Thanks for joining us to talk about the ELBO. So, give you a little brief introduction and then we'll kind of get going. And, you know, certainly we want this to be interactive. So, you know, if you have questions, please feel free to ask in between the talks. I'll give you a list of presenters and then we'll kind of hand it off. So, first we have Greg Stanavis talking to us about epidemiology of UCL tears. He comes to us from Ohio State University. I won't say the... Then I'll give you a talk about UCL repair. I'm here from Rothman. Eric Bowman is going to come next and talk to us a little bit about UCL reconstruction. How maybe the numbers on UCL reconstruction are dwindling a little bit. Pete Chalmers is then going to take over and talk to us about how to get these guys back to playing after UCL surgery, whether it's repair or reconstruction. Then Dr. Romeo is going to talk to us about UCL hybrid surgery. Maybe we can add in repair and reconstruction. And then Mark Shickendance is going to give us an idea of what complicated cases he's had. Maybe the panel will discuss, you know, ways that we can get these players back. Certainly if you have questions during that time, that's meant to be interactive. So please feel free to ask. So with that, I'll turn it over to Greg to start telling us about UCL epidemiology. All right. Thank you very much. And it's an honor to be presenting. So we'll be talking about ulnar collateral ligament, epidemiology, and risk factors. And then move on to some of the treatments for these with the other presenters. All right. So ulnar collateral ligament, we all know this is at risk in athletes, particularly overhead athletes and throwing athletes. And it has really become a very common injury in youth sports all the way up through the major league baseball players. Prevalence of medial ulnar collateral ligament injuries in professional baseball players is quite significant. Roughly 20% of all pro players have had UCL surgery. A little lower in minor leagues, a little higher in the major leagues. And this has trickled down to younger college, high school youth athletes as well. This leads to a significant amount of time out of play for major and minor league baseball players. It was overall the number six reason for time out of play, but one of the more common reasons for season-ending surgery for these players. And so this is an important thing to understand why this is happening and can we do anything to prevent this. Predominantly affects pitchers, can certainly hit other position players as well, but 80 plus percent of these are in pitchers. As mentioned, in younger age groups in a study, Brandon and others found there was a major spike in these, particularly in the 15 to 19 age range. And for those taking care of these athletes, I think we've also seen a lot of players in this age range who are developing these injuries younger and younger through youth sports specialization and other factors. So what are some of the risk factors for injury? I think one of the big ones to mention is earlier specialization with baseball. Age to begin dropping sports and focusing on one sport begins to be younger and younger and was eight years old in one study. The players don't necessarily like this if you survey them candidly. Many of them would be okay playing some other sports, were told to stop playing other sports because they had to focus on their travel teams and playing year round. And this is a significant problem in our youth sports culture that's hard to solve, but it's something we can work on education on an individual level and education on a broader level, I think. There are certainly a number of risk factors that we know of for medial elbow ulnar collateral ligament injury. And Chris Camp published a nice systematic review and categorized these into a few groups. So one is player characteristics. So taller player, higher BMI, losing shoulder total arc of motion is a risk factor that we know versus the more classic thought of the internal rotation deficit. The total arc is probably more important. Humeral retrotorsion, which is a developmental thing and elbow valgus laxity. We know that throwing too hard is a risk factor. So one consistent risk factor through the literature has been higher pitching velocity and a higher percentage of hard pitches, fastballs. Throwing too often is a consistent risk factor as well. So this is pitchers who are exceeding pitch counts, players who are playing year round specialized and pitching all year round and playing with a weighted balls can be a risk factor as well. There can be mechanics factors and this is one area that can certainly be modified. So Y balance score has been proposed, lateral release position versus more of a typical overhead release position. So this is the Y balance. Some of these aren't modifiable as you can tell. So you can't modify your retrotorsion that I know of. You can't really modify where you're from geographically, although you could take a break in the winter even if the weather's warm. And you can't necessarily modify your elbow valgus opening, but some are modifiable and I think pitch counts are one that are frequently discussed. Shoulder range of motion could be modified with physical therapy, with athletic trainers, exercises. Working on the core and the lower extremities and balance can be modified to have a better base for your throwing mechanics. And working with pitching coaches, other professionals and working on optimizing pitching mechanics to distribute the stresses and not concentrate them all on the elbow is a potentially modifiable factor. Dr. Erickson reported that with lighter baseball training regimen, you can achieve the goal of increasing velocity for improved pitching performance without the development of injury risk. So this was a study where they looked at pitchers, trained them with different baseballs and did not use weighted baseballs. And they found that they did not have injuries during this, but they were able to increase fastball velocity in 15 weeks in 98% of pitchers. So there can be ways to train without the use of some of the injury creating devices like the weighted baseball. As mentioned, glenohumeral range of motion has been debated throughout the pitching literature over the years. And this is one of the main studies from Kevin Wilk, James Andrews, looking at different deficits in range of motion. And one of the key points was that pitchers with a deficit of over five degrees in total arc of motion had a 2.6 times greater risk of injury. And this was correlated with injury where the glenohumeral internal rotation specifically was not. So they may shift their rotation to a more external position, but try to maintain that arc of motion. Pitch count recommendations certainly are important. This is a study from some of the authors here where they looked at the risk of exceeding pitch count recommendations during Little League World Series, increasing the risk of Tommy John surgery in the future. And for patients who followed it, the risk of UCL reconstruction was low. For patients who exceeded these pitch counts, there was quite a high risk of UCL reconstruction in these athletes. Finally, pitching mechanics. This was mentioned briefly earlier. There are pitching mechanics that vary among pitchers, and there certainly is not one perfect set of mechanics, but there has been that emphasis on the lateral release position as a risk factor and more of an overhead release as a better position. We think that with early trunk rotation, this is a potential risk factor for increasing stress on the elbow. So where you lose the hip and shoulder separation. And finally, we know that pitching with fatigue increases the risk of injury. And so this was a simulated baseball game where they threw among pitchers who were age 13 to 16. They assessed range of motion, velocity, and other metrics. And as the patients went through simulating a baseball game, the pitchers became more fatigued. They started to develop some pain, sort of a normal amount of pain for pitching, and their velocity dropped by a few miles per hour. The patients had a change in some of the mechanics of their pitching mechanics. So notably their knee flexion angle increased and their hip to shoulder separation increased with the pitch number. And these are their ways of trying to maintain their velocity while fatiguing. And so this is important to help train and strengthen these athletes and to work on their mechanics so that they aren't at risk of injury. So this is the recent study on the lateral release position. So among the patients undergoing ulnar collateral ligament reconstruction, they had a 12.2 centimeter more lateral release. So that more lateral cluster of ball release positions compared to controls. In the timeframe, just before the patient underwent surgery compared to the same control patient two years prior, their release position actually moved. So this is something that with advanced metrics they could track and see, is that release position moving? And so with the same pitcher compared to when they were supposedly healthy a few years prior, compared to right before their surgery, their release position was moving. And this could be a marker of something going wrong with the elbow. If you have a release position 10 centimeters more lateral, there was a 5% higher odds of needing an ulnar collateral ligament reconstruction. Consensus statement from many providers published last year. What are the risk factors for ulnar collateral ligament tear? Well, many of the ones we talked about. So overuse, repetitive sports, early specialization, limited shoulder rotation, throwing velocity, mechanics and conditioning, core weakness, pitching style, and then prior injury. And this was a strong consensus. So prevention is certainly the best treatment for these injuries. We'll hear about other more surgical treatments next. And we wanna keep that shoulder strong. We wanna keep the shoulder mobile and keep the core and legs strong. Rest is important. Try to diversify the pitch repertoire and try to do other sports if you can with your younger athletes. Thank you very much. Thank you. Thanks Greg. I think you're right. I mean, obviously the goal is to prevent these injuries in these players. And so I think it's important, certainly in the office, I think you hit on all the high points. I usually will measure their total arc of motion real quick and then have them lay on their back and check their internal rotation on their landing leg to see if it kind of stinks. And I get a little bit worried about that from some of the studies that have been done by our Japanese colleagues. So let me just fast forward past this part here to get rid of this and get up to our repair talk now. So now that you heard about potential non-operative treatment we'll get into a little bit more operative treatment. And first we'll talk about repair in these patients. Who would benefit from repair? How do they return to sport? What are the outcomes? And Greg kind of went over this about why we should discuss this, right? It's a huge problem. UCL tears are one of the most common injuries that we see in professional baseball. And Greg showed you this of where, in our adolescence, this has become a real problem over the last 10 or 15 years. And so initially when we first started talking about UCL injuries and thinking about surgical options for this, you know, John Conway had a study that was out a while back and they included 70 patients who had a UCL reconstruction and UCL repair. This was back in 92. Had a pretty good follow-up of six years. And their repair basically involved a direct repair of the anterior bundle of the UCL. The reconstruction was the Jobe technique as we can see here. And we've kind of modified this over time a little bit. And if you take a look at some of their results, what they found was that only 50% of the patients in the UCL repair group got back to playing at their previous level. And almost, or sorry, 29% got back to playing at their previous level. And 75% of the reconstructions got back. So from a return to sport perspective, UCL repair didn't do very well in this study. And so it started to fall out of favor pretty quickly. I took this from one of Chris and Maude's studies. This was funny. This was on the symptoms. And they talk about needing, you know, Tommy John surgery because it's kind of permeated the media throughout. And then what we've seen over the last several years is that the number of reconstructions has dramatically increased. But the issue with UCL reconstruction is that it takes guys a long time to get back to play, right? The average return