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

187 citationsUpdated Sep 2026

Overview

Femoroacetabular impingement in athletes is a condition where proper recognition and treatment allow most individuals to return to sports, though long-term implications of high-level activities must be considered [1]. Skeletally immature throwing athletes can undergo timely recovery and return to sport participation with minimal long-term effect when proper treatment, appropriate intervention, and a thorough understanding of injury prevention guidelines are applied [3]. The Team Physician Consensus Statement provides guidelines that best serve the health care needs of athletes and teams [15].

Surgical indications vary by injury type. Surgery is indicated for athletes with core muscle injury producing groin pain who fail nonsurgical management to allow return to sport [13]. For ulnar collateral ligament injuries, professional athletes and those with complete tears are indicated for surgery by consensus, while opinion is more divided on partial tears or nonprofessionals [40]. Surgeons should base operative decision making for ulnar collateral ligament injuries on patient sport and level of competition to optimize return to sport and minimize complication and reinjury risk [100]. 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 [36].

Return to sport outcomes are influenced by multiple factors. 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 [27]. Ranges of return to sport rates following anterior shoulder instability surgery are influenced by procedure type, clinical follow-up duration, athletic level, and revision surgery status [41]. Rehabilitation of the upper extremity athlete differs from other patients due to high functional demands and reinjury risk, requiring sport-specific protocols [45]. There is an urgent need for more robust, operationalized, and sport-specific return to performance criteria to support clinical decision-making in soccer [9]. A systematic review of 16 articles evidenced that there was no standardisation in how to evaluate postoperative outcomes in athletes and high-performance sports practitioners [17]. Level I Evidence comprises 10% of contemporary sports medicine literature, and randomized controlled trials comprise 6% [20]. Ongoing barriers for inclusion of all athletes in sport lead to reduced rates of para sport participation [46].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that afford bony stability [113]. The ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [113]. 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 [113]. The trochlea is covered by articular cartilage anteriorly, inferiorly, and posteriorly, creating an arc of almost 270 degrees [145]. The radiocapitellar joint is formed by the articulation of the capitellum and the radial head [113]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [113]. The proximal radioulnar joint (PRUJ) is formed by the articulation of the radial head with the lesser sigmoid notch of the ulna [113].

The distal humeral articular surface is angled 30° from the longitudinal axis of the humerus [113] and is angled 30 degrees anterior to the humeral shaft axis [132]. The axis of rotation of the elbow is 5° to 7° angulated in the coronal plane to the epicondylar axis, with the medial side more distal than the lateral side [113]. The distal humeral articular surface is aligned in 4 degrees to 8 degrees of valgus relative to the humeral shaft [145]. The distal humerus consists of medial and lateral columns [132]. The medial column diverges approximately 45 degrees from the humeral shaft in the coronal plane [145], while the lateral column diverges at approximately 20 degrees from the humeral shaft in the coronal plane [145]. The lateral column curves anteriorly, creating a 35 to 40 degrees angle with the shaft in the sagittal plane [145]. The olecranon fossa and coronoid fossa are separated by a thin bony septum which is occasionally absent [145].

The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [113]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [113]. The sublime tubercle, located just distal and medial to the coronoid, provides the attachment site for the anterior bundle of the medial ulnar collateral ligament [113]. The medial epicondyle forms the attachment site for the origins of the flexor pronator mass [113], and the lateral epicondyle is the origin of the lateral extensor musculature [113]. The olecranon provides a broad attachment site for the triceps [113].

Ligamentous Anatomy

Elbow stability is determined by primary stabilizers (ulnohumeral articulation, MUCL, LUCL complex) and secondary stabilizers (radiocapitellar articulation, common flexor tendon, common extensor tendon, joint capsule) [43]. The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus stress within functional elbow range of motion [132]. It originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [132]. The MUCL is comprised of the anterior bundle, posterior bundle, and transverse ligament [106]. 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 [106]. The posterior bundle of the MUCL is the primary restraint to valgus stress with the elbow in maximal flexion [132].

