But I'm very happy to moderate and introduce Mark Chickendance who's a professor of surgery in sports medicine at Cleveland Clinic. He's the head team physician for the Indians. He's also the director of the medical advisory committee, so he has quite a few obligations ahead of him that him and I will be part of later on this week. So Mark's going to present on medial elbow pain, that it's not always the UCL. This will be recorded for the learning management series for the AOS assignment will be available at some point in time in the next week or two. So all yours Mark. Thank you Steve and thanks Dr. Safran and everybody else who put together this fantastic program. Challenging times for all of us indeed. It's good to see that we can continue along with some education which is so important to the fellows. I thought I'd talk a little bit about other causes of pain in the throwing athlete. You know we hear so much about the ulnar collateral ligament. You know I speak about it and write about it and research it and Steve does as well. I mean it's just it's over the top. It's like the ACL of the elbow and I thought it might be interesting to talk about some other causes of pain on the medial side of the thrower's elbow. So just a few disclosures, none of which are of any significance to this discussion. So this talk actually goes all the way back to the 1940s. Bennett and it is the same Bennett that that the lesion in the shoulder is named after, published an article in JAMA back in 1941 that he described a condition that he called the so-called osteochondritis of the professional pitcher's elbow and he found semi-detached bodies by the medial epicondyle, loose bodies and olecranon fossa and he stated that removal does away with all symptoms. He's describing what we currently understand as valgus extension overload syndrome and posterior impingement and we'll talk about that going forward. In 1969 Graham King published an article in CORE that talked about the medial stress syndrome of the elbow in 50 professional baseball pitchers and he was very astute and understood that valgus and tension causes problems on the medial side and compression leads to lateral pathology, which implies then failure of structures on the medial side leading to the pathology that we see. If we jump forward quite a few years, Dave Olchek did a wonderful study, a categoric study with Daryl Osborne and Josh Dines and a couple other authors and documented increased contact pressures that were shifted medially and decreased contact area in UCL insufficient specimens and this implied then that abnormal contact can occur as a result of valgus laxity through increased contact pressures across the posterior medial aspect of the elbow and they concluded that this laxity throughout the throwing motion may lead to conor malatia that we see in the posterior medial aspect of the elbow and that brings us to the topic primarily we're going to be discussing tonight, which we currently know is valgus extension overload and posterior medial impingement of the thrower's elbow. What I'd like to do now is show a short little video presentation that one of my fellows, Josh Everhart, and I put together for a chapter that we just completed. Hopefully it'll play and we'll get some audio out of it. relevant history, physical examination, and the JIC. Finally, we will discuss... Mark, are you hearing an audio or? Yes, I'm hearing it. Can you hear it? Yeah, I don't I don't think we're getting the audio from it, Mark. I can't hear the audio. Any suggestions? Mark, are you doing your audio through your computer? Yes, so why don't you try to do this once you call in, do it by do your audio via phone. And that might help with the bandwidth on the computer and then the video will hopefully run better. And then you can try that instead. All right. Welcome to Zoom. Enter your participant ID or phone. Otherwise, just press home to continue. You are in the meeting now. There are more than 50 participants in the meeting. Hey, Mark, unmute me. You are unmuted. Take a look at your bottom, the bottom left of the computer screen and see if the mute button is clear or if it's got a line through it. Are you able to hear it now? I hear you, but I don't hear the video. Do you want to just do the voiceover yourself? I don't hear any video. All right, I'm trying to see if it'll pick up my speakers. The problem is if you use the audio for both your computer and your phone, it's going to double echo. All right, let's try this again. Mark what was your suggestion here? Mark do you think we could play the video or play the audio through my phone off of the computer? Mark I don't think you'll be able to have audio on both because it's going to it's echoing in your own. Okay so how can we turn the audio off on the presentation? So if you, Mark if you go to your audio there was originally it said do you want to do it by phone or by computer? So you can just do it by phone or you could actually turn off on your slide you can go to the animations I think oh no no actually if you go click on your video itself and it'll get so click on your video click on the video itself and you've got you'll have a thing that says playback option it should have a thing that says playback option where's your playback here so for playback there it is then you can put your volume or to mute click on volume and mute yeah all right let's see if that works hearing that you just put it to mute so you won't get any vote any any sound there right you wanted to mute it you said right yeah it's so I can hear it on my computer but