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Elbow injuries in throwing athletes: UCL pathology & reconstruction, medial epicondylitis, and considerations for return-to-play protocols.

194 citationsUpdated Oct 2026

Overview¶

Athletes with femoroacetabular impingement can expect to return to sports with proper recognition and treatment, though long-term implications of high-level activities must be considered [1]. For skeletally immature throwing athletes, appropriate intervention and a thorough understanding of injury prevention guidelines allow timely recovery and return to sport participation with minimal long-term effect [3]. Current evidence does not support early sport specialisation as a reliable predictor of long-term athletic success, as the majority of successful senior athletes were not standouts as youths [5].

Operative decision-making for ulnar collateral ligament injuries should be based on patient sport and level of competition to optimize return to sport and minimize complication and reinjury risk [98]. Professional athletes and those with complete ulnar collateral ligament tears were indicated for surgery by consensus, while opinion was more divided on how to treat partial ulnar collateral ligament tears or nonprofessionals [43]. In patients for whom repair is properly indicated, ulnar collateral ligament repair provides similar return-to-sport rates and clinical outcomes compared with reconstruction, with shorter return-to-sport timing [123]. Ulnar collateral ligament reconstruction using a cortical button suspension technique demonstrated a high rate of return to sport of 82.6% and good functional outcomes [42].

The definitive decision for return to sports after ACL reconstruction should be based on patient-related and sports-demand factors rather than time alone, as most athletes were not ready for a safe return 8 months postoperatively [29]. Return to competitive sport after meniscal allograft transplantation is associated with excellent graft survival and superior long-term outcomes, with no evidence of increased failure [25]. Athletes undergoing meniscal allograft transplantation had significant improvements in most outcome measures [11]. Surgery is indicated for athletes with core muscle injury producing groin pain who fail nonsurgical management to allow return to sport [38]. Cell-based therapies and regenerative medicine offer safe and potentially efficacious treatment for sports-related musculoskeletal injuries, although more clinical evidence is necessary to define the indications and parameters for their use [39].

Anatomy & Pathophysiology¶

Bony Anatomy¶

The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that afford bony stability [111]. The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [111]. This joint provides highly congruent anatomy through almost 180° of articular contact, with the exception of a bare area on the greater sigmoid notch devoid of cartilage [111]. The trochlea has a 300-degree arc of cartilage [131] and is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [143]. The olecranon fossa and coronoid fossa are separated by a thin bony septum which is occasionally absent [143]. The radiocapitellar joint is formed by the articulation of the capitellum and the radial head [111]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [111]. The proximal radioulnar joint holds the radius in close approximation to the ulna via the annular ligament [111].

The distal humeral articulation is angled 30° from the longitudinal axis of the humerus [111] and 30 degrees anterior to the humeral shaft axis [129]. The axis of rotation of the distal humerus is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side more distal than the lateral side [111]. The distal humerus consists of medial and lateral columns [129]. The medial column diverges from the humeral shaft at a 45-degree angle in the coronal plane [131], while the lateral column diverges from the humeral shaft at a 20-degree angle in the coronal plane [131]. The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [111]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [111]. The radial head should line up with the capitellum at all arm positions on all radiographic views [118]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [129].

Ligamentous Anatomy¶

Elbow stability is determined by primary stabilizers (ulnohumeral articulation, MUCL, LUCL) and secondary stabilizers (radiocapitellar articulation, common flexor tendon, common extensor tendon, joint capsule) [46]. The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus stress within functional elbow range of motion [129]. It originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [129]. The anterior bundle of the MUCL is the strongest component and provides reciprocal function with the anterior band tight in extension and the posterior band tight in flexion [104]. The posterior bundle of the MUCL is the primary restraint to valgus stress with the elbow in maximal flexion [129].

The lateral collateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), and the annular ligament [143]. The LUCL arises from an isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [143]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [143]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [143]. The LCL complex functions as an important restraint to varus and posterolateral rotatory instability [143]. Tensile forces are present at the medial elbow, while compressive forces are present at the lateral elbow [118]. The capsule allows maximum distension at approximately 70 to 80 degrees of flexion [118]. The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [118]. Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [118]. The ligament of Struthers is a variant anatomy arising from the supracondylar process to attach to the medial epicondyle and is a potential site of median nerve compression [118].

Muscular Anatomy¶

The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [118]. The biceps brachii inserts at the ulnar margin of the radial tuberosity and is a powerful supinator of the forearm [118]. The triceps is the primary elbow extensor and inserts on the olecranon process [118]. The triceps has three distinct insertional areas to the olecranon: posterior capsular insertion, deep muscular portion, and superficial tendinous portion [104]. The deep muscular head of the triceps corresponds to the medial head, while the tendinous portion corresponds to the long and lateral heads [104]. The width of the triceps insertion is 2.6 cm and is located 1.1 cm from the tip of the olecranon [104]. The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [118]. The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [118].

Range of Motion¶

The normal elbow has a range of motion from 0° to 140° from extension to flexion [46] and from 0 to 150 degrees in flexion/extension [129]. Normal forearm pronation is 75° and supination is 85° [46], with normal forearm pronosupination being 80 to 85 degrees in each direction [129]. A functional arc for elbow flexion and extension is 100° [46], and a functional arc for forearm rotation is 50 degrees [129]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [129]. Functional elbow range of motion necessary for activities of daily living may be greater than previously reported [242].

Biomechanics & Pathophysiology¶

Understanding the biomechanics of the elbow during sports activities helps physicians understand injury mechanisms and minimize risk [114]. Elbow loads in throwing or serving are not generated or regulated solely by local muscles and ligaments; distant body segments generate forces and regulate loads [224]. Pitching with fatigue may cause biomechanical changes associated with increased rates of elbow injury in the adult throwing population [170]. Elbow and shoulder kinetics increase with time, particularly after age 13 in youth baseball pitchers [172]. Pitch velocity is the most influential variable in predicting elbow and shoulder stress, though pitching mechanics also significantly influence these stresses [173]. Normalized elbow varus torque is associated with ball velocity and 10 other kinematic parameters in elite adult baseball pitchers [185]. Elbow valgus can be predicted based on 4 parameters of pitching mechanics [189]. Forearm position is not associated with the elbow varus moment, but the supination moment is associated with the elbow varus moment [207]. Valgus torque at the elbow during baseball pitching is associated with 6 biomechanical variables of sequential body motion [210]. Shoulder flexibility, arm speed, and elbow varus torque are interrelated and should be considered collectively when treating pitchers [241]. Pitchers with increased dynamic elbow laxity experience reduced medial elbow torque while pitching [243]. Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity in high school baseball players [252]. Elbow flexion strength and forearm supination strength differ between the dominant and nondominant sides [245]. Both elbow varus torque and swing velocity are greatest when swinging to the outside location during baseball hitting [239].

The kinematics in arm tackle and head-in-front rugby tackles are significantly different from shoulder tackles and may represent a distinct risk factor for shoulder dislocation [238]. Injury mechanisms in extreme sports are less understood than in traditional sports, with higher injury rates seen in new/inexperienced athletes and experienced extremists [6]. Injury rates increase during competitions rather than training in extreme sports, a trend also recognized in common team sports [6]. Sport injury profiles and rates often differ by sex/gender, and injury outcomes are often worse in female, woman, and/or girl athletes [26]. Biological differences and the interaction of sex/gender with sport context may drive disparities in injury risk and outcomes between female and male athletes [26]. A child athlete is not a small adult; children have open physes, are less coordinated, have poorer mechanics, and have less efficient thermoregulatory mechanisms than adults [272]. The female athlete triad—amenorrhea, disordered eating, and osteoporosis—places the female athlete at higher risk of insufficiency or stress fractures, overuse injuries, and recurrent injuries [272]. The female knee becomes more susceptible to injury at puberty due to differences in anatomy, sex hormone levels, neuromuscular control, and overall strength and coordination [272].

Prior injury or surgery is a known risk factor for reinjury of a given body part [63]. 31% of athletes with a prior knee injury will sustain an additional knee injury significant enough to miss at least 1 game of competition in the following season [63]. Infectious diseases in athletes can be common causes of time lost from training or competition [99]. Factors relating to immune function and potential exposures can alter an athlete’s risk for infectious diseases [99]. Maximizing preventive efforts in hygiene and environmental exposures is effective to decrease risks of infectious disease illnesses including gastroenteritis and MRSA [99]. Early identification and relative isolation of athletes with communicable diseases helps prevent rapid spread within the team setting [99]. Specific sports are frequently identified with distinct injury patterns, with a high prevalence of acute injuries in team or high-speed sports and overuse injuries in technical or repetitive motion sports [258]. Certain injury types have a higher potential for recurrence, which could compromise joint function and stability or disturb the integrity of neighboring anatomic structures [258].

The most common mechanism of injury in US high school boys' baseball practices was no contact (31.2%) and in competitions was no contact (24.3%) [256]. Overuse/chronic was a frequent mechanism of injury in high school baseball practices (18.3%) and college baseball practices (25.3%) [256]. Fielding was a common activity resulting in injury in high school baseball practices (24.6%) and competitions (20.9%) [256]. Pitching was a common activity resulting in injury in high school baseball practices (17.5%) and competitions (14.3%) [256]. The dominant self-reported injury mechanism in international elite junior rowers was overuse, while trauma was reported in 26.2% of cases [268]. Traumatic-onset injuries were significantly more frequent among male junior rowers, while overuse injuries were significantly more frequent among female junior rowers [268]. All complete proximal adductor avulsion injuries in high-performance athletes occurred during matches [4]. 83% of complete proximal adductor avulsion injuries occurred on the dominant leg [4]. 67% of complete proximal adductor avulsion injuries were due to overstretch [4]. 50% of complete proximal adductor avulsion injuries occurred while kicking a ball [4]. 17% of complete proximal adductor avulsion injuries occurred while sprinting [4].

Classification¶

Terminology: In the context of muscle injuries, the terms "classify" and "grade" do not refer to the same process [59]. Injury classification specifically describes or categorizes an injury by its location, mechanism, or underlying pathology [59], whereas injury grading provides an indication of injury severity [59]. These terms have frequently been used interchangeably and ambiguously in the literature regarding muscle injuries [59].

Salter-Harris: The Salter-Harris classification scheme is used to describe most pediatric lower extremity periarticular injuries [64]. Type I and II fractures have a more favorable prognosis after anatomic reduction and often can be managed nonsurgically [64]. Type III and IV injuries usually require open reduction with anatomic restoration of the joint surface [64].

Orchard Sports Injury Classification System: This system was used to collect injury data in a study of elite-level wrestling [45].

