Dr. Freehill is a board-certified, double fellowship-trained specialist in orthopaedic surgery with a sub-specialty certification in sports medicine. His concentration is in shoulder and elbow. Dr. Freehill is a team physician for the Stanford University athletics program and head physician for the Stanford University baseball team. Dr. Freehill also teaches in the Department of Orthopaedic Surgery at Stanford University School of Medicine.
Dr. Freehill’s practice focuses on all shoulder conditions. He treats rotator cuff tears, shoulder instability, shoulder arthritis, sports shoulder, arthopathy, complex shoulder pathology, and sports-related shoulder injury. In addition, he is also passionate about sports- related elbow injuries, with an emphasis on thrower’s elbow.
Professional and amateur athletes, as well as non-athletes, come to Dr. Freehill for expert care. His sports medicine training and specialization in shoulder replacement procedures enable him to treat patients across the lifespan. Depending on factors including the patient’s condition and occupation, he may recommend treatment ranging from non-operative solutions (such as physical therapy) to cutting-edge biologics procedures or complex surgery.
In addition to his positions within the Stanford University athletics program, Dr. Freehill serves as assistant team physician for the Oakland A’s. Previously, he was a team physician for the Detroit Tigers and the Winston-Salem Dash (affiliated with the Chicago White Sox); he assisted with the Baltimore Orioles. He has also served as Director of Sports Medicine for Wake Forest University Athletics.
As director of the imminent Stanford Performance and Pitching Lab, Dr. Freehill draws on his previous experience as a professional baseball player to help athletes of all skill levels. In the lab, he conducts cutting edge research on the biomechanics of overhead throwers in order to support advances in throwing performance. He has conducted a study on pitch counts in adolescent players funded by Major League Baseball. Dr. Freehill was also awarded a research grant from the National Institutes of Health to investigate stromal vascular fractionated mesenchymal cells and their potential for healing rotator cuff tendon tears.
Dr. Freehill has pioneered the use of some of the latest techniques and technology for leading-edge care. Among the advanced technologies he utilizes is a virtual reality (VR) system that enables him to perform a simulated shoulder arthroplasty procedure prior to entering the operating room with a patient. The system also enables him to predict and order customized implants if needed, which is believed to enable a more positive outcome for patients.
Peer-reviewed articles authored by Dr. Freehill explore rotator cuff injuries, shoulder arthroplasty, baseball-related injuries and performance interests, and more. His work has been featured in the American Journal of Sports Medicine, the Orthopedic Journal of Sports Medicine, Journal of Shoulder and Elbow Surgery, Arthroscopy, and elsewhere. He has written numerous book chapters and made over 200 presentations at conferences around the world.
Dr. Freehill’s honors include an Orthopaedic Residency Research Award while at Johns Hopkins University. He is also a Neer Award winner, denoting the highest research award selected annually by the American Shoulder and Elbow Society.
Currently, he serves on the Medical Publishing Board of Trustees for the American Orthopaedic Society for Sports Medicine. He is a member of the American Orthopaedic Association, and the Major League Baseball Team Physician Association. He is a committee member for the American Shoulder and Elbow Surgeons Society, International Congress of Arthroscopy and Sports Traumatology, the Arthroscopy Association of North America, and the American Academy of Orthopaedic Surgeons.
- Orthopaedic Surgery
Associate Professor - University Medical Line, Orthopaedic Surgery
Residency: Johns Hopkins University Hospital Dept of Orthopaedic Surgery (2010) MD
Board Certification: American Board of Orthopaedic Surgery, Sports Medicine (2017)
Board Certification: American Board of Orthopaedic Surgery, Orthopaedic Surgery (2014)
Fellowship: Massachusetts General Hospital Dept of Orthopaedic Surgery (2012) MA
Fellowship: Stanford University Orthopaedic Sports Medicine Fellowship (2011) CA
Medical Education: Tulane University School of Medicine Registrar (2005) LA
Biomechanical Comparison of a Novel Multiplanar, Perpendicular Whipstitch With the Krackow Stitch and Standard Commercial Whipstitch.
Orthopaedic journal of sports medicine
2022; 10 (8): 23259671221107034
Background: Using alternating orthogonal suture throws with the looped whipstitch technique may allow enhanced suture fixation.Hypothesis: It was hypothesized that this novel multiplanar, perpendicular looped whipstitch (MP) technique would have improved biomechanical properties compared with the standard looped whipstitch (WS) and Krackow stitch (KS).Study Design: Controlled laboratory study.Methods: A total of 30 cadaveric tibialis anterior tendons were randomly assigned into 3 groups of 10. Tendons were secured to a custom clamp, and the other end was sutured using 1 of 3 techniques: the KS, WS, or novel MP. The MP was performed with alternating orthogonal throws starting right to left, then front to back, left to right, and back to front. Each technique used 4 passes of No. 2 FiberWire spaced 5 mm apart and ending 10 mm from the tendon end. Tendons were preloaded to 5 N, pretensioned to 50 N at 100 mm/min for 3 cycles, returned to 5 N for 1 minute, cycled from 5 to 100 N at 200 mm/min for 100 cycles, and then loaded to failure at 20 mm/min. Elongation was recorded after pretensioning and cycling and was measured both across the suture-tendon interface and from the base of the suture-tendon interface to markings on the suture limbs (construct elongation). One-way analyses of variance were performed, with Bonferroni post hoc analysis when appropriate.Results: There were no differences in cross-sectional area or stiffness among the 3 techniques. The ultimate load for WS (183.33 ± 57.44 N) was less compared with both MP (270.76 ± 39.36 N) and KS (298.90 ± 25.94 N) (P ≤ .001 for both). There was less construct elongation for KS compared with WS and MP for total displacement, measured from pretensioning to the end of cycling (P < .001). All 3 techniques saw a decrease in length (shortening) at the suture-tendon interface during testing. There was more shortening at the suture-tendon interface for WS compared with KS (P = .006).Conclusion: The KS appears superior, as it maximized strength while minimizing construct elongation or graft shortening. The ultimate load of the MP technique was greater than that of the standard technique but not significantly different from that of the KS technique.Clinical Relevance: The KS is preferred. If using a WS, multiplanar, perpendicular passes should be considered.
