Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve.

Eighty-three athletes with medial elbow instability underwent reconstruction of the anterior band of the ulnar collateral ligament with a muscle-splitting approach without transposition of the ulnar nerve. The purposes of this study were to describe postoperative neurologic outcomes in all 83 athletes and to describe the 2-year follow-up in 33 athletes. Postoperatively, 5% of this group had transient ulnar nerve symptoms, all of which resolved with nonoperative management. There were no reoperations for nerve dysfunction and no permanent nerve problems. At 2- to 4-year follow-ups, 93% of the highly competitive athletes who had not had a prior surgical procedure had an excellent result. All athletes, regardless of whether they had a prior procedure, were able to return to their sport. These surgical modifications to the ulnar collateral ligament reconstruction yielded a decreased postoperative complication rate and improved outcomes compared with the results of prior procedures.

Medial elbow problems in the overhead-throwing athlete.

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.

Arthroscopy of the elbow: a long-term clinical review.

PURPOSE: The purpose of this study was to review a large group of patients who had arthroscopy of the elbow to determine the efficacy and relative risks of this procedure. TYPE OF STUDY: We retrospectively reviewed a convenient sample of 172 patients who underwent 187 arthroscopies of the elbow over a 7-year period. MATERIALS AND METHODS: All patients had their charts and radiographs reviewed, and 104 of these patients were also contacted for a telephone interview at an average follow-up of 42.3 months (range, 7 to 115 months). RESULTS: The procedures were performed primarily by 7 different surgeons, using all 3 standard operating positions and a variety of arthroscopic portals. The most common diagnosis was posterior impingement in 96 patients (51%), followed by loose bodies in 72 patients (31%), and degenerative joint disease in 32 patients (22%). The average preoperative modified Figgie score was 27.7 points (range, 17-43) for all patients. The average postoperative score was 45.4 points (range, 29-50), with the largest increase occurring in the pain score. There were 51 patients (56%) with an excellent surgical result, 37 patients (36%) with a good result, 12 patients (11%) with a fair result, and 4 patients (4%) with a poor result. The average modified Figgie score increased from 31.2 points (range, 22-43) to 46.9 (range, 29-50) postoperatively in professional athletes; from 26.3 to 42.6 in patients who had Workers' Compensation claims but were not professional athletes; from 29.4 to 45.6 in patients with a diagnosis of loose bodies; and from 30.1 to 43.7 in patients with degenerative joint disease. There were 3 known surgical complications (1.6%) overall, 1 of which was a patient who had a transection of the ulnar nerve requiring microsurgical repair. Of the 104 patients who were contacted, 6 patients felt that their symptoms had not improved after surgery. Eight of the 55 baseball players contacted were not able to return to their same level of competition. CONCLUSIONS: Arthroscopy of the elbow appears to be a safe and efficacious procedure with a relatively low complication rate.

A modification of the relocation test: arthroscopic findings associated with a positive test.

Thirteen overhand-throwing athletes who failed at least 3 months of physical therapy while restricted from throwing and who demonstrated a positive modified relocation test at 90 degrees, 110 degrees, and/or 120 degrees were clinically and arthroscopically examined. On arthroscopic examination, all patients demonstrated articular surface pathology. Eleven patients had fraying of the undersurface of the rotator cuff, and 10 patients had fraying of the posterosuperior labrum. With 90 degrees shoulder abduction, 8 patients had rotator cuff contact with the posterosuperior labrum. When the shoulder was abducted to 110 degrees, all patients demonstrated such contact. At 120 degrees of abduction, 12 patients revealed contact. The presence or absence of pain during the modified relocation test correlated with the presence or absence of cuff contact with the posterosuperior labrum 79% of the time. Six patients had a positive modified relocation test at all levels of abduction. These patients included 2 with SLAP lesions, 1 with a Bankart lesion, and 1 with a complete tear of the rotator cuff.

Anatomy of provocative tests for impingement syndrome of the shoulder.

The purpose of this study was to describe the extra- and intra-articular anatomic relationships present during the Neer and Hawkins tests. Nine fresh-frozen cadaveric shoulders were positioned in the impingement position described by Neer (n = 5) or that described by Hawkins (n = 4), embedded in polyurethane, and studied with the use of a cross-sectional technique. All shoulders placed in the Neer position demonstrated soft tissue contact with the medial acromion and contact between the articular surface of the rotator cuff tendons and the anterosuperior glenoid rim. Shoulders placed in the Hawkins position demonstrated consistent contact between soft tissues and the coracoacromial ligament. In all Hawkins positioned shoulders, contact between the articular surface of the rotator cuff tendons and the anterosuperior glenoid was observed. The subscapularis tendon was deformed by the coracoid in 1 of the Hawkins positioned specimens. Although factors inherent to human subjects such as edema and muscle tone may influence the anatomy, these provocative tests for subacromial impingement appear to elicit contact consistent with impingement.