Sport Specialization: Sport specialization status was classified using a 3-point scale to identify the degree of specialization along a continuum from low to high [24]. Specialization was classified as low for scores of 0-1, moderate for a score of 2, and high for a score of 3 based on responses to three specific questions [24].

DOSIS Scale: The DOSIS scale ranks athletes in homogeneous subgroups according to the type, frequency, and level of sport [254]. It assesses whether a sport requires full or almost full range of motion, whether it is an overhead sport, and the amount of stress and contact forces to the upper extremity [254].

Other Considerations: The definition of athlete is broad and spans the spectrum from occasional participant to weekend warrior, through the student-athlete, and progressing to the professional [155].

Clinical Presentation¶

Sport-related concussion diagnosis remains challenging due to non-specific symptoms and the lack of objective biomarkers [28]. These injuries are heterogeneous, requiring an individualized clinical approach [30]. Female athletes present with a higher symptom burden before and after a sport concussion compared to male athletes [66], may be more susceptible to the injury, experience prolonged symptoms, and are more likely to report a concussion than their male counterparts [74]. Relatively few athletes who are symptom-free at rest after a concussion will have a recurrence of symptoms when they resume exercise [36]. In intercollegiate water polo athletes, concussions were the most common injury diagnosis and had the worst return-to-play outcomes among common diagnoses [68], with most injuries sustained outside of competition [68].

Shoulder and Overhead Athletes¶

Clinical symptomatology in overhead athletes is commonly associated with more deficits than just local pathoanatomy, requiring a comprehensive evaluation of the kinetic chain and adaptive changes to guide treatment [76]. It is important for the athlete, coach, and clinician to be aware of the discerning characteristics among different shoulder injuries to ensure a proper diagnosis and treatment plan for competitive swimmers [69]. The diagnosis of unstable painful shoulder (UPS) is often missed but is important to consider in young hyperlax athletes [88]. Clinician awareness of Paget-Schroetter syndrome in athletes is critical to avoid delays in treatment and misdiagnosis [72]. The symptomatic axillopectoral muscle should be included in the differential diagnosis of shoulder or arm pain associated with swelling and/or neurovascular symptoms, particularly in overhead athletes [80]. Unenhanced magnetic resonance imaging of the shoulder in asymptomatic high-performance throwing athletes reveals abnormalities that may encompass a spectrum of nonclinical findings [40].

Lower Extremity and Specific Injuries¶

Symptomatic femoroacetabular impingement (FAI) causes substantial reductions in athletic performance compared to healthy competitors, placing these athletes at a distinct performance disadvantage [34]. Proximal hamstring strains of stretching type generally imply a prolonged rehabilitation period before returning to sport, despite relatively mild initial symptoms [7]. In high-performance athletes with complete proximal adductor avulsion, 83% of injuries occurred on the dominant leg [4]. Additionally, 67% of injuries were due to overstretch [4], 50% occurred while kicking a ball [4], and 17% occurred while sprinting [4]. All injuries in this study occurred during matches [4].

Elbow and Systemic Considerations¶

The most common diagnosis for posterior elbow pain in Japanese high school baseball players was posteromedial elbow impingement [85]. All Japanese high school baseball players with posterior elbow pain returned to competitive sports activity levels within 77 ± 47 days [85]. Exertional heat-related illness is a frequently encountered but preventable issue that remains a leading cause of death in athletes [70]. A thorough understanding of epidemiology, screening methods, and the differentiation of pathology from benign athlete's heart changes is essential for sports medicine physicians [67].

Epidemiology and Risk Factors¶

Sports injuries in young males and females differed by injury type, diagnosis, and body area [32]. Injury profiles and rates often differ by sex/gender, and injury outcomes such as return to sport and ongoing symptoms are often worse in female, woman, and/or girl athletes [26]. Athletes who presented to the sports medicine clinic for an injury had higher mean Athletic Identity Measurement Scale (AIMS) scores compared with those whose chief complaint was not an injury [71]. Higher injury rates in extreme sports are seen in new and inexperienced athletes who have just started engaging in extreme sports and experienced extremists [6]. An injury increase is observed during competitions rather than training in extreme sports, a trend well recognized in common team sports [6]. The significant injuries and diagnoses in professional American football appear congruent with the position-specific demands placed on the athletes [75].

Investigations¶

General Principles¶

A systematic approach integrating history, physical examination, imaging, and sport-specific treatment algorithms facilitates symptomatic improvement and return to play [2]. Orthopaedic Sports Medicine serves as a necessary reference for clinicians treating athletes [9]. Elbow evaluation requires an intimate understanding of anatomy, biomechanics, and diagnostic tests to interpret functional biomechanics, perform physical exam maneuvers, and order appropriate imaging [46]. Radiographic evaluation must be tailored to the specific suspected injury and requires thorough knowledge of normal anatomic relationships and common athletic injuries [140]. Athletes face neurovascular injury risks due to extreme forces on the shoulder girdle, necessitating high diagnostic acumen and proper selection of clinical assessment and imaging techniques [208]. Clinicians must consider only the best management of a distinct condition in a specific athlete with a unique set of circumstances and needs [31].

Shoulder¶

In painful shoulders of throwing athletes, MR imaging scans reveal changes in both the rotator cuff and the humeral head [192]. MRI evidence indicates that CAM impingement is more common in elite ice hockey athletes compared with non-athletes [149]. A high prevalence of both acute and chronic shoulder injuries exists in Olympic athletes receiving shoulder MRI [211]. Most baseball players participating in the 2023 MLB Combine had MRI evidence of rotator cuff abnormalities, and many showed evidence of an olecranon osteophyte [202]. However, MRI findings in asymptomatic MLB pitchers do not appear to be related to near future placement on the disabled list [200]. Awareness of the os acromiale in the young athlete, combined with appropriate clinical examination and image studies, is crucial to confirm diagnosis [179]. Significant findings assessing MRI measurements of the epiphyseal plate in asymptomatic adolescent elite tennis players might reflect a development of consecutive alterations in the epiphyseal plate in the dominant arm [180].

Elbow¶

Plain radiography: Plain radiographs remain the hallmark and best screening test for elbow evaluation [46]. The physical exam of the elbow is directed by history and the location of pain in the anterior, posterior, medial, or lateral aspect [46]. AP, lateral, oblique, and axillary views may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [176]. Radiographs should always be obtained for elbow stiffness, with AP, lateral, and oblique radiographs being standard [154].

MRI: MRI may be most helpful in evaluating associated injuries, including partial or complete tears of the medial collateral ligament in valgus extension overload syndrome [176]. MRI serves as the gold standard for detection of olecranon stress fracture [47]. A 3-year longitudinal evaluation suggests that MRI findings in Little League baseball players tend to progress, especially among athletes who play baseball year-round [178]. A high rate of abnormal magnetic resonance imaging findings exists in asymptomatic throwers' elbows [203]. MRI can be used to evaluate ligaments and tendons in elbow stiffness, but it is rarely indicated [154]. Early orthopaedic referral and early MRI may help prevent delay in diagnosis and allow expedient surgical intervention in appropriate candidates for pectoralis major avulsion [191].

CT: CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [176]. CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies in elbow stiffness [154].

Electrodiagnostics: Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists in the evaluation of elbow stiffness [154].

Other Considerations: Professional baseball players who suffer a latissimus dorsi or teres major injury have predictable clinical presentations and imaging findings [164].

Knee¶

Simpler methods using MRIs downgraded to a clinical-grade resolution can identify the same knee anatomic factors previously found to significantly contribute to ACL injury risk using sophisticated methods and research-grade resolution MRIs [206]. Careful examination comparing the involved and uninvolved knees, considering stress radiographs, and combining this with magnetic resonance imaging findings is currently the most accurate way to grade posterolateral corner injuries [214]. In athletes with a history of labral repair, assessment of labral integrity on MRI alone is not predictive of future short-term participation [215].

Spine¶

Systematic radiological examination of the lumbar spine is recommended in athletes considered to be at greater risk of developing spondylolysis [195]. Athletes who underwent spine MRI during the 2016 Summer Olympic Games show a high frequency of degenerative disc disease of cervical and lumbar spines [201]. A significant number of athletes demonstrated advanced spinal disease on MRI during the 2016 Summer Olympics, with approximately 1 athlete per 200 demonstrating moderate to severe spinal pathology [223].

Lower Extremity & Core¶

MRI: Clinicians should consider advanced imaging to rule out occult fracture in athletes with significant capsular distention or those who do not respond to nonoperative management after a suspected ankle sprain [217]. Athletes with a history of core muscle surgery at the NFL Combines achieved just as much as all the others with respect to NFL selection and performance, and residual postoperative MRI findings are common and may have no clinical significance [65]. Abnormal magnetic resonance imaging findings were also common in asymptomatic athletes, which decreases the value of magnetic resonance imaging in surgical decision-making for osteitis pubis [92]. Athletes with an MRI grade 0-2 adductor injury were clinically pain-free after approximately 2 weeks and returned to full team training after approximately 3 weeks [160]. Both location of the injury and severity determined by imaging should be considered for prediction of return-to-sports-time in athletes with stress fractures [15]. Early diagnosis using MRI and consistent conservative treatment are recommended for stress fractures in adolescent competitive athletes with open physis [227].

Treatment¶

General Principles & Return to Sport¶

With proper recognition and treatment, most athletes can expect to return to sports, although the long-term implications of high-level activities must still be considered [1]. For skeletally immature throwing athletes, proper treatment, appropriate intervention, and a thorough understanding of injury prevention guidelines allow for timely recovery and return to sport with minimal long-term effect [3]. The definitive decision for return to sports should be based on patient-related and sports-demand factors rather than time alone, as most athletes were not ready for a safe return 8 months postoperatively [29]. There is an urgent need for more robust, operationalized, and sport-specific return to performance criteria to support clinical decision-making [10].

Current evidence does not support early sport specialisation as a reliable predictor of long-term athletic success, as the majority of successful senior athletes were not standouts as youths [5]. Consequently, adolescent athletes should avoid specialization when possible [96]. Future prospective research is needed to define the risk of injury for young athletes who participate in early sport specialization [13]. Sport-specific training injury prevention programmes may benefit from considering biomechanical risk factor differences between specialized athletes [137]. Higher injury rates are seen in new and inexperienced athletes who have just started engaging in extreme sports and experienced extremists [6].