you can put the phone next to the computer All right, how many orthopedic surgeons does it take to work a presentation? All right, let me see. Here we go. Andrew Tan says, there's a way to share the computer audio. You need to undo the share screen, then you click share screen before you select your screen. There's an option to also share computer audio. So stop share. It says you need to undo the share screen, then when you click share screen before you select your screen, there's also an option to share computer audio. It's a check box, share computer audio. Let's see. Screen, whiteboard, iPhone, share computer sound, there it is. That's got to be one of the fellows that came up with that, right? Yep, exactly. That's why we pick them. All right. So let's do this. Let's go back. Presentation of an athlete with valgus extension overload syndrome. That sounded great. Joshua Everhart and together with Dr. Mark Shook and Dance, we will be narrating this video presentation of valgus extension overload syndrome. In this video presentation, we will go over the pathophysiology of valgus extension overload syndrome and discuss relevant pitching biomechanics. We will then discuss evaluation for this. I'll stay away from the screen. My name is Joshua Everhart and together with Dr. Mark Shook and Dance, we will be narrating this video presentation of valgus extension overload syndrome. In this video presentation, we will go over the pathophysiology of valgus extension overload syndrome and discuss relevant pitching biomechanics. We will then discuss evaluation for this elbow condition, including the relevant history, physical examination, and imaging. Finally, we'll discuss treatment of valgus extension overload syndrome, including non-operative and operative treatment. Valgus extension overload syndrome is an overuse syndrome resulting from repetitive valgus and extension forces generated across the elbow during overhand throwing. Valgus stress at the elbow during rapid elbow extension results in sharing forces across the olecranon. Extension forces are experienced during late phases of throwing as the arm decelerates, resulting in forceful abutment of the olecranon posteriorly against the olecranon fossa of the humerus. Thus, the olecranon is subject to injury from both valgus and extension forces, which has become described as valgus extension overload. The sheer forces within the posterior elbow result in the pathology characteristic of posterior medial impingement, most commonly manifested as olecranon osteophytes as shown in the figure. Clinically, throwers with valgus extension overload syndrome typically experience posterior medial elbow pain near full extension during the early follow through and ball release phases of throwing. This is represented by the two images on the lower right-hand side of this photograph series of a picture. This is in contrast to the complaint of medial elbow pain during the late cocking and early acceleration phases described with medial ulnar collateral ligament injury. The typical presentation of an athlete with valgus extension overload syndrome is a throwing athlete with atraumatic elbow pain during follow through and ball release phases of throwing. This pain is localized to the posterior medial elbow and tends to occur even after a period of rest and no throwing. However, providers must be aware that other conditions can occur at the same time in the setting of valgus extension overload syndrome, and it may not be isolated to posterior medial impingement as a result of olecranon osteophyte formation. Patients can have associated distal triceps tendonitis or tendonitis of the flexor pronator mass. There can be concomitant elbow arthritis, loose bodies, or OCD formation. In addition, you can have a stress reaction or a stress fracture of the olecranon. You can have associated ulnar neuritis, and importantly, you can have posterior medial impingement in the setting of medial ulnar collateral ligament insufficiency. Dr. Schickendance will now demonstrate the relevant physical examination of the elbow when evaluating for valgus extension overload syndrome. First, we're going to check range of motion, looking at flexion and extension as well as pronation and supination of the forearm. From there, we're going to palpate laterally looking for any swelling or effusion and a quick feel on the medial side. Again, looking for any swelling or deformity. We're first going to check in our throwers, the medial collateral ligament, which is done in this position, 30 degrees flexion, pronation, and resistance. We're then going to check for flexion and extension strength and see if there's any pain with these maneuvers. In the posterior medial corner back here is where the VEO and posterior impingement occur. Up on the epicondyle, we palpate more for medial epicondylitis, and then below will be the ligament. In the back, we percuss for any pain over the olecranon, and then we're going to flex the elbow and see if there's any instability of the ulnar nerve. From here, this is the bounce home test. Again, looking for pain reproduced in the back of the elbow with full extension. The arm bar test is a hallmark of posterior impingement and valgus extension overload. The athlete brings the shoulder into 90 degrees flexion, holds the arm in full pronation, and then it's overextended by the examiner. Positive sign is reproduction of pain. Multiple imaging modalities can be used to evaluate the elbow in an athlete with valgus extension overload syndrome. Plane radiographs are routinely obtained and have fair ability