So, thanks, everybody, for coming. So I'm going to talk a little bit about the Ulnar Collateral Ligament today and where we're at in kind of 2021 now. These are my disclosures, not relevant to this talk, and the other faculties will show theirs in there in the AOSSM meeting brochure. So what we're going to talk about is, first, I'll talk a little bit about UCL epidemiology, some risk factors. Then Jeff Dugas is going to come up and talk a little bit about UCL repair. Mark Shikindan is going to talk a little bit about UCL reconstructions. And then virtually, as you saw, Chris Amat is going to talk to us about other things outside of the UCL that causes elbow pain and throwers. And then we'll have some case presentations to talk about. So just to show our faculty a little bit, so as many of you know, Jeff Dugas is kind of the UCL repair king, so just a little about him. So he went to undergrad at NC State, went to Duke for med school, and then came up to the Northeast to join us at HSS, and then did his fellowship back down south, and has stayed down south since. And he's obviously the team physician for many teams, including the Troy Trojans. You can see him here taking care of some of his WWE athletes. And of course, Mark Shikindan, so he was at Montana State University, then went to St. Louis University for med school, did his Cleveland Clinic residency, Stedman Hawkins Fellowship, and then went back to Cleveland Clinic doing the return to where you're from. And you can see, almost getting to a World Series here. This was the World Series here? World Series champs here? Yeah. Very nice. So he's going to talk about UCL reconstruction. He obviously takes care of the Cleveland Indians. And then Chris Amat, who couldn't be here today, had a family issue, did his undergrad at Columbia, then was in med school at NYU, and it was not free to go there. Did his residency at Columbia, and then was a follow-out at KJOC, and then came back, and now works at Columbia, and of course, takes care of the New York Yankees and other teams as well. And I'm Brandon, I was at Notre Dame for undergrad, it's the only real undergrad school of all of our faculty today. And I went to Tufts and Rush and HSS, and so I've been doing a lot of research, and I just had a four-month-old baby at home now, so my poor wife is taking care of her while I'm here talking to you guys. So the real question is, you know, why do we talk about this? Why has the UCL issue become such a big thing in the last five or ten years? And if you look at some of the data that's out there, there's plenty of studies that basically show the number of UCL reconstructions are going up dramatically in our Major League Baseball pitchers. And if you look at this study by Chris Kemp, you can see that UCL injuries are basically the sixth most common injury that we see in our professional baseball players. So a very common issue that we're dealing with. And if you take a look here, when they break it down a little further, you can see the number of UCL injuries has really stayed stagnant over the last five or six years or so, kind of around 200-ish injuries per year. And if you look at the number of days missed, there's over 26,000 days missed in the last couple of years because of UCL issues, and the median number of days missed per injury is actually 56, which is less than you'd probably think. And if you go down here and you look at, obviously, who gets affected, we see pitchers get affected about 80% of the time. And that surgery actually is only required about 46% of the time in these Major League Baseball pitchers that have a UCL injury. So we always talk about surgery, and we're going to talk about surgery a lot today. But I'm also going to bring up to the panel a couple of questions on non-operative management here because the majority of what, at least I do for this, is non-operative management of these injuries in high school and college baseball pitchers, so it's something we should probably talk about. And the reason that it's become a bigger issue in the last couple of years is because it's not just happening in our Major League Baseball pitchers, it's happening in our adolescent and in our college pitchers as well. And you can see here, the incidence is going up at about 10% per year in these players, and it really spikes in that 15- to 19-year-old age group is where we're seeing a lot of these injuries. So just a little bit about risk factors for UCL tears. There's been a lot of work on this, and a lot of it's come out of what Dr. Dugas and his team down in Alabama have done, Glenn Fleissig, and if you take a look here, this is kind of what started it back in 2010, which was a long 10-year prospective study looking at different issues including workload and pitch counts and pitching on multiple teams and pitching a certain number of innings per year and kind of starting the conversation of maybe throwing a lot is not the best thing for the elbow because maybe the elbow starts to get fatigued over the course of a game or over the course of a season, and this can lead to issues with the ligament going forward. And we've looked at studies with fatigue where we tried to have a bunch of pitchers throw a simulated game and basically fatigue them and see if some of their biomechanical measurements, kind of their kinematic measurements changed throughout the course of a simulated game to see if we could determine when somebody actually got fatigued so that we could pull them out of the game and potentially prevent an injury. And when we did this, we found that we actually could fatigue these players. They got fatigued and their velocity went down throughout the course of our study, but we didn't find any real reliable measures of kinematic changes, elbow flexion angle, ball release, et cetera, that