The ideal scoring system for participating athletes has yet to be developed [20]. A systematic review of 16 selected articles did not present a standardisation in how to evaluate the postoperative outcomes in athletes and high-performance sports practitioners [18]. Most studies reported return to play to determine treatment efficacy, but significant variability was seen in how players were followed [78]. Innovations in sports medicine–related drugs, supplements, surgical techniques, and rehabilitation are plentiful and rapidly advancing, but many medications or procedures lack a sufficient evidence base to guide their use [84]. The deliberate pursuit of truly informed consent is paramount whenever a new treatment is being considered, and the physician must fully inform the athlete of the experimental nature of the treatment if only minimal or anecdotal evidence exists [84].

The foundation of independent medical care in college student-athletes is athlete-centered care with independent medical care provided focusing only on the individual patient’s needs and concerns [94]. The institution should have administrative structures in place to ensure the team physician and medical staff can act fully independently and have unchallengeable, autonomous authority for medical management and return-to-play decisions [94]. A recent survey of college and university athletic trainers found that only 51.7% followed the National Collegiate Athletic Association independent medical care model and only 76.3% felt they had medical autonomy in medical management of their athletes [94].

Concussion Management¶

Current recommendations for management after the initial diagnosis of concussion include a series of follow-up assessments until resolution of symptoms and impairments, followed by a closely monitored progression back to full academic activity and unrestricted play [73]. A short-term period of rest from cognitive and physical exertion followed by a gradual and systematic increase in these activities continues to be the foundation of appropriate concussion management [73]. Student-athletes who do not rest and continue to engage in activities that provoke their concussion symptoms have demonstrated longer recovery times [73]. Complete abstinence from cognitive and light aerobic activities, especially for an extended period, has not been shown to be beneficial [73].

Female Athlete Triad¶

The first step in return to play for the female athlete triad is to appropriately treat any secondary complications such as stress fractures [90]. Athletes deemed low risk for the female athlete triad can continue to compete and train with education to prevent increased risk of the condition and overt disease [90]. Athletes in the moderate-risk category for the female athlete triad often can have provisional clearance, which allows them to participate in physical activities with recommendations for modifications outlined by a multidisciplinary team [90]. Athletes at high risk for the female athlete triad or with specific significant pathology are fully restricted from training and competition so the medical conditions affecting the athlete can be treated [90]. A written treatment contract is recommended for athletes with the female athlete triad to allow the athlete to fully understand her disease, the treatment, and the expectations for follow-up and progression [90].

Orthobiologics & Regenerative Medicine¶

Cell-based therapies and regenerative medicine offer safe and potentially efficacious treatment for sports-related musculoskeletal injuries, but more clinical evidence is necessary to define the indications and parameters for their use [39]. Despite significant advances in stem cell and tissue engineering therapies for sports medicine, there remains a need for additional high-powered and well-designed clinical trials to confirm the safety and efficacy of treatment [93]. Orthobiologics, including PRP, mesenchymal stem cells, and tissue scaffolds, represent an exciting potential adjunct to traditional management of musculoskeletal injuries and sport-related pathology, although clinical data are currently lacking [95]. Careful review of available literature, with ongoing clinical studies, to further assess the efficacy of orthobiologic agents should be performed before widespread utilization [95]. The analysis of the literature shows promising preclinical results but contradictory clinical findings for the treatment of sport injuries with platelet-rich plasma [113].

Shoulder & Elbow¶

Non-Operative: Nonoperative treatment allowed 42% of athletes to return to their previous level of competition at an average of 24.5 weeks after diagnosis for ulnar collateral ligament injuries [12]. UCL injuries in high school baseball players can be successfully treated nonoperatively in most cases [158]. This group of overhead athletes (professional football quarterbacks) can be successfully treated nonoperatively, in contrast to baseball players, who more commonly need surgical reconstruction to return to competitive play [165]. For the athlete with chronic attenuation, a trial of nonsurgical treatment is preferred; however, UCL reconstruction is offered to the elite throwing athlete with acute deterioration in the setting of chronic UCL insufficiency [159]. While nonsurgical management can result in successful return to sport in carefully selected patients, UCL reconstruction remains the benchmark for tears not amendable to nonsurgical treatment [151].

Operative Indications: Professional athletes and those with complete ulnar collateral ligament tears were indicated for surgery by consensus, whereas opinion was more divided on how to treat partial tears or nonprofessionals [43]. Operative management is recommended for a symptomatic, persistent olecranon physis in the high-demand, skeletally mature overhead athlete in whom conservative management has failed [138]. Surgical treatment must be contemplated after a period of unsuccessful conservative therapy for athletes with osteochondritis dissecans of the elbow [166]. Conservative treatment leads to significant strength loss and prevents return to competitive sports for pectoralis major rupture in athletes [105].

Surgical Outcomes & Techniques: UCL reconstruction using a cortical button suspension technique demonstrated a high rate of return to sport (82.6%) and good functional outcomes [42]. Studies with at least 12 weeks of rehabilitation and studies using leukocyte-poor PRP demonstrated low heterogeneity and greater return to sport rates for ulnar collateral ligament tears [106]. Players have a 62% rate of return to sport after ulnar nerve decompression/transposition, which is lower than expected for this nonreconstruction or repair procedure [148]. Arthroscopic repair in athletes with symptomatic multidirectional instability appears to be an effective, reproducible treatment option [77]. Arthroscopic treatment resulted in 95.2% of excellent outcomes according to the Rowe score and these athletes were able to return to recreational sports activities at the same level for traumatic posterior shoulder instability [91].

Shoulder Instability & SLAP: At a mean of 5.5 years' follow-up, adolescent athletes had a high failure rate of revision stabilization surgery and modest functional outcomes [21]. Bracing is not effective as an adjunct to standard nonoperative management in allowing athletes to return and complete a subsequent season for unstable shoulders [89]. Whereas nonoperative treatment is associated with faster return to play, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity for shoulder instability in NFL athletes [168]. Although the clinical outcomes were not significantly different between collision and non-collision athletes, the level of return to sports was significantly higher in the non-collision group than in the collision group after the Latarjet procedure [169].

Midseason Anterior Instability: We recommend early surgical stabilization for patients with large bony Bankart lesions or significant glenoid or humeral bone loss for midseason traumatic anterior shoulder instability [263]. Athletes with an axillary nerve lesion or rotator cuff pathology are also offered surgery for midseason traumatic anterior shoulder instability [263]. Nonsurgical treatment can be considered in athletes with primary instability events and soft-tissue lesions for midseason traumatic anterior shoulder instability [263]. The time frame for return to play after nonsurgical treatment of midseason traumatic anterior shoulder instability is typically 3 weeks, but this can be accelerated in certain circumstances [263]. Patients opting for nonoperative treatment of acute, initial anterior shoulder dislocations underwent a supervised rehabilitation program with a sling used for comfort for 3 weeks, after which the patient began a restrengthening program [229]. Goals for nonoperative treatment of acute, initial anterior shoulder dislocations included return to full active and unrestricted athletic participation, including participation in the sport that had resulted in the original dislocation after 3 months of rehabilitation [229].

SLAP Tear Rehabilitation: Postoperatively for Type V SLAP tears, the shoulder was placed in a sling for 3 weeks while allowing non-resisted activities of daily living without elevation of the shoulder [235]. Return to contact in training was allowed after twelve weeks for Type V SLAP tears, while return to full contact and competition usually would follow within the next three months depending on progress of physiotherapy [235].

Other Shoulder & Elbow Pathology: The majority of athletes are able to return to sports with conservative treatment for rotator cuff contusions, though a minority might progress to more severe injuries such as rotator cuff tears [161]. Treatment of large, unstable OCD lesions of the capitellum in adolescent athletes allows reliable return to play, is safe, and has good clinical outcomes at short-term follow-up [101]. Olecranon stress fracture is an overuse injury primarily affecting throwing athletes, with MRI serving as the gold standard for detection [47]. Elbow tendinopathy is a common cause of pain and disability resulting from repetitive overuse activities, with nonsurgical treatment successful in most cases and surgical intervention reserved for those patients with continued symptoms after 6 months or more of treatment [87]. Elbow tendinopathy is not an inflammatory condition but rather a tendon degeneration resulting from continued microtrauma and failed attempts at healing [87]. Rest and activity modification are paramount in the nonsurgical treatment of elbow tendinopathy [87]. The current literature provides no definitive recommendations regarding efficacy of nonsurgical interventions for elbow tendinopathy [87]. Regardless of treatment type, most symptoms improve in elbow tendinopathy [87].

Latissimus Dorsi & Teres Major: The latissimus dorsi is one of the highest power generators in the acceleration phase of the pitching mechanism [259]. There are several points during the pitching cycle where an eccentric contraction of the latissimus dorsi occurred, which serves as a potential source of injury to the muscle [259]. The athletes in a series of professional baseball pitchers with latissimus dorsi or teres major injuries were treated nonoperatively with success [259].

Hip & Knee¶

Femoroacetabular Impingement: With proper recognition and treatment, most athletes can expect to return to sports for femoroacetabular impingement, although the long-term implications of high-level activities must still be considered [1]. Arthroscopic treatment of FAIS in recreational HIIT participants resulted in significant improvements in hip function and predictably high rates of patient satisfaction [103].

Lisfranc Injuries: The different treatment options for Lisfranc injuries allow for good sport-specific outcomes with 93% to 94% of athletes returning to any level of sports, and 74% to 88% of athletes returning to their preinjury level of sport [100].

Patellar Tendinopathy: Athletes with patellar tendinopathy after physical therapy can expect a generally acceptable long-term prognosis [14].

Spondylolysis: Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, and direct surgical repair can yield high rates of pain relief in recalcitrant cases [152].

Meniscal Pathology: Isolated repair of meniscal tears results in good to excellent sport-specific outcomes and a high return to sports rate in both recreational and professional athletes [115]. These athletes also had significant improvements in most outcome measures after meniscal allograft transplantation [11]. Return to sports following meniscal allograft transplantation is possible but remains questionable [267].

ACL Reconstruction Protocol: The operated knee was fixed at 0° in a postoperative brace for ACL reconstruction, but during daily physiotherapy sessions, the brace was removed and the knee was mobilized within a 0–40° range to gradually restore range of motion [255]. Isometric muscle strengthening exercises were initiated immediately after ACL reconstruction surgery [255]. Full non-weight bearing was applied in the first week after ACL reconstruction surgery [255]. Full range of movement was started at the 4th postoperative week after ACL reconstruction [255]. Patients could begin cycling at six weeks, swimming at ten weeks, and running in a straight line at twelve weeks after ACL reconstruction [255]. Sport-specific exercises were started at week 16 after ACL reconstruction [255]. Patients were allowed to return to sports within the ninth postoperative month after ACL reconstruction [255].