The lateral collateral ligament (LCL) complex consists of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), and the annular ligament [145]. The LCL complex functions as an important restraint to varus and posterolateral rotatory instability [145]. The LUCL is a posterolateral stabilizer of the elbow [120]. Its origin center is 10.7 mm from the lateral epicondyle and its insertion is 3.3 mm from the apex of the supinator crest [106]. The annular ligament attaches to the anterior and posterior margins of the lesser sigmoid notch [145]. The radial collateral ligament originates from an isometric point on the lateral epicondyle and fans out to attach to the annular ligament [145]. The LUCL arises from an isometric point on the lateral epicondyle and attaches to the crista supinatoris of the proximal ulna [145]. Osborne’s ligament stabilizes the ulnar nerve in the cubital tunnel [120]. 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 [120].

Muscular Anatomy

The brachialis is the strongest elbow flexor and attaches to the coronoid 11 mm distal to the tip [120]. The biceps brachii inserts at the ulnar margin of the radial tuberosity and is a powerful supinator of the forearm [120]. The triceps is the primary elbow extensor and inserts on the olecranon process [120]. The mobile wad consists of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis [120]. The flexor-pronator mass consists of the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [120]. The triceps has three distinct insertional areas to the olecranon: posterior capsular insertion, deep muscular portion (medial head), and superficial tendinous portion (long and lateral heads) [106]. The width of the triceps insertion is 2.6 cm and is located 1.1 cm from the tip of the olecranon [106].

Range of Motion

The normal elbow has a range of motion from 0° to 140° from extension to flexion [43] and from 0 to 150 degrees in flexion/extension [132]. The normal forearm pronation is 75° and supination is 85° [43], with normal forearm pronosupination being 80 to 85 degrees in each direction [132]. A functional arc for elbow flexion and extension is 100° [43], while a functional range of motion for elbow flexion/extension is 30 to 130 degrees [132]. A functional range of motion for forearm rotation is 50 degrees [132]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [132]. The overall valgus angle of the elbow in extension, including the ulna, is 10 to 17 degrees [145].

Biomechanics & Pathophysiology

Tensile forces are present at the medial elbow and compressive forces at the lateral elbow [120]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [132]. The capsule allows maximum distension at approximately 70 to 80 degrees of flexion [120]. The anterior capsule attaches at a point approximately 6 mm distal to the tip of the coronoid [120].

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 [226]. Valgus torque at the elbow during baseball pitching is associated with 6 biomechanical variables of sequential body motion [213]. Normalized elbow varus torque is associated with ball velocity and 10 other kinematic parameters [185]. Pitch velocity is the most influential variable in predicting elbow and shoulder stress, though pitching mechanics also significantly influence these stresses [173]. Shoulder flexibility, arm speed, and elbow varus torque are interrelated and should be considered collectively when treating pitchers [245]. Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity in high school baseball players [256]. Elbow and shoulder kinetics increase with time in youth baseball pitchers, particularly after age 13 [171]. Pitching with fatigue may cause biomechanical changes associated with increased rates of elbow injury in the adult throwing population [170]. Increased medial elbow torque is associated with greater ball velocity regardless of the history of medial elbow injuries in youth baseball pitchers [223]. Forearm position is not associated with the elbow varus moment, but the supination moment is associated with the elbow varus moment in collegiate baseball pitchers [210]. Elbow varus torque and swing velocity are greatest when swinging to the outside location during baseball hitting [243].

The kinematics in arm tackle and head-in-front tackle are significantly different from shoulder tackle and may represent a distinct risk factor for shoulder dislocation in rugby [242]. Complete proximal adductor avulsion injuries in high-performance athletes occur predominantly on the dominant leg (83%) and are frequently due to overstretch (67%) or kicking a ball (50%) [4]. Injury rates in extreme sports are higher in new/inexperienced athletes and experienced extremists, with an increase during competitions rather than training [6]. Sport injury profiles and rates often differ by sex/gender, with injury outcomes often worse in female athletes [24]. 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 [62].

