some insights. These are my faculty disclosures, none of which should come into play. Obviously UCL reconstructions and repairs are on increase. Obviously the rehab has to match the surgery. It's a little bit more than just elbow rehab. This is a biomechanics video from our lab that shows the stresses on the medial aspect, 64 Newton meters. Study by Fleissig actually show that it can rupture in a cadaveric specimen at 32 Newton meters. Unfortunately we see young people who have this injury. There's a 12-year-old baseball player that had UCL repair, 12-year-old javelin thrower. So we're seeing more and more younger individuals unfortunately that require surgery because of the extent of their damage. Certainly the pros, as you heard from all the other previous presenters, certainly can have this and about 25% of all major league baseball pitchers have had a UCL reconstruction. So here are some of the pearls in my mind at least. I've had a hard time kind of dwindling them down. But we're going to talk about each one of these just kind of quickly. As I mentioned, when I first started we were all reconstructions. Now there's repairs, there's hybrids, there's combinations. A lot of things going on. One thing I've learned through the years is maybe don't rush it. You have time. Slower sometimes reduces the re-injury rates as you've heard. You saw some time frames from Dr. Dobson as far as how fast we get our range of motion back. But we want to really delay is the stress on the medial aspect. That's why I showed you that video of throwing in the 64 Newton meters. Exercise that create UCL strain, external rotation, extremes motion at zero as well as 90 and also the weighted ball throwing which we'll talk about. Dr. Chalmers did a very nice study in American Journal of Sports Medicine that basically talked about peak velocity and mean velocity were the number one reasons for injury. But yet weighted ball throwing is probably the most popular thing that kids and even pros are doing. So if you're not familiar with weighted ball throwing programs, it's effective but there's also potential problems. And you can see in the still picture the amount of stress that's going on the medial aspect. So this is called the rocker in a knee position. And the good part is it's teaching the transfer of energy. The weighted balls go up to 32 ounces. A baseball is 5.5 ounces. So you can see it's about six times the weight of a baseball. Another one is the rocker standing. I left the sound on so you can hear the velocity of it hitting against the mat. He's probably throwing, it's hard to see what color that is. He's probably throwing probably a 16, maybe an 18 ounce baseball. And then the run and gun. Again, using legs, transferring energy. Great drill but the problem is if mechanics are off or fatigue or they do too much, especially kids. But it's all about velocity, right? All about velocity when you hear about college pitchers throwing 104, 105 miles an hour. It's probably ligament gradual attenuation. One thing interesting, Dr. Fleissig at our lab has looked at this. The average velocity in Major League Baseball has gradually gone up but also Tommy John's surgery has gradually gone up. The interesting part is if you look at ERAs or WHIP, which you've learned about WHIP from Dr. Allitrash, it doesn't correlate to fastballs. But yet everyone's enamored with the fastball and that's what coaches look for. Reinhold did a very nice paper, Journal of Sports Health, looking at a group of high school individuals that did weighted ball throwing. Excuse me, 16 in a study group and 16 in a control group and 25% were injured during the weighted ball throwing program. So 25%. He did a follow-up study looking at causative factors potentially and what he gleaned from the initial paper was that the overweight throwing increased the external rotation. We've done a study on this as well looking at range of motion related to elbow injuries, loss of flexion, gain in external rotation were the two causative factors that we found. What about long toss? We have people come in, had UCL surgery and I ask them what happened while I was throwing 320 feet. It's like, why were you doing that? Well, it's part of our program. And if you look at the forces that are generated at the longer distances, they're quite high. So we advocate 120, 150 feet but many times organizations change that. We did a study on this looking at college baseball pitchers in a biomechanical setting outside and we basically showed that once you get to your max distance, whatever that is and that has to be individualized, your mechanics change dramatically. You actually start pushing the ball. You lead with your elbow, you need more external rotation and you tend to have less trunk involvement and that can be all detrimental. Less is more. We know Davis law shows