ACL Testing & Grafts: The time point for the first functional test battery following ACL reconstruction was determined by the patient, the treating surgeon and the physiotherapist as well as being by subjective and objective criteria [265]. The patients performed the test battery on average 170.7 ± 75.1 (range 100–494) days following unilateral ACL reconstruction [265]. The patients were retested on average 239.1 ± 79.7 (range 145–574) days post-operatively after ACL reconstruction [265]. Hamstring tendon grafts were used in 47 (68.1%) cases, quadriceps tendon grafts in 12 (17.4%) and bone patellar tendon bone grafts in 10 (14.5%) patients for ACL reconstruction [265]. In 12 (17.4%) of the 69 patients, the surgery was an ACL revision [265].

Subtalar & Sinus Tarsi: Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic population, with favorable return to sport level, return to sport time, clinical outcomes and safety outcome measures for sinus tarsi syndrome [19]. Six out of ten patients with sinus tarsi syndrome returned to pre-injury type of sport after subtalar arthroscopy [19].

Adductor & Core Injuries: All injuries occurred during matches for complete proximal adductor avulsion in high-performance athletes [4]. Five of the six injuries (83%) on the dominant leg, four (67%) due to overstretch, three (50%) while kicking a ball and one (17%) while sprinting for complete proximal adductor avulsion in high-performance athletes [4]. Surgery is indicated for athletes who fail nonsurgical management to allow return to sport for core muscle injury producing groin pain [38]. Return to sport after treatment of athletic pubalgia should involve a multifaceted assessment process [261]. Conservative treatment is classically recommended before surgery is performed for athletic pubalgia [261]. The length of conservative management before failure of such modality is declared is undefined for athletic pubalgia [261]. Even if successful, conservative management of pubalgia resulted in slower return to sport compared with operative treatment [261]. If conservative management fails, surgery should be considered for pubalgia, as it allows a relatively fast return to sport provided that a well-controlled and active postoperative rehabilitation regime is introduced [261].

Hamstring Injuries: Surgical treatment of distal hamstring tendon injuries yield a higher return-to-sports rate [56]. 53.6% of patients initially treated conservatively for distal hamstring tendon injuries required surgery, delaying return to sports time without affecting the final return-to-sports rate [56].

Foot & Ankle¶

Stress Fractures¶

Treatment decision making for high-risk stress fractures should be based on radiographic findings with less consideration given to symptom severity [82]. The immediate goal of treatment of a high-risk stress fracture is to avoid progression and get the fracture to heal [82]. Typically, treatment of a high-risk stress fracture requires either complete elimination of loading of the site or surgical stabilization [82]. Ideally, while the fracture is healing, one works to avoid deconditioning of the athlete while minimizing the risk of a significant complication of fracture healing [82]. Overtreatment of a low-risk stress fracture may result in unnecessary deconditioning and loss of playing time [82]. Undertreatment of a high-risk injury puts the athlete and indeed all patients at risk of significant complications [82]. The presence of a visible fracture line on a plain radiograph in a

Complications¶

Early Sport Specialization and Injury Risk¶

Early sport specialisation is an independent risk factor for chronic overuse lower extremity injuries in youth athletes [54]. A considerable number of high school athletes specialize in one sport during their underclass years [27]. Athletes whose training hours exceeded their age or whose sports hours exceeded free play by a factor greater than 2 were more likely to develop injuries [212]. Training >8 months out of the year in a single sport is associated with sports-related concussion and prior history of concussion [62]. High school athletes specialized at an earlier age than current collegiate or professional athletes and recalled a higher incidence of sports-related injury attributed to specialization [55].

Concussion and Head Injury Complications¶

Second-impact syndrome is a repeat injury that occurs when an athlete has not fully recovered from a previous injury, resulting in diffuse cerebral swelling with delayed catastrophic deterioration, and on occasion brain stem herniation [231]. This condition has been documented in 14- to 18-year-olds in whom death occurs from diffuse cerebral edema and possible herniation [231]. The National Center for Catastrophic Injury Research has data that suggest a possible risk factor for a catastrophic injury is the presence of a recent head injury [231]. Postconcussion syndrome is inadequately defined, the etiology is poorly understood, and the term is commonly interchanged with postconcussion symptoms [231]. Players with concussion did not experience a reduction in performance metrics in the short- or long-term setting when compared with matched controls [53]. Adolescent athletes with a concussion history who sustained a lower extremity musculoskeletal injury across a 1-year study period had a relatively suppressed acoustic startle reflex compared to those who remained injury free [171].

Musculoskeletal Injury Complications and Prognosis¶

Patellar Tendinopathy: Athletes with patellar tendinopathy after physical therapy can expect a generally acceptable long-term prognosis at 5-year follow-up [14]. However, patellar tendinopathy in elite male soccer players has a high recurrence rate of 12%-27% [230]. There is little evidence on how to prevent recurrent episodes of patellar tendinopathy in athletes, and eccentric training has not shown similarly good results for the prevention of recurrent patellar tendinopathy episodes [230].

ACL and Knee Instability: In the 24 months after ACL reconstruction and return to sport, patients are at a greater risk to suffer a subsequent ACL injury compared with young athletes without a history of ACL injuries [57]. Additionally, 31% of athletes with a prior knee injury will sustain, in the following season, an additional knee injury significant enough to miss at least 1 game of competition [63]. Strength deficits persist at 6 months following stabilization surgery for recurrent lateral patellar instability, especially in those undergoing concomitant tibial tubercle osteotomy, which may delay return to sport [58].

Shoulder and Upper Extremity: Adolescent athletes had a high failure rate of revision anterior shoulder stabilization surgery and modest functional outcomes at a mean of 5.5 years' follow-up [21]. The level of evidence for return to sport outcomes after surgical treatment for high-grade acromioclavicular dislocation was low, and subgroup analyses were not feasible due to methodological heterogeneity [8]. Nonoperative treatment allowed 42% of athletes with ulnar collateral ligament injuries to return to their previous level of competition at an average of 24.5 weeks after diagnosis [12]. At a minimum of 2-year follow-up, nearly 90% of adolescent baseball patients returned to their preinjury level of sport after ulnar collateral ligament reconstruction [50]. The arthroscopic Trillat technique for chronic anterior shoulder instability enables a rapid return to sport and at the previous level in the majority of cases [17].

Hip and Pelvis: With proper recognition and treatment, most athletes with femoroacetabular impingement can expect to return to sports, although the long-term implications of high-level activities must still be considered [1]. Thirty-five athletes (78%) with femoroacetabular impingement remain active in professional sport at an average follow-up of 1.6 years following arthroscopic decompression [41].

Spine and Core: A systematic approach involving history, physical examination, imaging, and sport-specific treatment algorithms can facilitate symptomatic improvement and return to play for athletes with back pain [2]. Athletes with a history of core muscle surgery at the NFL Combines achieved just as much as all the others with respect to NFL selection and performance [65]. Residual postoperative MRI findings after core muscle surgery are common and may have no clinical significance [65].

Other Considerations: Return to competitive sport after meniscal allograft transplant is associated with excellent graft survival and superior long-term outcomes, with no evidence of increased failure [25]. Athletes who underwent meniscal allograft transplantation had significant improvements in most outcome measures [11]. Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic population, with favorable return to sport level, return to sport time, clinical outcomes and safety outcome measures [19]. Early unprotected return to contact sport after metacarpal fixation in professional athletes was associated with no appreciable increase in clinical complications or deterioration in sporting performance [219]. The pitch clock has not increased short-term injury risk in Major League Baseball, although ongoing research is needed to assess its long-term effects [139]. Injury rates in NCAA student-athletes increased after COVID-19 lockdowns, with some sports disproportionately affected [233]. Increased caution is recommended when returning to play after prolonged restrictions on athletics for the safety of student-athletes [233]. The majority of variability between studies on ice hockey injury rates is explained by differences in the definitions of both injury and athlete exposure [51]. Incidence of season-ending shoulder injuries in NCAA athletes varies widely by sport and injury, with a number of associated risk factors [61]. High-intensity and prolonged training and competition load is associated with an increased risk of both subclinical immunological changes that may increase the risk of illness, and actual symptoms of illness or diagnosed illness [232]. Frequent and prolonged international travel may be related to increased risk of illness in athletes [232]. In children, bone injury occurs through the weakest point of the traumatized region, which is often the epiphyseal plate [64]. Annual injury rates in high school football are 41-46% [64]. Annual injury rates in high school wrestling/gymnastics are 40-46% [64]. Annual injury rates in high school basketball are 31-37% [64]. Annual injury rates in other high school sports (volleyball, baseball, soccer, cross-country, softball, track) are 7-18% [64]. Data on injuries suffered while performing specific skateboarding styles or tricks do not exist [225].

Recovery¶

General Principles & Return-to-Sport Frameworks¶

The Return-to-Sport Clearance Continuum proposes an evolving continuum of healing and testing rather than a single decision point to help professional athletes return to sport at their maximal performance level safely and timely [60].

Shoulder & Upper Extremity¶

Rehabilitation protocol: An accelerated rehabilitation programme after arthroscopic Bankart repair in professional footballers resulted in a return to play time of 11 weeks, compared to previously reported times of between 5 months and 9 months in the contact sports population [237]. For ulnar collateral ligament injuries, nonoperative treatment allowed 42% of throwing athletes to return to their previous level of competition at an average of 24.5 weeks after diagnosis [12]. The postoperative course for ulnar collateral ligament reconstruction in javelin throwers is associated with an extended period of time until return to previous level of competition when compared with baseball players [266].

Functional milestones: At a minimum of 2-year follow-up, nearly 90% of adolescent baseball patients who underwent ulnar collateral ligament reconstruction returned to their preinjury level of sport [50]. All competitive contact athletes with recurrent anterior shoulder instability who underwent arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation returned to athletic activity at a level similar to the preintervention period [257]. All patients with posttraumatic axillary nerve palsy returned to their high level of athletic activity, with maximal recovery occurring at twelve months [273].

Other Considerations: At a mean of 5.5 years' follow-up, adolescent athletes had a high failure rate of revision anterior shoulder stabilization surgery and modest functional outcomes [21]. Extended follow-up is needed to definitively assess the success of arthroscopic intratendinous repair for delaminated partial-thickness rotator cuff tears in returning high-caliber overhead athletes to their previous level of competition [184].

Hip & Pelvis¶

Other Considerations: Thirty-five athletes (78%) with femoroacetabular impingement remained active in professional sport at an average follow-up of 1.6 years following arthroscopic decompression [41]. Although there was no decline in overall activity level at a mean of 3 years after periacetabular osteotomy for acetabular dysplasia, self-assessed athletic performance was attained and maintained in approximately one-half of the adolescent and young adult athlete study population [271].