View details for DOI 10.1177/23259671221107034
View details for PubMedID 35982831
Using Advanced Data to Analyze the Impact of Injury on Performance of Major League Baseball Pitchers: A Narrative Review.
Orthopaedic journal of sports medicine
2022; 10 (7): 23259671221111169
Major league baseball (MLB) pitchers are at risk of numerous injuries during play, and there is an increasing focus on evaluating their performance in the context of injury. Historically, performance after return to play (RTP) from injury has focused on general descriptive statistics, such as innings or games played, or rate statistics with inherent variability (eg, earned run average, walks and hits per inning pitched, strikeouts per 9 innings, or walks per 9 innings). However, in recent years, MLB has incorporated advanced technology and tracking systems in every stadium, allowing for more in-depth analysis of pitcher-specific data that are captured with every pitch of every game. This technology allows for the ability to delve into the pitching performance on a basis that is more specific to each pitcher and allows for more in-depth analysis of different aspects of pitching performance. The purpose of this narrative review was to illustrate the current state of injury recording for professional baseball pitchers, highlight recent technological advances in MLB, and describe the advanced data available for analysis. We used advanced data in the literature to review the current state of performance analysis after RTP in MLB pitchers after injury. Finally, we strived to provide a framework for future studies to more meticulously assess RTP performance given the current available resources for analysis.
View details for DOI 10.1177/23259671221111169
View details for PubMedID 35898207
View details for PubMedCentralID PMC9310227
Limited Biomechanical Evidence Behind Single Row Versus Double Row Repair of Subscapularis Tears: ASystematic Review.
Arthroscopy, sports medicine, and rehabilitation
2022; 4 (3): e1193-e1201
Purpose: To systematically review the literature for studies investigating the biomechanical properties of constructs used to repair isolated subscapularis tears in time zero human cadaveric studies.Methods: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases were searched for studies that reported on the construct technique and biomechanical outcomes for the repair of isolated subscapularis tears in human cadaveric specimens. Ultimate load, gap formation, stiffness, and failure mode were documented. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS) scale.Results: Six articles qualified (104 shoulders [72 single-row, 26 double-row, 6 transosseous]; mean QUACS score 10.5 ± 1) and were analyzed. Studies varied in the number and type of anchors and construct technique (1-2 anchors single-row; 3-4 anchors double-row; bioabsorbable or titanium anchors) and suture(s) used (no. 2 FiberWire or FiberTape), subscapularis tear type (25%, 33%, 50%, or 100% tear), and whether a knotless or knotted fixation was used. In studies that created full-thickness, upper subscapularis tears (Fox-Romeo II/III or Lafosse II), no significant differences were seen in ultimate load, gap formation, and stiffness for knotted versus knotless single-row repair (2 studies) and single-row versus double-row repair (1 study). Double-row repair of complete subscapularis tears demonstrated higher ultimate load, stiffness, and lower gap formation in 1 study. Ultimate load differed between the studies and constructs (single-row: range, 244 N to 678 N; double-row: range 332 N to 508 N, transosseous: 453 N). Suture cutout was the most common mode of failure (59%).Conclusion: Because of the limited number of studies and varying study designs in examining the biomechanical properties of repair constructs used for subscapularis tears, there is inconclusive evidence to determine which construct type is superior for repairing subscapularis tears.Clinical Relevance: Results from biomechanical studies of clinically relevant subscapularis repair constructs are important to guide decision-making for choosing the optimal construct for patients with subscapularis tears.
View details for DOI 10.1016/j.asmr.2022.01.009
View details for PubMedID 35747639
Ulnar Collateral Ligament Reconstruction Does Not Decrease Spin Rate or Performance in Major League Pitchers.
