The Baseball Elbow

Picture reprinted from: Daniel J, Getty Images. Stephan Strasburg and the Tommy John elbow. Bleacher Report. http://bleacherreport.com/articles/1672080-dr-frank-jobe-tommy-john-and-the-surgery-that-changed-baseball-forever. Published July 17,2013. Accessed April 20, 2017.

The Baseball Pitcher’s Elbow

Lauren Kozar, SPT

Background

A continuing education course that I attended at the Hospital for Special Surgery’s 10^th Annual Sports Medicine Symposium on the upper extremity in baseball pitchers inspired this project.  During the conference, top-tiered sports medicine physicians that specialized in the treatment of professional baseball pitchers discussed a new surgical technique, known as the Docking Procedure, for the treatment of ulnar collateral ligament (UCL) tears in elite baseball pitchers. As a retired softball pitcher, whose coach was a long-term baseball pitcher for the Kansas City Royals, I have always enjoyed learning about upper extremity injuries that are common amongst baseball and softball pitchers. I have also had a significant number of upper extremity injuries secondary to softball pitching over the course of my athletic career, and in turn, have developed an even deeper interest in this topic. Upon graduation from the University of North Carolina’s Doctorate of Physical Therapy program, I plan to earn a position as a physical therapist in a sports medicine clinic, and I intend to pursue continuing education courses that enable me to specialize in the treatment of upper extremity injuries in the athletic population.

Considering my deep love for sports medicine physical therapy and upper extremity baseball injuries, a significant rise in the prevalence rate of UCL tears amongst baseball pitchers, and recent changes in surgical techniques for UCL reconstruction I decided to develop an educational presentation for the physical therapy staff at Loudoun Sports Therapy Center (my final clinical rotation) that critically assessed the baseball pitcher’s elbow using the best available evidence to date on the anatomy and biomechanics of the elbow joints, pitching mechanics, UCL prevention, UCL diagnosis, treatment options, prognoses for said treatment options, and rehabilitation guidelines including return to play protocols and pitch counts, while also discussing the need for future research on the before mentioned topics.

Project Purpose

Baseball is the second-most popular sport in the United States (US), second only to football, so there is a very high chance that I, in addition to fellow sports medicine physical therapists, will encounter a number of baseball players experiencing upper extremity injuries throughout our physical therapy careers.¹ In fact, there are approximately 15 million baseball players in the United States,² 868 of which are Major League Baseball players and about 5.7 million are children in the 8^th grade or younger.^2,3  Approximately 25-30 Major League Baseball pitchers undergo Tommy John surgery per year, 15% of minor league pitchers experience Tommy John surgery per year, and although “accurate numbers are difficult to find regarding amateur athletes, anecdotal evidence suggests that younger pitchers are undergoing the procedure at an unprecedented rate.”⁴  Considering the large number of baseball players in the US and the relatively high rate of UCL tears in baseball pitchers, sports medicine physical therapists should anticipate providing care for a large number of baseball patients that have sustained UCL injuries. Thus, it is imperative for our professional development and the treatment of our patients that we have a solid understanding of the clinical presentation of UCL tears, in addition to the most successful treatment options and the best return to play protocols as supported by evidence.

Due to recent changes in surgical techniques and rehab protocols in the treatment of UCL tears, I developed a capstone project that critically assesses the baseball pitcher’s elbow by delving deep into the anatomy and biomechanics of the elbow joints, pitching mechanics, UCL injury prevention, UCL injury diagnosis, treatment options, prognoses for said treatment options, and rehabilitation guidelines including return to play protocols and pitch counts, while also discussing the need for future research on the before mentioned topics.

After conducting a Critically Appraised Topic for the University of North Carolina Doctorate of Physical Therapy Course: Evidenced Based Practice II, I realized there is very limited research on pitching performance following UCL reconstruction. The research is even more limited when trying to find studies that compare the post-operative results for different surgical techniques.  Thus, the overall purpose of my capstone is to provide fellow sports medicine therapists with a more thorough understanding of the baseball pitcher’s elbow, placing added emphasis on new information regarding the treatment of UCL tears in baseball pitchers, in conjunction with information regarding current gaps in literature, in hopes that the presentation will spread awareness about the lack of information on pitching performance post UCL reconstruction and will spark future studies on this topic.