Knee & Lower Extremity¶

Rehabilitation protocol: Intensive rehabilitation after arthroscopic autologous chondrocyte implantation may safely allow a faster return to competition and positively influence the clinical outcome at medium-term follow-up in highly competitive athletes [175]. Athletes with patellar tendinopathy who received physical therapy can expect a generally acceptable long-term prognosis at 5-year follow-up [14]. It is important to inform subjects that proximal hamstring strains of stretching type, despite relatively mild initial symptoms, generally imply a prolonged rehabilitation period before returning to sport [7].

Functional milestones: Patients with excellent performance on isokinetic strength and functional testing at 6 months after ACL reconstruction have superior knee function and higher activity levels at midterm follow-up [205]. Athletes who returned to high-level sport after meniscal allograft transplantation had significant improvements in most outcome measures [11]. Subtalar arthroscopy for sinus tarsi syndrome yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic populations, with favorable return to sport level, return to sport time, clinical outcomes, and safety outcome measures [19].

Other Considerations: An early return to sports is possible after plate fixation of displaced midshaft clavicle fractures; however, the time to return is highly variable [222]. 53.6% of patients with distal hamstring tendon injuries initially treated conservatively required surgery, delaying return to sports time without affecting the final return-to-sports rate [56].

Concussion & Neurological¶

Other Considerations: The diagnosis of sport-related concussion remains a challenge due to non-specific symptoms and lack of objective biomarkers [28]. Mean recovery time across all groups for concussion was 29.4 days, which showed considerably longer return to play than the most commonly cited concussion recovery time window of 7-10 days for collegiate athletes [269]. Players with concussion did not experience a reduction in performance metrics in the short- or long-term setting when compared with matched controls in the National Hockey League [53]. Sports participation was similar between groups during the year-long monitoring period in a randomized clinical trial evaluating an 8-week neuromuscular training program after concussion [49].