to play for somebody that had a UCL reconstruction is going back to playing Major League Baseball is somewhere around 15 to 17 months. We did a study a while back looking at how fast guys got back to their same level of play. And those that got back a little bit sooner, in case we were trying to rush them back for something, they had a little bit higher risk of needing a revision reconstruction than those that got back at a little bit longer time. So regardless, you're looking for 15 to 18 months to get these guys back. So that's a season and a half. And in a pro, maybe not as big of a deal because they're getting paid for that time off. But in a high school athlete, if you take 12 to 18 months away from them, that's really a big deal for them because they could potentially miss two seasons of what is a four season, you know, high school run. So then we had Dr. Savar kind of resurrect the UCL repair from the ashes and started to talk a little bit more about maybe this wasn't such a bad thing. Maybe we can tweak how we did this and people might do okay. So his study back in 2008 that we all like to cite, basically showing that in adolescents, so those with an average age of 17 that had a UCL tear that he basically primarily repaired, no suture augmentation in this, the majority of them, 93% had a really good outcome and 97% got back to sports at six months after their surgery, which is extremely important because we're talking about a 15 to 18 month timeframe for a reconstruction. They're talking about six months. So now you're shortening the time from people not missing two seasons to maybe missing one season or maybe not even a season at all. And so if you take a look at some of their scores here, they all did quite well. We tried to do a systematic review a few years back and there wasn't much data on repair at the time, but we started to see that the newer studies that were coming out with repair started to be promising. So then Jeff Douglas took this idea of UCL repair and then kind of buffed it up a little bit. So he added in a suture to kind of augment the repair with almost a backstop called, you know, he called it the internal brace augmentation. And so the hope was that, yes, you get the repair. So you get stability, but you also get a backstop behind this to protect your repair, to maybe start throwing a little bit faster. So you don't have to worry about your repair quite as much. And he tested this in the lab biomechanically. So he tested his UCL repair with the brace augmentation against just a modified job technique. And he basically saw that the repair replicates time zero failure strength of the reconstruction and actually is a little bit more resistant to gapping at the elbow, which is obviously what we want to decrease when these guys throw. We saw another biomechanical study that was done just a couple of years ago, looking at kind of torsional stiffness and gap formation, looking at UCL repair, UCL repair with an internal brace or UCL reconstruction. And basically what they found was that, that UCL repair with internal brace had basically higher torsional stiffness, higher residual torque. So basically a stiffer construct at the start. And so the thought was maybe, again, at the start, this is a pretty stiff contract that might afford our athletes a pretty good return to sport. So then Jeff published his initial results back in 2019 and 128 overhead athletes, and he had a minimum one-year follow-up. And it included, obviously, as you'd imagine, mostly baseball pitchers. As Greg told you, this is a baseball pitcher problem for the most part, although not exclusively. And the majority of his players were high school and college athletes, which is what most of us treat, right? Most of us are treating high school and college level athletes. And what he found was a 92% return to sport rate to the same or higher level of competition at just under seven months. So again, less than half the time of getting back from a reconstruction, really good K-jock scores. He had a couple of complications, mostly ulnar nerves that needed to be transposed afterwards and one person wound up torn their UCL a couple years after. But if you look at his data, pretty good based on the repair that he did. And so this trend has started to really take off. So now people are thinking, okay, maybe I should do more repairs and not so many reconstructions. And so if you look at some of the data that's coming out now about repairs, if you look at this Texas database that James Gregory did, what they found was that in 2010, repairs basically made up 23% of all UCL surgeries in Texas. By 2019, it was 40%. And it likely will still continue to rise over time because of how attractive the post-operative rehabilitation is and how fast people get back to sport is. We did the same, a similar study in New York, looking at kind of repair versus reconstruction in the New York database, and basically found that over time, the number of repairs were creeping up. So repairs kind of gaining on reconstruction, if you will. And we kind of divided things up into higher and lower volume centers. There were a couple of high volume centers in New York, a couple of lower volume centers. Wasn't really much difference in outcomes with this, with the exception of that actually Medicaid patients tended to do a little bit worse. That was the only factor that didn't do so well. So if we say we're gonna start doing more UCL repairs, we have to understand who the right patient for this is. Not everybody can have a UCL repair. It's really important to not just do a repair on everybody that comes into your office. And so the things that you have to remember when you're doing repair, at least for me personally, that I like to think about when I'm indicating somebody for a repair, are that you want it to really be a proximal or distal injury. Dugas is starting to think a little more about doing these in mid-substance tears, but we're not quite there yet as far as data is concerned. You want pretty good quality tissue. So in somebody who's 25, 28 years old who's beaten up their elbow for a long time, a lot of times that ligament gets pretty thin and they can be pretty tissue deficient. Just trying to repair that back down, you're basically just relying on that internal brace suture at that point to kind of give them stability to their elbow. That's not a great idea. And certainly younger athletes, and that kind of goes in kind of step with not having too much stress on the elbow or less mileage on the elbow over time. And to Greg's point about the consensus statement, this was kind of the indications from the group about reconstruction versus repair being basically tissue deficient. Obviously patients preferring this and then doing the repairs on patients that didn't have any other chronic ligament type changes. And what I mean by chronic ligament type changes, you know, we get elbow x-rays and everybody comes in. These are kind of a standard set of elbow x-rays. When somebody's had a chronic UCL tear over time, we can sometimes see the sublime tubal enthesivitis you see on the left, or we can start to see some ossicles that are formed within the ligament. The problem with somebody that has an ossicle like that is that the area where that ossicle is, that ligament is not healthy. They're gonna be tissue deficient there when you take that ossicle out. So you can't just go in and repair these most times because if you try to do that, you're gonna wind up having a little bit of a gap, okay? And so what we'd like to see on our MRIs of these players is something that looks like this. Guy that comes in, acute injury, proximal, complete emulsion off of his meat alpaconda, a lot of fluid around it, right? Pretty easy to see. And so this is the perfect patient for a UCL repair. So the question is, all right, so then how do you do a UCL repair? How do you do this successfully to get people back? So for me, I'm still a baby. I don't have them get a nerve block before surgery. I don't move the nerve. I do a flexor splitting approach. So I don't move the nerve. I like to make the move the nerve afterwards before I give them a nerve block. So this is done under general anesthesia for me. You expose the flexor pronator, you get the medial entebrachial continuous nerve out of the way. It's gonna be crossing distal in your incision. So it crosses from anterior to posterior distal aspect of your incision. So just make sure you're kind of paying attention. Usually I take a lap and I just spread all of that fat and soft tissue off of the flexor pronator mass. You can really mobilize that tissue quite well. And if you do that, then the nerve generally stays in that tissue. So you don't really have to worry about it very much. There's this really thick white raffia in the flexor pronator that if you split will take you right down to the ligament. And it's very distinctly different. You can see anteriorly there's striations, but where I have that knife, that's the raffia that you want to look for because that'll take you right down to the ligament. And then you bluntly spread. I usually use an elevator and a freer to just spread the flexor pronator, get down. So you can say I have a gelby up top holding the tissue away. And then I have a Wheatlander that's holding my flexor pronator spread apart as I'm getting down to the ligament. You can see the ligament pretty nicely there. And the thing is when you do this, you'll see the ligament looks pretty good. So you're looking at it, you say, this doesn't look like a bad ligament. Why are we here? Well, then you wind up splitting it and you see that there's some gapping on the inside of the elbow, which you shouldn't see by just making a longitudinal split in the ligament. And then you can start to, oh, this didn't play, but this is just showing you that if you pull the ligament around, you'll see that it's a little bit lax. And so what we do is we put our first anchor in and this person is not the patient that you saw on the MRI. This is a different person that had a distal tear. So the first anchor goes wherever the tear is. So this is a distal tear. The first ankle goes at the distal insertion point, just distal sublime tubercle. Make sure you're aiming your trajectory for this anchor a little bit distal, because you can kind of get fooled that some of that medial bone that comes up proximal and you don't want to put that anchor into the joint. So you put your first suture in that has a high tensile suture in the suture tape. You pass your suture through the ligament that you're gonna repair back down. You can see this is what it looks like before we do our repair. And then I also put a bunch of fiber wire stitches in the ligament to sew it up side to side and almost imbricated a little bit. And so we tie a couple of these and then we don't tie the most proximal ones so that we can see where we're going for our proximal anchor. We put our proximal anchor in place. And by the way, when you tie that distal suture, there's not great consensus on where to put the elbow as far as position. Usually between 30 and 60 degrees of flexion is about right. Mine, I put it about 45 and then a varus stress place in the elbow. So just a couple of towels under the hand when you're tying that down to avoid any valgus stress when you tie that. And then we put the proximal anchor in and this you can't see the ligament as well cause I've incorporated with a couple of suture tapes, but the internal braces in there. And then we check range of motion, which unfortunately, to your point, Dr. Romeo, these videos aren't working out here. But we check range of motion to make sure you don't capture the elbow and to make sure that the brace needs to loosen a little bit. It does. You've already checked your isometric point before you put that second anchor in. So usually it stays pretty isometric. Sometimes it'll loosen just a touch. And that may be because you may have put it in a little bit too tight, which there's a question about how tight you can put that in. If we move the nerve, obviously you just transpose this anteriorly in a subcutaneous manner. And I use that fat to kind of hold this anterior. To the point of overtightening this, when Jeff initially described this, he talked about putting a freer under the tape when you put the second anchor in to avoid over constraining the elbow. And then there are some, George Pauletta mainly, that started to say you can't really overtighten these. Just put it in as tight as you can and it'll stretch out over time. So I think Jeff has moved on to that as well. I've started to adopt that as well and just basically put these in where it wants to sit and