Electromyographic analysis of deltoid and rotator cuff function under varying loads and speeds.

The purpose of this study was to compare the effect of increasing loads and doubling speed on the deltoid and rotator cuff muscles during isotonic scapular plane abduction (scaption) with neutral humeral rotation. These muscles were studied in 16 volunteers with asymptomatic shoulders with the use of fine wire electromyography. The addition of load to the arm during scaption caused an increase in electromyographic activity during the first 90 degrees of motion. Furthermore electromyographic activity decreased during the final 30 degrees of motion with each increase in load. Doubling the speed caused an increase in electromyographic activity during the first 60 degrees of motion while causing a decrease in activity in the final 60 degrees. This study demonstrates the response of the rotator cuff and deltoid muscles to varying loads and speeds during the most basic shoulder motion. With the data obtained in this study, rehabilitation exercises and experimental shoulder models can be refined to reflect this more physiologic situation.

Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff.

SUMMARY: The purpose of this article is to describe the outcome of an arthroscopic examination and the pathology in symptomatic shoulders of 41 professional overhand throwing athletes. With the arm in the position of the relocation test, 100% of the subjects had either contact between the rotator cuff undersurface and the posterosuperior glenoid rim or osteochondral lesions. Other key findings included undersurface cuff fraying in 93%, posterosuperior labral fraying in 88%, and anterior labral fraying in 36% of the subjects. This study supports the concept of impingement of the posterior cuff undersurface with the posterosuperior glenoid rim in the overhand throwing athlete with shoulder pain.

Electromyographic analysis of the deltoid and rotator cuff muscles in persons with subacromial impingement.

The purpose of this study was to compare subjects with subacromial impingement and subjects with normal shoulders with respect to muscle activity. Fifteen subjects in each group were studied by means of fine-wire electromyography. The middle deltoid and rotator cuff muscles were evaluated during isotonic scaption from 30 to 120 degrees. Overall, the impingement group demonstrated decreased mean muscle activity in comparison with the group of normal subjects. The magnitude of diminished activity was statistically significantly different (P < .05) during the 30- to 60-degrees arc for the infraspinatus, subscapularis, and middle deltoid muscles; in addition, the infraspinatus muscle demonstrated significantly depressed activity during the 60- to 90-degrees arc. In the impingement group, the supraspinatus and teres minor revealed a diminution of muscle function in comparison with shoulders in the normal group; the difference was not significant. This study demonstrates that muscle activity in subjects with impingement is most notably decreased in the first arc of motion. Also of clinical relevance is the fact that the inferior force vector (from the infraspinatus and subscapularis) is less functional in subjects with impingement than is the superior compressive vector (from the supraspinatus). Thus, humeral head depression during the critical first portion of elevation may be insufficient in people with subacromial impingement.

Medial collateral ligament instability and ulnar neuritis in the athlete's elbow.

Athletes who participate in overhand sports may sustain a host of injuries to the medial elbow. The chronic repetitive stress caused by the high velocity nature of the overhand throwing mechanism predisposes these athletes to overuse injuries. Medial collateral ligament instability and ulnar neuritis are common disorders seen in this patient population. A thorough understanding of the anatomy of the medial elbow as well as the pathophysiology of these disorders and their nonsurgical and surgical treatments are essential to providing these athletes with optimal care and hastening their return to sports.

Electromyographic analysis of shoulder function during the volleyball serve and spike.

The purpose of this study was to describe the electromyographic (EMG) pattern and relative intensities of 8 shoulder muscles during the volleyball serve and spike in 15 professional or collegiate-level athletes. The EMG analysis was synchronized with high-speed cinematography to discern phases of the spike and serve. During the spike, the anterior deltoid and supraspinatus functioned together to elevate and place the humerus throughout all phases. During cocking the infraspinatus and teres minor acted together to rotate the humerus externally. In acceleration, however, these muscles behaved independently; activity of the teres minor remained high, whereas the activity of the infraspinatus declined. The anterior wall muscles functioned to decelerate the humerus during cocking and acted as internal rotators during acceleration. Muscle activities recorded for the serve followed similar patterns as those seen for the spike, but with lower amplitudes. These data illustrate the complex sequence of shoulder muscle activity necessary to play competitive volleyball.

Electromyographic and nerve block analysis of the subscapularis liftoff test.