Key Evidence¶

[L5] With proper recognition and treatment, most athletes can expect to return to sports, although the long-term implications of high-level activities must still be considered. [1] (10.1177/0363546513499136)
[L5] A systematic approach involving history, physical examination, imaging, and sport-specific treatment algorithms can facilitate symptomatic improvement and return to play. [2] (10.5435/00124635-200612000-00004)
[L5] Proper treatment, appropriate intervention, and a thorough understanding of injury prevention guidelines can allow these young athletes to undergo a timely recovery and return to sport participation with minimal long-term effect. [3] (10.5435/jaaos-d-25-00186)
[L4] [4] (10.1007/s00167-015-3669-6)
[L5] Current evidence does not support early sport specialisation (ESS) as a reliable predictor of long-term athletic success, as the majority of successful senior athletes were not standouts as youths. [5] (10.1002/ksa.70601)
[L4] [6] (10.1186/s13018-017-0560-9)
[L4] It is important to inform the subject that this type of injury, despite its relatively mild initial symptoms, generally implies a prolonged rehabilitation period before returning to sport. [7] (10.1177/0363546508315892)
[L4] However, the level of evidence was low and due to methodological heterogeneity between studies, subgroup analyses of return to sport outcomes were not feasible. [8] (10.1007/s00167-019-05528-w)
[Paper] Orthopaedic Sports Medicine is a necessary reference for those clinicians who treat athletes. [9] (10.1197/j.jht.2004.04.010)
[L1] There is an urgent need for more robust, operationalized, and sport-specific return to performance criteria to support clinical decision-making. [10] (10.1002/ksa.70180)
[L4] These athletes also had significant improvements in most outcome measures. [11] (10.1016/j.arthro.2012.10.027)
[L4] Nonoperative treatment allowed 42% of athletes to return to their previous level of competition at an average of 24.5 weeks after diagnosis. [12] (10.1177/03635465010290010601)
[L5] Future prospective research is needed to define the risk of injury for young athletes who participate in early sport specialization. [13] (10.1177/0363546515576899)
[L3] Athletes with PT after physical therapy can expect a generally acceptable long-term prognosis. [14] (10.1177/03635465251336466)
[L3] Both location of the injury and severity determined by imaging should therefore be considered for prediction of return-to-sports-time. [15] (10.1186/1471-2474-13-139)
[L5] Ultimately, this statement provides guidelines that best serve the health care needs of athletes and teams. [16] (10.1177/03635465000280033002)
[L4] This simple and quick technique enables a rapid return to sport and at the previous level in the majority of cases. [17] (10.1016/j.jse.2024.08.029)
[L4] This systematic review evidences that the 16 selected articles did not present a standardisation in how to evaluate the postoperative outcomes in athletes and high-performance sports practitioners. [18] (10.1136/jisakos-2019-000286)
[L4] Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic population, with favorable return to sport level, return to sport time, clinical outcomes and safety outcome measures. [19] (10.1007/s00167-020-06385-8)
[L4] The ideal scoring system for participating athletes has yet to be developed. [20] (10.1016/s1058-2746(97)90015-x)
[L4] At a mean of 5.5 years' follow-up, adolescent athletes had a high failure rate of revision stabilization surgery and modest functional outcomes. [21] (10.1016/j.arthro.2014.05.037)
[L1] Level I Evidence and RCTs comprise 10% and 6% of contemporary sports medicine literature, respectively. [22] (10.1016/j.arthro.2013.11.015)
[L3] [24] (10.1177/0363546517690848)
[L4] Return to competitive sport after MAT is associated with excellent graft survival and superior long‐term outcomes, with no evidence of increased failure. [25] (10.1002/ksa.70137)
[Paper] [26] (10.1136/bjsports-2025-109904)
[L2] A considerable number of high school athletes specialize in one sport during their underclass years. [27] (10.1177/2325967119s00408)
[L5] The diagnosis of sport-related concussion (SRC) remains a challenge due to non-specific symptoms and lack of objective biomarkers. [28] (10.1136/bjsports-2021-104235)
[L5] The definitive decision for return to sports should be based on patient-related and sports-demand factors rather than time alone, as most athletes were not ready for a safe return 8 months postoperatively. [29] (10.1007/s00167-015-3600-1)
[L5] Sport-related concussions are heterogeneous and require an individualized clinical approach. [30] (10.1007/s00167-013-2791-6)
[L5] He or she must consider only the best management of a distinct condition in a specific athlete with a unique set of circumstances and needs. [31] (10.1016/s0278-5919(05)70091-0)
[L3] Sports injuries in young males and females differed by injury type, diagnosis, and body area. [32] (10.1177/0363546514522393)
[L2] Symptomatic FAI causes substantial reductions in athletic performance compared to healthy competitors placing these athletes at a distinct performance disadvantage. [34] (10.1007/s00167-019-05683-0)
[L3] Relatively few athletes who are symptom free at rest after a concussion will have a recurrence of symptoms when they resume exercise. [36] (10.1177/2325967117732516)
[L5] Surgery is indicated for athletes who fail nonsurgical management to allow return to sport. [38] (10.5435/jaaos-d-22-00739)
[L4] Cell-based therapies and regenerative medicine offer safe and potentially efficacious treatment for sports-related musculoskeletal injuries, but more clinical evidence is necessary to define the indications and parameters for their use. [39] (10.1177/2325967113519935)
[L4] Unenhanced magnetic resonance imaging of the shoulder in asymptomatic high performance throwing athletes reveals abnormalities that may encompass a spectrum of nonclinical findings. [40] (10.1177/03635465020300012501)
[L4] Thirty-five athletes (78%) remain active in professional sport at an average follow-up of 1.6 years. [41] (10.1007/s00167-007-0332-x)
[L4] The technique demonstrated a high rate of return to sport (82.6%) and good functional outcomes. [42] (10.1016/j.jse.2018.04.009)
[L4] Professional athletes and those with complete tears were indicated for surgery by consensus, whereas opinion was more divided on how to treat partial tears or nonprofessionals. [43] (10.1016/j.jse.2017.08.005)
[L4] Ranges of return to sport rates are influenced by procedure type, clinical follow-up duration, athletic level, and revision surgery status. [44] (10.1016/j.arthro.2025.07.032)
[L2] [45] (10.1177/23259671251403160)
[L5] Olecranon stress fracture is an overuse injury primarily affecting throwing athletes, with MRI serving as the gold standard for detection. [47] (10.1016/j.csm.2020.02.005)
[L5] Despite these benefits, ongoing barriers for inclusion of all athletes in sport still lead to reduced rates of para sport participation. [48] (10.1136/bjsports-2022-106192)
[L1] Sports participation was similar between groups during the year-long monitoring period. [49] (10.1177/03635465211069372)
[L4] At a minimum of 2-year follow-up, nearly 90% of patients returned to their preinjury level of sport. [50] (10.1177/2325967118769328)
[L4] The majority of variability between studies is explained by differences in the definitions of both injury and athlete exposure. [51] (10.3390/sports7110227)
[L3] Players with concussion did not experience a reduction in performance metrics in the short- or long-term setting when compared with matched controls. [53] (10.1177/23259671211052069)
[L5] Early sport specialisation is an independent risk factor for chronic overuse lower extremity injuries in youth athletes, and sport diversification is recommended to minimise injury risk and support long-term athletic development. [54] (10.1136/jisakos-2019-000288)
[L3] High school athletes specialized at an earlier age than current collegiate or professional athletes and recalled a higher incidence of sports-related injury attributed to specialization. [55] (10.1177/2325967117703944)
[L4] Furthermore, 53.6% of patients initially treated conservatively required surgery, delaying return to sports time without affecting the final return-to-sports rate. [56] (10.1002/ksa.12075)
[L2] In the 24 months after ACLR and return to sport, patients are at a greater risk to suffer a subsequent ACL injury compared with young athletes without a history of ACL injuries. [57] (10.1177/0363546514530088)
[L4] However, strength deficits persist at 6 months, especially in those undergoing concomitant TTO, which may delay return to sport. [58] (10.1007/s00167-016-4409-2)
[L5] [59] (10.1136/bjsports-2014-093551)
[L5] The Return-to-Sport Clearance Continuum proposes an evolving continuum of healing and testing rather than a single decision point to help professional athletes return to sport at their maximal performance level safely and timely. [60] (10.1016/j.asmr.2021.10.026)
[L3] Incidence of these injuries varies widely by sport and injury, with a number of associated risk factors. [61] (10.1177/0363546518773062)
[L3] Training >8 months out of the year in a single sport is associated with sports-related concussion and prior history of concussion. [62] (10.1177/2325967121s00537)
[L5] [63] (10.1177/0363546515598994)
[L5] [64] (10.5435/00124635-200706000-00005)
[L5] Athletes with a history of core muscle surgery at the NFL Combines achieved just as much as all the others with respect to NFL selection and performance, and residual postoperative MRI findings are common and may have no clinical significance. [65] (10.1016/j.arthro.2017.02.005)
[Paper] Current evidence is mixed regarding sex differences in cognitive performance after a sport concussion; female athletes have a higher symptom burden before and after injury, and regardless of biological sex, athletes diagnosed with a sport concussion should be managed based on clinical presentation. [66] (10.1016/j.csm.2017.05.002)
[L3] Concussions were the most common injury diagnosis, had the worst return-to-play outcomes among common diagnoses, and were mostly sustained outside of competition. [68] (10.1177/23259671221110208)
[L5] It is important for the athlete, coach, and clinician to be aware of the discerning characteristics among these different injuries to ensure a proper diagnosis and treatment plan to aid the swimmer in his or her return to competition. [69] (10.5435/jaaos-d-15-00313)
[L4] Athletes who presented to the sports medicine clinic for an injury had higher mean AIMS scores compared with those whose chief complaint was not an injury. [71] (10.5435/jaaosglobal-d-24-00195)
[L4] Clinician awareness of PSS in athletes is critical to avoid delays in treatment and misdiagnosis, and to allow for a timely return to sport with minimal complications. [72] (10.1016/j.jse.2020.05.015)
[L3] This systematic review demonstrates that female athletes may be more susceptible to concussion, have prolonged symptoms after a concussion, and are more likely to report a concussion than their male counterparts. [74] (10.1177/2325967120932306)
[L3] The significant injuries and diagnoses appear congruent with the position-specific demands placed on the athletes. [75] (10.1177/0363546508329542)
[L5] Clinical symptomatology in overhead athletes is commonly associated with more deficits than just local pathoanatomy, requiring a comprehensive evaluation of the kinetic chain and adaptive changes to guide treatment. [76] (10.1016/j.jse.2023.09.001)
[L4] Arthroscopic repair in athletes with symptomatic MDI appears to be an effective, reproducible treatment option. [77] (10.1177/0363546509335464)
[L1] Most studies reported return to play to determine treatment efficacy, but significant variability was seen in how players were followed. [78] (10.1177/0363546517697690)
[L4] It should be included in the differential diagnosis of shoulder or arm pain associated with swelling and/or neurovascular symptoms, particularly in overhead athletes. [80] (10.1177/0363546513486768)
[L3] The most common diagnosis for posterior elbow pain was posteromedial elbow impingement, and all players returned to competitive sports activity levels within 77 ± 47 days. [85] (10.1016/j.jse.2016.05.004)
[L4] The diagnosis of unstable painful shoulder (UPS) is often missed but is important to consider in young hyperlax athletes. [88] (10.1016/j.jse.2010.05.020)
[L3] Bracing is not effective as an adjunct to standard nonoperative management in allowing athletes to return and complete a subsequent season. [89] (10.1016/j.jse.2018.02.027)
[L4] Arthroscopic treatment resulted in 95.2% of excellent outcomes according to the Rowe score and these athletes were able to return to recreational sports activities at the same level. [91] (10.1111/j.1758-5740.2010.00069.x)
[L4] Abnormal magnetic resonance imaging findings were also common in asymptomatic athletes, which decreases the value of magnetic resonance imaging in surgical decision-making. [92] (10.1177/0363546507305454)
[L5] Despite significant advances in stem cell and tissue engineering therapies for sports medicine, there remains a need for additional high-powered and well-designed clinical trials to confirm the safety and efficacy of treatment. [93] (10.1016/j.arthro.2014.11.033)
[L2] Adolescent athletes should avoid specialization when possible. [96] (10.1177/2325967119s00111)
[L1] Surgeons should base operative decision making on patient sport and level of competition to optimize return to sport and minimize complication and reinjury risk. [98] (10.1016/j.xrrt.2025.02.005)
[L1] The different treatment options for Lisfranc injuries allow for good sport-specific outcomes with 93% to 94% of athletes returning to any level of sports, and 74% to 88% of athletes returning to their preinjury level of sport. [100] (10.1136/jisakos-2020-000477)
[L4] Treatment of large, unstable OCD lesions of the capitellum in adolescent athletes allows reliable return to play, is safe, and has good clinical outcomes at short-term follow-up. [101] (10.1016/j.jse.2015.03.014)
[L4] Arthroscopic treatment of FAIS in recreational HIIT participants resulted in significant improvements in hip function and predictably high rates of patient satisfaction. [103] (10.1177/0363546518776638)
[L4] Conservative treatment leads to significant strength loss and prevents return to competitive sports. [105] (10.1007/s001670050085)
[L1] Studies with at least 12 weeks of rehabilitation and studies using leukocyte-poor PRP demonstrated low heterogeneity and greater return to sport rates. [106] (10.1016/j.arthro.2024.03.017)
[L3] Pain management should be actively addressed, and high-quality studies with standardized return to sport definitions are needed. [109] (10.1016/j.jisako.2025.100925)
[L4] However, one-third of patients reported no benefit from surgery in terms of sporting activity, and improvement was dependent on sport demands and patient age. [110] (10.1016/j.arthro.2015.04.087)
[L4] The analysis of the literature shows promising preclinical results but contradictory clinical findings for the treatment of sport injuries. [113] (10.1007/s00167-010-1306-y)
[L5] Understanding the biomechanics of the elbow during sports activities, including the forces, torques, and muscle activities involved, helps physicians better understand injury mechanisms and minimize potential risk for injury while maximizing performance. [114] (10.1016/j.csm.2004.06.003)
[L4] This systematic review suggests that isolated repair of meniscal tears results in good to excellent sport-specific outcomes and a high return to sports rate in both recreational and professional athletes. [115] (10.1007/s00167-017-4463-4)
[L4] However, there was a high variety between studies and many reasons were unspecified, warranting unified definitions for reasons of patients that do not return to sport. [116] (10.1016/j.jseint.2023.01.001)
[Paper] Rehabilitation of the upper extremity athlete differs from other patients due to high functional demands and reinjury risk, requiring sport-specific protocols. [117] (10.1016/j.hcl.2016.08.016)
[L4] A positive trend for return to sport was observed with respect to rehabilitation protocols favoring earlier active mobility. [121] (10.1177/03635465241295618)
[L4] In patients for whom repair is properly indicated, UCL repair provides similar return-to-sport rates and clinical outcomes with shorter return-to-sport timing after repair compared with UCL reconstruction. [123] (10.1177/2325967116682211)
[L2] Sport-specific training injury prevention programmes may benefit from considering these differences between specialized athletes. [137] (10.1007/s00167-014-2873-0)
[L4] Operative management is recommended for a symptomatic, persistent olecranon physis in the high-demand, skeletally mature overhead athlete in whom conservative management has failed. [138] (10.1067/mse.2003.12)
[L3] These findings suggest that the pitch clock has not increased short-term injury risk, although ongoing research is needed to assess its long-term effects. [139] (10.1177/23259671251403066)
[L5] Radiographic evaluation should be tailored to the specific injury suspected and requires a thorough understanding of normal anatomic relationships as well as familiarity with common injuries affecting these athletes. [140] (10.1177/03635465030310032601)
[L3] Players have a 62% rate of return to sport, which is lower than expected for this nonreconstruction or repair procedure. [148] (10.1177/0363546519829159)
[L3] MRI evidence suggests that CAM impingement is more common in the elite ice hockey athlete in comparison with non-athletes. [149] (10.1007/s00167-013-2598-5)
[L5] While nonsurgical management can result in successful return to sport in carefully selected patients, UCL reconstruction remains the benchmark for tears not amendable to nonsurgical treatment. [151] (10.5435/jaaos-d-24-00392)
[L5] Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, and direct surgical repair can yield high rates of pain relief in recalcitrant cases. [152] (10.2106/00004623-200402000-00027)
[Paper] The definition of athlete is broad and spans the spectrum from occasional participant to weekend warrior, through the student-athlete, and progressing to the professional. [155] (10.1016/s0278-5919(05)70029-6)
[L3] UCL injuries in high school baseball players can be successfully treated nonoperatively in most cases. [158] (10.1016/j.jse.2020.09.022)
[L5] For the athlete with chronic attenuation, a trial of nonsurgical treatment is preferred; however, UCL reconstruction is offered to the elite throwing athlete with acute deterioration in the setting of chronic UCL insufficiency. [159] (10.1016/j.jhsa.2014.04.011)
[L2] Athletes with an MRI grade 0-2 adductor injury were clinically pain-free after approximately 2 weeks and returned to full team training after approximately 3 weeks. [160] (10.1177/2325967119897247)
[L4] The majority of athletes are able to return to sports with conservative treatment, though a minority might progress to more severe injuries such as rotator cuff tears. [161] (10.1177/0363546506295082)
[L4] Limited evidence exists for outcomes in non-throwing athletes after UCL injury, but current research suggests 86% of athletes may return to sport at the same or higher level with good functional outcomes and low complication rates. [162] (10.1016/j.xrrt.2025.04.012)
[L1] Professional baseball players who suffer a LD or TM injury have predictable clinical presentations and imaging findings. [164] (10.1016/j.asmr.2023.100787)
[L4] This group of overhead athletes can be successfully treated nonoperatively, in contrast to baseball players, who more commonly need surgical reconstruction to return to competitive play. [165] (10.1016/j.jse.2010.05.028)
[L2] This review suggests that surgical treatment must be contemplated after a period of unsuccessful conservative therapy for athletes with OCD. [166] (10.1016/j.arthro.2011.01.002)
[L3] Whereas nonoperative treatment is associated with faster return to play, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity. [168] (10.1016/j.arthro.2020.12.225)
[L4] Although the clinical outcomes were not significantly different between collision and non-collision athletes, the level of return to sports was significantly higher in the non-collision group than in the collision group. [169] (10.1007/s00167-017-4775-4)
[L5] These findings demonstrate that pitching with fatigue may cause biomechanical changes that have been associated with increased rates of elbow injury in the adult throwing population. [170] (10.1016/j.jse.2024.05.050)
[L4] Adolescent athletes with a concussion history who sustained a lower extremity musculoskeletal injury across a 1-year study period had a relatively suppressed ASR compared to those who remained injury free. [171] (10.1177/2325967126s00184)
[L3] Elbow and shoulder kinetics increase with time, particularly after age 13. [172] (10.1177/0363546517732034)
[L3] Pitch velocity was the most influential variable in both models, but pitching mechanics also significantly influenced both elbow and shoulder stress. [173] (10.1177/03635465211054506)
[L3] Intensive rehabilitation may safely allow a faster return to competition and also influence positively the clinical outcome at medium-term follow-up. [175] (10.1177/0363546509348490)
[L2] This 3-year longitudinal evaluation suggests that these findings on MRI tend to progress, especially among athletes who play baseball year-round. [178] (10.1177/0363546519888647)
[L4] Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis. [179] (10.1016/j.jseint.2020.02.008)
[L4] Significant findings assessing MRI measurements of the epiphyseal plate in the asymptomatic adolescent elite tennis player might reflect a development of consecutive alterations in the epiphyseal plate in the dominant arm. [180] (10.1007/s00167-016-4024-2)
[L4] Extended follow-up is needed to definitively assess the success of this technique in returning high-caliber athletes to their previous level of competition. [184] (10.1016/j.arthro.2007.08.016)
[L4] Normalized elbow varus torque was associated with ball velocity and 10 other kinematic parameters. [185] (10.1177/23259671241300560)
[L4] The results indicate that a prediction of elbow valgus can be made based on 4 parameters of pitching mechanics. [189] (10.1067/mse.2002.121481)
[L4] Early orthopaedic referral and early MRI may help prevent delay in diagnosis and allow expedient surgical intervention in appropriate candidates. [191] (10.1177/0363546509351559)
[L4] In painful shoulders of throwing athletes, not only the rotator cuff but also the humeral head changed on MR imaging scans. [192] (10.1016/s1058-2746(96)80540-4)
[L4] We recommend systematic radiological examination of the lumbar spine in athletes considered to be at greater risk of developing spondylolysis. [195] (10.1177/03635465000280012101)
[L2] The MRI findings in asymptomatic MLB pitchers do not appear to be related to near future placement on the DL. [200] (10.1177/0363546513491093)
[L4] Athletes who underwent spine MRI during the 2016 Summer Olympic Games show a high frequency of DDD of cervical and lumbar spines. [201] (10.1186/s12891-020-3057-3)
[L4] Most baseball players who participated in the 2023 MLB Combine had MRI evidence of rotator cuff abnormalities, and many showed evidence of an olecranon osteophyte. [202] (10.1177/03635465251339773)
[L4] This study demonstrates a high rate of abnormal magnetic resonance imaging findings in asymptomatic throwers' elbows. [203] (10.1177/0363546503262646)
[L3] Patients with excellent performance on isokinetic strength and functional testing at 6 months after ACL reconstruction have superior knee function and higher activity levels at midterm follow-up. [205] (10.1007/s00167-015-3697-2)
[L2] Simpler methods using MRIs downgraded to a clinical-grade resolution can identify the same knee anatomic factors previously found to significantly contribute to ACL injury risk using sophisticated methods and research-grade resolution MRIs. [206] (10.1177/03635465211024249)
[L4] The results demonstrated that forearm position was not associated with the elbow varus moment, but the supination moment was associated with the elbow varus moment. [207] (10.1177/0363546517733471)
[L5] Athletes are at risk for neurovascular injuries due to extreme forces on the shoulder girdle; a high index of diagnostic acumen and proper selection of clinical assessment and imaging techniques are needed to diagnose these conditions. [208] (10.5435/00124635-200704000-00008)
[L4] Valgus torque at the elbow during baseball pitching is associated with 6 biomechanical variables of sequential body motion. [210] (10.1177/0363546509336721)
[L4] The study demonstrated a high prevalence of both acute and chronic shoulder injuries in the Olympic athletes receiving shoulder MRI. [211] (10.1186/s12891-018-2224-2)
[L2] Athletes whose training hours exceeded their age or whose sports hours exceeded free play by a factor greater than 2 were also more likely to develop injuries. [212] (10.1177/2325967120922764)
[L5] Careful examination comparing the involved and uninvolved knees, considering stress radiographs, and combining this with magnetic resonance imaging findings is currently our most accurate way to grade these injuries. [214] (10.1016/j.arthro.2017.11.001)
[L4] In athletes with a history of labral repair, assessment of labral integrity on MRI alone is not predictive of future short-term participation. [215] (10.1016/j.arthro.2017.07.007)
[L4] Clinicians should consider advanced imaging to rule out occult fracture in athletes with significant capsular distention or those who do not respond to nonoperative management after a suspected ankle sprain. [217] (10.1177/0363546508324965)
[L4] There was no appreciable increase in clinical complications or deterioration in sporting performance. [219] (10.1302/0301-620x.99b10.bjj-2016-0686.r3)
[L4] An early return to sports is possible; however, the time to return is highly variable. [222] (10.1177/0363546513501494)
[L4] A significant number of athletes demonstrated advanced spinal disease on MRI during the 2016 Summer Olympics, with approximately 1 athlete per 200 demonstrating moderate to severe spinal pathology. [223] (10.1136/bmjsem-2017-000335)
[L5] Most research shows that elbow loads in throwing or serving are not generated or regulated solely by local muscles and ligaments; distant body segments generate forces and provide mechanisms to regulate loads for optimal performance with minimal injury risk. [224] (10.1016/j.csm.2004.04.010)
[Textbook] The text provides a historical overview of skateboarding, describes skateboard design and styles, and lists various tricks, but explicitly states that data on injuries suffered while performing specific styles or tricks do not exist. [225] (10.1007/978-3-319-28265-7_14)
[L4] Early diagnosis using MRI and consistent conservative treatment are recommended. [227] (10.1007/s00167-005-0003-8)
[L3] [229] (10.1177/03635465010290051101)
[L2] [230] (10.1177/0363546511408877)
[Paper] [232] (10.1136/bjsports-2016-096572)
[L4] [233] (10.1177/2325967123s00339)
[L3] [235] (10.1007/s00167-020-06388-5)
[L4] An accelerated rehabilitation programme resulted in a return to play time of 11 weeks compared to previously reported times of between 5 months and 9 months in the contact sports population. [237] (10.1177/1758573216647898)
[L5] The kinematics in both the arm tackle and the head-in-front tackle is significantly different from that in the shoulder tackle and may represent a distinct risk factor for shoulder dislocation. [238] (10.1016/j.jse.2018.06.023)
[L5] Additionally, both elbow varus torque and swing velocity were greatest when swinging to the outside location. [239] (10.1016/j.jse.2025.02.001)
[L4] Shoulder flexibility, arm speed, and elbow varus torque are interrelated and should be considered collectively when treating pitchers. [241] (10.1177/0363546517719047)
[L4] Functional elbow range of motion necessary for activities of daily living may be greater than previously reported. [242] (10.2106/jbjs.i.01633)
[L2] Pitchers with increased dynamic elbow laxity were found to experience reduced medial elbow torque while pitching. [243] (10.1016/j.arthro.2020.12.208)
[L4] Elbow flexion strength and forearm supination strength differ between the dominant and nondominant sides. [245] (10.1016/j.jse.2017.05.031)
[L5] Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. [252] (10.1016/j.jse.2023.11.001)
[L3] [254] (10.1177/0363546515597485)
[L3] [255] (10.1186/s13018-025-05935-5)
[L4] [256] (10.4085/1062-6050-239-17)
[L4] All athletes returned to athletic activity at a level similar to the preintervention period. [257] (10.1016/j.jse.2024.05.047)
[L5] [258] (10.2106/jbjs.19.01245)
[L4] [259] (10.1177/0363546511422219)
[L2] [261] (10.1186/s13018-022-03376-y)
[L5] [263] (10.5435/jaaos-20-08-518)
[L3] [265] (10.1007/s00167-015-3546-3)
[L4] However, the postoperative course is associated with an extended period of time until return to previous level of competition when compared with baseball players. [266] (10.1177/0363546511422350)
[L4] [267] (10.1016/j.arthro.2021.11.003)
[L4] [268] (10.1177/0363546508331205)
[L3] Mean recovery time across all groups (29.4 days) showed considerably longer return to play than the most commonly cited concussion recovery time window (7-10 days) for collegiate athletes. [269] (10.1177/2325967118760854)
[L4] However, although there was no decline in overall activity level at a mean of 3 years, self-assessed athletic performance was attained and maintained in approximately one-half of the study population. [271] (10.1177/0363546516632743)
[L4] All patients returned to their high level of athletic activity, with maximal recovery occurring at twelve months. [273] (10.1016/s1058-2746(96)80256-4)