put them in pretty tight and then arrange the elbow to make sure that you don't capture the elbow at all. And I haven't had any issues with these guys getting tight. But this is a biomechanical study that was done this year looking at whether or not you can overtighten the UCO when you do a UCO repair. They didn't really come to a great conclusion on the study. They saw some different contact pressures between the maximal tension group and what's called the non-maximal tension group, where if you look at Jeff's initial way to put this in, you go about four or five millimeters down, you line the suture tape up with the hole for the anchor, and then you put the anchor about four or five millimeters down, and then you put the anchor in so you don't tension it all the way. But it's hard to know how clinically relevant some of these findings are. So we'll see this going forward. I won't belabor the point of rehab because Peter's going to talk to you about this a little bit later, just knowing that from a repair versus a reconstruction perspective, you're going to start throwing sooner. You're going to start throwing at three months instead of four and a half months. You're going to get back to return to sport usually around seven months instead of 18 months. And again, this is just to think about, you know, patience when you're checking them post-op. You really want to see people get their full range of motion back by about six weeks after repair to make sure that elbow isn't getting too tight. And then the throwing progression, like we talked about, usually around three months after this is what the consensus group said. And there's no minimum amount of time to let guys go back based on our consensus statements. Probably around six to seven months is about average. If there's no time constraint, don't rush them back. There's no reason to. But if you have to get them back for their season, I think six to seven months is a pretty reasonable time to get this back. So obviously we know UCL injuries are pretty common. Repair, I think, is a really viable option. We just have to make sure that we're not swinging the pendulum too much to just doing repairs on everybody. Because if we start doing that, we will start to see some failures down the road. And we know that revising a reconstruction to another reconstruction doesn't give us great results. We don't have great results on revising a repair to a reconstruction. I've only had to revise one repair that was done by somebody who does these a lot to a reconstruction many years out from it. And he's done well from it. But I don't know if we start to do these too frequently in people that needed a reconstruction if we wind up hosing them down the road. So maybe there's another technique, maybe a hybrid technique, that we can hear about in a little bit that may help this a little bit more. So thank you very much. All right. So next we'll have Eric come talk to us about UCL reconstruction, kind of the stuff that I was trying to phase out with the repair. All right. Good morning, everyone. Thanks, Brandon, for putting this together. Great faculty. I'm honored to work with these guys. But yeah, I think Brandon's right. We're sort of edging out just the standard UCL reconstruction. We'll sort of explain a little bit. I think you're going to see a lot more repairs, especially as kids getting these ages are dropping and getting younger. You're also going to see more sort of these more advanced reconstruction techniques, hybrid, augmented reconstruction. And so you're really going to see sort of this kind of narrowing in with what we would consider the standard UCL reconstruction. Now, if you don't realize it, you're here helping celebrate 50 years of the UCL reconstruction. So the first one, of course, done on Tommy John 20 or series in 1974. So, you know, of all the surgeries we perform in orthopedics, to have a 90% success rate is pretty awesome. So one of the true career and life changing procedures that we can do in orthopedics. So today we'll be talking about UCL reconstruction. All right. So you got this player, 31-year-old left-handed starting pitcher. And he's basically been pitching about 175 per year, innings per year, which is pretty average. He's 154 innings into this year. And he has a really good record. He all of a sudden feels a pop. And he says it's the strangest sensation I've ever known. The body moving forward, but left my arm in right field. He complains of pain on the owner's, excuse me, on the owner's side of the elbow. And basically he's tossing the ball up into the net. He has no control, loss of velocity. He's had previous arm and shoulder injuries. Actually, when he was 13, he had his first elbow injury. And when you examine him, he does have laxity on that elbow. So he's initially diagnosed with overuse syndrome. He went through a course of conservative treatment. And so you recognize that he has UCL deficiency. So what starts going through your mind? Treatment-wise, he's failed conservative treatment. Is this a repair candidate? He's had elbow injuries in the past. He's a major league pitcher. Is repair a possible option? What about reconstruction? What are you going to use for graft? Is this going to be a durable procedure? And then what are you going to do with the ulnar nerve? These are all things that we're thinking. So if you haven't figured it out, this was Tommy John. His procedure was performed on September 25, 1974. And Frank Jobe basically said, hey, there's this thing that we've been doing for kids with certain diseases, polio, we can transfer this ligament, this pulmaris, and turn it into your UCL. You have about a 1 in 100 chance of making it back. And Frank Jobe was famous for saying, you didn't see many major league pitchers with scars on their arms. Well, given the 1 in 100 chance, Tommy John said, go for it. And so therefore, we came out with this new procedure. Now, it wasn't a straightforward recovery for him. He actually did have a complete ulnar nerve injury, had the Pope sign afterwards, ended up going back for ulnar nerve transposition. Missed the 75 season, came back in 76. Since then, he had 14 more seasons. He had 2,500 more innings, 164 games, and three World Series appearances. When he was 42, he was asked, you know, how many more years are you going to keep pitching? And he said, well, my arm's only 11 years old. So you can just sort of see the evolution of this, how Sandy Koufax, just a decade or two before, you know, they didn't have this option. And so really, you know, as far as procedures, pretty impactful one. So the incidence of UCL reconstruction, obviously, has gone up. You've heard that from a couple of the speakers today. Actually, as of, I think, as presented earlier at this meeting, I don't know if it's actually in the publication yet, but today, about 34% of MLB pitchers have undergone UCL reconstruction. At least 15% of minor league pitchers have had the surgery. More UCL reconstructions were done last year than the entire 1990s. So you can see that these are dramatically increasing in an epidemic, certainly among our youth overhead athletes. So let's design the perfect UCL reconstruction. Well, you want, with the intact ligament being the gold standard, you want the stiffest construct. You want to maintain range of motion. You want to have the best and quickest rehab that you can. You want very high return to sport, durability, meaning low retear rate. You want to spare the bone and limit soft tissue disruption, and of course, keep the nerve happy. Now, back when Tommy John had this done, the average velocity was about 88 miles per hour. Today, it's about 95. So you fix these players, and they're going to go back to basically trying to destroy it from day one. And what you're seeing is that our techniques are going to need to adapt to that. So to kind of understand where we're going, I think it's important to understand some of the constructs that are out there and where we've evolved over time. So kind of breaking this down a little bit, starting with the figure eight techniques. The Jobe technique, first described in 1986, what he did was actually detached the flexor pronator and had a V-shaped tunnel on the ulnar side and a Y-shaped tunnel on the humeral side. And did a submuscular ulnar nerve transposition. Now, you can see the return to sport was modest and a high preponderance of ulnar nerve neuritis, neuropathy. Then you have the ASMI technique come along. And what they did is they started to split the FCU, and then they did a subcutaneous ulnar nerve transposition. Now, this had excellent outcomes, still some ulnar neuropathy. And then the modified Jobe, basically, instead of detaching, they then started splitting the flexor pronator mass. And that's where you really see the outcomes between ASMI and modified Jobe equilibrate, essentially. So here's just a couple examples of the early Jobe, modified Jobe, and then what they call kind of the docking plus. So moving on to the docking techniques, which were described about 20 years ago. Basically, they decreased bone removal from the humerus. So you're making a socket instead of two separate tunnels. Very high return to sport, low ulnar neuropathy. And there's three-stranded, four-stranded modifications. And then some hybrid techniques as well, where they use suture anchors instead of tunnels. Then you move on to sort of these triangular constructs. And then finally, the linear constructs, where you can use interference screws, you can use endo buttons. There are a variety of ways to do this. And in some of them, it's helpful to know if you get in a situation where you have to get creative, a revision, or if you do have some of your tunnel break out or widen, it's good to know a couple of these different options so that you can bail yourself out. And then Dr. Camp has been discussing the anatomic technique that he uses, where he uses suture anchors to really reconstruct that centimeter plus one to two centimeters, actually, of the sublime tubercle attachment there. So which one do you use? Well, as far as modified job versus docking technique, really no clinical difference between the two once you control for the pronator mass detachment early on. Really no difference in complications, depending on which technique you'd like to use. What about the ulnar nerve? Well, again, it really doesn't matter as far as if you, in clinical outcomes or return to sport. There was a study that Brandon and his group did a few years ago that basically showed that if they had ulnar nerve symptoms present beforehand, there's about a 13% chance that those would persist. But if they didn't have ulnar nerve symptoms, none of those patients ended up having persistent ulnar nerve problems. So if they have symptoms beforehand, move it. If not, probably leave it alone, unless you feel strongly or your technique forces you to do one or the other. What about allograft? So there's certainly some techniques that have come out recently. And I would say there's only a small amount of data. But in this one study here, this systematic review, allograft failure was slightly higher than autograft, so 2.6% versus 1.8%. Is that statistically relevant? Is it clinically relevant? We're not sure. But allograft is potentially becoming a little bit more common based on a couple of these studies. So what about outcomes? Overall, return to play at any level, about 80 to 95%. However, when we start digging into it a little bit closer, return to same level of play, 70 to 90%. And we know that the return to play times about 12 to 16 months. Non-pitchers have a little bit lower rates, actually, than you might be surprised, with catchers being probably the most impacted, about 59%. Infielder and outfielder, kind of around that 80 to 90%. And then time to return, probably a little bit quicker for an infielder than for an outfielder or catcher as well. So where are we in 2024? Well, I won't spoil Dr. Romeo's talk. But basically, as we move towards more substantial constructs, just putting tissue in there to replace that tissue may not be enough. We may need to augment it. So for the athletes, that basically a young athlete with good tissue, you're going to be tending more towards repair. And honestly, most of my reconstructions going forward are going to be some version of probably an augmented reconstruction. And if the tissue is good tissue, you probably do some type of baseball stitch and you bring those sutures up into the tunnel along with your graft and tie them over your bone bridge. If you're tissue deficient, then what you can do is you can basically do your internal brace type setup along with your tunnels and your graft. So