to detect posterior medial osteophytes or loose bodies. An AP view of the elbow in acute flexion can provide a profiled view of the posterior medial joint. We find MRI to be the most helpful advanced imaging modality for these athletes. Posterior medial osteophytes can be easily identified on MRI, and you can assess for concomitant medial ulnar collateral ligament injury. This also allows for assessment of the articular cartilage and whether or not there's any associated marrow edema or stress reaction associated synovitis or tendonitis of the medial border of the triceps. We do not routinely obtain CT scans for evaluation of athletes with this condition. However, when we do, this does provide accurate assessment of osteophyte size and location in the posterior medial elbow, but it does not allow for assessment of concomitant soft tissue injuries or cartilaginous loose bodies. The following imaging studies are all obtained from the same professional baseball pitcher with symptoms consistent with valgus extension overload syndrome. This lateral radiograph demonstrates a fragmented osteophyte of the olecranon tip. There is evidence of concomitant elbow osteoarthritis. However, the athlete is only having symptoms with terminal elbow extension in late phases of throwing. An elbow MRI was obtained, which was helpful to evaluate for any concomitant medial ulnar collateral ligament pathology, or the presence of bony or cartilaginous loose bodies. In this sagittal T2 sequence, you can appreciate that there is associated synovitis in the posterior compartment, as well as ulnar humeral cartilage thinning. A CT scan with 3D reconstructions was also obtained of the elbow, which allowed for ready identification and sizing of the olecranon tip osteophyte. When athletes initially present with valgus extension overload syndrome, we do recommend initial non-surgical treatment. This begins with a period of relative rest, as well as oral anti-inflammatory medication, which can be supplemented as needed with intra-articular corticosteroid injection. And we can start athletes on a return to play program following rehabilitation. This is an example of our non-operative rehabilitation program. And in the first phase, we focus primarily on decreasing pain and swelling and normalizing range of motion. In the second phase, which lasts approximately one month, we focus on normalizing strength in preparation for returning to a throwing program. This is focused primarily on the elbow flexors, as this is a primary muscle group that's utilized to control deceleration during late stages of injury. Finally, in the third phase, we continue to focus on strengthening and then start with an interval throwing program. When athletes fail conservative treatment, we do recommend proceeding with surgery. When athletes have continued posterior medial impingement, we typically proceed with elbow arthroscopy using a posterior lateral viewing portal, as well as a direct posterior working portal in order to remove any associated osteoarthritis. Importantly, when you resect the olecranon tip osteophyte, you want to avoid over resection, as this will increase load on the medial ulnar collateral ligament, as demonstrated in multiple laboratory studies. Additionally, during the resection, be aware the ulnar nerve and posterior band of the medial ulnar collateral ligament are in close proximity. Can you guys hear me? Okay, so this is a skull, this is a right elbow of a pitcher with vagus extension overload. There was audio on this, I'm not sure where it went. But anyway, so what we're seeing there is that osteophyte and it's typically softer, it looks different, it's distinctly different than the native bone. So you typically come in with it with your shaver first. If it's large and you want to make it real pretty, you can come in with your burr very carefully, 3.5 millimeter barrel burr, and take that down as well. You know, this is going to be over that poster medial side. Make sure you get a good view of that, you know, stay well away from the ulnar nerve. And you want to be a little careful with how much of this bone you resect. Like I said, typically it's quite a bit softer than the bone around it. And once that's out, you know, you can see clearly that there's plenty of room back here for that elbow to demonstrate. Our post-operative rehabilitation protocol is similar to our initial non-operative protocol with an early focus on range of motion followed by focus on strengthening particularly elbow flexors and then this is followed by supervised throwing program with anticipated return to competitive throwing at three to four months. So how do these athletes do? There's not a lot written strictly on vagus extension overload. One of the first articles was of course by Jimmy back in 1995 looking at a 14% reoperation rate for VEO and at that time he was hinting that there was a relationship with ulnar collateral ligament insufficiency in the presence of VEO noted a better result long term with athletes who had a concomitant ulnar collateral ligament reconstruction. Joshua was referring to some of these studies. This is Kevin Eddy's work he's got three published articles on this very subject measuring ulnar collateral ligament strain with increasing amounts of bone resection and clearly demonstrated that resection should only include the olecranon spur and not the native bone. If you take the native bone you increase strain across the ligament which is probably already a little insufficient in some cases and you can actually make their problems worse. In adolescence