The American journal of sports medicine
Ulnar collateral ligament reconstruction (UCLR) is commonly performed in Major League Baseball (MLB) pitchers, with variable reported effects on velocity and traditional rate statistics. Currently, no studies have evaluated spin rate in the context of return to play (RTP) after injury. Greater spin rate has become increasingly sought after in the baseball community, as it is believed to be a vital aspect of pitch effectiveness.The purpose was to evaluate the effect of primary UCLR on fastballs (FB) and sliders (SL) of MLB pitchers in terms of spin rate, velocity, hard-hit rate, and whiff rate. It hypothesized that the post-UCLR FB and SL spin rates, velocity, and whiff rate would be significantly decreased versus their pre-UCLR levels, while the FB and SL hard-hit rates would be higher in comparison with pre-UCLR levels.Case series; Level of evidence, 4.In total, 42 pitchers who underwent UCLR and returned to MLB play were identified from public records from 2016 to 2019. The Statcast system was used to collect spin rate, velocity, hard-hit rate, and whiff rate for 4-seam FB (4FB), 2-seam FB (2FB), and SL for pitchers in the preinjury year as well as the 2 years after return from UCLR. Data were analyzed using the appropriate statistical tests.A total of 36 pitchers met the inclusion criteria, and 31 of the eligible 36 players (86.1%) were able to return to MLB pitching (RTP). There were no significant decreases for 4FB, 2FB, or SL in spin rate, measured in revolutions per minute (rpm), when comparing preinjury levels with the first and second seasons after return. There was a significant decrease in velocity for the 2FB in the first season (92.9 vs 93.7 miles per hour [mph]; P = .045) but not the second season (93 mph; P = .629) after RTP in comparison with pre-UCLR levels. For the 2FB, there was a significant increase in spin rate between preinjury and RTP season 2 (2173.5 vs 2253 rpm; P = .022). For the SL, there was a significant increase in spin rate between preinjury and RTP season 2 (2245.1 vs 2406 rpm; P = .016).A cohort of MLB pitchers who underwent UCLR and returned to the MLB level demonstrated no significant decreases in the spin rate, velocity, whiff rate, or hard-hit rate of 4FB, 2FB, or SL at 2 years after UCLR.
View details for DOI 10.1177/03635465221097421
View details for PubMedID 35616521
Revision Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers: Effects of Fastball Velocity and Usage.
Journal of shoulder and elbow surgery
Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and can cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is becoming increasingly common, with little known about the effects on fastball velocity (FB) and usage (FB%) in this setting.The purpose was to evaluate the effect of revision UCLR on MLB pitchers with respect to post-operative FB velocity and FB% usage at one and two years after return-to-play. The hypothesis was post-operative FB velocity and FB% usage would significantly decrease versus pre-revision levels, and that revision UCLRs would result in significantly decreased FB velocity and FB% usage in comparison to a matched group of MLB pitchers after primary UCLR.Twenty-one pitchers who underwent revision UCLR and returned to MLB play were identified from public records from 2008-2021. The PITCHf(x) system collected FB velocity for four-seam (4FB) and two-seam (2FB) fastballs and total FB% for pitchers in the pre-revision year as well as the two years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison.There were no significant differences in FB velocity between pre-revision levels (4FB 92.9 mph, 2FB 91.4 mph) and years one (4FB 92.5 mph) (2FB 91.2 mph) and two (4FB 93.4 mph) (2FB 91.1 mph) after revision UCLR. FB% decreased from the pre-revision season (60.1) and the first (56.2, p=0.036) and second years (52.5, p=0.002) after return. There were no significant differences between FB velocity or FB% or between the revision and primary UCLR groups.Pitchers returning to the MLB level after revision UCLR can expect similar FB velocity pre-revision FB velocity and to pitchers undergoing primary UCLR; however, they do demonstrate a decrease in FB% usage, which may suggest less confidence in their FB after RTP.
View details for DOI 10.1016/j.jse.2022.02.026
View details for PubMedID 35351655
Anatomic Total Shoulder Arthroplasty: Component Size Prediction with 3-Dimensional Pre-Operative Digital Planning.
Journal of shoulder and elbow arthroplasty
2022; 6: 24715492221098818
Background: The rate, complexity, and cost of total shoulder arthroplasty (TSA) continues to grow. Technology has advanced pre-operative templating. Reducing cost of TSA has positive impact for the patient, manufacturer, and hospital. The aim of this study was to evaluate the accuracy of implant size selection based on 3-D templating. Our hypothesis was that pre-operative templating would enable accurate implant prediction within one size.Methods: Multicenter retrospective study of anatomic TSAs templated utilizing 3-D virtual planning technology. This program uses computed tomography (CT) scans allowing the surgeon to predict component sizes of the glenoid and humeral head and stem. Pre-operative templated implant size were compared to actual implant size at the time of surgery. Primary data analysis utilized unweighted Cohen's Kappa test.Results: 111 TSAs were analyzed from five surgeons. Pre-operative templated glenoid sizes were within one size of actual implant in 99% and exactly matched in 89%. For patients requiring a posterior glenoid augment (n=14), 100% of implants were within one size of the template and 93% matched exactly. For stemless humeral components (n=87) implanted, 98% matched the pre-operative template within one size with 79% exactly matched. For stemmed components (n=24), 88% of cases were within one size of the preoperative plan and exactly matching in 83%. Humeral head diameter matched within one size of the pre-operative template in 84% of cases and exactly matched in 72%.Conclusion: Pre-operative 3-D templating for TSAs can accurately predict glenoid and humeral component size. This study sets the groundwork for utilization of pre-operative 3-D templating as a potential method to reduce overall TSA costs by managing cost of implants, reducing inventory needs, and improving surgical efficiency.
View details for DOI 10.1177/24715492221098818
View details for PubMedID 35669622
Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review.
British journal of sports medicine
To examine the current evidence regarding return-to-play (RTP) and performance after Achilles tendon rupture in elite athletes treated with operative intervention.Scoping review.Published sources identified through a PubMed search of elite athletes, defined as professional or division one collegiate athletes in baseball, basketball, American football or soccer.Our search yielded a total of 2402 studies, with 13 studies fulfilling the study criteria of reporting elite athletes with objective measures of their athletic performance. A total of 709 elite athletes were included from the NBA, NFL, Major League Baseball (MLB), National Collegiate Athletic Association (NCAA) football and professional soccer.Overall, 61%-100% of elite male athletes RTP after Achilles tendon rupture and operative repair. NBA players had inferior performance compared with their preoperative status as well as controls of non-injured players. Studies did not show significantly different performance after Achilles injury for MLB players. Professional soccer, NFL and NCAA football studies reported varying performance after injury.Evidence suggests that sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention after Achilles rupture.