we'll look forward to hearing what Dr. Romeo has to say about that. But at least the biomechanical studies have been looking pretty good so far. Also, in 2024, what we're looking at is how we can get these athletes back quicker. So there's high variability in post-op rehab. We know that there's poor quality and consistency of publicly available ones. This is the ones that your kids are going to go and say, hey, I found this online. It's getting me back to pitching in seven months. I'm going to do this one. Basically, we need better agreement among surgeons and we need high-level data to help guide this. And really, it's about educating the patient, the parent, the trainer, the therapist, getting everybody on board on the same plan. So looking forward to the discussion coming up. Okay, great. Good setup from everyone, especially since the title is where do we stand in 2024. And I'm going to speak to you about ulnar collateral ligament repair and reconstruction. Is that a good idea or is it kind of crazy? And we've had a lot of experience with UCL reconstructions for a variety of different athletes, the young athletes all the way to the professional athletes. My disclosures are updated regularly. Why are we having a whole ICL on the UCL for baseball players? Because when this happens and that ligament is torn, it's a very expensive injury. Baseball is going to spend about $5 billion this year on payroll and more than 20% will be on players that can't play. If we could figure out a way to eliminate this problem, if we could figure out a way to repair it so they always come back, or we can shorten the recovery time, there's a lot of money involved. So we're highly motivated. Why then is there so much variability among surgeons? It's because we're still looking for the best answer to try to figure this out. I think we're getting close. We know that the ulnar tunnel is the preferred technique of the vast majority of surgeons who do this procedure on a regular time. We also know that most of them, like the humeral docking technique. We know from Mike Ciccotti that it probably doesn't matter if you do the job with a tunnel on the humeral side or not, but most of us find the docking technique easier and more reliable in our hands. When you ask experts in shoulder and elbow, you find out that very few of them do a lot of UCLs. So they're just reporting the literature to you. What are the differences in return whether we use a different graft? There really is no evidence that one is better than the other. Some places say we use gracilis all the time, some say palmaris unless it's not there. The reality is that the technique used by those individuals will overcome whatever graft they have. We do believe that autograft is better than allograft. And you've already heard And you've already heard about the return to sport rate, which is good, could be improved. And the question is, what about return back to the same level of participation? It takes a long time to recover from a reconstruction. These grafts take a while and the bone that's around it takes a while to really adjust. And when you really look at this even in more recent studies, it's a long time for the young athletes. And they oftentimes will lose a full season and may be part of a second season. And for most young athletes, two seasons, you're done. You're going to go into a different sport. So this idea of doing a repair and accelerating the recovery is a great idea. And really, Jeff Dugas deserves a lot of credit going back to Buddy Savoie's work and saying that maybe we can figure out a better way to do this with our current implants and devices that we have. And we know from some of the work that's being done that at least biomechanically at time zero, when you put this tape in there, you equal the biomechanics of the normal UCL. You don't do that when you just put a soft tissue graft. But Mike Ciccotti has shown when you follow up the reconstructions over time that they do match the normal UCL within about one millimeter of laxity. So at first, it's very hard to make it that tight. But with this internal brace, we're able to do that very effectively biomechanically. This was just talked about this week at the Herodicus Society. And really, it's Dugas versus Cain. Jeff took this effort to do the repairs. And Lyle waited to see how it was going to do. And the results were overall spectacular, no matter what technique they used. But 80% of the time, Jeff did the internal brace. 80% of the time, Lyle did the reconstruction, gracilis graft, tunnels on the ulna, docking on the humerus. And the only major difference was the time to return to play. And it was initially thought it was only seven months. But when they looked at the mean of over 200 patients in each of these groups, it's about nine months. So we get them back to throwing very good. And they start to become competitive around six or seven months. But it's about nine months. And then if you do a full reconstruction, it's about 13 months. And I think this paper will be published probably by the early part of next year. The repair has been a really nice addition. Very few complications have been reported. We don't over tighten this. We don't put anything underneath the tape. We just put it down. It slides within the tape anchor interface. And it will find the right position. So if you can move the elbow at the time of surgery, you don't have to worry that you've over tightened this. And so it becomes very reliable in many surgeons' hands. This is a technique that's very reproducible even if you don't do a lot of these. And we've seen tremendous increase in our younger athletes in college and high school. And Brandon presented this paper. It sort of looks like a heat map of the upper east side of Manhattan basically. But what it shows is that certainly this is being embraced. But does it work for everybody? What if you have a mid-substance tear? What if you pull it off the ulnar side and it's tissue deficient? What if you have an obstacle? Maybe it won't work as Brandon said. So maybe we need to add a graft. But why throw away the internal brace if it's working so well? You have to make sure if you're going to incorporate this concept, you really understand the anatomy. And two of the people that really published nicely on this is Dr. Shikinance and Dr. Erickson to really point out what we need to know about making this correct and in the right position so we make it as isometric as possible. And really there's been a number of reports, and I won't go through all of them, but adding this extra synthetic material makes a big difference in how strong that is. And we actually came up with the idea of adding this with a single point of fixation on the ulnar side so you can actually drill a hole, put in a suture that's got a loop in it, and pull in your graft, and then fix it with the interference screw. And the interference screw has both the repair suture and the tape. So now you've got them all three in one spot on the ulnar side, and now you've got to fix it on the humeral side. And our initial thought is to do somewhat of a docking technique and use a suture anchor on that side. And what we showed in our biomechanical studies is this is a very, very strong repair, very reliable, and reproduces the normal anatomy of the UCL in terms of the biomechanics. You have to have special equipment to do these kind of things, but this is a really nice way to use the technique of the internal brace with repair and our known successful reconstruction. The only difference is instead of a tunnel on the ulnar side, you use a single point of fixation. And this is really rock solid when we do this. And then once you've got all of that on the ulnar side, you can do repair of your ligament. You can then do your reconstruction and then put your internal brace over the top and fix that on the humeral side. And we've described that, and this is available for publication. So when it's all done, this is what it looks like. And you move this through here, and you feel really comfortable that you've got a super strong reconstruction. And in our first small group of patients, we did see an improvement and a return back to sport faster than the 13 months. It was about 11 months, so right in between the two, which makes some sense. Now, when you look at the Major League Baseball team physicians, probably Keith Meister from the Texas Rangers is doing the most UCLs right now. He does over 200 a year. This year, maybe 250, and a lot of them are professional. And so I ask him, what are you doing? He goes, I'm doing hybrids on all of them. And I said, why? And he says, why not? And his technique is that he uses a palmaris. Unless it's not available, then he uses a gracilis. He likes to use the ulnar tunnel, just like the standard technique that's been showed. And then he puts that a little distally, and then he fixes the internal brace, just the way you're doing an internal brace without a reconstruction on the ulnar side. On the humeral side, no interference group. He just docks everything, docks the graft, drops the tape, and ties it over the medial condyle. And the results have been really remarkable. And even when you look at Lyle Kane and Jeff Dugas, when you take out the athletes who just decide not to go back, not necessarily because their elbow's bothering them, and you look at all the reasons, they're getting more than 95% of their athletes back to pitching at the same level or better in their most recent series. And this is what it looks like when it's done. And Keith takes excellent pictures because he's an amazing underwater photographer. These are his pictures, too. So in 2024, I kind of think we're getting to the point where you do, if there's good tissue there, it just happened to pop off the ulnar side or the humeral side, you do a repair with the internal brace. And if you're going to do a reconstruction, then do both. You get the benefits of both of them, and the complication rate seems low, and I think we're more reliable on our return back to sport. Thank you very much. Thank you. I think Peter's up next, right, Peter? Okay, well, Lewis, we've had great talks already this morning. I'm super honored to be part of this ICL. The idea here is that you've heard three different ways to do the surgery. You've heard about who gets these tears to begin with. No matter what surgery you do, you're going to then end up with a player that you need to get back to play. And a lot of the art is trying to figure out, once you have that player, how do I actually get them back onto the mound? So I have disclosures. None of them are particularly relevant to this talk. So the beginning of the rehab program is like any other surgery you've ever done. You know, get your range of motion, get your strength, make sure that you have good strength in your core and in your shoulder. But then the critical decision is, when are you ready to return to throwing? And I think this is always a difficult decision. I think it makes a lot of sense to evaluate your players before you return them to play. These are usually the criteria that I'm using to make that decision. I want that player to have no pain. So I want at baseline, no pain. And I want them to have a full shoulder rotational motion arc and abduction, no rotational strength deficits, no dyskinesis. So you've got to actually have the player take their shirt off, look at their scapula, look at it through repeated flexion and declination motion to make sure there's really no abnormal motion within that scapula. I usually like to evaluate hip and core strength with a negative cross-toe touch. So you have them stand on their right leg and touch their right big toe with their left index finger, and then vice versa. And then for me, the players have to complete plan metrics. And that means you take a baseball and you throw it into a trampoline that's angled, and you catch it and have you bring it back. You can also do that with the player laying down, have them throw a ball in the air and then catch it and bring it back, or throw a ball into the wall and then catch it and have it bring you back. They have to do that with no pain before they can throw. And then I give them a throwing program and I give them these instructions, which is to say, you don't want to do this with your team. This is not competitive. And then the program is a speed limit, which is to say you can go no faster than the program. You cannot skip steps. I usually tell them to throw with a parent or a friend or a therapist, not with their team during practice. And you need a field with distance marked. Alternate deals of hitting and throwing. And it's a distance-based