the operation actually works fairly well for isolated cases 85% return to play in the adolescent athlete and again we know concomitant ulnar collateral ligament insufficiency less optimal results. Bottom line always be suspicious that there's something going on with the ulnar collateral ligament when you see your athletes with VEO and posterior impingement. Moving on to other problems on the medial side of the elbow with epicondylitis and flexor strains you're going to have medial sided pain similar but in a little bit different location than you do with ulnar collateral ligament injuries. This hurts during the acceleration phase of throwing motion hurts a ball strike and your hitters can be aggravated by a tight grip on a ball or the bat it's gradual onset for high-grade injuries it can occur it can happen very quickly but there's usually prodomal symptoms and some athletes who have had this for a long period of time who experience a rupture actually resolve the problem much like our patients with proximal biceps problems that finally rupture and get rid of the pain generator. The physical findings on these and I'll show you some comparisons are most notable for tenderness over the epicondyle itself and it's tender anterior to the proximal ulnar collateral ligament more up on the epicondyle so it's a little bit more volar where these athletes hurt they have pain with resistive pronation and wrist flexion they may have some valgus laxity but typically not and again a complete rupture can show a defect and some swelling so what do we do with these athletes you know the typical stuff avoidance of throwing and other other aggravating activities topicals work very good here anti-inflammatories careful ultrasound guided injection you can consider corticosteroids leukocyte rich PRP we do some work with the central tissue matrix in our our institution you be careful with these they ought to be done under ultrasound guides you got to watch the nerve keep the elbow extended keep the nerve behind the medial epicondyle some athletes respond well to counter force trapping and taping kinesio taping and we reserve throwing when they're symptom free I'm gonna move along here so how do we differentiate the athlete with medial elbow pain does he have an ulnar collateral ligament sprain or a flexor strain well here's some tips so ulnar collateral ligament athletes will complain of pain at late cocking and early acceleration your athletes with flexor problems have pain at acceleration and a follow-through UCL sprain athletes will complain of a drop in velocity and those with flexor strains leave their pitches up in the zone the reason they do that is because they can't they can't forcefully flex their wrist so everything stays up high UCLs will have pain of vagus stress and there's usually no pain of vagus stress if it's strictly a medial epicondyle flexor problem UCLs will have tenderness over the over the ligament and it's usually over the sublime tubercle interestingly even if it's a proximal injury they tend to hurt over the sublime tubercle flexor pronator strains are tender up over the medial epicondyle more more anterior and more volar and a little bit more proximal typically UCLs will have loss of extension and swelling and acute injury your flexor strains will have pain with resisted wrist flexion and forearm pronation and you'll see vagus laxity sometimes in high-grade UCLs and you just don't see that typically in your flexor strains other things that you'll see that are less common pronator Terry syndrome a pain in the medial forearm near the antecubital fossa is even more volar up right where the pronator is it's very reproducible you can get medium nerve symptoms and their pain is reproduced with resisted pronation and wrist flexion we treat this with anti-inflammatories and physical therapy less common things we published a series of stress injuries of the proximal ulna away from the physis all the way back in 2002 these are relatively uncommon but they are a source of posterior medial elbow pain that occurs during acceleration follow-through simple I'm sorry very similar to what you see with your vagus extension overload and posterior medial engagement this is gradual onset and results from trabecular failure of the prick proximal medial ulnar trabecular bone and of note your regular x-rays are going to be with the normal limits in our study every patient that had this had an intact ulnar collateral ligament and I think that what's happening is a laxity in the ulnar collateral ligament and those athletes with UCL insufficiency allows for shear across the posterior medial joint that leads to the VEO that we just talked about those with intact ligaments result in constant stress on the ulna that leads to trabecular failure in these cases stress injury to the proximal and this is a treated non-operatively unless there's a fracture line which is extremely rare we consider we use bone growth stimulators for these they return to throw based on their clinical response we usually don't repeat MRIs but if you got somebody who's lagging behind you may want to add an MRI during treatment just to make sure that things are going in the right direction this is distinctly different than a lepron on apophysis fracture we've all seen these this is associated with immediate severe pain during follow-through of a throw sudden sharp pain in the back of the elbow this has been categorized by the Japanese folks if you're interested in in looking at this a little bit more detail they have a classification system based on the fracture location and