The inability to perform the "liftoff" test has been attributed to a subscapularis muscle or tendon injury. The goals of this study were to evaluate the activity of the glenohumeral muscles during performance of the "liftoff" maneuver and to identify the most effective initial upper extremity placement that isolates the subscapularis musculotendinous unit. In the first phase of this study 15 subjects accomplished four proposed versions to the "liftoff" test while their intramuscular electromyographic activity in select glenohumeral muscles was recorded. The second phase of this study assessed the ability of five subjects with a nonfunctional subscapularis musculotendinous unit to perform the same proposed versions. On the basis of electromyographic data none of the proposed versions to the "liftoff" maneuver isolated the upper and lower subscapularis muscle from either the teres major, latissimus dorsi, posterior deltoid, or rhomboid muscles (p > 0.05). In the presence of a nonfunctional subscapularis musculotendinous unit, the subjects were able to perform all of the proposed versions of the "liftoff" maneuver except one: elevation of the dorsum of the hand from the posterior-inferior border of the scapula (maximum internal rotation test). Although significant electromyographic activity was generated in the potentially confounding shoulder girdle muscles during the maximum internal rotation "liftoff" test, a successful test appears to be dependent on the isolated glenohumeral internal rotation function of the subscapularis muscle.

Shoulder muscle firing patterns during the windmill softball pitch.

The purpose of this study was to describe the activity of eight shoulder muscles during the windmill fast-pitch softball throw. Ten collegiate female pitchers were analyzed with intramuscular electromyography, high-speed cinematography, and motion analysis. The supraspinatus muscle fired maximally during arm elevation from the 6 to 3 o'clock position phase, centralizing the humeral head within the glenoid. The posterior deltoid and teres minor muscles acted maximally from the 3 to 12 o'clock position phase to continue arm elevation and externally rotate the humerus. The pectoralis major muscle accelerated the arm from the 12 o'clock position to ball release phase. The serratus anterior muscle characteristically acted to position the scapula for optimal glenohumeral congruency, and the subscapularis muscle functioned as an internal rotator and to protect the anterior capsule. Although the windmill softball pitch is overtly different from the baseball pitch, several surprising similarities were revealed. The serratus anterior and pectoralis major muscles work in synchrony and seem to have similar functions in both pitches. Although the infraspinatus and teres minor muscles are both posterior cuff muscles, they are characteristically uncoupled during the 6 to 3 o'clock position phase, with the infraspinatus muscle acting more independently below 90 degrees. Subscapularis muscle activity seems important in dynamic anterior glenohumeral stabilization and as an internal rotator in both the baseball and softball throws.

Dynamic stability of the elbow: electromyographic analysis of the flexor pronator group and the extensor group in pitchers with valgus instability.

The medical collateral ligament is a common site of injury in baseball pitchers, causing substantial morbidity and loss of pitching time. Twenty-six skilled baseball pitchers with medial collateral ligament insufficiency were studied before surgery with high-speed cinematography and fine-wire electromyography of eight muscles around the elbow. Data from the pitchers with injured elbows were compared with data obtained from uninjured pitchers. The flexor carpi radialis muscle in the pitchers with medial collateral ligament deficiencies revealed significantly decreased firing during the acceleration and deceleration phase of the fastball when compared with that of the pitchers with normal elbows, and the flexor carpi radialis muscle was significantly depressed during the early cocking and deceleration phases. The extensor muscles revealed slightly increased activity in the injured elbows; however, this was not statistically significant. Although the muscles of the flexor pronator group (especially the flexor carpi ulnaris muscle and the flexor digitorum superficialis muscles) are anatomically positioned to provide dynamic stability of the elbow, they did not demonstrate increased electrical activity in pitchers with medial collateral ligament deficiencies. This finding suggests that the muscles on the medial side of the elbow do not supplant the role of the medial collateral ligament during the fastball pitch.

Comparative electromyographic analysis of shoulder muscles during planar motions: anterior glenohumeral instability versus normal.