program, so this is really critical. You tell the players, you don't try and throw the ball as hard as you can 45 feet. You throw the ball on an arc with enough force just to reach 45 feet. Again, the program is a speed limit. And it's okay to have some discomfort. This is from a paper we did with Brandon when I was a resident where we looked at just how much pain and fatigue players report during a normal simulated game. And you can see that as you get to 90 pitches, it's pretty normal for players to have 1, 2, 3 out of 10 kind of pain. So I tell them that's okay, but beyond that is not. This is the program that I'm usually using. I'll note that we're in the process of modifying it. This is a slight modification of ASMI's program. And again, as you'll see, it's distance-based, so 45 feet and 60 feet. And it tells you the number of throws. This takes about 11 weeks to get back to play. And you can see that on the back end, it involves a little more rest. And you get towards batting practice, a simulated game, and live batting. The colors are this. So red is no play. Yellow is you can return to the field. Green is you could return to even the outfield. And then again for pitchers, red is no play. Yellow means that if that pitcher also plays in the field, they could return to that position. I have a modification that's an accelerated program. So this is in the middle of the season, minor injury, already in shape, brief amount of time off. There's a two-week program to get that player back to play. This is extremely useful if you're in the middle of the season. So that program, as you see, takes 12 weeks. How long does this actually take after surgery is much longer. So this is data from a paper that Chris Camp wrote where it takes you about four and a half months to get back to the mound, seven months to get back to live batting, and a live game takes 10 months. And this is kind of a survival curve for how long it took for players to get back to their first throw after UCL reconstruction. And you can see that there's a lot of players where it takes close to nine months to get back to the first throw, even though the fastest you can go is four months, which is really when players start. And there's still a substantial number of players that are returning even beyond 12 months to their first throw. So this is, I think, a real critical thing to know, is that it can take a long time after the first throw to really get back to play. So for that reason, I also have an extended program. And this is, I think, also useful if you have a pitcher, a high-level guy, throws with a lot of force, you want to give them a really long runway instead of a short runway. Okay, so here are some things that are useful for the player that's inside of their throwing program, I think, useful tidbits. Number one is that long force is as much as pitching. So if you have a player and they're throwing 120 feet, it's very useful to tell that player, this is about as much force as you're going to put through your elbow when you get back onto the mound. If you can make it to 120 feet, it's kind of all fine-tuning from there. And there's a lot of data to support that statement. There's this paper, which Gunn-Fleisig published a long time ago. There's also more recent data from Eric Mockney showing that you can see here, when you look at ball velocity, once you get to 120 feet, it's pretty similar to where it is once you get to the end of the program. The same is true for arm speed. And the same is true for elbow-valgus torque. So again, 120 feet, to me, is really a useful landmark. If you can throw 120 feet, we're going to be okay. And from there, it's just a little bit of fine-tuning and figuring out where that player is as they get back to kind of the mental effort of throwing from the mound and then throwing facing a live batter. Okay, some other tidbits around here is some of this program uses reduced-effort throws. And generally, our players are very bad at that. So if you tell someone to throw with 50%, no one actually throws with 50%. So you can see subjected-effort pitchers. When you tell someone to throw 50%, they actually throw 80%. So I think it's useful to have a radar gun if you really want someone to actually throw 50%. What I usually do is I think you just need to keep this in mind, that if they're throwing 50%, what they say is 50%, that's not actually what's happening. Okay, so that's the return to play. I want to talk a little bit about outcomes and success because I think it can be difficult to define success. Obviously, this is a matter of your expectations as to what you think is or is not successful. And this is a good example. So we heard about this a little bit earlier from Tony Romeo, that traditionally we've defined return to play as greater than zero pitches in greater than zero games. And if you define success that way, the success rates are quite high. But if you try and say at the same or at a higher level, because really that's how the player would like to find success, the rates of retained player are much lower in those same studies. And this is data from a study we did using LLB data of return to play after shoulder surgery, where you can say, okay, if you count as any return success, 63%, which is not great, but it's greater than 50%. But if you start to dig deeper and say at at least the prior level, that rate goes down. The challenge with this is if you ask most of the players that are at the single A or the double A level what their goal is, their goal is to get back not to that level, but they all want to play in the show. They all want to play at the major league level. And if you define success as return to a higher level or if they start at the MLB level returning to that level, all of a sudden the success rates really dive down and it's only 40% that are successful. So this is, I think, really critical to understand about the player's psychology. When they talk about what their goal is, their goal is not just return to play. And the challenge is for how long? Nobody pitches professionally forever. Currently the oldest pitchers you can see here are, you know, 38 to 41. So our traditional orthopedic outcomes of, you know, what is return to play at 2 years, 5 years, 10 years, these are probably meaningless when it comes to pitching because 10 years, no one's pitching anymore. And we have that same data from this study from the MLB, where if you look at 5 years later, how many players are still actually even in professional baseball? By 5 years, most of them are no longer playing professional baseball. So, again, the longer term you look, the worse things look. It gets even more complicated because a lot of those players retire for reasons that have nothing to do with their injury, and instead they retire because of performance attrition. So really when we get beyond return to play, we have to talk about performance, which is that among those returned after, and this is again MLB data. If we look at rotator cuff surgery, among those who returned, they had significantly fewer wins per year, games per year, innings per year, significantly lower warp. And that's probably the number that's the most important. So can we really, even if we say these players return to play, can we really consider them successes? That gets challenging also because performance degrades with age. So I personally think that moving forward, if we really wanted to find success, we have to use age-matched controls and match them by draft year to understand where are those players that we operate on, not relative to where they were before surgery, but relative to controls that would have been progressing at that same level with regards to win-loss percentage, then WIP, FIP, and then warp I think really being our most useful statistic in that regard. Thank you. Okay. Good morning, everybody. Thanks for all the great talks, guys. Great lead into this. What I'd like to do is present a few cases, and obviously our panels could be involved, but I want everybody in the room to think about this and participate, if at all possible. So don't be shy. If I call on you, this is all about you guys, not about us. So just take a little pulse here. How many of you take care of baseball players on a regular basis? How many of you do ulnar collateral ligament reconstructions or repairs? How many of you do more than 20 in a year? One. Okay. Chris does a few more. I see him back there hiding in the back. Yeah, I mean, it's not really – it's kind of an esoteric thing, but it's important, and obviously we love it. So let's get right into it here. All right. This is a 32-year-old right-hand dominant Major League Baseball starting pitcher, someone I saw about six weeks ago, about seven weeks ago. When he came to see me, he'd had about seven days of medial-sided elbow pain that was gradual in onset. It was localized to the medial epicondyle. I'm talking to him a little bit more detailed. It was his slider that was really bothering him more than anything else. He was able to throw his fastball pretty effectively. He hadn't had any drop in his velo. He was just feeling a lot of pain when he's trying to throw his slider. No other symptoms at all with regards to his elbow or shoulder. Pertinent past history is that he missed 75 days back in 2022 with a documented flexor pronator strain. He was with another organization at that time. It states that this isn't that bad at this time. We started him on some anti-inflammatories just before he came to see me. He'd been getting treatment and the training with our guys and feeling better. Of note, he's still pitching. He's modified kind of how he pitches a little bit. Still pitching. He's throwing more fastballs and fewer sliders, but he is able to pitch. On exam, big man, major league player, 6'4", 230, hips and shoulder within normal limits for a throwing athlete. Right elbow is good motion. He's tender directly over the medial epicondyle. He's not tender at the sublime tubercle. His pain is reproduced with testing of his flexor pronator group. His nerve is stable with negative TNLs. He has no posterior findings, and he has negative dynamic and static UCL testing. These are his images here. Let me see if I can get this to play. Oh, come on, play. So standard coronal MRI. What do we see in there? Anybody? Any thoughts about that? Chris, what do we see? Anybody? Tony? So standard coronal MRI. As you follow it through, you can see he's got a partial thickness tear of his ulnar collateral ligament. It would have been nice to have an x-ray at a time because it looks like there may be some bone in there in this one position. And then he definitely has an injury to his flexor pronator attachment also. And what's remarkable is that some pitchers can be completely asymptomatic with exactly this MRI. And that's great in terms of them being able to participate, but it's ominous in terms of their risk of the injury progressing. So we didn't talk about this during any of the presentations, but this is his fever view MRI of that same elbow. How many in the audience are familiar with this? So this is an on-plane image that's loaded. It's a static load that opens with the valgus stress on the medial side of the elbow. There's not a lot known about it clinically. There's only one good published paper that talks about the fever view. My esteemed colleagues up here, any of you using this on a regular basis? And how do you use this information, or is it useful at all? So at Vanderbilt, we're not typically getting these, although with the Brewers players, they're now getting pre-season fever views that we can compare. And so if there's a substantial difference between a subsequent MRI and this, then we can make that determination. They're also getting the contralateral side to see, although you're right, there's not much normative data on this. We know that pitchers are going to have a widened area on the medial side there anyway, so it's more of a comparative thing for us rather than an absolute. Although you can certainly look at some of these and say, wow, that looks very expanded in that area. So we're still defining that. So Pam Lund, who is a radiologist who does a lot of work for Major League Baseball, including reviewing the Brewers MRIs, really their group has espoused this as being very helpful in determining some characteristics of the UCL almost in a dynamic way. Really, the best way probably would be with ultrasounds, both ultrasound before injury and then ultrasound after injury, and seeing the difference, like Mike Ciccotti and their group has done for the Phillies, but most people don't do that. And so I think that we have more to learn about how predictive this