pattern and correlates with their with the age of the patient fixation options and options include cannulated screws plus or minus a washer a single home run screw tension bands with wire suture we prefer suture for these versus wires plate and screws for the rare case we've done those in non-unions just to get maximal fixation this is not a benign injury a lepron on fractures it needs to be taken seriously this is a study that dr. Andrews published back in 2013 with 17 out of 25 patients returned to play at the same or higher level 56% I'm wondering with 13 more surgeries it's a big number that were that were related to the index procedure and this included 33% with hardware removal two of them got infected so this thing isn't isn't a benign problem it's not a slam-dunk we need to take a fixation of electron fractures very seriously throwing athletes Brandon Erickson Tony Romeo just published this article last May AJSM demonstrating or return to the same level of play of about 67% in athletes at the professional level who undergo open reduction internal fixation of electron fracture 67.5% so again not a benign problem cubital tunnel syndrome will finish with the nerve problems here can be due to compression of the nerve either the FCU ligament of Struthers or Osborne's ligament symptoms include pain in the cubital tunnel the carotid down the forearm we're very familiar with the classic course of this pain and numbness down into the into the small finger in advanced cases you get weakness with grasping and pinching typical gradual onset and hurts during all stages of the overhead throwing motion due to both compression and traction of the nerve as it courses through the cubital tunnel beneath Osborne's ligament physical findings include diminished sensation on the ulnar digits tunnel sign and the positive from inside demonstrating weak intrinsics diagnostic studies you know throwers were typically going to do an MRI to rule out associated pathology not necessarily to look specifically at the nerve itself EMG nerve conduction studies reserve that for people with advanced atrophy motor changes and weakness initial treatment unless they've got the motor changes activity modifications we use an elbow sleeve or a rapid night to keep their elbow extended I like to use and at bedtime this has got about a 50% success rate unless you're dealing with a significant structural problem such as subluxation of the nerve which is what we're going to talk about next it's important to intervene in these athletes early if they have painful subluxation or if they've got motor changes motor changes are a poor prognostic indicator if they've gotten that far in this disease and they have motor changes and atrophy with correlated with intrinsic atrophy your outcomes are not as good so we need to jump on these early on pay particular attention to any motor changes in in our throwing athletes rather than simple decompression the cubital tunnel most of us are doing inter transpositions for there's a variety of ways you can do that I do a do some special type of transposition I'm going to show you here in a minute but if you just do it inside to decompression it doesn't eliminate the traction portion of the problem you may eliminate some of the compression but you do not eliminate the traction and the results are not as good with inside to decompression alone in the throwing athlete so let's move on to a case here this is a case of a 20 year old right-hand dominant collegiate pitcher who has had symptoms of ulnar neuritis as well as instability and subluxation of the ulnar nerve he has undergone extensive non-surgical care and has come to the operating room and what we see here is the ulnar nerve exposed with Osborne's ligament having been released as well as some proximal dissection and the nerve then is seen as it travels into the two heads of flexor carpi ulnaris and what you notice is some inter subluxation of the nerve as well as some hourglass compression as it courses distally through the cubital tunnel here's a close-up view of the hourglass constriction of the ulnar nerve as it exits the cubital tunnel and enters the FCU in this slide we see the motor branches going to the flexor carpi ulnaris as they come off the ventral surface of the ulnar nerve just distal to the cubital tunnel it's important to recognize and locate these in each case here we see the medial intramuscular septum which has been dissected free of soft tissue on its dorsal and ventral surface it's important to get a good long strip of this we recommend at least two centimeters in length and a centimeter in width in order to have adequate size for the sling that this is going to create once the nerve is transposed in this image we see depicted the medial intramuscular septum after it has been released proximally and laterally with a remaining attachment distally firm onto the medial epicondyle you can see also the amount of shrinkage that this tissue has undergone since being released again emphasizing the need for a good long and wide segment of intramuscular septum to be isolated prior to releasing it in this slide we see the ulnar nerve has been transposed and is held gently in place with a sling that was created from the strip of medial intramuscular septum the strip again is based on the medial epicondyle and is sewn back to the fascia of the common flexor origin using multiple absorbable sutures it's important that this sling not be placed too tightly and that the nerve can glide freely beneath the sling with flexion and extension of the elbow you can see ideal