First, I want to thank the Academy for inviting us to share our research with you guys today. I want to thank also our co-authors for their help with this particular project. It's no surprise, there's obviously been an increase in medial elbow injuries over the past few decades. We continually see it year in and year out. As a matter of fact, Mihur et al. pretty much showed us or predicted what we're going through right now. We predicted that UCL reconstructions would rapidly increase between 2016 and 2025. Anatomically, if we switch directions for a moment, we want to talk about the anatomy. We can go back to the Davidson study in 92 or we can just go back to this study in 2018. It really shows the intimate nature between the FDS and the FCU and how it helps to support that anterior bundle of the UCL. We can look at Park and Ahmad's study in 04 and we can show when they put the elbow at a 90 degree angle that once again the FCU and the FDS provide a dynamic stability to the medial elbow with a little bit lesser contribution from the pronated teres. If we want to look at this more recent study, we want to talk about actual in pitchers. If we look at this 2018 study by Pecsa, he showed us that if we loaded the elbow in a pitcher with 2.2 kilograms, we got significant gapping at the medial elbow. However, if that athlete contracted their fist and squeezed as hard as they could, they could approximate the medial joint space, showing us two things, right, is that the importance of the secondary stabilizers to supporting the UCL as well as maybe this is a good way that we can start looking at fatigue of the medial elbow. However, that's been unfortunate because multiple studies have really failed to show that marked grip strength is an actual indicator of pitching fatigue. Unfortunately, I've been a part of a couple of the studies. We have pitchers that threw 99 pitches. We showed no grip strength back in 06. A few years ago, 62 pitches, 5% strength loss in the grip strength. A recent study in PRESS and IJS-PT, 58 pitches, 5% strength loss. A narrow study also in PRESS for JSES, 100 pitches, no grip strength loss. So possibly grip strength test may not really be selective for the FDS or the FCU. How we look at McHugh's study, McHugh looked at middle finger and ring finger EMG activity and looked at if we contracted the middle finger or the ring finger, we showed significant FCU and FDS muscle activity with minimal pronator teres activity. So maybe this middle finger, ring finger testing may be more selective test for FCU and FDS fatigue. And that's kind of where we went, is we wanted to look at the middle finger and ring finger fatigue and how it reacted to fatigue during a pitching performance. And we also wanted to determine if high elbow valgus stress during pitching compromised the medial elbow dynamic stabilizers. So we had 18 pitchers. They threw for four innings. They were allowed to warm up however they wanted to. And then once it was time to study, we did five pitches warm off the mound, 10 fastballs, four curveballs, two changeups. So 84 pitches total were calculated with their velocity recorded. And we instrumented them with inertial sensors at their medial elbow to look at the valgus. We used these four tests five times prior to them originally pitching and then after each inning. We looked at the full grip test, we looked at a three finger grip test, we looked at a ring finger break test, and we looked at the middle finger break test. Now if you look at our results based on percent of baseline strength, you can see the middle finger in the red, you can see there's significant decrease in strength from prior to the game all the way to the fourth inning, so all the way up to about 22% strength loss. Ring finger, full grip, and three finger grip, they showed, similar to what we showed in other studies, about a 5% strength loss by the end of the pitching performance. Interestingly enough, 50% showed marked middle finger strength loss from the start to the finish of the game. If we want to look at the torque, we broke them into two different torque levels. Those pitchers that had a greater, a torque that was greater than 50 newton meters versus those less than 50 newton meters, the ones with over 50 newton meters had significantly and faster, showed greater middle finger test fatigue. So if we take a step back, we're looking at a couple different things, right? We're looking at the middle finger could be one of these good tests moving forward in terms of having the ability to look at fatigue from inning to inning. It's obviously more sensitive than the ring finger test. Think full grip or the three finger grip test for fatigue. And then high elbow stress equals increased fatigue, right? So that's what we showed with the inertial sensors. Increased fatigue is probably going to cause potential increased stress to the UCL, which could be an issue. So in conclusion, obviously the middle finger is showing that there's increased dynamic stabilizer fatigue. One of the things we're starting to look at now is the potential for an intervention to minimize this dynamic stabilizer fatigue. And then finally, maybe this test can actually look to possibly developing some sort of in-game assessment for pitcher fatigues, especially those who throw with an elevated torque at the elbow. With that, I want to thank you and I thank the Academy for your time. Thank you, nice study. I do have a couple of thoughts as I went through this paper with regard to what you're actually measuring and what you're testing. Does this really reflect so much fatigue in the flexor mass itself from the loads across the elbow or does it reflect the manner in which this given pitcher has the ball coming off his fingers and he's controlling the pitch? And then with that information that you get when you're finding fatigue and you can document fatigue in the long finger, I know you said you're looking for ways to try to apply it. That's really going to be the issue. In real time, during a season, how do you see that affecting our ability to use a pitcher in games or in a series of games and how do you see using that to help us look for, evolve in increasing risk for an injury in that particular pitcher? I think one of the questions, the first question is yeah, we've been trying to measure this for a long time and not having the right answer yet and this is the first time we're starting to see something that's panning out in terms of seeing more fatigue based on the EMG studies that are out there that that's getting more FDS or FCU. So we think that obviously we're going in that direction. Is it just isolating that muscle? It's hard to say, right? Because there's a lot going on at that time in that split second. So maybe not. I think the other thing is starting to look at programs that we can do to try to intervene. We want to try to intervene whether it's something that we can do prior to the season or in the season so they can prevent this fatigue from happening as much. In terms of measuring during a game, I think there's a lot of different ways to go. I think the current way that we're doing it, I use the MMT all the time, so I'm, put somebody in the dugout? Probably not, right? So I think there's, we're messing around with other ways to possibly be able to utilize it in an in-game situation to try to decrease that fatigue. Okay, thank you very much. Thank you.

medial elbow injuries

pitchers

anatomy of the elbow

ulnar collateral ligament

dynamic stabilizer fatigue