View details for DOI 10.1136/bjsports-2021-104835
View details for PubMedID 35144918
Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon.
Sports medicine and arthroscopy review
2022; 30 (1): 17-23
Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.
View details for DOI 10.1097/JSA.0000000000000335
View details for PubMedID 35113838
Arthroscopic Single and Double Row Repair of Isolated and Combined Subscapularis Tears Result in Similar Improvements in Outcomes: A Systematic Review.
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association
PURPOSE: To systematically review the literature to 1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and 2) compare outcomes following single and double row subscapularis repair in both of these settings.METHODS: A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis re-tears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis.RESULTS: The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2,406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 + 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs utilized single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in five studies comparing isolated to combined tears. Subscapularis re-tear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and re-tear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (p > 0.05 for all).CONCLUSION: Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless if tears were isolated or combined or if repairs were single or double row.
View details for DOI 10.1016/j.arthro.2021.05.032
View details for PubMedID 34052379
The Science and Biomechanics of Long-Toss.
Current reviews in musculoskeletal medicine
PURPOSE OF REVIEW: Overhead throwing is a particularly violent motion that requires a complex sequence of timed muscle activations to efficiently transfer energy up the kinetic chain to throw a ball. Long-toss has long been utilized as a means of increasing shoulder range of motion, strength, and endurance, as well as an important component of rehabilitation in interval throwing programs. The purpose of this review is to assess the current literature on the science and biomechanics of long-toss.RECENT FINDINGS: While long-toss is ubiquitously utilized in throwing programs for pitchers of all ages, the definition of long-toss, as well as its primary function in a throwing program, is debated. Throwing biomechanics in long-toss differ from that of mound pitching, although much of the variation is determined by the type of long-toss: shorter distance and on a line versus maximum distance and not on a line. Biomechanical factors including the kinematic changes of increased maximum glenohumeral external rotation, increased maximum elbow flexion, decreased trunk forward flexion at front foot contact, kinetic changes of increased shoulder internal rotation torque, increased elbow varus torque, and increased elbow extension velocity can occur with maximum distance long-toss throwing. Long-toss is a highly variable training supplement that is used in throwing programs at all levels of baseball competition. Current literature has demonstrated a number of kinetic and kinematic changes in the throwing arm and throwing motion related to increasing long-toss distances. However, the exact benefits of long-toss are difficult to quantify due to the numerous definitions and various utilizations of long-toss.
View details for DOI 10.1007/s12178-021-09706-7
View details for PubMedID 33830422
Reported Technical Aspects of Type II SLAP Lesion Repairs in Athletes.
Arthroscopy, sports medicine, and rehabilitation
2021; 3 (2): e289-e296
Purpose: To systematically review the available literature to further describe and report the available data on SLAP repair techniques and the association with outcomes.Methods: A systematic review of literature was performed on manuscripts describing type II SLAP repairs in athletes. Selection criteria included studies reporting exclusively type II SLAP tears without concomitant pathology, minimum 2-year postoperative follow-up, use of anchor fixation, and return to previous level of play data available. We extracted patient outcome as well as surgical construct details from each article. Average outcomes and return to play rates were calculated and substratified further by athlete type. Return to play rates were compared by repair constructs with the Student t test.Results: Initial search resulted in 107 articles. After exclusion criteria were applied, 17 articles were included in the final analysis. Overall, 84% of patients had good-to-excellent results. Of all athletes, 66% returned to previous level of play. There was significant variation in reported technique in terms of anchor number, location, material, suture type, and knotless versus knotted constructs. No significant difference was reported in outcomes in comparison of suture type (P-value .96) or knotted versus knotless constructs (P-value .91). Given the significant variability in reporting, no statistical analysis was felt able to be performed on anchor location and number.Conclusions: Repair of type II SLAP tears in athletes is a difficult problem to treat with overall low return to play despite a high rate of "good" outcomes when assessed by outcome measures. Significant variability exists in surgical technique, as well as reporting of surgical technique, potentially limiting the ability to define the best or most effective technique for SLAP repair.Level of Evidence: IV, systematic review of level III and level IV studies.