view is, but more and more teams are using this as an evaluation, particularly when it's not a complete tear, it's a partial tear, and they're symptomatic. You get more information that would point you in the direction that it's not worthwhile to continue with conservative management, you may need to proceed with surgery. I think the time point that you talk about is important, though, because generally in the players that come to see us, we don't have pre-injury data. With the Phillies, obviously we do, because we get stress ultrasounds on all the guys before the season, so we can compare something later. And if you have that, it's great, because then you can see, okay, are they gapping a little bit more than they were before when you used the TLS machine? Have any of the guys complained about having it loaded when they do that? It is uncomfortable. It is uncomfortable, and that is a problem. So does this help us make decisions? I think that it's like we're getting it not infrequently now, and the challenge I have is you look at that, and it looks bad. Like every single fever view I've gotten, there's gapping. So if you're going to get this view, just so everyone knows in the audience, it's always gapped. You're not going to see it where the stress and non-stress views look the same. So what I usually do is I'll get the view, and then I make multiple measurements on it, and I compare them to Pamela Lund's paper, because in her paper, there's dramatic gapping in normal players. So I think that's the most critical thing to know about this is that you should not look at that and think, because it's gapped, the UCL is torn. You have to compare it to the normative data, and I think the best comparison is what you mentioned already, which is the comparison for that specific player. I do think it's a beautiful view of the ligament, though. It is a great view of the ligament. Does it make you think anything different about that ligament, Tony? I think it looks better. Same. Yeah, I think the ligament quality looks better, but there's definitely gapping there, and having some sort of normalized data to that player would be helpful. Yeah, but to Brandon's point, we just don't have it. We have more of the ultrasounds than the fever. Yeah, we do as well. I think, Mark, at this point, you know, we're not radiologists. We're orthopedic surgeons, and so our clinical examination and the patient's progress with and without treatment is what really guides us. This just gives us some more information. If he was symptomatic with your valgus testing of the elbow and you had what appeared to be additional length on your ligament on this test, then that would, again, guide you that my exam is probably accurate. It's probably the UCL along with the flexor pronator mass causing some discomfort, and therefore we have to proceed with appropriate treatment. I agree completely. So what are we going to do with this guy? Any thoughts? He's still pitching. He just can't throw his slider as effectively as he wants to. It's always funny when you ask the pitchers after the game, they say, is your elbow hurting? And they will say, you mean like it always does after every game, or is it hurting differently than it usually does? So you have to be specific on the way you ask them. That's true. You have to ask about their normal soreness. Especially if they throw a lot of sliders. They're always sore in their forearm. Yeah. Anybody in the audience have any thoughts about this? Anybody want to chime in? Chris, do you want to comment at all? Yeah, so thank you, Chris. So I obviously encourage everybody to look into this a little bit and kind of draw your own conclusions. We find it somewhat useful. We do a lot of dynamic ultrasound as well. I know everybody doesn't have that kind of access, but we count on the ultrasound quite a bit. So would anybody – what are we going to do with this guy? Are we going to operate on this? Are we going to give him an injection? Are we going to do a PRP shot? I mean, what are we going to do? There's not much on his physical exam other than he's got tenderness over his medial epicondyle, and he has pain when he throws his slider. He's still pitching at the major league level. How bad is his edema now on that flexor part compared to two years ago when he missed time? That's a great question, and I don't know. I didn't look. So I would say if he thinks he's – I mean, if he's throwing effectively and his velocity hasn't dropped and his location's okay and he's managing with this, you can consider maybe trying to shut him down for a week or two to see if you can get rid of some of that edema from his flexor pronator. But we just did a study looking at edema in a flexor pronator after he's thrown. So I don't know how long after he finished pitching that MRI was, but there is some residual – That was the next day. So there is some residual edema that happens in the flexor pronator mass in guys who throw. We did in our minor league guys down in Clearwater. And so I wouldn't jump to anything on this guy. I mean, if he's throwing effectively, I don't even know that I would necessarily shut him down if he feels like the training room's getting him back effectively and everything else is normal. So I would probably let it be. Can I give one caveat? I totally agree with that, and that's obviously what you did. But I do cite Chris Amad's data to these players to tell them that this can be a harbinger of ligament problems in the future. Sure. If your flexor pronator is not functioning properly, you're not protecting your ligament, and then the ligament can tear. So to that point, do we do anything here? Off-season, 32-year-old veteran guy with that elbow? What do we do? The challenge we have, obviously, with someone who's that long of a vet, is he has an off-season routine that you're probably not going to want to disrupt. So I think the first thing I would do is move away from the elbow. And I would really examine his shoulder. I would evaluate whether he's lost some of his external rotation, and he has some rotation in his total glenohumeral range of motion. I'd make sure that all of his mechanics are in place, because you would like to get the elbow to feel sort of the normal forces and not continuing to go down the potential pathway that this may lead to. So I would take a step back and really evaluate the athlete, make sure he's in great shape from his entire kinetic chain, really evaluate that shoulder, make sure he's got all of that in place, and then go to the elbow. And I would work on his muscular strengthening of the flexor pronator group. And, you know, these guys need to take some time off in the off-season, and that will also help him out in terms of his overall recovery. Very good. One thing I might add, we've been using biofeedback in this kind of 3D-printed scimitar-like device that gets you more leverage on the flexor pronator that I probably would add for this player. Not now, in the off-season. Is there any change in his, you know, his mechanic or the way he's throwing his slider that may have impacted this? No, not that we're aware of. I mean, I echo. I mean, I guess the consideration is do you do a PRP injection in the off-season, right, for this guy? And I think I'd probably give him a couple of weeks to quiet down. If the season's over, maybe you can get him to re-MRI the elbow and see if he still has any edema in there. If he does, maybe consider a PRP shot. But I wouldn't mess with somebody who's been in the league for that long too much. Yeah, so I think everybody would agree this guy does not need an operation, probably in November. Okay. Very good. Any thoughts or questions from the audience? Anybody? Comments? Okay. All right, this is – whose case is this? Is this yours, Eric? You want to take us through it? Sure. 25-year-old left-handed pitcher. He presented with acute medial elbow pain, was removed from the game, no one or nerve symptoms, no significant elbow history previously. When we examined him, he was tender over the sublime tubercle and flexor pronator. He had pain with resisted wrist flexion, temple pressure testing, did have a positive milking maneuver and dynamic valgus stress test for pain and otherwise normal neurovascular exam. So this is his coronal MRI. Is there a reason why we don't get x-rays on these patients? Because I'm just wondering if I waste the time now? Because that always really helps me. That's a great point, Tony. Okay. Who's asking? Sorry, Eric. No, that's a great question. He was in Milwaukee when he had this done. I would have gotten that. Sorry. So those previous MRI that you just saw were from March. Those were his preseason MRIs. This is his post-injury MRI. And right there on kind of the posterior aspect of the humorous hair, you can start to see that edema, and that's also into the flexor pronator as well. And so, as I mentioned, we've been getting these preseason and then post-injury fever views. And you can see a pretty substantial difference. I sort of questioned whether that initial fever view, whether it was done well or if it was resisting because it barely opened, but then there was substantial widening on his fever view subsequently. So, you know, considering he's got a flexor pronator injury, the UCL, he's got a high-grade partial probably posterior band of the anterior UCL, sort of this is a high-level guy. What would be our next steps of treatment? He had some periligaments, edema, on his pre-injury MRI. Definitely worse on the post, but he did have some edema. Yeah, if you go back, Mark, yeah. If you roll that coronal, and this is something that Chris and I talked about, and just showing that there may be a little something going. You see a little bit of swelling that's just outside of the ligament on that previous one that he had. Obviously worse on the post-injury. You know, again, to your fever view, I don't know clinically what to make of the fever view gapping and stuff. Certainly there's been some injury to his UCL. I would not rush to anything aggressive in him. I would probably shut him down for... My usual treatment is I shut them down until they're not symptomatic to valgus stress testing. So I think if they have pain when you do a moving valgus stress test or a milking maneuver, and we can run through any of these tests with anybody here afterwards if you want to see how we do them. But if they have pain with that, I think they're definitely going to have pain when they throw. So I try to shut them down for long enough, whether that's three weeks, four weeks, five weeks, six weeks, until they don't have pain with that. And when they don't have pain with that, I start them with a return to throwing program. And to Peter's accelerated return to throwing program, I usually, my rule of thumb is your throwing progression is roughly the same amount of time as you were shut down for. So if you shut down for a week or two, usually a week or two. If you shut down for three or four weeks, then you get into a longer throwing progression. So that's what I would do. One word of caution about interpreting preseason and during season stress images the same. In the prospective study, we did dynamic ultrasounds on all the angels, pitchers. And we looked at before the season, during spring training, and then we looked at the end of the season. And normal pitchers with no injury definitely have more laxative and ligament at the end of the season. So I think these numbers are beyond that. But if it was like 1.2 and then 1.8, I might say that's pretty normal. Any other thoughts or comments? Anybody in the audience have any thoughts, comments about this? Anybody feeling the urge to operate on this kid's elbow? Not at this point, right? Okay. Peter, I think this is your case. You want to take us through this? Yeah. So this kid's a little bit younger than the prior two. He's a collegiate pitcher. And he has the classic story. He was pitching and he felt a pop, and since then he can't throw. But he also has numbness and tingling, ringing small fingers. He's tried rest. He was given a dose back by an outside doc. He was even given a cortisone injection, diclofenac cream. He's been, as you can see, maximally anti-inflammatory. And he has full range of motion but is stable to MVST, and he had ulnar nerve inability. There you go, Tony. I got an X-ray because Tony Roman taught me that you need an X-ray. I learned that in residency, and I haven't forgotten it. Thank you. So what does everyone think? How old is he again? 20. 