The "moving valgus stress test" for medial collateral ligament tears of the elbow.

BACKGROUND: The diagnosis of a painful partial tear of the medial collateral ligament in overhead-throwing athletes is challenging, even for experienced elbow surgeons and despite the use of sophisticated imaging techniques. HYPOTHESIS: The "moving valgus stress test" is an accurate physical examination technique for diagnosis of medial collateral ligament attenuation in the elbow. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Twenty-one patients underwent surgical intervention for medial elbow pain due to medial collateral ligament insufficiency or other abnormality of chronic valgus overload, and they were assessed preoperatively with an examination called the moving valgus stress test. To perform the moving valgus stress test, the examiner applies and maintains a constant moderate valgus torque to the fully flexed elbow and then quickly extends the elbow. The test is positive if the medial elbow pain is reproduced at the medial collateral ligament and is at maximum between 120 degrees and 70 degrees. RESULTS: The moving valgus stress test was highly sensitive (100%, 17 of 17 patients) and specific (75%, 3 of 4 patients) when compared to assessment of the medial collateral ligament by surgical exploration or arthroscopic valgus stress testing. The mean shear range (ie, the arc within which pain was produced with the moving valgus stress test) was 120 degrees to 70 degrees. The mean angle at which pain was at a maximum was 90 degrees of elbow flexion. CONCLUSIONS: The moving valgus stress test is an accurate physical examination technique that, when performed and interpreted correctly, is highly sensitive for medial elbow pain arising from the medial collateral ligament.

Valgus torque in youth baseball pitchers: A biomechanical study.

The purpose of this study was to determine the biomechanical and anthropometric factors contributing to elbow valgus torque during pitching. Video data of 14 youth pitchers throwing fastballs were used to calculate shoulder and elbow kinematics and kinetics. Peak elbow valgus torque averaged 18 Nm and occurred just before maximal shoulder external rotation. The magnitude of valgus torque was most closely correlated with the thrower's weight. When subject weight and height were controlled for, maximum shoulder abduction torque and maximum shoulder internal rotation torque were most strongly associated with elbow valgus torque, accounting for 85% of its variance (P <.001). When only kinematic variables were considered, maximum shoulder external rotation accounted for 33% of the variance in valgus torque. Given that the biomechanical variables correlated with peak valgus torque are not easily modifiable, limiting the number of innings pitched is likely the best way to reduce elbow injury in youth pitchers.

Validity of index of suspicion for pulmonary embolism after hip arthroplasty.

Pulmonary embolism after total hip arthroplasty is problematic, and intravenous heparin treatment in the absence of pulmonary embolism carries risk. Algorithms for treating pulmonary embolism often cite clinical index of suspicion as a basis for initiating intravenous heparin, but most information regarding variables to predict pulmonary embolism originate from studies of patients rather than only from patients who had arthroplasty. We studied the hypothesis that a more homogenous subpopulation, patients who had total hip arthroplasty, may have findings more accurately predictive of pulmonary embolism. One hundred fifty records of patients who had total hip arthroplasty who were suspected of having pulmonary embolism and who were evaluated for pulmonary embolism were assessed. Complaints, physical findings, heparinization status, and test results were analyzed with univariate and multivariate assessments to determine predictors of pulmonary embolism. No significant differences were found between patients with or without pulmonary embolism regarding subjective complaints, physical examination, blood gas results, electrocardiogram findings, radiographs of the chest, and imaging of the veins of the legs. All attempts to model these variables into an index of suspicion that accurately predicted pulmonary embolism were unsuccessful. We advise adherence to established treatment algorithms rather than clinical suspicion when deciding whether to initiate heparin therapy.

Pediatric shoulder instability: presentation, findings, treatment, and outcomes.

There is no one large study on pediatric shoulder instability. The purposes of this study were to characterize patients with shoulder subluxation or dislocation, the treatments provided, outcomes, and the predictors of good outcomes. Seventy shoulders in 66 patients were retrospectively reviewed, all with follow-up >2 years. The authors defined characteristics, treatment, outcomes, and associations between patient and treatment variables and outcome measures. Instability was associated with boys, adolescents, and trauma. Forty-two shoulders received physical therapy, and 28 required surgery. At follow-up, 54 of 70 described their shoulders as "better" or "much better," and 90% were performing at the same or higher levels of sports and work. Surgically treated patients were less likely to have recurrent instability or to report limitations. The current study is a large study of pediatric shoulder instability. Surgery improved stability, but overall, stability improved over time, with few patients having limitations at moderate- to long-term follow-up.