMG) activity of the supraspinatus muscle and reported conflicting results. OBJECTIVE: To quantify EMG activity of the supraspinatus, middle deltoid, and posterior deltoid muscles during exercises commonly used in rehabilitation. DESIGN: One-factor, repeated-measures design. SETTING: Controlled laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-two asymptomatic subjects (15 men, 7 women) with no history of shoulder injury participated. MAIN OUTCOMES MEASURE(S): The dominant shoulder was tested. Fine-wire EMG electrodes were inserted into the supraspinatus, middle deltoid, and posterior deltoid muscles. The EMG data were collected at 960 Hz for analysis during maximal voluntary isometric contraction (MVIC) and 5 repetitions of 3 exercises: standing elevation in the scapular plane ("full can"), standing elevation in the scapular plane with glenohumeral internal rotation ("empty can"), and prone horizontal abduction at 100 degrees with glenohumeral external rotation ("prone full can"). We calculated 1-way repeated-measures analysis of variance (P < .05) and post hoc 2-tailed, paired t tests to detect significant differences in muscle activity among exercises. RESULTS: No statistical difference existed among the exercises for the supraspinatus. The middle deltoid showed significantly greater activity during the empty-can exercise (77 +/- 44% MVIC) and prone full-can exercise (63 +/- 31% MVIC) than during the full-can exercise (52 +/- 27% MVIC) (P = .001 and .017, respectively). The posterior deltoid showed significantly greater activity during the prone full-can exercise (87 +/- 53% MVIC) than during the full-can (P = .001) and the empty-can (P = .005) exercises and significantly greater activity during the empty-can exercise (54 +/- 24% MVIC) than during the full-can exercise (38 +/- 32% MVIC) (P = .012). CONCLUSIONS: While all 3 exercises produced similar amounts of supraspinatus activity, the full-can exercise produced significantly less activity of the deltoid muscles and may be the optimal position to recruit the supraspinatus muscle for rehabilitation and testing. The empty-can exercise may be a good exercise to recruit the middle deltoid muscle, and the prone full-can exercise may be a good exercise to recruit the posterior deltoid muscle.

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Autologous chondrocyte implantation (ACI) has now been performed for over a decade in the United States. ACI has been demonstrated as a reproducible treatment option for large, full-thickness, symptomatic chondral injuries of the knee. As clinical experience has expanded and indications broadened to more complex cartilage defects, it has become evident that aggressive treatment of coexisting knee pathology is essential for optimal results. This includes management of malalignment, ligamentous, and/or meniscal deficiency, and subchondral bone loss to make the intra-articular environment as ideal as possible for successful cartilage restoration. Additionally, refinements in the rehabilitation necessary for biologic cartilage repair have been made, based on better understanding of the maturation process of the repair cartilage, allowing for earlier initiation of knee range of motion, strengthening exercises, and weight bearing. These changes have enhanced the recovery for the patient and decreased the risk of motion deficits. This article will discuss patient selection for ACI, review ACI surgical technique, including management of coexisting knee pathology, present postoperative ACI rehabilitation guidelines, and summarize clinical outcomes after ACI.

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