This document discusses shoulder and elbow injuries in baseball players. It provides an overview of labrum and ulnar collateral ligament (UCL) anatomy and the typical treatment approaches for shoulder dislocations and UCL injuries. Specifically, it discusses why surgery is often recommended for recurrent shoulder instability, the rehabilitation process after shoulder labrum repair, and reasons why Red Sox players Ellsbury and Crawford may not have required surgery for their injuries.

1. What the Hell is Going On
Over There…
Christopher Geary, M.D.
Chief of Sports Medicine Division -
Department of Orthopedics, Tufts Medical
Center
Assistant Professor, Tufts Medical School

2. Introduction

3. What the hell is a labrum?
 Ringof fibrocartilage around the shoulder
socket (glenoid)
– Also found in the hip and other joints
 Aids in the stability of the shoulder joint
– Shoulder is inherently unstable to allow for
greater range of motion

11. Why do we operate on
shoulder dislocations?
 Traditionallyhigh rates of recurrence with
non-operative management
– McGlaughlin 1950
 90% < 20 yo, 60% 20-40 yo
– Rowe 1961
 94% < 20 yo, 79% 20-30 yo
– Arciero 2002
 75% 18 to 26 yo (vs. 11.1% in group repaired
arthroscopically)

12. How much of a problem is
recurrent instability?
 Weber, et al, AAOS 2006
 89% redislocation risk for athletes under age 30
– 50% of recurrent dislocators redislocated only
once
– No predictors of who will recurrently
redislocate

14. How do we do it
 Open had long been the “gold standard”
 More recent reports show results with
arthroscopic fixation to be at least as good
– Deberardino et al 2001 AJSM: 12% recurrence
at avg. 37 month f/u
– Barber et al 2003 Arthroscopy: 7% failure at 24
month f/u
– Bottoni et al 2006 AJSM: 1 of 32 failed at avg
32 month f/u (vs. 2 of 29 done open)

18. Rehab
 Sling full-time for four weeks, ER to 0
degrees
 4 to 6 wks: D/c sling, start passive overhead
 6 wks: Start ER stretching, aim for 50% of
contralateral ER by 12 wks; also start
Thera-bands at 6 wks
 3 months: Gym workouts
 6 months: RTP

19. So why the hell didn’t Ellsbury
have surgery?
 Subluxation is a “partial dislocation”
 May result in a torn labrum, which can lead
to instability
 Even more difficult to predict than
instability after “full” dislocation

20. So What Was Done for
Ellsbury?
 PT
– ROM
– Strength
– Functional tasks (batting, catching, sliding)
 Restoration of confidence in the shoulder

21. So what the hell is up with
Carl Crawford’s elbow?

22. Anatomy and Biomechanics of
the Elbow
 UCL is the primary restraint to valgus forces in the
throwing elbow
– UCL is composed of 3 bundles: anterior, posterior, and,
variably, transverse oblique
– Anterior bundle
 Origin – Inferior aspect of medial epicondyle
 Insertion – Sublime tubercle of ulna
 Has 2 bands
– Anterior oblique more important 0-90
– Posterior functional >60

23. Ulnar Collateral Ligament

24. Biomechanics of Overhead
Athletes
 Elbow is exposed to high valgus and extension
loads
– Valgus forces up to 64 Nm during late cocking and
early acceleration
– Compressive forces up to 500 N at the radiocapitellar
joint
– Velocity up to 3000 deg/sec
 Cadaveric testing has shown the ultimate load to
failure of the UCL to be approximately 33 Nm
 This combination produces tensile forces
medially, compressive forces laterally, and shear
forces posteriorly

25. Imaging
 MRI
– No contrast vs. IV contrast vs. intra-articular Gado

26. UCL Injury
Non-Operative Treatment
 Initial tx consists of rest, NSAIDs, PT
 Low-demand or non-throwing athletes can almost always
be managed non-operatively
– Warren, Behr, et al reported 4 out of 4 NFL players
were able to return to play without surgery (1 QB)
 Jobe et al (JBJS 1986) recommended surgery after failure
of two 3-month cycles of PT
 Conway et al (JBJS 1992) recommended surgery if pt fails
to advance past 75% velocity despite 6 months of
conservative tx

27. Success of Non-Operative
Treatment
 Rettig, et al (AJSM 2001) –
13 of 31 (42%) throwing
athletes were able to return
to play at an average of 24.5
weeks
 Paletta (unpublished data)
– Success = degree of
medial laxity
– 68% return if partial tear
+ < 2 mm medial laxity
– 30% return if partial tear
+ > 2 mm medial laxity
– 9% return if full thickness
tear

28. Operative Treatment of UCL
Injury
 Indications for operative management
– Acute rupture in throwing athlete
– Chronic pain/instability despite adequate non-
surgical management
– After debridement of symptomatic calcification
without sufficient ligament to repair
– ? Sublime tubercle avulsion

30. Operative Treatment
 First case
– Frank Jobe, 1975
– Tommy John
– Palmaris Longus graft
passed through humeral
and ulnar drill holes in
figure-of-eight
– Submuscular ulnar nerve
transposition

31. Smith and Altchek AJSM 2000
Muscle Splitting Approach
 Purpose – to avoid morbidity
of detaching/elevating the
flexor/pronator mass
 Neuroanatomic mapping to
find a safe plane
 Internervous plane between
the median and ulnar nerves
 Split just anterior to the FCU
 Extends from medial
epicondyle to 1 cm distal to
sublime tubercle

32. Muscle Splitting Approach

46. Post-op Rehabilitation
 Phase I – Weeks 0-6
– Splint immobilization wks 1-2
– Hinged brace wks 3-6
 30-90 degrees wks 3-4
 15-105 wks 5-6
 gentle forearm strengthening
 NO valgus load
 Phase II – Weeks 7-12
– Out of brace @ wk 6
 forearm strengthening
 elbow flex/ext strengthening
 shoulder ROM
 NO valgus load

47. Post-op Rehabilitation
 Phase III – wks 12-16
– Preparation for return to throwing
– Begin 90-90 work, progressive valgus load
 Phase IV – months 4-7
– Interval long toss throwing program
 Phase V – months 8-10
– Return to throwing from mound program
 ground pitching
 mound pitching (catcher up)
 mound pitching (catcher down)

48. Post-op Rehabilitation
 Pitching Return
– breaking pitches @10 mo
– full mound/simulated games
 10-12 mo
– competitive return
 12-14 mo

49. So, back to this guy…

50. Why is he still playing?
 Can’t really hurt his elbow worse that it is now
 UCL, not ACL
 Likely will head back to Alabama at some point…

51. Thank You
cgeary@tuftsmedicalcenter.org
@ChrisGearyOrtho