we could kind of put our money on and say, okay, your elbow flexion angle has gotten a lot lower throughout the course of this game. We should pull you out before you get hurt. The only thing we did find was that hip to shoulder separation really changed a lot during the course of the study. So in slide A, that's at front foot contact as is slide B. Slide A is in the first inning, slide B is in the sixth inning, and you can see where their hips and shoulders are when their front foot hits the ground, where their hips are always pointing towards home plate. But their shoulders in slide A are pointing towards third base, but in slide B it's more towards the third baseline. So you can see that now they have to rotate more, not only through their trunk, but through their shoulder and elbow in slide B as they're getting fatigued and increasing the stress on their shoulder and elbow. So you can see here as fatigue and pain go up, the hip to shoulder separation starts to go down. And if you look at some other risk factors, we thought maybe geography might be a risk factor for UCL Terps because, you know, before we had year-round pitching up in the Northeast, down in the South, players could play all year. And so if we kind of drew a line of where, you know, the warm states versus the cold states were, and then we looked at what happened to these guys when they got into the majors, you can see that there was a higher percentage of players who had a UCL reconstruction from the warm weather states than the cold weather states. And not only were there more guys from those warm weather states having UCL surgery, but they were having them at an earlier age. So they were having them about a year to a year and a half earlier than guys who grew up in a cold weather state, and they pitched a lot fewer years in Major League Baseball before they started to have these surgeries. So this workload talk that we're talking about, this volume of pitches, is really coming to fruition. And then there's been some good studies looking at range of motion. A lot of this, again, has been done by Kevin Wilk, who did a couple of excellent studies looking at range of motion exams on 300 pitchers over the course of a few years, and basically found that a decrease in total arc of motion, so if you take the internal-external rotation with the arm at 90 degrees and then laying supine, if you had a decrease of it more than five degrees between your throwing and your non-throwing shoulder, you were at a 2.6 times increased risk of getting a shoulder or elbow injury during the course of the season. And if you had a decrease in flexion compared to your contralateral non-throwing side, you had a higher risk for injury as well. And interestingly, in this study, internal rotation deficit was not correlated with injury. And so this gets to the point of maybe the lack of internal rotation is not coming from posterior capsular tightness, but maybe it's coming from cubital retroversion because guys started throwing earlier. Some recent studies that some people in this audience have put out have basically showed that if you start throwing a little sooner, your humerus becomes a little more retroverted, so your internal rotation goes down, your external rotation goes up. And that may be what we're seeing in the decrease of internal rotation instead of just posterior capsular tightness like we used to think. And then hip range of motions, the other thing that's come up recently, and there's been some good studies by our Japanese colleagues looking at this, and basically seeing that over the course of the season, the players that wound up having elbow or shoulder pain when their hip range of motion measurements were taken were noted to have significantly less internal rotation on their stride leg, so their front leg, their landing leg. So as you put your leg down and you go to rotate over, you don't have as much motion through your hips. So as you start to rotate through your trunk and your shoulder and elbow, it increases the stress on your shoulder and elbow, increases the risk of shoulder and elbow pain throughout the course of this study. It's something we probably need to look at a little bit more as we start to better understand the kinetic chain. Now, of course, the biggest risk factor, at least in my opinion, is velocity for these guys. So the faster somebody throws, the more likely they are to get injured. Pete Chalmers did a study a couple of years ago looking at velocity and as it relates to UCL, the number of UCL reconstructions, and there's basically a linear relationship that shows as you start to throw harder, there's a much higher chance that you're going to have a UCL reconstruction, and that's for both peak pitch velocity as well as average pitch velocity. It's basically a linear line for both these things, and interestingly, weight was also correlated with the chance that you're going to have a reconstruction, but as people start to throw harder, we know that the number of UCLs are going to go up, and if you look at the charts over the last 10 years on fan graphs of the average fastball velocity for Major League Baseball teams, and if you compare them between 2010 and 2019, what you see is that basically amongst all Major League Baseball teams, their average fastball velocity has gone up about 2.5 miles an hour per year since 2010, and this is because scouts are very focused on velocity, pitchers are very focused on velocity coming up with weighted baseball programs, etc., and their velocity is going up, but it's also going to increase their risk of injury as that happens. You can see it's really across the boards. If you take the top and the bottom of this kind of 30-team spread here, you can see that everybody's basically gone up 2.5 miles an hour on average