This information will be presented via a PowerPoint presentation to the staff at Loudoun Sports Physical Therapy Center in Northern, VA during the week of July 24^th,2017. Loudoun Sports Physical Therapy Center offers orthopedic and sports physical therapy services, in conjunction with return to play and sports performance programs. This capstone will be ideal for this facility because it will provide them with the most up to date information needed to design the most successful post-operative UCL reconstruction rehabilitation programs and return to play progressions. It will also benefit their sports performance program, which is designed to help athletes play better and to prevent common sports injuries, because the information in this project will also discuss the best prevention strategies for UCL tears as supported by current evidence. Each member of the facility will also be provided with a handout of the presentation’s key information, including the new rehabilitation guidelines; however, the handout will emphasize the need to make changes to said guidelines based on individual differences and needs amongst patients.  They will also be provided with a handout that contains pitch count guidelines, which can be provided to coaches, parents, and younger pitchers that are seen in the clinic. I received permission from my soon-to-be clinical instructor, Devin Wurman, to proceed with this project. According to Devin, the information included in this presentation will benefit the clinical practice of her fellow orthopedic physical therapists.

Capstone Products

• An educational PowerPoint presentation designed for physical therapists on the baseball pitcher’s elbow
• A Physical Therapist Guide to the Baseball Pitcher’s Elbow
• A Baseball Pitch Count Handout for coaches, parents, and youth baseball athltetes
• A presentation Evaluation Form that will be administered to the physical therapists at Loudoun Sports Therapy Center

Associated Work:

In the fall of 2016, I developed a Critically Appraised Topic (CAT) that assessed the effects of two different UCL reconstruction techniques (the Docking Procedure and Tommy John Surgery) on the pitching performance statistics of 27 year old Major League Baseball Pitchers. This assignment, which served as the starting point for my capstone project, provided me with knowledge and skills needed to properly conduct a literature search and to effectively and efficiently appraise studies.  The CAT also provided me insight regarding UCL reconstruction outcomes in professional baseball pitchers, while helping to identify gaps in current literature regarding UCL reconstruction outcomes.

PowerPoint Evaluation to “Avoid Death by PowerPoint”

Prior to beginning my project, I reviewed the two part chapter on designing effective instruction from Plack and Driscoll (eds) Teaching and Learning in Physical Therapy: From Classroom to Clinic (2011) in order to gain a better understanding on how to develop project objectives, on what issues to consider in thinking about content and learning activities, and on how to develop a quality assessment tool for a presentation.⁵ When developing my project objectives I made it a point to remember that the audience (physical therapists in a sports medicine clinic) will want to know what they are expected to learn, how the learning will occur (PowerPoint presentation and handouts) and how it will be evaluated (9-item evaluation form handed out prior to the presentation), and why it is important for them to learn what I am teaching (there is a newly developed UCL reconstruction technique that was introduced at the Hospital for Special Surgery’s 10^th Annual Sports Medicine Symposium in the spring of 2016 that is becoming more common; however, most therapists are unaware of the new technique).⁵

What I felt was most helpful from this section of the book on “What adult learners want to know,” is that you need to base your project around the needs of your learners.⁵  In doing so, your audience will be more motivated, and you will have greater success with your presentation.⁵ Thus, I ran my project proposal by the rehabilitation director, Devin Wurman, at the Loudoun Sports Therapy Center, which is where I intend to present my capstone project during the summer of 2017.  Devin stated that there was a definite need for this in-service because her staff has not received any information on this new technique, and she agreed that a physical therapist guide and patient handout would be extremely beneficial to her clinic.

In regards to the development of the PowerPoint presentation, I decided to refrain from reviewing the online resources and their recommendations on how to properly develop a presentation until I had a significant portion of my draft completed. My goal in doing so was to allow myself time to reflect on my project and to determine my areas for improvement in the construction of presentations so that I can enhance these skills during future work. After I reviewed the online documents and evaluated my draft presentation, I noticed I had a tendency to include significantly too much verbiage on each slide.⁵  Not only were the slides very busy, but the PowerPoint template I selected was rather plain.  These characteristics can make it hard to maintain the audience’s attention, so I spent countless hours cutting out the “nice to know” information, while retaining and consolidating the information that is imperative to my presentation. I also added in colorful diagrams and pictures to a majority of the slides.⁵  The chapter also recommended the addition of a slide or activity that engaged the audience at least once every twenty minutes.⁵  Unfortunately, both my draft and final product do not meet this recommendation. I felt there was far too much information that needed to be discussed that the inclusion of audience activities fell to the back burner.  After reflecting on my project, this is the one aspect that I wish I had done differently. Thus, when developing future presentations, I will make a concerted effort to enhance audience engagement because I know how important this is to maintain the audience’s attention to enhance learning.

