1/9/17

1

RehabilitationofUlnarCollateralLigamentInjuriesandReconstruction

StanConte,PT,DPT,ATCConteInjuryAnalytics

RehabilitationversusSurgery

Nonoperative treatmentofUCLinjuriesinthrowingathletes.

Rettig,etal,2010AJSM

• 31OverheadAthletes• Restx2-3months,PT,Throwat3months• Only13(42%)returned• TookAverageof24week(6monthstoreturn• Couldnotdetermineanyhistoryorexamthatwaspredictiveofwhowouldsucceed.• QuotedstudytodoReconstruction

TreatmentofpartialUCLtearsintheelbowwithplatelet-richplasma.

Podesta,etal,2013AJSM.

• UsedPRPon34OverheadAthletes(27baseball)• FailedPTx2month,• 88%Returned• Averagereturnin12weeks• Quotedstudytoattemptnon-surgerical andPRPinjection

1/9/17

2

Return-to-PlayOutcomesinProfessionalBaseballPlayersAfterMedialUlnarCollateralLigamentInjuries:ComparisonofOperativeVersusNonoperative TreatmentBasedon

MagneticResonanceImagingFindingsFord,G,Genuario,J,Kinkartz,J,Githens,T,Noonan,T.AJSM2016

• 43UCLinjuries(2006-11)• GradedMRIfindings• I, intactligamentwithorwithoutedema;IIA,partialtear;IIB,chronichealedinjury;andIII,completetear.

• 8Complete(RTSP=63%)and7PartialTearstreatedwithreconstruction(RTSP=86%)• 28(18Pitchers)treatednonoperatively• PitcherRTSP=94%PositionRTSP=90%

• RehabProcedure• Reducepain/inflam andregainfullROM,strengthofRTCandscap backtobaselineorbetter.

• Throwingwasstartedwhenasymptomaticwithgoodstrength(4-6weeks)

1/9/17

3

4PhaseRehabProgramElbowUlnarCollateralLigamentInjury:AGuidetoDiagnosisandTreatment

ByEllenbecker,WilkDines,Altchek,Andrews,ElAttrache,YocumCopyright2012byLipincott Williams&Wilkens.

• ImmediatePostOp(0-3weeks)• IntermediatePhase(3-7weeks)• AdvancedStrengtheningProgram(8-12weeks)• ReturntoActivityPhase(14-26months• StartIntervalThrowing(4.2.months)• Mound-asearlyas6months.• Returntocompetition(12-18months?)

KevinWilk,DPT“FatherofUCLRehab”

ImmediatePostOp(0-3weeks)

• RangeofMotion-Critical• Extension-nostressonGraft• FlexionpastXincreasestress

• PosteriorSplintfor7days• AdjustableROMBrace• MustgetROMduringfirst6weeks.• NoShoulderExternalRotation

1/9/17

4

IntermediatePhase- 4-8weeks

• ObtainallElbowROM• OutofBraceby6weeks• Lightresistivewristexercises• ShoulderandScap Exercises-Thrower’s10initiatedat6weeks.• AddTricepswork

AdvancedStrengthening

• Initiateeccentricelbowflexion/extension• Continueisotonicprogram;forearmandwrist• Continueshoulderprogram—ThrowersTenProgram• Manualresistancediagonalpatterns• Emphasizescapularandcoreexercises• Initiateplyometrics—2handdrillsonly• Mayinitiateintervalhittingprogramforbaseballplayers

1/9/17

5

ReturntoActivityStage

• StartIntervalThrowingProgram4.2months.• MoundWorkat6-7months• ReturntoCompetition9-12months.