View details for DOI 10.1016/j.asmr.2020.09.003
View details for PubMedID 34027434
- Introduction OPERATIVE TECHNIQUES IN SPORTS MEDICINE 2021; 29 (1)
The Effect of Straight-Line Long-Toss Versus Ultra-Long-Toss Throwing on Passive Glenohumeral Range of Motion Recovery After Pitching
SPORTS HEALTH-A MULTIDISCIPLINARY APPROACH
Repetitive throwing in baseball pitchers can lead to pathologic changes in shoulder anatomy, range of motion (notably glenohumeral internal rotation deficit), and subsequent injury; however, the ideal strengthening, recovery, and maintenance protocol of the throwing shoulder in baseball remains unclear. Two strategies for throwing shoulder recovery from pitching are straight-line long-toss (SLT) throwing and ultra-long-toss (ULT) throwing, although neither is preferentially supported by empirical data.ULT will be more effective in returning baseline internal rotation as compared with SLT in collegiate pitchers after a pitching session.Cohort study.Level 3.A total of 24 National Collegiate Athletic Association Division I baseball pitchers with mean age 20.0 ± 1.1 years were randomized to either the ULT group (n = 13; 9 right-hand dominant, 4 left-hand dominant) or SLT group (n = 11; 10 right-hand dominant, 1 left-hand dominant). Measurements (dominant and nondominant, 90° abducted external rotation [ER], internal rotation [IR], and total range of motion [TROM]) were taken at 5 time points across 3 days: before and immediately after a standardized bullpen session on day 1; before and immediately after a randomized standardized ULT or SLT session on day 2; and before practice on Day 3.ULT demonstrated significantly greater final ER compared with baseline (+10°; P = 0.05), but did not demonstrate significant IR changes. Similarly, SLT demonstrated significantly greater post-SLT ER (+12°; P = 0.02) and TROM (+12°;P = 0.01) compared with baseline, but no significant IR changes. Final ER measurements were similar between ULT (135° ± 14°) and SLT (138° ± 10°) (P = 0.59). There was also no statistically significant difference in final IR between ULT (51° ± 14°) and SLT (56° ± 8°) (P = 0.27).The routine use of postperformance, ULT throwing to recover from range of motion alterations, specifically IR loss, after a pitching session is not superior to standard, SLT throwing. Based on these findings, the choice of postpitching recovery throwing could be player specific based on experience and comfort.The most effective throwing regimens for enhancing performance and reducing residual impairment are unclear, and ideal recovery and maintenance protocols are frequently debated with little supporting data. Two strategies for throwing shoulder recovery from pitching are SLT and ULT throwing. These are employed to help maintain range of motion and limit IR loss in pitchers. The routine use of ULT throwing for recovery and to limit range of motion alterations after a pitching session is not superior to SLT throwing.
View details for DOI 10.1177/1941738120980016
View details for Web of Science ID 000620309900001
View details for PubMedID 33539268
Pitch Break and Performance Metrics Remain Unchanged in Those who Returned to the Same Level of Play after Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.
Journal of shoulder and elbow surgery
The ulnar collateral ligament is commonly injured in overhead throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR.This is a retrospective case series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from PITCHf/x for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated measures ANCOVA was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between pre- and postoperative timeframes. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as starter, innings pitched as reliver, and total pitches thrown.In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to pre- or postoperative timeframes. In addition, postoperative timeframes had clinically insignificant differences in pitch performance metrics.Pitch break and performance metrics are not significantly affected for pitchers who return after UCLR.
View details for DOI 10.1016/j.jse.2021.04.036
View details for PubMedID 34015435
Outcomes After Resection Arthroplasty Versus Permanent Antibiotic Spacer for Salvage Treatment of Shoulder Periprosthetic Joint Infections: A Systematic Review and Meta-Analysis.
Journal of shoulder and elbow surgery
Although revision to new components is favored following shoulder periprosthetic joint infections (PJI), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs.A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of 0.05 was set as significant.The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37 to 78.5 years, mean MINORS score 9.6 + 0.7) were included and analyzed. The pooled infection eradication rate was 82% [72% - 89%] following resection arthroplasty and 85% [79% - 90%] after permanent antibiotic spacer. The pooled mean forward flexion (71.5˚ versus 48.7˚; p < 0.001) and mean American Shoulder and Elbow Surgeons (ASES) score (53.5 versus 31.0; p < 0.001) was significantly higher for patients treated with permanent antibiotic spacer compared to resection arthroplasty. No significant differences were found for mean external rotation (13.5˚ versus 20.5˚; p = 0.07), abduction (58.2˚ versus 50.3˚; p = 0.27), or visual analog scale (VAS) pain (3.7 versus 3.4; p = 0.24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 versus 30.0; p < 0.001).When implant exchange following shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures which provide similar rates of infection eradication. Though both can decrease pain levels, permanent antibiotic spacer may result in better functional outcomes compared to resection arthroplasty.
View details for DOI 10.1016/j.jse.2021.10.016
View details for PubMedID 34774777
Comparison of mechanical properties between Nice knot, Modified Nice knot, and surgeon's knot.
Clinical biomechanics (Bristol, Avon)
2021; 90: 105486
The success of surgical repairs rely on the effectiveness and integrity of the surgical knots used to secure the repair. The purpose of this study is to examine and compare the performance of the Nice knot, the modified Nice knot, and a commonly used combination of surgeons' and square knots with respect to cyclic loading and load-to-failure usiflueng a high-strength suture composed of ultra-high molecular weight polyethylene in the hands of experienced surgeons.Two experienced surgeons threw 3 different knot types 9 times, consisting of the Nice knot, modified Nice knot, and a surgeon's knot utilizing Ultrabraid #2 sutures. Each knot was subject to cyclic loading and load to failure testing.Both surgeons had similar displacement data for the surgeon's knot, while the identity of the surgeon impacted displacement for the Nice knot (p = 0.03) and the modified Nice knot (p = 0.0002). The load to failure for the modified Nice knot (p < 0.001) and the Nice knot (p = 0.001) were significantly impacted by the surgeon tying the knot, while the surgeon's knot was not. Specimens failed where the sutures passed through the loop at the "base" of the knot.The strength and integrity of complex surgical knots are variable between surgeons. While the proposed Modified Nice Knot has a theoretical advantage because the half hitches reinforce the primary knot, in load to failure testing both the Modified Nice Knot and the Nice Knot failed where the suture passed through the loop in the primary knot.