Self-Reflection

Overall, this assignment was an amazing learning opportunity.  I thoroughly enjoyed applying the evidenced based practice and critical appraisal skills that I acquired and enhanced when developing my Critically Appraised Topic during the fall of 2016.  I have always learned best when I have the opportunity to apply the foundational skills I learn in class to real life situations, and this project allowed me to do just that.  Throughout the course of the semester, I felt as though I did an excellent job adhering to the project timeline that I developed in the first week of class, and I always allowed ample time for my project committee members to evaluate my project materials and to return feedback forms and any additional recommendations that they felt would further enhance my PowerPoint presentation and educational resources. I was open to any form of communication, and tried my best to make the process as stress free as possible for my capstone committee.

If I were to do this process again, I would review the resources provided in class on how to most effectively create a PowerPoint presentation prior to developing the PowerPoint.  As previously mentioned, I decided to refrain from reviewing any presentation resources until I completed my PowerPoint, with the intention of using the resources as an evaluation tool to identify my strengths and weaknesses in the development of presentations.  Although I achieved my goal, it resulted in over twenty eight hours of editing, which may have been avoided had I reviewed the materials earlier on in the process. I would also attempt to incorporate more activities that engaged the audience in order to maintain their attention and enhance learning throughout the course of the presentation.

Acknowledgments

I would first like to thank my advisor, Dr. Mike Gross (PT, PhD, FAPTA) for his guidance, support, and very timely feedback throughout the entire capstone experience.  He was always readily available to offer advice and to answer any questions I had on the project.  He was also very influential on the development of the Baseball Pitch Count Handout, suggesting I develop some form of a guide to provide to coaches, parents, and youth baseball pitchers.  Next, I would like to thank my amazing committee members Devin Wurman (DPT), Michael McMorris (PT, DPT, OCS), and Jon Hacke (PT, DPT, MA, OCS). Devin Wurman is a full time clinician and Director of Rehabilitation at the Loudoun Sports Therapy Center in Sterling, Va.  Despite her busy schedule, Devin was readily available to communicate, and she always gave her undivided attention when reviewing my capstone products. She has been an extremely beneficial asset to my project, and I am eternally grateful for her time and efforts.  Michael McMorris and Jon Hacke are both Doctorate of Physical Therapy professors at the University of North Carolina – Chapel Hill and part-time clinicians. Despite their demanding schedules, they too have devoted their time and energy to helping me develop a polished product that I am proud to share with my fellow physical therapists and physical therapy students. Not only have they served as valuable resources throughout the development of this project, but they have been amazing mentors over the past 3 years that have further fostered my love for sports physical therapy. Thank you to you all!

References 

1. Snyder M. Poll finds baseball second most popular American sport. CBS Sports. http://www.cbssports.com/mlb/eye-on-baseball/21511690/poll-finds-baseball-as-secondmost-popular-american-sport. Published January 7, 2013. Accessed August 29, 2016.
2. Fleisig G, Andrews J, Cutter G, Weber A, Loftice J, McMichael C, Hassell N, Lyman S. Risk of Serious Injury for Young Baseball Pitchers A 10-Year Prospective Study. American Sports Medicine Institute. 2012; 4(5):419-424.
3. MLB Staff. Opening day rosters feature 230 players born outside the U.S. com. http://m.mlb.com/news/article/116591920/opening-day-rosters-feature-230-players-born-outside-the-us/. Published April 6, 2015. Accessed August 29, 2016.
4. Andrews. Tommy John FAQ. Pitch Smart USA. http://m.mlb.com/pitchsmart/tommy-john-faq. Updated February 12, 2016. Accessed August 29, 2016.
5. Plack M, Driscoll M. Teaching and Learning in Physical Therapy: From Classroom to Clinic. 1^st Thorofare, NJ: Slack Incorporated; 2011.