ReturntoSport• Cain,etal(2010)

• 743athletes(95%baseball,highschool,college,pro)

• 83%Returntosameorhigherlevel• Vital/Ahmad,etal(2008)

• SystematicReview(7studies)• 405athletes• 83%returntoplay

• Erikson,etal(2015)• SystematicReview(20Studies)• 82%ExcellentResults• 86.2%ReturntoPlay

• Makhani,etal(2014)• 147MLBPitchers• 80%RTPatleastonegame• 67%RTPfor>10gamesinaseason

1/9/17

6

PerformanceMetrics• Makhani,etal(2014)

• 92MLBpithers• 3yr beforeandafterTJS• ComparedtoControls• Declineinperformancebutregressionsweresimilartocontrol

• Erikson,etal(2014)• SimilarStudytoMakhani withcontrols• DecreaseinERA,WHIPcomparedtocontrols

• Fleisig,etal,(Biomechanics)(2015)• MinorLeaguepitchers• Cohort(NonTJScomparedtoTJS)• Mechanicsshownosignificantdifferences

Velocity

• Jiang,etal(2014)• Matchedpaircohorts• SmallbutstatisticallydecreaseinvelocityinUCLr butnotstatisticallysignificanttocontrolgroup

• Makhani,etal(2014)• FoundsimilarresultstoJiang.• Nogreaterdeclinesthantocontrolgroup

• Larsdown,etal(2014)• MeanFBvelocityfrom91.3to90.6mph.• EspeciallyinUCLr pitchersover35yo• Otherpitchtypesdidnotdecrease.

1/9/17

7

Longevity

• Osbahr,etal.(2014)• 10yearfollowupstudy• 256UCLr• Careerlongevitywas3.6yearswitha2.9yearsathighestlevel.

• 86%retiredforotherthan“elbow”reasonsandsubsequentshoulderreasonswerethemostcommonreason.

• 93%weresatisfiedwithsurgery• 98%werestillabletothrowatleastonrecreationallevel

Withsuchgoodresults,why

1/9/17

8

TheProblem

15

BRANDONBEACHY

REVISIONDATE:03/21/14MONTHSSINCE:16YEARSAFTER1ST:1.7RETURN-TO-MLB:07/11/15

REVISIONDATE:03/18/14MONTHSSINCE:16YEARSAFTER1ST:3.6RETURN-TO-PLAY:07/20/15

REVISIONDATE:03/24/14MONTHSSINCE:16YEARSAFTER1ST:4.4RETURN-TO-PLAY:NOTYET

REVISIONDATE:06/18/13MONTHSSINCE:25YEARSAFTER1ST:0.9RETURN-TO-PLAY:09/03/14

KRISMEDLEN

DANIELHUDSON

JARRODPARKER

REVISIONDATE:05/16/13MONTHSSINCE:26YEARSAFTER1ST:8.4RETURN-TO-MLB:NOTYET(HAD3RD TJON09/16/14)

REVISIONDATE:04/24/14MONTHSSINCE:15YEARSAFTER1ST:6.7RETURN-TO-PLAY:NOTYET

REVISIONDATE:02/18/14MONTHSSINCE:17YEARSAFTER1ST:1.7RETURN-TO-PLAY:NOTYET

REVISIONDATE:07/24/14MONTHSSINCE:12YEARSAFTER1ST:8.6RETURN-TO-PLAY:NOTYET

JONNYVENTERS

JOSHJOHNSON

CORYLUEBKE

TYLERCHATWOOD

RevisionStudiesOutcomesinRevisionTommyJohnSurgeryinMajorLeague

BaseballPitchers(JSES-2016)

JosephLiu,M.D.;GrantHGarcia,MD;StanConte,DPT,ATC;NealElAttrache,MD;DavidWAltchek,MD;JoshuaSDines,MD

• Since1999,235MLBpitchersunderwentTJS.• 31pitchers(13.2%)underwentrevisionsurgery• 37%underwentrevisionwithin3yearsoftheirindexyearofprimaryTJS

• 26revisionshadmorethan2-yearfollowup• 17/26(65.4%)pitchedatleastoneMLBgame• Only11/26(42.3%)pitchedmorethan10games• Comparedtocontrols:shortercareerafterrevisionsurgery(4.9vs2.6seasons,P = .002),pitchedfewerinnings,andhadfewertotalpitchesperseason.(workload)

• AveragereturntoMLB=20.76months• RevisionRate=13.2%

PitchingperformanceandlongevityafterrevisionulnarcollateralligamentreconstructioninMajorLeagueBaseball

pitchers.(AJSM-2015)Marshall,NE,Keller,RA,Bey,M,Moutzourous,V

• 33MLBpitcherswhounderwentrevisionandcomparedwith33age- andposition-matchedcontrol

• 65.5%ofUCL-RpitchersreturnedtotheMLBlevel

• UCL-Rpitchersplayed0.8yearslessinthemajors(P<.01)thandidthecontrolpitchers.

