All right, well, it's a real honor to be here and talk about return to throwing. So once you've done your repair, your reconstruction, the purpose of this talk is to talk about how do you get that player from the time of surgery back onto the field, and then how likely is it to work? And we've heard some of those outcomes already, so I'm not going to belabor those. I do have some disclosures. None of them are really relevant to this, none of them are rehab programs. So the first question is, when are you ready to throw? This is always a challenge in clinics. You see that player, the player says, I'm itching to put the ball in my hand, am I ready? And these are the criteria I've been using. I think you need to be pain-free. You need to have an elbow that doesn't hurt anymore. You want to have no motion deficits. So the way I test this is with the arm and abduction, does the patient have an equivalent external rotation, internal rotation arc to the contralateral side? Doesn't have to be exactly the same external, internal, but it has to be the same total arc. You want to have no rotational strength deficits with the arm and abduction, again, inter-rotation, external rotation. You want to have no scapular dyskinesis. You want to have a negative cross-toe touch. And the way that works is you stand on the right foot, you touch the right big toe with the left index finger, and vice versa. That's a test of core and hip strength to make sure that the patient's really got sufficient support in the middle. And then you want to have completed plyometrics, and this one's particularly critical. So I think that you also want to give the player an overview. So usually before I hand the player an interval progression program, I give them this speech. I say, this is not a competition. You can't skip steps. You want to throw with a friend, a therapist, a parent, not with your team, because the team is going to bring up those competitive juices for you. You need to field with some marked distances. You want to alternate days between throwing and hitting, and your throws are distance-based. So it's not like you're going to throw 45 feet as hard as you can. You're going to throw the ball hard enough on an arc to get to 45 feet. While you're doing this, it's acceptable to have mild pain or fatigue. You heard earlier about the study we did on fatigue, and one of the things that I think was the most remarkable is we asked players for pain scores as they did a simulated game, and we found that players get up to 1 to 3 out of 10 pain normally. That's a normal thing during play. So I tell players routinely, if you're doing your program and you get to 1 to 2 or 3 out of 10 kind of pain, that's okay. If you're getting to moderate or severe pain for an above, that's too much. And I think it's also important to recognize that many players will take a step back. So if you get to 90 feet, you feel sore, I usually tell players that's okay, that's expected. Take an additional day off, take a step back, maybe go back one step on the program, take two extra days on that day, on that step. That's not abnormal. It doesn't mean you failed. So this is the program, and this is modified from ASMI's program, and the basic way that it works is fielders have a shorter distance than pitchers. For fielders, you start, again, with 45 feet, and you work up from there. The red means you can't play at all. The yellow means you can play in the infield, and the green means that you could play in the outfield. For pitchers, you notice that BP comes back around week eight. That's the time at which you start seeing live batting. So for pitchers, red means you're not seeing any live batting. Yellow means you see some live batting, and then obviously green is return to play. Okay, so you may look at this and say, God, 11 weeks, that looks like it's going to work just great. This works great for a repair. You have them start throwing it three months. By six months, you're back out to play. I will say that I have modifications to the program. These are not necessarily relevant to UCL reconstruction, but it's useful to have a modification if you have an in-season athlete. So for instance, all the time in our players, I'll see someone, it's July, they have a minor tweak of something. We're looking to get them back by August. You take a brief period of time off. The player is still in shape. You go through this accelerated two-week program, you get them back. Let's talk about what we're really here to talk about, though. With only collateral reconstruction, how long does this actually take? So I showed you that three-month program. The truth of the matter is that it usually takes much longer. So if you look at the average time to return to play, and this is a study that Chris Camp did, it's actually more like 10 months to get all the way back. And this is the percent of players returning. So if you start throwing at four months, this shows you how long is it until you get all the way back to return to play. And you can see that surely there are these outliers. There's this 10% of players that gets back at six months. But if you want to talk about the average player, it's this timeline you just heard from Dr. Romeo, that the 50% mark is somewhere around nine to 12 months. So I do have an extended protocol. And this is the one that I'll definitely use most often for you're recovering from an only collateral ligament. We're going to do this formally. It's going to take you eight months from the time. When you start throwing at four months, we have another eight months until you get back to play. So this is when another extended protocol can be helpful to make sure we're taking the length of time that it's actually going to take that player. Okay, some other things, some caveats, things to recognize as you're doing this. Thing number one is this. We talk in this protocol as though we're slowly improving the amount of force you put through your elbow and it's this graduated return. But the truth of the matter is that long tosses as much force as pitching. In particular, once you get to 120 feet, the ball velocity, the arm speed, and the elbow vagus torque are basically the same as what they are when you're throwing from the mound. So I usually tell players, if we can get you to 120 feet, you're going to be fine. If we get to 120 feet and you can throw, everything from there is fine tuning and icing on the cake. Because that's basically what the biomechanics suggest. The second thing is, you'll notice that when we get to the mound part of the program, we have these reduced effort throws. And pitchers are generally very bad at that. If you tell a player to throw 50%, this study shows that they're going to throw 80%. So this is a place where a radar gun can be helpful to show that player, your throw that you think is 50% is not 50% to really make sure that we're modulating the effort correctly. Okay, so we're going to talk a little bit about outcomes here. And when we talk about return to play, things get complicated. And the reason why is because that's not really a stable concept. So if by return to play, you mean that player threw more than one pitch in more than one game, then you can get very high rates of return to play. If you want to talk about a player returning at the same level, so this is a triple A player, you did surgery on them and they get back to double A, I promise you that player counts out as a failure, even if they return to play. So if you want to talk about getting back to at least the same level or a higher level, all of a sudden the rates go down. And you'll notice these are the same papers where if you take the same players and define return to play differently, you get different numbers. But I think the literature basically suggests this. So these are the three largest papers that have been performed on ulnar collateral ligament reconstruction, excuse me. And you'll notice that the return to play rates are somewhere between 80 and 90%. And this is, again, in three different players with over, if you include them all, 1,700 players included. So I think that's a stable number that you can tell players. If we do an ulnar collateral ligament reconstruction, the return to play rate is somewhere between 80 and 90%. All right, thank you.

returning to throwing

reconstruction surgery

readiness criteria

interval progression program

ulnar collateral ligament reconstruction