Prior injury or surgery is a known risk factor for reinjury of a given body part [64]. 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 [64]. 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 [277]. 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 [277]. Children are less coordinated and have poorer mechanics than adults, making them susceptible to injury [277]. Children have less efficient thermoregulatory mechanisms than adults, including a less efficient sweating response, and cannot acclimatize as rapidly [277].

In baseball, the most common mechanism of injury during practices is no contact (31.2% in high school, 44.3% in college) [261]. In baseball, overuse/chronic is a frequent mechanism of injury during practices (18.3% in high school, 25.3% in college) [261]. In international elite junior rowing, the dominant self-reported injury mechanism is overuse, while trauma was reported in 26.2% of cases [272]. Traumatic-onset injuries are significantly more frequent among male junior rowers, while overuse injuries are significantly more frequent among female junior rowers [272].

Classification

Terminology: In the context of muscle injuries, "classification" and "grading" refer to distinct processes, although the terms have frequently been used interchangeably and ambiguously in the literature [57]. Injury classification specifically describes or categorizes an injury by its location, mechanism, or underlying pathology [57]. Injury grading provides an indication of injury severity [57].

Salter-Harris: This classification scheme is used to describe most pediatric lower extremity periarticular injuries [66].

Sport Specialization: Sport specialization status can be classified using a 3-point scale that identifies the degree of specialization along a continuum from low to high [22]. Specialization is classified as low for scores of 0-1, moderate for a score of 2, and high for a score of 3 on this scale [22]. The degree of sport specialization can also be categorized as low, moderate, or high based on answers to three specific survey questions regarding main sport selection, exclusion of other sports, and year-round training duration [65]. An expanded definition of sport specialization classifies athletes as "extremely specialized" if they answer "yes" to all four questions, including specializing under the age of 12 years [65].

DOSIS Scale: The DOSIS scale ranks athletes in homogeneous subgroups according to the type, frequency, and level of sport [259]. 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 [259].

Other Considerations: Return-to-Sport Clearance Continuum: This model proposes an evolving continuum of healing and testing rather than a single decision point for return to sport [60]. Concussion Management: Sport-related concussions are heterogeneous and require an individualized clinical approach [28]. Orchard Sports Injury Classification System: This system is used to collect injury data in elite-level wrestling [42].

Clinical Presentation

General Assessment & Diagnosis

A systematic approach integrating history, physical examination, imaging, and sport-specific treatment algorithms facilitates symptomatic improvement and return to play [2]. Clinician awareness of the discerning characteristics among different shoulder injuries is essential for proper diagnosis and treatment planning [71]. In young hyperlax athletes, the diagnosis of unstable painful shoulder (UPS) is often missed but must be considered [89]. Similarly, clinician awareness of Paget-Schroetter syndrome is critical to avoid treatment delays and misdiagnosis [74]. Symptomatic axillopectoral muscle should be included in the differential diagnosis for shoulder or arm pain associated with swelling and/or neurovascular symptoms, particularly in overhead athletes [81]. Athletes are at particular risk of neurovascular compromise distal to the brachial plexus [90]. Clinical symptomatology in overhead athletes is commonly associated with deficits extending beyond local pathoanatomy, requiring a comprehensive evaluation of the kinetic chain and adaptive changes [77]. Unenhanced magnetic resonance imaging of the shoulder in asymptomatic high-performance throwing athletes reveals abnormalities that may encompass a spectrum of nonclinical findings [37]. Exertional heat-related illness is a frequently encountered but preventable issue that remains a leading cause of death in athletes [72]. A thorough understanding of epidemiology, screening methods, and the differentiation of pathology from benign athlete's heart changes is essential for sports medicine physicians [69].