• Returningpitcherssimilarstatscomparedtocontrolgroups(ERAandWHIP)

• DeclinesinIP,Walks,Wins.• AlsononsignificantdeclinesinWARandRunsabovereplacement.

1/9/17

9

RevisionsUpdate- MLBPlayers1996-2016

0

2

4

6

8

10

12

1996 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

ReturntoPlay(1996-2014)=65%(26/40)

RevisionRateincreasedfrom1-3%to13.2%

#ofUCLRevisionsperYear,2010-2016

RevisionSurgeriesPerYear

6 6 7 912

5 5

92

3

232015

11

2013

16

11

2012

11

2011

3

12014 2016

15

2010

3

0

MinorMLB

1/9/17

10

TheoriesonWhyanIncreaseinRevisions

• Changeinthetechniqueofthesurgery?• ModifiedFigure8,DockingProcedures

• Changeinthesurgeons?• 11/15surgeonsonRevisionsunder3yearswereMLBSurgeons

• Returntopreviousmechanicalissues?• Fleisig studyshowsPitcherswithTJsurgeryhavesimilarmechanicsasnon-TJ.

• Overusagewhentheyreturn?• Pitchcountshavebeeninplaceforthepast20years• Reliever’sappearances(?)

• Improvementinvelocity• Notaccordingtovelocitystudies

• Changeintherehab?• MostMLBTeamshavefollowedsimilartimeframesinearlyandintermediaterehab.

MLBAverageThrowingProgramProgression

20

IntervalThrowing

Flat-GroundPitching

MoundPitching

Change-ups

BreakingPitches

LivetoBatters

RehabGames

4mos.

5mos.

6mos.

7mos.

8mos.

10mos.

11mos.

9mos.

12mos.

4.8months

7.5months

8.4months

8.9months

9.9months

10.6months

11.5months

AVERAGEPOST-SURGERY

2.7months(11.7weeks)

0.9months(3.9weeks)

0.9months(3.9weeks)

0.7months(3.0weeks)

1.0month(4.3weeks)

0.5months(2.2weeks)

AVERAGETIMEBETWEENSTEPS

1/9/17

11

ThrowingVelocityandtheUCL

• MechanicsandVelocityhaveadirectrelationshipwithvarus torquesforcesonthemedialelbow.

• Bothofthesecanbeproblemsintheprogressionoftherehabprocess

• NothingputsmorestressontheUCLthanvelocity.

• Thegraftstrengthandmaturationisunknownduringtherehabprocessbutonecanassumethatitisweakestattheearlyrehabandstrongerlater.

• AcommontheoryofUCLinjuryisrepeatedmicrotrauma anddamagetotheUCLfibers.

• EarlyloadingoftheyoungUCLcouldcausemicrotearingoftheligament.

• However,thehealinggraftrespondspositivelytogradualsubmaximalstress.

MyTheoryonGoingSlower

• Theproblemisnottheimmediatepostoporintermediatephases.• Thedecisionofwhenandhowhardtothrowisthebiggestpotentialproblem• Throwingprogramsaregenerallynotcontrolled.• PerceivedExertionisaninaccuratemethodtomeasurevelocity.(Fleisig study)• Whydowestartat4months?• Howstrongisthegraft?• Youcan’tteachsheeptothrow!

• Radargunsorbettertechnologyisrequired.

1/9/17

12

MyRecommendations

• Throwingshouldnotstartuntil6 months.• Allvelocitiesorvalgusstressshouldmeasuredoneverythrow.• Moundworkmaybesaferthanlongtossaslongasvelocityiscontrolled.• Goalshouldbereturntocompetitivelevelatminimum14months.

ThankYou

Conte Injury Analyticsconteinjuryanalytics.com