positioning of the nerve and of the sling which allows for freedom of movement but also a good stability holding it above the medial epicondyle well away from the cubital tunnel and what we also notice here is there's no kinking or binding of the nerve in any position along its new course up on the medial epicondyle in this final slide we see the closure of the cubital tunnel which is accomplished by sewing the deep fascia to the soft tissue on the back side of the medial epicondyle at the level of the cubital tunnel which eliminates the cubital tunnel space and what this does is provide extra support in case the nerve were to tend to sublux in a posterior direction this would prevent the nerve from engaging underneath the medial epicondyle as the cubital tunnel has basically been eliminated so real quick on that so post operatively what we do is I'll put them in a splint for just a week a little poster splint and we take them out of that get them moving right away they're typically not throwing for about three months but the rehabs actually pretty quick from the from the ulnar nerve transposition so you know just to kind of summarize you know I think it's important for us to understand that not all throwers with elbow pain have a UCL injury many of them many of them do we need to be aware that there are other problems and you're all oftentimes multiple problems and we just need to be aware and keep our mind open to those possibilities and it can often arise you know poster medial pain can arise from from the joint it can it can come from the bony structures as well if the if our athletes are not having mechanical symptoms, locking, true loose body type symptoms, they're safe to manage throughout a season. You can do corticosteroid injection if you need to. Get these athletes through, sculpt them at the end of the season. If they've got some debris in the back, that's not an unreasonable approach to this. If you do go to the operating room for VEO, make sure that you're just taking out the osteophyte, leaving that native bone. Again, the osteophyte's gonna be smaller, it's gonna be softer. You can use it, it's usually fairly discernible from the native bone. We always want to consider UCLA's efficiency and our athletes with VEO. And we need to aggressively treat any fractures that we see with solid AO fixation and sticking to our AO principles. We don't take this very lightly. Don't just throw a single, a little tiny cannulated screw down one of these electron fractures. These things are in a lot of stress on these throwing athletes. Good history is essential to accurate diagnosis. As we went through, a lot of the history can tell you and help you differentiate between UCL problems and medial epicondyle flexor problems. And then finally, we're gonna treat recalcitrant and ulnar nerve symptoms and subluxation with a subfascial anterior transposition of the ulnar nerve, not simply an insight to decompression. So thank you very much. I appreciate everybody's patience with my IT illiteracy. And I'm very thankful for the young fellows who are much brighter than me, able to help us through this. I'm happy to take any questions. So thank you very much. Thank you, Mark. That was excellent way to navigate through the medial side of the elbow and just overall throwing injuries of the elbow. You talked a little bit about electron stress fractures, but didn't really kind of discuss medial epicondyle fractures or avulsions. Can you talk a little bit about your process on how you would manage them surgically, non-surgically? What are your indications? Sure, you know, our medial epicondyle avulsion fractures are typically seen in our adolescent throwers, as you're well aware. You know, our traditional teaching with those has been anything less than five millimeters of displacement can probably be left alone. You know, the challenge, I think, with medial epicondyle fractures is accurately assessing the amount of displacement. And the typical three-view radiographs that we get have been shown to be very inadequate in determining the amount of displacement of the medial epicondyle fragment. There are special views, and I can't recall the names of them that we can get to look at more accurately the amount of displacement that you see in those fractures. I think at a high-level athlete, you know, I guess you could argue how many high school athletes are truly high-level, but I think if you're concerned and you're not getting adequate visualization on your radiographs, you know, MRI or CT may be helpful. There's argument, there's been some argument that in your young athletes that are throwers, that evolves their medial epicondyle, even if it's only displaced minimally, that you probably ought to fix it. That's not been shown to increase union rates in minimally displaced fractures, and it's not been correlated with increased success or return to play. You know, so for me, you know, I try to go by the five millimeter rule, but again, it's hard to assess that. I've got to admit, I probably have fixed more that are probably less than five millimeters based on just the fact that I can't accurately measure it, but I stick to the five millimeter displacement rule, and I like to use something absorbable if you can. If you can't, go with a 4-0 cannulated screw and a washer. You know, these can be a little tricky, sometimes difficult to find the fracture line. What you don't want to do is take the whole thing apart and, you know, go looking for it, you know, use your C-arm and do it under direct visualization. Okay, Brandon Erickson asked a question. Do