that soft tissue heals according to applied stresses. Chalmers show this as well. In season, the UCL actually thickens and becomes thinner in the off season. So we do a lot of manual techniques. Here I'm doing a lot of flexor pronator because I want load sharing capabilities. So what he's doing is he's flexing his wrist and his elbow at the same time. And we'll do this concentrically and eccentrically because of the overlay of the flexor carpi ulnaris. We do laser therapy. We also do shockwave therapy and try to get more collagen lay down. We do a lot of ball flips, getting hand strength back, especially with palmaris longus grafts as you see here. Individualized rehab. With kids it's more about their legs than their hips. We do a lot of single leg stuff, a lot of core exercises. So it's pretty rare for me to have a player lay on the table and do exercises past about two or three weeks. You're going to be on a stability ball, you're going to be in a lunge position, a squat position and those types of things. Obviously something like this is very, very beneficial for hips. In my mind, the young throwers, high school and younger, they're probably the biggest weakness in their kinetic chain is actually their legs and their core, not necessarily their arm. So we do a tremendous amount of these exercises for the scapula, for control, posterior cuff. If you were in the other room in the shoulder injuries, the HSS study that looked at return to play, the ones that didn't make it back to 25% that didn't test very well, weakness in the posterior cuff. So we really emphasize posterior cuff. Plyometrics, a rule that Dr. Andrews has always had through our years is you have to do plyometrics before you start your throwing program. Not weighted ball throwing, but plyometrics, which is very controlled. So here he's doing a two-hand chest pass. Obviously the question is, when do you start that with a repair or reconstruction? And then later, much later, we'll do one hand. That ball weighs one, maybe two pounds. It's very controlled. It's not max. It's submaximal, working on their mechanics and getting some stress on the UCL. And then we'll increase it a little bit, as you see here, with end range rhythmic stabilization. But never really pushing it toward excessive ER. Delay throwing for an extended period of time. But you have to delay with purpose. If you just tell a person we can't let you throw for six months, it's not going to be meaningful, especially to a young person. So we tell them we want you to work on other things, transfer of energy, the plyometrics. I think plyometrics is a nice niche. So sometimes we start you at four or five months after a reconstruction, sometimes longer. Don't be afraid to push it back. This is a really big component in my mind, adjusting workloads. We think, and athletes think, that they can just gradually ramp up. And what we're learning more and more, no matter what body part is, you need to deload to be able to load. So you need these breaks in the program. So once we start a throwing program, you'll throw for four weeks, but you'll do light throwing for a week, and then you'll gradually ramp up again for four more weeks. And we think that can calm down tissue. Mike Reinhold has done some nice work on this with the interval throwing program, using the modus sleeve, and so forth. Last couple is to mention adjust your interval throwing program. Don't lock in. Just because it's on paper, many times we make adjustments, particularly the ramp-ups. The ramp-ups for me are throwing off the mound. Most people can long toss. It really matters when they hit 80% of their max. That's when things, the rubber hits the road, and you'll see if they'll be able to make it. Big steps, starting plyos, starting interval throwing program, and throwing hard, as I mentioned before. And lastly is endurance, especially with young people. We've done a study at our center some years ago, 36 times greater risk of injury if a young person, little leaguer, throws when fatigued. So we do a lot of high rep types of things like you see here. He's got a dumbbell in one hand, it's four pounds. He's on a stability ball. Posterior chain, core is all engaged. That's a two-pound ball. He's dropping, and we do these staves at end range. A lot of control. And that would be a 30-second, 45-second bout of exercise. Same thing with this. So hopefully I gave you some insights as far as maybe when to delay, maybe when to speed up. Restore motion gradually, usually by six weeks. And again, be careful of the person who just thinks they can push themselves and be the superman. You want to slow it down whenever possible. Thank you very much for your attention. That's great. Thank you very much, Kevin.

UCL reconstructions

UCL repairs

rehab matching surgery

weighted ball throwing programs

UCL injuries