View details for DOI 10.1016/j.clinbiomech.2021.105486
View details for PubMedID 34560347
Pain Management in Shoulder Arthroplasty: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.
Journal of shoulder and elbow surgery
Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials (RCTs) reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use.A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-II RCTs that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, or other modalities. The two primary outcome measures were pain level measured on a 0-10 visual analog scale (VAS) and opioid use. The risk of study bias and methodological quality was analyzed using the Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for pain VAS at post-surgical timepoints and opioid use using a frequentist approach and random effects model, with heterogeneity quantified using the I2 statistic. Treatments were ranked using the P-score, and statistical significance was set at p < 0.05.The initial search yielded 2391 articles (695 duplicates, 1696 screened, 35 full-text review). Eighteen articles (1358 shoulders; 51% females; mean age range 65 to 73.7 years; four low risk, 12 some risk, and two high risk of bias studies) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) (p < 0.001 for 4 and 8 hours) or local ropivacaine injection (p < 0.001 for 4 hours; p = 0.019 for 8 hours) had significantly more pain compared to patients who received either a continuous (cISB) or single-shot interscalene block (ssISB). No differences (at p<0.05) in opioid use were detected between modalities. P-scores of treatments demonstrated that ssISBs were most favorable at timepoints <24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of ssISB with local LB injection.ISBs are superior to local injection alone at managing pain after TSA. ssISBs are optimal for reducing early postoperative pain (< 24 hours), whereas pain at 24 to 48 hours after surgery may be best managed with cISBs or a combination of ssISBs with local LB injection.
View details for DOI 10.1016/j.jse.2021.06.008
View details for PubMedID 34284094
Superior Capsular Reconstruction: A Systematic Review of Surgical Techniques and Clinical Outcomes.
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association
PURPOSE: To evaluate surgical techniques and clinical outcomes for arthroscopic superior capsular reconstruction (SCR) for treatment of massive irreparable rotator cuff tears.METHODS: A systematic review was registered with PROSPERO and performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane databases were searched. Studies investigating SCR with reported surgical technique were included. Animal studies, cadaveric studies, review studies, and letters to the editor were excluded. Technical aspects of surgical technique for SCR were analyzed in each article, which included: graft type, glenoid fixation method, greater tuberosity fixation method, graft passage technique, suture management, margin convergence, concomitant procedures, and post-operative rehabilitation protocol. Clinical outcomes, when available, were also analyzed.RESULTS: Three hundred sixty-five articles were screened with 29 found that described surgical technique for SCR. According to the Modified Coleman Methodology Score, 24 articles were poor (scores <55), 4 were fair (scores between 55 and 69), and 1 was good (scores between 70 and 84) with an average score of 25.8 ± 20.9. The most commonly used technique for SCR utilized: acellular dermal allograft, two biocomposite suture anchors for glenoid fixation, transosseus equivalent double-row suture anchor fixation for greater tuberosity fixation with two biocomposite medial row anchors and two biocomposite lateral row anchors, double-pulley technique combined with an arthroscopic grasper and/or pull suture to pass the graft into the shoulder, performance of both anterior and posterior margin convergence, and native rotator cuff repair when possible. Only 8 of the studies reported clinical outcomes, and they showed that SCR provides significant improvement in patient-reported outcomes, significant improvement in shoulder ROM, variable graft failure rates, low complication rates, and variable reoperation rates. There were no studies comparing outcomes between the various surgical techniques.CONCLUSIONS: Many surgical techniques exist for arthroscopic SCR. However, no superior technique was demonstrated, as there were no studies comparing clinical outcomes among these various techniques.
View details for DOI 10.1016/j.arthro.2020.09.016
View details for PubMedID 33227320
Quantifying Throw Counts and Intensities Throughout a Season in Youth Baseball Players: A Pilot Study.
Journal of biomechanical engineering
Overuse injuries in youth baseball players due to throwing are at an all-time high. Traditional methods of tracking player throwing load only count in-game pitches and therefore leave many throws unaccounted for. Miniature wearable inertial sensors can be used to capture motion data outside of the lab in a field setting. The objective of this study was to develop a protocol and algorithms to detect throws and classify throw intensity in youth baseball athletes using a single, upper arm-mounted inertial sensor. Eleven participants from a youth baseball team were recruited to participate in the study. Each participant was given an inertial measurement unit and was instructed to wear the sensor during any baseball activity for the duration of a summer season of baseball. A throw identification algorithm was developed using data from a controlled data collection trial. In this report, we present the throw identification algorithm used to identify over 17,000 throws during the 2-month duration of the study. Data from a second controlled experiment was used to build a support vector machine model to classify throw intensity. Using this classification algorithm, throws from all participants were classified as being "low," "medium," or "high" intensity. The results demonstrate that there is value in using sensors to count every throw an athlete makes when assessing throwing load, not just in-game pitches.