over the course of the last 10 years. And then pitch counts are something that we continue to look at, and there's a great panel of some of the people that are here today that have come up with Major League Baseball guidelines and pitch smart guidelines to try to decrease the number of pitches and try to figure out what the correct number of pitches that somebody should throw in a game and in a season are, and the reason for this is because we think that if you throw over a certain number of pitches per game, your risk for injury is going to be higher, and so there used to be an inning limit that we set on players in Little League Baseball, and then it changed to a pitch count limit back in 2007, and so we tried to look at that and see if that was maybe a risk factor for the players before 2007 when it was an inning limit compared to after 2007 when it was a pitch count limit, if those players pre-2007 violated the kind of new pitch count guidelines, were they more likely to have a Tommy John when they got to the Majors? And basically what we found was that the guys that would not have followed the pitch count recommendations at the time, so pre-2007, although they did follow the current recommendations, which was for inning limits, they had a much higher chance of having a Tommy John surgery when they went to the Majors than guys who did follow pitch count limits. And we see this kind of in our Japanese colleagues who did a nice recent study looking at, again, inning limits and pitch count limits, and what they found was that over the course of their study, that the inning limit group, which was in 2017, and they changed to a pitch count limit group in 2018, that the number of players that had elbow pain was much lower when they changed to a pitch count limit than to an inning limit. So there probably is something in the pitch count. We don't know exactly what the right pitch count could be, but you can see here that just subtle variations in pitch count can really lead to a big increase in the number of pitches over the course of a season. This is a Petromer study looking at basically players that did have a history of injury, adolescents and those that did not, and you can see there were 10 more pitches per game, which doesn't seem like a lot in the players that did have an injury versus those that did not, but over the course of the season, that amounts to 500 pitches, which is a substantial number of pitches in these players. These are the current pitch count recommendations that PitchSmart and Major League Baseball have put out. This is based on number of pitches they should throw a day and the number of days of rest they should have in between how many pitches they're throwing. And this is just looking at ligament laxity, and this is getting to that pitch count issue again. After you throw a certain number of pitches, does the laxity of the UCL increase, and so they did basically a study looking at UCL strain as well as flexor pronator muscle strain. This was done recently out of Japan, and what they found basically was that after 100 pitches, the elasticity within the UCL went up, but the flexor pronator mass didn't change much. So they concluded that basically you shouldn't be throwing more than 100 pitches in a game because the lax in the UCL is going to increase and it's going to increase your risk for injury, as you can see here. Once they get to 100 pitches, it didn't really happen up to 80 pitches, but when they got to 100, there was a big difference. So these are kind of the risk factors that we've talked about just for your reference, and we're still trying to figure some out, and I would tell you, you know, one thing that we're still trying to figure out is how to define workload, and some of the new studies that we're going to start putting out with Major League Baseball in the coming months are going to be looking at the association of workload with injuries, because we always talk about the increase in workload and the risk for injury, but there aren't really any studies on this in the literature. And so what we did was we combined the HITS database, which is the Major League Baseball's health injury tracking system database, and player usage data that they had, and tried to basically see how player usage affected the amount of injuries that they had. And if you take a look at the UCL study that we did recently, this isn't out yet, but this is just for you to see, a little over 400 pitchers that had a UCL tear between 2011 and 2017, and intuitively, as you'd think, pitchers that threw more innings per game had a higher risk of having a UCL tear. What you probably wouldn't think, or at least what I didn't think, players that had more than five days of rest had a one and a half time increase in sustaining a UCL tear compared to guys that pitched on fewer days rest. So totally contrary to what I would have thought, and what we think right now, and how we treat our Major League Baseball starters, if you take a look at the graphs here, you can see days rest, once they get past more than four days rest, the risk of having a UCL reconstruction goes up significantly. Similarly, if they pitch more than four innings in a game, or if they face more than 20 batters in a game, the risk goes up. But this is something we're going to have to look at a little more, and I know this sounds crazy, but I wonder if there'll be a shift at some point in how we use our starting pitchers, and whether or not we have them throw us fewer number of innings per game, but pitch more frequently throughout the season, based on what we're starting to see with some of this workload data. But that's kind of still to be seen. So I will toss it over to Jeff Dugas now.

Ulnar Collateral Ligament

UCL injuries

UCL reconstruction

elbow pain

pitch counts