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[106] Return to Sport After Ulnar Collateral Ligament Tears Treated with Platelet‐Rich Plasma Injections is Influenced by Length of Rehabilitation and Leukocyte Content of Injections: A Systematic Review. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.03.017

[109] Return to sports and recreational activities after patellofemoral arthroplasty: A systematic review. Journal of ISAKOS. 2025. DOI: 10.1016/j.jisako.2025.100925

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[113] Platelet‐rich plasma (PRP) to treat sports injuries: evidence to support its use. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1306-y

[114] Biomechanics of the elbow in sports. Clinics in Sports Medicine. 2004. DOI: 10.1016/j.csm.2004.06.003

[115] Sport-specific outcomes after isolated meniscal repair: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4463-4

[116] Why do patients with anterior shoulder instability not return to sport after surgery? A systematic review of 63 studies comprising 3545 patients. JSES International. 2023. DOI: 10.1016/j.jseint.2023.01.001

[117] Therapy and Rehabilitation for Upper Extremity Injuries in Athletes. Hand Clinics. 2017. DOI: 10.1016/j.hcl.2016.08.016

[118] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > TABLE 2.3 Shoulder Spaces.

[121] Return to Sport After Distal Biceps Tendon Repair: A Systematic Review. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465241295618

[123] Treatment of Ulnar Collateral Ligament Tears of the Elbow. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967116682211

[129] Miller S Review Of Orthopaedics. ELBOW.

[131] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > INJURIES AROUND THE ELBOW.

[137] Differences in ACL biomechanical risk factors between field hockey and lacrosse female athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-2873-0

[138] Persistence of the olecranon physis in baseball players: Results following operative management. Journal of Shoulder and Elbow Surgery. 2003. DOI: 10.1067/mse.2003.12

[139] Pitch Counts and Injury Incidence in Major League Baseball: Responses to Pitch Clocks and Defender Rule Changes. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251403066

[140] Imaging of the Elbow in the Overhead Throwing Athlete. The American Journal of Sports Medicine. 2003. DOI: 10.1177/03635465030310032601

[143] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Pathoanatomy and Applied Anatomy Related to Distal Humerus Fractures.

[148] Performance and Return to Sport After Ulnar Nerve Decompression/Transposition Among Professional Baseball Players. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519829159

[149] Femoroacetabular impingement in elite ice hockey players. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2598-5

[151] Ulnar Collateral Ligament Injuries in Overhead Athletes: Diagnosis, Management, and Clinical Outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-24-00392

[152] Low-Back Pain in Athletes. The Journal of Bone & Joint Surgery. 2004. DOI: 10.2106/00004623-200402000-00027

[154] Aaos Comprehensive Orthopaedic Review 3. Elbow Stiffness* > IV. Evaluation.