This study compared the electromyographic activity of rotator cuff and scapular muscles between subjects with anterior instability and subjects with normal shoulders. Thirty-eight patients were studied; 23 had anterior instability that was subsequently surgically confirmed, and 15 had normal shoulders. Fine wire electrodes were inserted into the subscapularis (upper and lower portions), supraspinatus, infraspinatus, rhomboid, serratus anterior, and trapezius (upper and lower portions) muscles. Abduction, scapular plane abduction (scaption), and forward flexion were performed over the range of motion and later divided into 30 degrees intervals. In both abduction and scaption, the supraspinatus demonstrated significantly less electromyographic activity from 30 degrees to 60 degrees in shoulders with anterior instability compared with normal shoulders (p < 0.05). During all three motions, shoulders with anterior instability demonstrated significantly less electromyographic activity in the serratus anterior when compared with normal shoulders (p < 0.05). This occurred at 30 degrees to 120 degrees of abduction and at 0 degree to 120 degrees of scaption and forward flexion. None of the other muscles demonstrated significant differences. These differences during planar motions were similar to those demonstrated during challenging overhead sport motions. Early rehabilitation efforts should focus both on the rotator cuff and scapular muscles to establish smooth, coordinated shoulder motion.

Shoulder pain in golf.

This discussion and the three case examples illustrate different etiologies of shoulder problems in the golfer. Age and the mechanics of an individual swing are factors to consider when defining the core problem. In summarizing shoulder pain in the golfer, perhaps the key point is that a thorough patient evaluation is essential to diagnose the problem accurately. It is only with a specific and accurate diagnosis that an optimal treatment program can be designed, and successful outcomes will be the result.

Preventative exercises in golf: arm, leg, and back.

In summary, a sport-specific exercise program for golfers includes warming up, stretching, strengthening, and cardiovascular conditioning. The goals of such a program incorporated with playing the game of golf are to optimize performance and prevent injuries. The integration of each of these components represents a well-balanced fitness approach to sport and enhances the enjoyment of the game.

Shoulder instability in the overhand or throwing athlete.

In the young throwing athlete with shoulder pain, it is essential to recognize that glenohumeral joint instability (occult subluxation, rather than impingement) is the primary underlying pathology. Fortunately, conservative management is effective in most chronic overuse injuries. For those athletes with continued symptoms, surgical intervention may become necessary. The anterior capsulolabral reconstruction addresses the problem of glenohumeral joint instability by correcting the capsular redundancy, labrum damage, or both. The authors believe this most recent surgical technique and postoperative rehabilitation program has resulted in a significant improvement in our ability to more predictably and successfully return these athletes to prior competitive levels.

Electromyographic analysis of the hip and knee during the golf swing.

As golf increases in popularity, more golfers seek the proper mechanics necessary for the perfect golf swing. Surprisingly little scientific work has been published on the contribution of the hip and knee muscles during the golf swing even though most professionals have recognized their vital contribution. Recent studies have described the electromyographic (EMG) muscle activity of the shoulder, back, and trunk during the golf swing. The purpose of this study was to describe the electrical muscle activity in seven hip and knee muscles of both the left (lead) and right (trail) leg in competitive golfers while performing the golf swing. Sixteen golfers were studied with indwelling electrodes and high-speed cinematography. The EMG was synchronized with the film to discern five phases of the golf swing. Means, SDs, and t-tests were done. The results revealed that the trail hip extensors and abductors in conjunction with the lead adductor magus initiated pelvic rotation during forward swing. The lead hamstrings maintained a flexed knee and provided a stable base on which pelvic rotation took place. The peak EMG muscle activity recorded in the hips and knees occurred in an earlier phase than that measured previously in the trunk and shoulder. This confirmed the sequential firing pattern of the hip and knee muscles that takes place during the competitive golf swing. Information gained from this study can be used by players and coaches to optimize performance and to minimize injury.

Functional anatomy of the flexor pronator muscle group in relation to the medial collateral ligament of the elbow.

To describe the relationship of the pronator teres, flexor carpi radialis, flexor digitorum superficialis, and flexor carpi ulnaris muscles to the medial collateral ligament at 30 degrees, 90 degrees, and 120 degrees of elbow flexion, we dissected 11 cadaveric specimens. The flexor carpi ulnaris muscle is the predominant musculotendinous unit overlying the medial collateral ligament in the majority of cases and is the only one at 120 degrees of elbow flexion. The flexor digitorum superficialis muscle is the only other significant contributor. The medial collateral ligament is the primary stabilizer of the medial elbow with elbow flexion greater than 30 degrees, as in throwing. The flexor carpi ulnaris muscle, because of its position directly over the medial collateral ligament, and the flexor digitorum superficialis muscle, with its near proximity and relatively large bulk, are the specific muscles best suited to provide medial elbow support. This is especially relevant to overhand throwing athletes who encounter extreme valgus force across the elbow during the cocking and acceleration phases of the throwing motion. Exercise and conditioning of the medial elbow musculature, specifically the flexor digitorum superficialis muscle and the flexor carpi ulnaris muscle, may prevent injury or assist in rehabilitation of medial elbow instability, especially in overhand throwing athletes.