View details for DOI 10.1115/1.4049025
View details for PubMedID 33156351
Optimizing the Double-Row Construct: An Untied Medial Row Demonstrates Equivalent Mean Contact Pressures in a Rotator Cuff Model
ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE
2020; 8 (4): 2325967120914932
The merits of a double-row rotator cuff repair (RCR) construct are well-established for restoration of the footprint and lateral-row security. The theoretical benefit of leaving the medial row untied is to prevent damage to the rotator cuff by tissue strangulation, and the benefit of suture tape is a more even distribution of force across the repair site. These benefits, to our knowledge, have not been evaluated in the laboratory.Leaving the medial row untied and using a suture bridge technique with suture tape will offer more even pressure distribution across the repair site without compromising total contact force.Controlled laboratory study.A laboratory model of RCR was created using biomechanical research-grade composite humeri and human dermal allografts. The pressure distribution in a double-row suture bridge repair construct was analyzed using the following testing matrix: double-loaded suture anchors with the medial row tied (n = 15) versus untied (n = 15) compared with double-loaded suture tape and anchors with the medial row tied (n = 15) versus untied (n = 15). A digital pressure sensor was used to measure pressure over time after tensioning of the repair site. A multivariate analysis of variance was used for statistical analysis with post hoc testing.The total contact force did not significantly differ between constructs. The contact force between double-loaded suture anchors and double-loaded suture tape and anchors was similar when tied (P = .15) and untied (P = .44). An untied medial row resulted in similar contact forces in both the double-loaded suture anchor (P = .16) and double-loaded suture tape and anchor (P = .25) constructs. Qualitative increases in focal contact pressure were seen when the medial row was tied.An untied medial row did not significantly affect the total contact force with double-loaded suture anchors and with double-loaded suture tape and anchors. Tying the medial row qualitatively increased crimping at the construct's periphery, which may contribute to tissue strangulation and hinder clinical healing. Qualitative improvements in force distribution were seen with double-loaded suture tape and anchors.Both tied and untied medial rows demonstrated similar pressures across the repair construct.
View details for DOI 10.1177/2325967120914932
View details for Web of Science ID 000535799900001
View details for PubMedID 32426405
View details for PubMedCentralID PMC7218996
Thrower's Exostosis of the Shoulder: A Systematic Review With a Novel Classification.
Orthopaedic journal of sports medicine
2020; 8 (7): 2325967120932101
A variety of thrower's exostoses are grouped under the term Bennett lesion, which makes understanding diagnosis and treatment difficult.To identify all types of reported thrower's and overhead athlete's exostoses and categorize them into a classification system to allow a morphology-based classification.Systematic review; Level of evidence, 4.A systematic review of all articles pertaining to Bennett lesions and thrower's exostosis was performed. The classification and treatments were evaluated to describe the types, proposed causes, diagnosis, and treatment options.A total of 27 studies were included in the systematic review. The anatomic locations referenced in the study demonstrated posteroinferior, posterior, and posterosuperior glenoid lesions. Aggregate radiographic data demonstrated 158 of 306 patients (52%) with a thrower's exostosis of any type and location. Of these 158 patients with a radiographic lesion, 119 (75%) patients were symptomatic. The locations were posteroinferior in 110 patients (70%), directly posterior in 2 patients (1.3%), posterosuperior in 44 patients (28%), and unknown in 2 patients (1.3%). Avulsed lesions were present in 9 (5.7%) posteroinferior lesions, 0 direct posterior lesions, and 2 (1.3%) posterosuperior lesions. Treatment plans included both nonoperative and operative strategies, but operative intervention was more commonly reported for detached lesions. After operative intervention, only 61% of reported athletes returned to preinjury performance.Based on a comprehensive review of the literature, we identified several anatomic locations for a thrower's exostosis beyond the classic Bennett lesion. We categorized the reported exostoses into a new classification system for description of location and type (subperiosteal or free fragment) of the thrower's exostosis, which may be used to study future treatments. Current treatment strategies recommend that surgical treatment of thrower's exostosis is considered only after exhausting nonoperative management because reported return to sport is variable after surgery. The effectiveness of excision or repair for both subperiosteal and detached lesions has not been established.
View details for DOI 10.1177/2325967120932101
View details for PubMedID 32704507
View details for PubMedCentralID PMC7361505
Osseous Healing With Nonrigid Suture Fixation in the Arthroscopic Latarjet Procedure.
Orthopaedic journal of sports medicine
2020; 8 (11): 2325967120964489
The Latarjet procedure is a popular means to surgically address anterior glenohumeral joint instability. Although the Latarjet procedure is becoming increasingly common, challenges persist and include postoperative complications secondary to use of the conventional 2 bicortical fixation screws. Recently, a novel surgical technique using a guided surgical approach for graft positioning with nonrigid fixation via a suture suspensory system has been described.To evaluate healing rates and stability of the grafts in patients who underwent this new Latarjet technique.Case series; Level of evidence, 4.We retrospectively gathered anonymized computed tomography (CT) data sets from a total of 107 patients who underwent nonrigid suture fixation using a cortical button fixation for anterior glenohumeral instability. Of the 107 patients, 45 had CT scans performed at 2 different time periods. The CT scans of each patient were compared by 2 fellowship-trained musculoskeletal radiologists. Data recorded included age, sex, date of scan, initial graft position on the glenoid, presence and degree of graft migration relative to the equator on follow-up scan, and percentage of osseous healing (as assessed by osseous bridging) on the follow-up scan. Descriptive statistics were calculated to evaluate the average migration and average percentage of healing at both time points.Our population (n = 45) consisted of 38 men (84.4%) and 7 women (15.6%). The mean age was 27.1 ± 1.1 years. The mean time between initial CT scan (2 weeks postoperatively) and follow-up CT scan was 26 ± 2 weeks. On follow-up scan, reviewer 1 found 75.6% of patients had greater than 75% healing, and reviewer 2 found 70.2% of patients had greater than 75% healing. The center of the graft was measured at or below the equator on follow-up examination in 43 of 45 (95.6%) patients by reviewer 1 and 44 of 45 (97.8%) patients by reviewer 2.Based on these findings, nonrigid suture fixation using a cortical button device offers an effective alternative to traditional screw fixation for the Latarjet procedure with a high level of osseous healing and minimal graft migration.