you always use a sling when you transpose the nerve, or do you hold the nerve anteriorly and sew the fat down to the medial epicondyle and keep the nerve anterior? I've done the fat. I like the, and I'm going to give a shout out to my colleague and friend, Jeff Dougas. It was Jeff that taught me the intermuscular septum trick. It works very, very well. That, for me, has been my go-to since I learned it from him several years ago. I used to take a strip of fascia off of the flexor group there. It looks kind of similar to what you're doing with the intermuscular septum, but this is not, you know, you're not violating any of the flexor at all by using this intermuscular septum strip. And I'm not aware of any studies that have compared different method, that method versus the subcutaneous fat method. A lot of the hand surgeons like to use that little fat tunnel. And I know what Brandon's talking about, and I've done it. Sometimes in these thinner athletes, it's hard to find enough fat to use to make that adequate. I've unmuted some of the other faculty. Mike Freehill, Will Workman, I think are on there as well. So anybody who wants to participate from the faculty side, feel free to do that. Mark, while we're waiting for another question, talking about the nerve and UCLs, I know we all know that Jimmy transposes, and you know, the Birmingham group transpose every nerve. What are you doing for UCLs? I don't transpose a nerve unless it's unstable or they have motor changes. For me, if you've got an athlete that has an injury to his ulnar collateral ligament, he's got ulnar collateral ligament insufficiency and has developed simultaneously some ulnar neuritis, I have to say, although this is pretty unscientific, I have to say that to a person, at least in my practice, once you've stabilized the medial side of that elbow, that neuritis goes away. If they have neuropathy or instability, I think that those are two indications to move the nerve, but transient neuritis that you think is probably related to an acute dogus injury probably is not an indication to move the nerve. You know, our colleagues that do the nerve transpositions are extremely facile at doing that procedure. I'm not so sure that everybody else in the community is as good at doing that. I mean, that's the way they're taught. That's the way they've done it for thousands of cases, you know, and it works well in their hands. I have no problem with the way they approach that. It's just not the way that I do it. Agreed. Looking back, how often do players that you've transposed their ulnar nerve then ultimately have some UCL symptoms or UCL reconstruction? Do you think that that might've been a precursor to some of their ulnar nerve symptoms? That's a great question. You know, that may be one of those things that's seen me that I haven't seen yet. I would say, Mike, over the course of, you know, almost 30 years of doing this, it'd be on one hand that I could count those cases. I think to me, it's been pretty rare. You know, I think if you're pretty diligent, you know, and obviously any of your athletes that come in with medial-sided elbow pain, you always think about the ulnar collateral ligament, and sometimes it's difficult to tease out, you know, do they have any underlying, you know, ulnar collateral ligament problems? I think if you've got, you know, reliable imaging that shows, you know, an intact ligament with just ulnar nerve symptoms, I think you can be pretty safe assuming that it's an isolated ulnar nerve problem. You don't see as much isolated ulnar nerve problems as you do ulnar collateral ligament problems, for sure. So, you know, certainly we always think about that, but I think that's relatively uncommon. For your olecranon stress fractures, are you only treating them surgically if you actually have a fracture line? Yes. Or if there's some displacement? For the apophyseal fractures that are hot on MRI, we fix those. And if it's just a stress reaction in the proximal ulna with no cortical fracture line, those get better with a bone growth stimulator and a little bit of rest. But if you've got an apophyseal fracture that's hot, that lights up on an MRI, even if it's minimally displaced, you probably ought to fix that. Are you typically doing some sort of a corticosteroid or local anesthetic injection for your posterior mutal impingement patients before you consider taking them to the OR? Yeah, I would say to an athlete, we certainly try. That's our typical protocol. I don't think that there's, at least in my hands, I don't see a role for biologics there. You know, I think if you've got an athlete with that mechanical type stuff in the back of his elbow that's not locking and it's reproducible and you know it's just all back there in the back, they get some sinusitis, they get some swelling back there, you can get that swelling taken care of with a very safe corticosteroid injection. I don't think I would do them. I prefer not to do it multiple times during the season. But I think if you can, you know, early in the season, you know, give them a shot, get them through. You know, if they fail, they fail. You stick a scope in them, clean them out. But it's safe to do that, again, unless they're having true mechanical stuff where they're locking, you know, and blocking and having problems with obvious loose body symptoms. Do you see a correlation with the loss of extension? You know, kind of the athlete that you see that, you know, they're losing two, three degrees every year and, you know, by the time they've been in the league 10 years, they've got a, you