Concussion & Neurological

The diagnosis of sport-related concussion (SRC) remains a challenge due to non-specific symptoms and the lack of objective biomarkers [26]. No definitive diagnostic tools for SRC exist because no radiological imaging or biomarkers are 100% sensitive and specific for the condition [129]. Incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion in collegiate athletes [80]. Female athletes have a higher symptom burden before and after a sport concussion [68]. They may be more susceptible to concussion, experience prolonged symptoms, and are more likely to report a concussion than their male counterparts [76]. Relatively few athletes who are symptom-free at rest after a concussion will have a recurrence of symptoms when they resume exercise [34]. In intercollegiate water polo athletes, concussions were the most common injury diagnosis [70]. These injuries had the worst return-to-play outcomes among common diagnoses in this population [70]. Concussions in intercollegiate water polo athletes were mostly sustained outside of competition [70].

Musculoskeletal & Sport-Specific

Symptomatic femoroacetabular impingement (FAI) causes substantial reductions in athletic performance compared to healthy competitors [32]. Proximal hamstring strains of stretching type generally imply a prolonged rehabilitation period before returning to sport despite relatively mild initial symptoms [7]. The most common diagnosis for posterior elbow pain in Japanese high school baseball players was posteromedial elbow impingement [86]. Sports injuries in young males and females differed by injury type, diagnosis, and body area [29]. Significant injuries and diagnoses in professional American football appear congruent with the position-specific demands placed on the athletes [31]. Injury mechanisms in extreme sports are less understood than in traditional sports [6]. Higher injury rates 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 [6]. All proximal adductor avulsion injuries in the studied high-performance athletes occurred during matches [4]. Five of six proximal adductor avulsion injuries (83%) occurred on the dominant leg [4]. Four of six proximal adductor avulsion injuries (67%) were due to overstretch [4]. Three of six proximal adductor avulsion injuries (50%) occurred while kicking a ball [4]. One of six proximal adductor avulsion injuries (17%) occurred while sprinting [4]. Shoulder complaints in wheelchair athletes are a subject of systematic review due to the lack of standardized checklists for this specific population [114].

Psychosocial & Epidemiological Context

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 [73]. Sport injury profiles and rates often differ by sex/gender [24]. Injury outcomes such as return to sport and ongoing symptoms are often worse in female, woman and/or girl athletes [24]. Biological differences may partly drive disparities in injury outcomes between sexes [24]. The interaction of sex/gender and sport context may drive disparities in injury outcomes [24]. Female/woman/girl athletes may have different training histories, sport exposure or facilitators and barriers to participation than male/man/boy athletes [24]. Screening athletes for conditions associated with sudden death varies by country, competition level, and physician opinion [84].

Investigations

General Principles

A systematic approach involving history, physical examination, imaging, and sport-specific treatment algorithms facilitates symptomatic improvement and return to play for athletes with back pain [2]. The evaluation of the elbow requires an intimate understanding of the anatomy, biomechanics, and diagnostic tests for this complex joint [43]. Radiographic evaluation of the elbow 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 overhead throwing athletes [142]. 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 [211]. Awareness of the os acromiale in the young athlete, appropriate clinical examination, and image studies are crucial to confirm diagnosis [179]. Early orthopaedic referral and early MRI may help prevent delay in diagnosis and allow expedient surgical intervention in appropriate candidates for pectoralis major avulsion [194]. 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 [219]. 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 in elite athletes [216].

Shoulder

MRI findings in asymptomatic Major League Baseball pitchers do not appear to be related to near future placement on the disabled list [203]. 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 [205]. A study demonstrated a high prevalence of both acute and chronic shoulder injuries in the Olympic athletes receiving shoulder MRI [214]. In athletes with a history of labral repair, assessment of labral integrity on MRI alone is not predictive of future short-term participation [217]. Professional baseball players who suffer a latissimus dorsi or teres major injury have predictable clinical presentations and imaging findings [164].