View details for DOI 10.1177/2325967120964489
View details for PubMedID 33244477
View details for PubMedCentralID PMC7678400
Outcomes Evaluation of the Athletic Elbow
SPORTS MEDICINE AND ARTHROSCOPY REVIEW
2014; 22 (3): E25-E32
The high-level athletic population poses difficulty when evaluating outcomes in orthopedic surgery, given generally good overall health and high function at baseline. Subtle differences in performance following injury or orthopedic surgery are hard to detect in high-performance athletes using standard outcome metrics; however, attaining these subtle improvements after injury or surgery are key to an athletes' livelihood. Outcome measures serve as the cornerstone for critical evaluation of clinical outcomes following orthopedic surgery or injury. In the age of "evidence-based medicine" and "pay-for-performance" accountability for surgical intervention, understanding clinically relevant outcome measures is essential for careful review of the published literature, as well as one's own critical review of surgical performance. The purpose of this manuscript is to evaluate clinical outcome measures in the context of the athletic elbow. An emphasis will be placed on evaluation of the 5 most clinically relevant outcome measures for sports-related elbow outcomes: (1) American Shoulder and Elbow Committee; (2) Mayo Elbow Performance Index; (3) Andrews-Timmerman [and its precursor the (4) Andrews-Carson]; and (5) Kerlan-Jobe Orthopaedic Clinic overhead athlete score. A final outcome measure that will be analyzed is "return to play" statistics, which has been published in various studies of athletes' recovery from elbow surgery, as well as, the outcomes metric known as the "Conway-Jobe scale." Although there is no perfect outcomes score for the athletic elbow, the Kerlan-Jobe Orthopaedic Clinic score is the only outcomes tool developed and validated for outcomes for elbow injuries in the overhead athlete, as compared with the Andrew-Timmerman and Conway-Jobe metrics, which were not validated outcome measures for the elbow in this patient population. Despite the Disabilities of Arm, Shoulder, Hand (DASH) (and DASH-Sport module) being validated in the general population, this upper extremity scale is not specific for elbow function.
View details for Web of Science ID 000340731700004
View details for PubMedID 25077753
Biomechanical evaluation of a coracoclavicular and acromioclacicular ligament reconstruction technique utilizing a single continuous intramedullary free tendon graft.
Journal of shoulder and elbow surgery
2013; 22 (7): 979-985
Reconstruction of only the coracoclavicular (CC) ligaments may restore superior-inferior (S-I) but not anterior-posterior (A-P) stability of the acromioclavicular (AC) joint. Concomitant reconstruction of both the AC and CC ligaments may more reliably restore intact biomechanical characteristics of the AC joint.Ten matched pairs of shoulders were utilized. Five specimens underwent CC ligament reconstruction while an equal number underwent combined AC and CC ligament reconstruction utilizing an intramedullary tendon graft. Each of the reconstructions was compared with the intact contralateral control. Translational and load to failure characteristics were compared between groups.No difference was found in S-I translation between intact specimens and CC-only reconstructions (P = .20) nor between intact specimens and AC/CC reconstructions (P = .33) at 10 Newton (N) loads. Significant differences were noted in A-P translation between intact specimens and CC-only reconstructions (P < .001) but no difference in A-P translation between intact specimens and AC/CC reconstructions (P = .34).The A-P and S-I translational biomechanical characteristics of the AC joint were restored using the new technique described. Reconstruction of the CC ligaments only (versus AC/CC combined) led to significantly increased translational motion in the A-P plane as compared to intact control specimens.
View details for DOI 10.1016/j.jse.2012.09.013
View details for PubMedID 23313367
Diagnosis and Management of Ulnar Collateral Ligament Injuries in Throwers
CURRENT SPORTS MEDICINE REPORTS
2011; 10 (5): 271-278
Although ulnar collateral ligament (UCL) injuries are reported most commonly in baseball players (especially in pitchers), these also have been observed in other throwing sports including water polo, javelin throw, tennis, and volleyball. This article reviews the functional anatomy and biomechanics of the UCL with associated pathophysiology of UCL injuries of the elbow of the athlete participating in overhead throwing. Evaluation, including pertinent principles in history, physical examination, and imaging modalities, is discussed, along with the management options.
View details for DOI 10.1249/JSR.0b013e31822d4000
View details for Web of Science ID 000294685000005
View details for PubMedID 23531973
The Labrum of the Hip: Diagnosis and Rationale for Surgical Correction
CLINICS IN SPORTS MEDICINE
2011; 30 (2): 293-?
The treatment of labral pathologic condition of the hip has become a topic of increasing interest. In patients undergoing hip arthroscopy, tears of the acetabular labrum are the most commonly found pathologic condition and most common cause of mechanical symptoms. Although a labral tear may occur with a single traumatic event, often another underlying cause may be already present, predisposing the individual to injury. This article discusses the structure and function of the acetabular labrum, the diagnosis of labral injury through physical examination and imaging modalities, and the current treatment options, including labrectomy, labral repair, and reconstruction.
View details for DOI 10.1016/j.csm.2010.12.002
View details for Web of Science ID 000289811500007
View details for PubMedID 21419957