know, 15 to 20 degree flexion contracture. If you do a scope on them, do you see an improvement in their extension or do you see that they'll always have some chronic flexion contracture? No, I always tell them that, you know, I never expect them to increase their range of motion. If they get it, it's a bonus, but that's not our goal. Our goal is to prevent, you know, pain at that range that they currently have. You know, as you know, you know, many of these athletes over time will have multiple scopes. You know, every three or four years, they'll get a little clean out, you know, until they're in their 30s. You know, so I think, you know, it's reasonable to do that and you don't really expect any improvements in motion if you do great. Hey, Mark. Hey, Will. Hey. A couple things. You know, first of all, thanks. Great talk. You know, I just want to say I've been learning from you for a very long time, well before I was involved with major leagues and you still look better than I do. I don't know how that's possible. But a couple of things. First of all, with the physical exam, you know, I'm a big fan of the physical exam and the elbow to me is one of those that's sort of quasi satisfying because like you pointed out, we can tease out a lot of things by poking around. And I just want to mention, I think, I guess for my own learning in the fellows, I've always been a little frustrated with my slash our ability to assess instability in the elbow, say, you know, compared to what you can do with the knee, like the knee is very straightforward, the elbow isn't. I want to get your thoughts on that. Number two, with regards to the medial stress syndrome, so-called, you know, the olecranon in the younger throwers, you know, sometimes we see that in combined, in combination with an ulnar collateral ligament injury, usually a ulnar olecranon, or sorry, ulnar sided tear. You know, sometimes they have like a stripped off tear on the ulnar side, there's some medial, there's some bony stress along with it. And I think sometimes that gets diagnosed as stress syndrome versus a tear. And it's sometimes a little bit difficult to tease out which is which, I think. I think you're right. I'll start with that. I think in that situation, the ligament's the primary problem. I think that's your index of concern, and everything else that you're seeing is secondary to that. You know, we'll repeat again, the first question you were talking about. It's more, you know, I think with the elbow, we can figure out a lot of stuff in terms of, you know, like soft tissue injuries, but in terms of instability. Instability, yeah. Not straightforward, like you can't, to me, there's no instability associated with valgus extension overload. There's no instability. I mean, overt, objective, like one plus, two plus, the way there is with the knee. You're right, there's not. Unless you're, you know, in baseball, you're not gonna see it. You'll see it in gymnastics, you'll see it in wrestlers with dislocations, but you're not gonna see it in these athletes. You know, rarely do you get an athlete that just tears his whole medial, you know, soft tissue supporting structures off. Pull off his flexor, pull off his proximal ligament. You know, in that athlete, you're gonna see gross instability. You know, Mike Ciccotti's done fabulous work with the ultrasound looking at, you know, how much, you know, how much, you know, even the healthy, uninjured elbow gaps open with valgus stress, you know, and we're talking less than, you know, tenths of a millimeter. It's very, very, very difficult, and I would argue almost impossible to pick that up clinically. I don't think any of us are that good. We really rely on the history, and for me, I rely on the location of the pain and the reproduction of the pain. The moving valgus stress test is the best test for the ulnar collateral ligament. Sean O'Driscoll published that. Highly sensitive, highly specific. I think it's the best thing that we have to determine that you've got an injury to the medial ulnar collateral ligament. You know, if somebody comes out of the room and has examined a thrower and tells me that they've picked up some valgus laxity, I'm not so sure that that's really what they're finding. Yeah, I think the only thing, like a mid-substance blowout in an older pitcher sometimes, they can get pretty sloppy, I guess. Yeah, yeah, but like you said, it's really rare. It's very different than the knee. Greg, yeah, I mean, Mark, obviously we've done a lot with the ultrasound, and we're using 1.5 to two millimeters as our cutoff for increased laxity. There you go. So as you say, determining that on a clinical exam, if we had one to two millimeters of play in a knee, we wouldn't barely probably even sense that at all. So yes, it is clearly, and I think Will's point is, it's not always so satisfying with your clinical exam to really get a sense for instability. Yeah, it's pretty typical. Shoulder and elbow stuff, we really count on our history as much as anything else. Yeah, well, excellent. Mark, thank you for an excellent presentation. We appreciate you taking the time out and presenting to the fellows. I know I'll be seeing you later in the week, but we appreciate you getting on board and doing this. You're very welcome, guys. Thanks so much for having me, and thanks to all the fellows, and good luck to all of you.

medial elbow pain

throwing athletes

ulnar collateral ligament

valgus extension overload syndrome

posterior medial impingement

evaluation

treatment options

accurate diagnosis

comprehensive treatment plans