Elbow

MRI serves as the gold standard for detection of olecranon stress fracture, an overuse injury primarily affecting throwing athletes [44]. 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 study demonstrates a high rate of abnormal magnetic resonance imaging findings in asymptomatic throwers' elbows [206]. CT with two-dimensional reconstruction and three-dimensional surface rendering best visualizes the pathology of valgus extension overload syndrome [176]. 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]. AP, lateral, oblique, and axillary views of the elbow may reveal posteromedial olecranon osteophytes and/or loose bodies in valgus extension overload syndrome [176]. Radiographs should always be obtained for the evaluation of elbow stiffness, including AP, lateral, and oblique views [156]. CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies in elbow stiffness [156]. Three-dimensional CT is used to check for heterotopic ossification in elbow stiffness [156]. MRI can be used to evaluate ligaments and tendons in elbow stiffness, but it is rarely indicated [156]. Electromyography/nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists during the evaluation of elbow stiffness [156]. Radiographic evaluations are essential when diagnosing an osteochondritis dissecans lesion of the knee and elbow; however, important aspects of the OCD lesions may be better seen with MRI [192]. Nonoperative management of MRI-documented isolated grade III lateral collateral ligament injuries in NFL athletes results in more rapid return to play without subjecting the player to the risks of surgery, while achieving an equal likelihood of return to play at the professional level [182].

Hip

MRI evidence suggests that CAM impingement is more common in the elite ice hockey athlete in comparison with non-athletes [151]. Symptomatic femoroacetabular impingement causes substantial reductions in athletic performance compared to healthy competitors placing these athletes at a distinct performance disadvantage [32].

Spine

We recommend systematic radiological examination of the lumbar spine in athletes considered to be at greater risk of developing spondylolysis [197]. Athletes who underwent spine MRI during the 2016 Summer Olympic Games show a high frequency of degenerative disc disease of cervical and lumbar spines [204]. 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 [225].

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 [209].

Lower Extremity & General

Evaluation with radiographic examination or bone scan is indicated for acute transverse patellar fracture associated with weightlifting, and reduction of training load may prevent acute fracture [232]. Early diagnosis using MRI and consistent conservative treatment are recommended for stress fractures in adolescent competitive athletes with open physis [229]. Both location of the injury and severity determined by imaging should therefore be considered for prediction of return-to-sports-time for athletes with stress fracture [14]. 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 [94]. Residual postoperative MRI findings are common and may have no clinical significance in athletes with a history of core muscle surgery [67].

Treatment

General Principles and Return to Play

With proper recognition and treatment, most athletes with femoroacetabular impingement can expect to return to sports, although long-term implications of high-level activities must 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 [27]. There is an urgent need for more robust, operationalized, and sport-specific return to performance criteria to support clinical decision-making in soccer after musculoskeletal injury [9]. Rehabilitation of the upper extremity athlete differs from other patients due to high functional demands and reinjury risk, requiring sport-specific protocols [45]. Athletes with patellar tendinopathy after physical therapy can expect a generally acceptable long-term prognosis [12].

Concussion management is founded on a short-term period of rest from cognitive and physical exertion followed by a gradual and systematic increase in these activities [75]. Student-athletes who do not rest and continue to engage in activities that provoke their concussion symptoms have demonstrated longer recovery times [75]. Complete abstinence from cognitive and light aerobic activities, especially for an extended period, has not been shown to be beneficial for concussion management [75]. An individualized management plan should be created for each adolescent athlete with a concussion [75].

