left for questions. I'd like to thank all the presenters for a great job. Don't forget about the app. It's very easy to do it. If I can do it, you can do it too. We've only had two questions so far and it looks like a pretty big audience. So if you've got any questions you'd like to ask them, make sure you submit them via the app. I'm going to start with a question of my own though. I have to torture Beamer a little bit because he did residency with us. So it's unfortunate for him that I'm moderating his session. I had the advantage of being able to look at your paper. Great job with the paper, by the way. I think it's going to be very helpful and it's certainly something that will continue to develop over time. But I noticed in your protocol, particularly with the range of motion measurements, you're comparing a lot to the other side in order to get a passing grade. And I was actually surprised in some of the measurements that you were able to give them a passing grade, particularly because a lot of these pitchers, as you know, throwing athletes have some baseline range of motion differences from side to side. And so how did you decide on the range of motion difference that would give them a passing grade? And are you worried at all in not having baseline information on these pitchers and if that's going to cause them to fail this protocol? Certainly not having baseline data can impact it because some pitchers do have flexion contractures or other range of motion deficits. For us, just looking at previously published literature, it's not uncommon for pro pitchers to have anywhere from a 5 to 7 degree flexion contracture. So we kind of targeted close to that with a less than 10 degree difference. And then similarly for elbow flexion, shoulder becomes a little bit more arbitrary just given the hyperloxity nature of some of these athletes versus others. So I do think that this is a limitation of the study. It certainly is. But I think the overall point of trying to obtain objective criteria before we let our patients take that next step in throwing is still an important point. No, I absolutely agree. And one last question for you. What's your plan for validating in the future? This is obviously a small group of patients. How are you going to move that forward? For sure. So we are still actively enrolling. This was kind of like a pilot study of sorts at our institution. So we are just going to continue to actively enroll all of our pro soccer and baseball players so that we can get a larger cohort. And we also have thought about maybe expanding the protocol and trying some different tests to see what the pass and fail rate are for various published tests to try to use some linear regression models to determine the most accurate protocols moving forward. Fantastic. Good study. So we've got a few questions from the app. I'm going to start with Jacob. And so Jacob, the question from the audience was, did you ask left-handed pitchers if they were ambidextrous or not? And do you think that would affect your results? So we did not ask about the left-handed pitchers being ambidextrous. I do think that that would affect the results. I know in something like anthropology literature they spoke about being a left-hander living in a right-handed world, that maybe they have to do things differently because things are done by right-handed people. So they at baseline might have more retroportion in their non-throwing arm just because they're used to doing things the way that right-handed people might. And they might have to do things with their non-throwing arm that most right-handed people would not do. That's good. Good answer. All right. So next question, and this goes along with the question I also had for the last paper from Marcus. And so my particular question about that paper is a little outside actually the topic of the study, but briefly, in less than 30 seconds, what are the indications for UCL repair versus UCL reconstruction? Because you included both of them, and they certainly could influence the results. Sure. That's a great question. I think that's a critical question for this group of patients specifically as non-baseball throwers and non-throwers. I think the key thing is the quality of the ligament. So typically, we see patients who are amenable to UCL repair, particularly our younger patients. And again, most of these patients were high schoolers. So we look at the native quality of the ligament and to see if it's an indivulged or a mid-substance repair. So location and quality. And then the question from the audience related to this is why the predominance of UCL repairs in non-throwers? Could you at least hypothesize on that? And do you think it's the mechanism of injury? Is it a different type of injury than a thrower? I think it's simpler than that. I think when we looked at the data, we saw that these were just later in the series. We started doing UCL repairs in Birmingham in 2013. And so that's the blessing and the curse of having a large registry is we got a few patients from all the way back in 2001. Those happen to be from the other cohort nailing out reconstructions. Okay. Makes sense. So the next question is for Chris. And so the question is, did you look at fastball control with the PitchFX system post-revision? They're concerned maybe about possibly decreased control led to less fastball use. So that's a great question. So thank you. We did in a way. So we looked at the walks per nine innings where there was no difference afterwards. It's kind of a surrogate for command. We also looked at the strikeouts per nine innings as well, which also was showing no difference. But specifically for control, there is some ability to look at the movement in the horizontal and vertical directions, which we did not look at in this study. And my question to add on to this, because I see collegiate baseball players quite frequently in the office. How are you going to interpret the results of this study for them? My concern about these findings is that they're not going to be all that worried after they've had their first UCL reconstruction, not necessarily try to adjust anything about how they pitch because they can take away from this that they're just going to be as good as they were beforehand. And so how do you counsel them about the information you found? What's the important take home points to tell a pitcher? Yeah. So I think the one is that the return to play rate is definitely lower than the primary. So I think that's very important to emphasize with them. It was only 60% to the MLB level. And I think also it's important that just because your fastball returns doesn't necessarily mean that you're going to be at the same level. And that's something I think that we'll have to continue looking at other metrics and see if there's anything else that explains why the pitchers seem to be trusting their fastball less. Great answer. All right. We have time for one more question. And so this question said, reason the testing before the ITP. For those that fail due to strength or range of motion, how did they gain enough range of motion or strength in just two weeks after their first round of testing? And so that's for you, Beamer. How did two weeks change people? Your failure rate was not insignificant and then two weeks later they all passed. Did they learn how to do the test better or is there something that they're able to modify in two weeks? It's certainly possible. I think for a lot of these players that didn't initiate plyometrics, usually the plyometric phase is about two weeks of our protocol. So if they haven't initiated, that was an automatic fail. And so I think for most of these patients, or let me rewind, I think basically a lot of therapists may be afraid to really focus on shoulder range of motion because they want to protect the UCL graft. They don't want to put that internal rotation torque through plyometrics and strengthening. So I think educating these patients that it's okay and safe and required to do this to be safe to throw kind of liberated them to then really focus on strengthening over a couple weeks, really work on their plyometrics, and then be able to perform those two weeks later. Fantastic. All right. Well, thanks to our presenters. You all can head on back to the audience. If I could invite our next three speakers up, save us a little time in between. Our first talk is going to...

range of motion measurement

criteria

baseline data

UCL repair

collegiate players