[155] PREFACE. Clinics in Sports Medicine. 1997. DOI: 10.1016/s0278-5919(05)70029-6

[158] Return-to-play outcomes in high school baseball players after ulnar collateral ligament injuries: dynamic contributions of flexor digitorum superficialis function. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.022

[159] Medial Collateral Ligament of the Elbow: Acute Deterioration in Throwing Athletes. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.011

[160] Return to Sport After Criteria-Based Rehabilitation of Acute Adductor Injuries in Male Athletes: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967119897247

[161] Rotator Cuff Contusions of the Shoulder in Professional Football Players. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546506295082

[162] Outcomes after ulnar collateral ligament injuries in non-throwing athletes: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.04.012

[164] Baseball Pitchers who Suffer Latissimus Dorsi and Teres Major Tendon Injuries Have a High Return to Play Rate After Either Operative or Nonoperative Treatment. Arthroscopy, Sports Medicine, and Rehabilitation. 2023. DOI: 10.1016/j.asmr.2023.100787

[165] Ulnar collateral ligament injuries of the elbow in professional football quarterbacks. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.028

[166] Arthroscopic Surgery in Athletes With Osteochondritis Dissecans of the Elbow. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.01.002

[168] Career Longevity and Performance After Shoulder Instability in National Football League Athletes. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2020.12.225

[169] Return to sports after the latarjet procedure: high return level of non-collision athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4775-4

[170] Increasing pitch count is associated with increasing elbow flexion angle at ball release in youth baseball pitchers. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.050

[171] Acoustic Startle Reflex and Subsequent Musculoskeletal Injury in Adolescent Athletes with a Concussion History: A Pilot Study. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/2325967126s00184

[172] Changes in Youth Baseball Pitching Biomechanics: A 7-Year Longitudinal Study. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517732034

[173] Machine Learning and Statistical Prediction of Pitching Arm Kinetics. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211054506

[175] Does Intensive Rehabilitation Permit Early Return to Sport without Compromising the Clinical Outcome after Arthroscopic Autologous Chondrocyte Implantation in Highly Competitive Athletes?. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509348490

[176] Aaos Comprehensive Orthopaedic Review 3. Elbow Injuries in the Athlete* > III. Valgus Extension Overload Syndrome and Posterior Impingement.

[178] Progressive Elbow Magnetic Resonance Imaging Abnormalities in Little League Baseball Players Are Common: A 3-Year Longitudinal Evaluation. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519888647

[179] The unstable os acromiale: a cause of pain in the young athlete. JSES International. 2020. DOI: 10.1016/j.jseint.2020.02.008

[180] Asymptomatic elite young tennis players show lateral and ventral growth plate alterations of proximal humerus on MRI. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4024-2

[184] Arthroscopic Intratendinous Repair of the Delaminated Partial‐Thickness Rotator Cuff Tear in Overhead Athletes. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.08.016

[185] Kinematic Parameters Associated With Elbow Varus Torque in Elite Adult Baseball Pitchers. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671241300560

[189] Relationship between throwing mechanics and elbow valgus in professional baseball pitchers. Journal of Shoulder and Elbow Surgery. 2002. DOI: 10.1067/mse.2002.121481

[191] Pectoralis Major Avulsion in a Skeletally Immature Wrestler. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546509351559

[192] MR imaging of painful shoulders in sports. Journal of Shoulder and Elbow Surgery. 1996. DOI: 10.1016/s1058-2746(96)80540-4

[195] The Prevalence of Spondylolysis in the Spanish Elite Athlete. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280012101

[200] Glenohumeral Findings on Magnetic Resonance Imaging Correlate With Innings Pitched in Asymptomatic Pitchers. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513491093

[201] MRI-detected spinal disc degenerative changes in athletes participating in the Rio de Janeiro 2016 Summer Olympics games. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3057-3

[202] Musculoskeletal Findings of the Major League Baseball Combine: A Description of the “Normal” Prospective Professional Baseball Player. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251339773

[203] Evidence of Subclinical Medial Collateral Ligament Injury and Posteromedial Impingement in Professional Baseball Players. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0363546503262646

[205] Return to sport: Does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes?. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3697-2

[206] Clinical-Grade MRI-Based Methods to Identify Combined Anatomic Factors That Predict ACL Injury Risk in Male and Female Athletes. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211024249

[207] A Biomechanical Analysis of the Association Between Forearm Mechanics and the Elbow Varus Moment in Collegiate Baseball Pitchers. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517733471

[208] Neurovascular Injuries to the Athleteʼs Shoulder: Part I. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200704000-00008

[210] Correlation of Throwing Mechanics With Elbow Valgus Load in Adult Baseball Pitchers. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509336721

[211] The epidemiology of MRI detected shoulder injuries in athletes participating in the Rio de Janeiro 2016 Summer Olympics. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2224-2

[212] Risk of Injuries Associated With Sport Specialization and Intense Training Patterns in Young Athletes: A Longitudinal Clinical Case-Control Study. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120922764

[214] Editorial Commentary: Posterolateral Corner Injuries in Elite Athletes Remain a Challenging Diagnostic Problem. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.11.001

[215] Recurrent Labral Tearing on Magnetic Resonance Imaging Is Not Predictive of Diminished Participation Among National Football League Athletes. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.07.007

[217] Unusual Presentation of a Talar Neck Fracture in an Intercollegiate Varsity Football Player. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508324965

[219] Early unprotected return to contact sport after metacarpal fixation in professional athletes. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b10.bjj-2016-0686.r3

[222] Return to Athletic Activity After Plate Fixation of Displaced Midshaft Clavicle Fractures. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513501494

[223] Evaluation of spine MRIs in athletes participating in the Rio de Janeiro 2016 Summer Olympic Games. BMJ Open Sport & Exercise Medicine. 2018. DOI: 10.1136/bmjsem-2017-000335

[224] Kinetic chain contributions to elbow function and dysfunction in sports. Clinics in Sports Medicine. 2004. DOI: 10.1016/j.csm.2004.04.010

[225] 14. Skateboarding Injuries. Extreme Sports Medicine. 2017. DOI: 10.1007/978-3-319-28265-7_14

[227] Stress fractures in adolescent competitive athletes with open physis. Knee Surgery, Sports Traumatology, Arthroscopy. 2005. DOI: 10.1007/s00167-005-0003-8

[229] Prospective Evaluation of Arthroscopic Stabilization of Acute, Initial Anterior Shoulder Dislocations in Young Athletes. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290051101

[230] Epidemiology of Patellar Tendinopathy in Elite Male Soccer Players. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511408877

[231] Chapter 53 Special Considerations in Head Injuries in Adolescent Athletes. 2019.

[232] How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness. British Journal of Sports Medicine. 2016. DOI: 10.1136/bjsports-2016-096572

[233] Poster 376: Injury rates in NCAA student-athletes increased after COVID-19 lockdowns: A descriptive epidemiological study. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00339

[235] Type V superior labral anterior–posterior tears results in lower rates of return to play. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-020-06388-5

[237] Accelerated rehabilitation after arthroscopic Bankart repair in professional footballers. Shoulder & Elbow. 2016. DOI: 10.1177/1758573216647898

[238] The kinematics of 1-on-1 rugby tackling: a study using 3-dimensional motion analysis. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.06.023

[239] Medial elbow torque during baseball hitting: considerations for return to play. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.001

[241] The Relationship of Throwing Arm Mechanics and Elbow Varus Torque: Within-Subject Variation for Professional Baseball Pitchers Across 82,000 Throws. The American Journal of Sports Medicine. 2017. DOI: 10.1177/0363546517719047

[242] Functional Elbow Range of Motion for Contemporary Tasks. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.i.01633

[243] Elbow Torque Is Reduced in Asymptomatic College Pitchers With Elbow Laxity: A Dynamic Ultrasound Study. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.12.208

[245] Elbow flexion and forearm supination strength in a healthy population. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.05.031

[252] Weakening and factors of medial elbow dynamic stabilizers against elbow valgus laxity after repetitive pitching in high school baseball players. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.11.001

[254] Design and Testing of the Degree of Shoulder Involvement in Sports (DOSIS) Scale. The American Journal of Sports Medicine. 2015. DOI: 10.1177/0363546515597485

[255] Higher revision and secondary surgery rates after ACL reconstruction in athletes under 16 compared to those over 16: a case-control study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05935-5

[256] The First Decade of Web-Based Sports Injury Surveillance: Descriptive Epidemiology of Injuries in US High School Boys' Baseball (2005–2006 Through 2013–2014) and National Collegiate Athletic Association Men's Baseball (2004–2005 Through 2013–2014). Journal of Athletic Training. 2019. DOI: 10.4085/1062-6050-239-17

[257] Return to sport after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation in competitive contact athletes with recurrent anterior shoulder instability. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.047

[258] Global Forum: Orthopaedic Physicians in the Winter and Summer Olympic Games. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01245

[259] Management and Outcomes of Latissimus Dorsi and Teres Major Injuries in Professional Baseball Pitchers. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511422219

[261] Return to sport after conservative versus surgical treatment for pubalgia in athletes: a systematic review. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03376-y

[263] Management of Mid-season Traumatic Anterior Shoulder Instability in Athletes. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-08-518

[265] Functional assessments for decision‐making regarding return to sports following ACL reconstruction. Part II: clinical application of a new test battery. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3546-3

[266] Elbow Ulnar Collateral Ligament Reconstruction in Javelin Throwers at a Minimum 2-Year Follow-up. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511422350

[267] Return to Sports Following Meniscal Allograft Transplantation Is Possible but Remains Questionable: A Systematic Review. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2021.11.003

[268] Traumatic and Overuse Injuries Among International Elite Junior Rowers. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546508331205

[269] Reconsidering Return-to-Play Times: A Broader Perspective on Concussion Recovery. Orthopaedic Journal of Sports Medicine. 2018. DOI: 10.1177/2325967118760854

[271] Return to Play After Periacetabular Osteotomy for Treatment of Acetabular Dysplasia in Adolescent and Young Adult Athletes. The American Journal of Sports Medicine. 2016. DOI: 10.1177/0363546516632743

[272] Chapter 137 Musculoskeletal Conditions and Injuries in the Young Athlete. 2019.

[273] Posttraumatic axillary nerve palsy in athletes. Journal of Shoulder and Elbow Surgery. 1996. DOI: 10.1016/s1058-2746(96)80256-4

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