For the female athlete triad, the first step in return to play is to appropriately treat any secondary complications such as stress fractures [92]. Athletes deemed low risk can continue to compete and train with education to prevent increased risk of the female athlete triad and overt disease [92]. Athletes in the moderate-risk category often can have provisional clearance, which allows them to participate in physical activities with recommendations for modifications outlined by a multidisciplinary team [92]. Athletes at high risk or with specific significant pathology are fully restricted from training and competition so the medical conditions affecting the athlete can be treated [92]. A written treatment contract is recommended for female athlete triad patients to allow the athlete to fully understand her disease, the treatment, and the expectations for follow-up and progression [92].

Treatment decision making for high-risk stress fractures should be based on radiographic findings with less consideration given to symptom severity [83]. The immediate goal of treatment is to avoid progression and get the fracture to heal [83]. Treatment typically requires either complete elimination of loading of the site or surgical stabilization [83]. The presence of a visible fracture line on a plain radiograph in a high-risk stress fracture should prompt serious consideration of operative management [83]. If an incomplete fracture is present on plain films with evidence of fracture on MRI or CT in a high-risk location, immobilization and strict non-weight bearing is indicated [83]. Worsening symptoms or radiographic evidence of fracture progression despite nonoperative treatment is an indication for surgical fixation of high-risk stress fractures [83]. All complete fractures at high-risk sites should receive serious consideration for surgical treatment [83]. Surgical fixation is considered to expedite healing, minimize the risk of nonunion, delayed union, and refracture, and prevent catastrophic fracture progression [83].

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 [85]. The deliberate pursuit of truly informed consent is paramount whenever a new treatment is being considered [85]. If a treatment has not been investigated or if only minimal, anecdotal evidence exists, the physician must fully inform the athlete of the experimental nature of the treatment [85]. The team physician should fully convey the risks and benefits associated with a treatment so the physician and the athlete can cooperatively arrive at an informed decision [85]. The foundation of independent medical care in college student-athletes is athlete-centered care focusing only on the individual patient’s needs and concerns [96]. 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 [96]. Medical staff have responsibilities to the best interests of the athlete, integration of current best evidence and practices, and shared decision making to account for the needs and preferences of each patient [96].

Shoulder Instability

Arthroscopic repair in athletes with symptomatic multidirectional instability appears to be an effective, reproducible treatment option [78]. Arthroscopic treatment of traumatic posterior shoulder instability 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 [93]. Bracing is not effective as an adjunct to standard nonoperative management in allowing athletes to return and complete a subsequent season for unstable shoulders [91]. 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 in NFL athletes with shoulder instability [168]. Although the clinical outcomes were not significantly different between collision and non-collision athletes after the Latarjet procedure, the level of return to sports was significantly higher in the non-collision group than in the collision group [169]. Despite similar outcome measures to nonthrowers, throwing athletes are less likely to return to their preinjury levels of sport after arthroscopic capsulolabral repair for posterior shoulder instability [172].

Patients opting for nonoperative treatment of acute anterior shoulder dislocations underwent a supervised rehabilitation program involving a sling for 3 weeks, followed by a restrengthening program emphasizing muscles used for internal rotation and adduction [231]. Early surgical stabilization is recommended for athletes with midseason traumatic anterior shoulder instability who have large bony Bankart lesions or significant glenoid or humeral bone loss [267]. Athletes with an axillary nerve lesion or rotator cuff pathology are also offered surgery for midseason traumatic anterior shoulder instability [267]. Nonsurgical treatment can be considered in athletes with primary instability events and soft-tissue lesions for midseason traumatic anterior shoulder instability [267]. The rehabilitation protocol for nonsurgical treatment consists of simple sling use, gentle ROM exercises, and cryotherapy to regain comfort during the first week postinjury [267]. During the second week, a strengthening protocol for the dynamic stabilizers, including the rotator cuff, as well as periscapular strengthening exercises is initiated [267]. When ROM and strength are similar to those of the contralateral side, sport-specific drills are initiated and return to play with a brace is considered [267]. The typical time frame for return to play after nonsurgical treatment is 3 weeks [267]. At a mean of 5.5 years' follow-up, adolescent athletes had a high failure rate of revision stabilization surgery and modest functional outcomes [19].