20, yeah. That's a fair amount of... You've got a bunch of bone back there, Tony. What do you make of that? Do you think you look at that and you think it's chronic? How do you know? Well, I mean, looking at these X-rays, I think it's chronic, but there may be a possibility you may have cracked one of those osteophytes. But your examination didn't suggest that. Is that correct? You didn't have posterior elbow pain per se. It was mostly on the medial side. He's got posterior elbow pain, and he's got something Chris Amad told me. He will not allow me to bounce him. I go to bounce him, and he's like, no, no, you're not going to bounce me. I know what happens when you do this. So, I mean, I think we'll know from the MRI whether it's acute or chronic. There certainly has been. This didn't just happen overnight. And then the question is, did he crack one of those osteophytes, which can become very painful. They can feel a pop. They can't throw anymore. They can't extend their elbow out all the way. And clearly he has ulnar symptoms based on your clinical exam. What do you guys make of his ligament? I didn't think it looked that bad on first pass. A little thin distal, but it doesn't look torn. Yeah, it looks good. But he did have some, if you catch that coronal slice correctly, this is what Hollis Potter likes to do, you can see that osteophyte through. Right there. Yeah. And then you can see that little bit of edema surrounding it. You miss it if you go further back. It's just as you get past the olecranon file, so you can see it on the coronal slices. I don't have a fever for him. And, I mean, you know, that posterior medial osteophyte has probably been protective of his UCL. And, you know, so I don't think his UCL is a problem here. He's got ulnar symptoms and he's got a problem in the back of his elbow. I can't remember. Can you go to the next slide? Next slide is going to give it away. Tommy, you said it would be protective of his UCL, right? So if he broke that off and you go in and scope his elbow and you clean it up and, say, Peter takes care of the nerve, are you worried then down the road that he's going to pop his ligament? Yeah, we're always worried about that. And so that's why we've learned from Chris and others that if you do go in and you remove that bone, you should be very accurate to remove the bone just back to the patient's native olecranon at the very most. So I like whenever I'm removing bone from the elbow, I always get CT scans and 3D reconstructions, to actually measure the amount of bone I need to remove because once you're in there, sometimes it's hard to tell whether it's 3 millimeters or 4 millimeters or 5, and it doesn't always have that clean interface between what's a normal olecranon, and I really want to determine that ahead of time. So the most important thing is just to get it back to the normal olecranon. Don't try to over-resect that area. So with the nerve, because his nerve six weeks later was still really irritated, I wanted to move his nerve, and then we found this incidentally. He's got this epitrochlaris. So I think that his nerve is just pinched between anconeus epitrochlaris and broken osteophyte, and that's one of the reasons why even six weeks later I said, look, I think we should probably just proceed. Question for you guys. If you know you're going to move the nerve, would you do the back of the elbow arthroscopically, just do it open? What are everyone's thoughts? My personal preference is to scope the elbow. I do all of that arthroscopically. You could easily do this through an open. You could extend this posteriorly in terms of your soft tissue plane to get back there, but I really want to make sure I see the whole thing very well from both medial to lateral and, again, reshape that olecranon tip so it's back to its normal level. And so I prefer to do that arthroscopically, and then I would proceed with the open procedure. So your order of events then would be do the scope first, then do the nerve? Yes. I routinely go for my elbow releases from the medial side, so I always move the nerve to get to the back of the elbow. I think sometimes to see appropriately, I mean, in an elbow release, it doesn't matter if you get into part of the U-cell because you want to get motion, but to really see the olecranon sometimes, there is some part of that posterior bundle that can obscure your view occasionally, at least my hand's going open. So I would also do it arthroscopically. I probably would move the nerve first and then do it arthroscopically so I could feel a little more comfortable just making sure that as I go medial, like obviously you've scoped a lot more elbows than I have, so I would just move the nerve first and it's out of my way, and then I know where it is and then scope it after. So you'd move the nerve first just for visualization of the nerve so that when you're making your anterior portals, posterior portals, where are you? Because you know how sometimes you have to go pretty posterior medial if the osteophyte extends there a little bit? So I get a little nervous using the shaver over there sometimes. I know the nerve's close by. If you have it dissected out, you don't even have to move it permanently. If you have it dissected out, it doesn't matter. You know it's not there anymore, so you don't have to worry about anything in the back of the elbow. That's just me. What are your thoughts, Greg? I've never tried moving it first. I would do what Tony said, which is scope like normal, unless it was previously transposed and you needed to dissect it out open first. That would be the exception. But if it was in the groove or minimal subluxation, I could safely scope him. I would do that as normal because that's how I would typically treat that pathology if there was no nerve involvement, and then open and move the nerve after. Do we have to move this nerve with the presence of the ankines, the epitrochlearis, is removal of that enough? I don't know. What do you guys think? I personally felt with the osteophyte it made sense to move the nerve. That epitrochlearis has been there since birth. He's never had ulnar nerve symptoms until six weeks ago. I guess if you didn't dissect, because it looks like you got to the muscle a little bit after you'd already kind of freed it up approximately. So I think by that point you've kind of destabilized it. I don't know that leaving it alone after you've dissected it out, I think they'll wind up having some subluxation issues and snapping down the road. So I usually err on the side of, for me, any baseball player, I actually don't anybody just do an in situ decompression. I just move everybody's nerve. I've been pretty happy with it, so I move it. Peter, take us through what you're doing here. Yeah, so I had a lot of internal debate with this case, whether to do this open or arthroscopic, and I thought it was broken. And I was really worried about exactly what you said, Tony, which is if I remove too much bone, then he'll be unstable. So what I thought is I'm going to do this open and just take out the broken part, because I know that's the part that's offending his elbow. So the benefit of doing this open for me is that I already have that exposure. You know, we come to the back. It's a muscle splitting approach. We just elevate the triceps. We do a little bit of a posterior capsulotomy. And I think removing a little bit of posterior capsule is okay as long as you get them moving quickly to make sure they got all their flexion back. And then the benefit here is that as soon as we did that, the piece is like immediately in our face, and then we just remove it. So it's a little bit quicker to do this open. The disadvantage, of course, is when you do an arthroscopy, you get much better visualization of the rest of the joint. So like going to the front and seeing if there's anything in the front that's also problematic, I don't have the opportunity to do that here. If you do an elbow scope, you have that. But you have the disadvantage that you've violated the front of the elbow, and he has no real clear issue with that. So again, that was my thought process. I don't know if it's wrong, but that was what I was thinking. So there's the piece. You can see it's kind of mobile. And just with a freer, we were able to kind of just, there's the piece, pop it off. So I don't know, what do you guys think? Should I have taken more than just the piece? No. It's a big piece. I thought that was gonna be harder to see, honestly. Again, I think it's hard to know. I mean, I think you solved his current problem by taking off that piece. But that's why I like to get the 3D CT scans ahead of time, which really just helps me be a little bit more accurate with exactly how much bone, and it may have been just that piece that all needs to be done, just smoothed off the interface. That's the piece. It's a pretty big piece. So then for rehab for this kid, you know, we do the transposition. Because of the size of the dissection for a transposition for me, I usually splint them for two weeks because I really want all that soft tissue to go on together. And then from there, he goes as quick as he can. So he's back to throwing six weeks later. The splint, I move them immediately. Why do you splint them for two weeks? For me, it's mostly about, you know, hematoma prevention, getting the soft tissues to heal in that area. It's probably overcautious, but it's just my preference. I don't know that it matters in the long run. How do you like to hold the nerve in place? I do subcutaneous transposition. That's what I've been doing. You know, I don't think it works for everyone. I've had two players, one where I did it for a kid and then his dad died and he lost 60 pounds. The kid only weighed like 190 pounds to begin with because he like stopped eating and then he had no fat and no fat to hold the nerve and he started transposing again. And then another kid who gained like 60 pounds of muscle and then the muscle was so much that he pushed his nerve to become unstable. So subcutaneous transposition, not perfect. I think if you would use a fascial sling, that makes some sense, but I'd prefer to not violate the fascial flexor peroneator if I can. Very good. Any thoughts from the audience? Any questions? Brandon, we're coming up on to 8.30. Keep going. Yeah, we have like four minutes left. More questions? You can go through them more if any. I mean, certainly questions anybody has or, you know. So this is a case of mine. This is a 15-year-old left-handed thrower. Had a history of a pop in his elbow five years prior to seeing another provider and then five years before he saw me as well. But he had a new injury with a throw from the outfield. Tender over the medial side of the elbow and moving velocity. Stress test was painful with instability. Presented to another provider with the X-ray that you see there. He saw another provider who obtained these X-rays. What do you guys think about what we're seeing there? Anybody want to comment on that? It looks like possibly a chronic avulsion of the medial epicondyle to me. Old X-rays would be helpful. MRI could give you some guidance there. Yeah, those are the old ones, actually. Yeah, and I think the other thing, if you're worried, I'm not on this one, but if you're worried that's more of a, you know, bone within the ligament, you just get an X-ray of the opposite elbow and you'll be able to see the contour of the medial epicondyle. And I'm sure this looks like this is the tip of the medial epicondyle that was avulsed five years ago. So the ligaments can be attached to that piece of bone. It's just gonna be fibrous tissue above it. So the other provider that saw him prior to me did this. Any thoughts on that? That wasn't what I was thinking for treatment. Yeah, me neither. Try to get the screw, is that his guide? Why are these using the hole that's in that other hole that's up there and that didn't work so well? There's no way you're gonna get it back to where it's supposed to go at this point. Yeah, these are, even when these are relatively acute, they're hard to get back exactly in the right spot. In fact, I know some people talk about doing these percutaneously, but I actually prefer to make a small incision because there's a three-dimensional deformity. It pulls down and rotates, and you really get it into the correct position. You wanna be able to see that. You wanna see that whole cortical edge and then put a screw in there. And it can be kind of challenging, but years later, that would not be the recommendation. Yeah, so these x-rays are three months post-op, and then he comes to see me at six months post-op. Ooh. That's the x-ray that I get. Oh. Now what are we gonna do? Well, that's fine. It's gonna come out anyway. I mean, he should get the surgery that he needed from the jump, which is he needs some kind of tissue-adding UCL surgery, in my opinion. So he's not a kid to the point where he can't be a kid to UCL repair. I mean, we can get an MRI and see, but to Dr. Ramos' point, there's gonna be no ligament tissue there. So for me, this is a hybrid technique. That piece of bone, that screw that's in the humerus, that's gonna stay there for the rest of his life, because I don't think that's gonna impede your ability to get your tongue in the right spot. The screw head and the washer and the rest of it come out, and this is a hybrid technique for me. And I definitely, as you put down there, move the ulnar nerve. When you have a flexion contracture at 90 degrees, even if they don't have ulnar nerve symptoms, when they try to go past that point, they'll be inhibited, or they won't feel right, and if they really push themselves, then their nerve symptoms will come out, and now it's too late, now you gotta do a second surgery. So with this kind of contracture, I would definitely move the ulnar nerve at the time of the surgery, too. So any thoughts about bone loss on the medial epicondyle? You see how big that fragment is? I've got that Coker on it, after we've got the screw out of it. Do we concern ourselves? Are we gonna be able to dock this thing? Are we gonna have to use an anchor? You're gonna have to modify your technique a little bit, I think, but Mark, you've done so many of these, I'm sure you've figured out a way around this, but I wouldn't add bone to this. I would figure out what bone I have, and try to get my reconstruction as close to possible. I mean, people used to do medial epicondylectomies for symptoms of just tendonitis and stuff, so I think you can get by with it functionally. You just gotta get that ligament as close to a normal position as possible. Yeah, so this is a case from a few years back. This predates even the internal brace, so the thought of a hybrid wouldn't even cross my mind at that time. Today certainly would, with all this tissue deficiency that he has. He has no capsule and no ligament, basically, at all, right? So he's counting on what we've done. This is one where I wouldn't try to use his palmaris as a hamstring reconstruction. Yeah, yeah, and we were fortunate enough to be able to have just enough bone to do a docking technique. This was post-op x-rays. You can kind of see kind of where our tunnel is there on the epicondyle. He was fortunate and had a nice return to play. These are at four months post-op with full motion. Has returned to play without any restrictions at all. Yeah, I think being prepared, sort of like a revision reconstruction there for the bone loss and backup options if the docking looks like there's not room for the tunnels, having anchors or buttons or different plans for ways to get fixation. And I agree with getting a hamstring for this because he's got no tissue there, so you don't even have part of a native ligament to reinforce. You said, Jake, it's a couple years back, so obviously you weren't doing the hybrids. You know, it's interesting because you don't have any capsule to protect anything there, so sometimes you worry if you put that brace or put a high tensile suture over an area of exposed bone and cartilage like that, I mean, it could wear, so that, it may have not, I don't know, like thinking about it, like how big your exposure was. I haven't, usually when I've done them, I mean, we have some capsule and ligament there, and I usually sew that together before I lay everything over the top. That, you don't have that, so I don't know, maybe be the one you'd be a little cautious in. That's a great point. All right, one more, just because it's fun. This is a 24-year-old female crossfitter. I think some of you guys have seen this before. Attempting a personal best overhead press. 250 pounds. Can we get audio on this? This is so much more fun when it's got the audio. Yeah, we got it. Always gotta put it on Instagram. Gotta make sure you video it. Ouch. Ouch. So she comes to see me, you know, obviously pretty sore elbow. Positive static and moving vagus stress test. Regular x-rays here. You can see a little something going on there. Here's her MRI scan. Thoughts about this, guys? Yeah, you taught us that this one doesn't heal well at all, so I would fix this one. Wouldn't even hesitate. Right, anybody non-op this? She's not a thrower. No, I think she's got a pretty unstable elbow. It's a pretty high-grade injury. This is what she looks like at the time of surgery. A little deficiency there, and we popped this little, this little guy kind of popped out at us. Spoiler alert, we went ahead and did a repair on this, and actually came together pretty nice. She's actually returned to play, returned to participate in her lifting as of about four months post-op. I haven't seen her back, so she either hates me or she's doing well, so. Audience, any thoughts, comments? What haven't we gone over today that you need to hear about? Anybody? Serge. Anybody using any orthobiologics to augment our repairs or reconstructions? Tony. No, unless the athlete asks for it, and some of them do. So there's no evidence that that makes a difference. I think the use of orthobiologics at the time of surgery is kind of a waste in many of these, because you already have a lot of orthobiologics going on. If you were gonna do something to try to augment the healing process, you probably should come back in seven to 10 days and give them another injection at that point, and that would be a better way to stimulate the healing process just the way it goes. But at the time of surgery, you have all that in place, so I'm not convinced that we'll ever be able to show it makes a difference doing it at the time of surgery. Is there any downside to it, other than the cost? No, other than the cost, there's no downside to it. Yes, sir. It was a great session, thanks again. Question about the rehab or repairs, or with the timelines, are you using an accelerated program for that as well? Are you giving the same program you started earlier? Is that how they're getting back earlier, or are you modifying that at all? I'm usually using the same throwing program, but I think the players progress through it more quickly and have fewer delays. It's, for me, the main advantage is that you just have them start throwing earlier, and I think that's really where we get the, do you guys agree with that? Yeah, you know, I'm not sure that even that's a big advantage, if we, you know, we initially thought we'd heard reports, you know, they're back by six months, they're doing great. So then, if you start at four months, that's too late. You gotta start at three months, really. But if the average time to get back is somewhere between seven and nine months, or closer to nine months, then I start them at the same time. I try to take from month three to four to really work on, you know, their non-pitching, strengthening, range of motion, core, all of that, so getting ready to pitch again, and then go at four months, and like Peter said, then they progress rapidly, versus someone who has no collagen surgery in there. And the ones that we have, the internal brace with collagen, also progress, but not quite as fast. And if we're just doing a reconstruction, they take a little bit more time, and may have, you know, a couple of obstacles with the slow down a little bit, take a little bit more time off to get back to their level. That's what I've done in practice as well, is I've used some strange screens that aren't validated, and then I look at the repairs, and a lot of them aren't quite ready, based off of what I've been using for my reconstruction of the throat. So, as far as, you know, that needs some validation too as well, but that's my question, is if everybody's really ready to start throwing this program through the tunnel. Yeah, I mean, if you look at the Major League Baseball teams, there's between six and eight of the teams don't start their players back to throwing until about six months. They really, if you're doing a reconstruction, like why, if it's gonna take a year, why do you have to get them started at four, four and a half months? Why not just really push them through everything else, and then when they're, everything else is rock solid, shoulder looks great, then we'll go ahead and start throwing. And, you know, I think there's some reasonable consideration of that too. One of the things I've learned from the people on this panel is that, tell them that it's not necessarily gonna be a straight line. So, as far as improvement, they're gonna have steps back, that's normal. That's, you know, taking a step back when it's hurting is the right thing to do, and giving them a little bit longer timeframe, say, yeah, some people get back at six months, but usually we're kind of shooting seven, eight, nine months. Just give yourself some leeway there, and really setting up the patient expectations, I think, that make the biggest difference. And one of the things I would also mention, Brandon looked up, and that is, you know, when can they go back to hitting? So, all these young kids, you know, they're just chomping at the bit to get back to baseball, and what we found is, after reconstruction, there's sort of a basement effect. Nobody really starts before three months, but if you start at three months, there doesn't seem to be increased risk of UCL tear. So, at that point, when they wanna go back to throwing, say, listen, we're gonna get you back into batting, and I know some of the pitchers, as they get older, they don't do any batting at all, but certainly for our high school kids, and some of the collegiate kids, if you just get them back into batting, just get them back into baseball, you can put them off for another month, month and a half, give them that time, and then go through the pitching program. Speaking of that, we don't know the stress on the medial elbow when you hit, right? I mean, most guys that come with UCL tear say it doesn't hurt to hit, it just hurts to throw. Obviously, the older guys don't hit anyway, but the younger guys, to Dr. Romero's point. So, that's just based on data that we know. I couldn't tell you there's this amount of newton-meter force on the medial elbow when they hit, but yeah, we let them go back three months or so. Yeah, and programs like Driveliner, converted from weighted balls now weighted bats, as part of the, you can increase your bat speed, and they have some good evidence to show you'll hit better with all that, so we just have to be careful about that. But just letting them go back to batting and fielding, and not back to a throwing program, will kind of get them so they get off the ledge, and then keep working out, and then maybe when you look good in another four to six weeks, we'll let you go ahead. And again, I think the main thing is that, depending on the procedure you do, you have less and less of these little stops and starts kind of things, and that's very clear with the repair, and the right patient that does pretty smoothly go through it, and then we think with most of the augmentation repairs, it's also pretty smooth, it just takes a little bit longer, and then you just have to be patient with the full-time reconstruction. What do you think, Mark, is that fair? I think it's a great discussion, I know you guys have nailed it. One more question. So the range of motion, what do you do when the patient's leaving the ambulatory surgery center, what do you write for the next four weeks for their range of motion program? So for me, I used to splint them for two weeks outdoors, actually now I just find it easier to get in the hinge double brace ahead of time, put it on them and lock it. I usually lock it about 70 degrees. I see them back about 10 days, and then I start the range of motion. Ideally, like Shaq said, you want their range of motion back by somewhere between four and six weeks. I don't differ that based on a repair versus a reconstruction, I don't know if you guys do, but the elbows tend to get stiff if you just leave them bent for a while, so you wanna get their motion back, you don't wanna go crazy, but you wanna get their motion back by four to six weeks. Yeah, what you've got at six weeks is what they're gonna have in six weeks is a magic number for sure. When you see them back at that one to two week mark, do you, if they're in a hinged elbow brace, do you block them at 20 until four weeks or you just let them go? I let them go. Okay, great. All right, well thanks everybody.

Ulnar Collateral Ligament

UCL injuries

baseball players

diagnosis

imaging

non-surgical treatment

surgical treatment

PRP injections

UCL repair

UCL reconstruction

rehabilitation

return to play

post-surgery monitoring