Ulnar Collateral Ligament (UCL)

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 [5]. 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 [40]. The cortical button suspension technique for ulnar collateral ligament reconstruction demonstrated a high rate of return to sport (82.6%) and good functional outcomes [39]. 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 [153]. 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 [160]. UCL injuries in high school baseball players can be successfully treated nonoperatively in most cases [159]. 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]. UCL repair is an effective procedure in helping female athletes return to sport with low complication rates [118]. 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]. 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 [150]. 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 treated with platelet-rich plasma injections [108].

Patients can manage partial UCL tears non-operatively with rest, supportive measures, and physical therapy, while more severe injuries require surgical intervention [266]. Surgery for UCL injuries necessitates a minimum of 9 months lost from sports, which can cause significant economic or contractual implications for professional athletes [266]. A systematic review of RTS after non-operative management of UCL tears reports a shorter RTS than surgery, with a mean RTS time of 91.9 ± 46.2 days (13.1 weeks; range, 1–54 weeks) [266].

Elbow Overuse and Other Elbow Injuries

Elbow tendinopathy is a common cause of pain and disability resulting from repetitive overuse activities [88]. Nonsurgical treatment is successful in most cases of elbow tendinopathy, with surgical intervention reserved for those patients with continued symptoms after 6 months or more of treatment [88]. Elbow tendinopathy is not an inflammatory condition but rather a tendon degeneration resulting from continued microtrauma and failed attempts at healing [88]. Rest and activity modification are paramount in the nonsurgical treatment of elbow tendinopathy [88]. The current literature provides no definitive recommendations regarding efficacy of nonsurgical interventions for elbow tendinopathy [88]. Regardless of treatment type, most symptoms improve in elbow tendinopathy [88]. Olecranon stress fracture is an overuse injury primarily affecting throwing athletes, with MRI serving as the gold standard for detection [44]. 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 [103]. Surgical treatment must be contemplated after a period of unsuccessful conservative therapy for athletes with osteochondritis dissecans of the elbow [166].

Hip and Femoroacetabular Impingement

Arthroscopic treatment of FAIS in recreational HIIT participants resulted in significant improvements in hip function and predictably high rates of patient satisfaction [105].

Knee

Nonoperative treatment and return to play after complete proximal adductor avulsion in high-performance athletes: All injuries occurred during matches [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 in complete proximal adductor avulsion cases [4]. Surgical treatment of distal hamstring tendon injuries yield a higher return-to-sports rate [54]. 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 [54]. 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 [117]. These athletes also had significant improvements in most outcome measures after meniscal allograft transplantation [10]. 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 [102]. Athletes conservatively managed returned 40% faster than those with surgery for clavicular fractures, though this appears to be associated with the severity and complexity of fractures treated surgically [147].

The operated knee was fixed at 0° in a postoperative brace for ACL reconstruction in athletes under 16, with the brace removed during daily physiotherapy sessions to mobilize the knee within a 0–40° range to gradually restore range of motion [260]. Isometric muscle strengthening exercises were initiated immediately after ACL reconstruction surgery in athletes under 16 [260]. Full non-weight bearing was applied in the first week after ACL reconstruction surgery in athletes under 16 [260]. Full range of movement was started at the 4th postoperative week after ACL reconstruction in athletes under 16 [260]. Patients could begin cycling at six weeks, swimming at ten weeks, and running in a straight line at twelve weeks after ACL reconstruction in athletes under 16 [260]. Sport-specific exercises were started at week 16 after ACL reconstruction in athletes under 16 [260]. Patients were allowed to return to sports within the ninth postoperative month after ACL reconstruction in athletes under 16 [260]. All patients followed the same standardized, criterion-based rehabilitation program supervised by the same physiotherapy team, without any graft-specific modifications for ACL reconstruction with hamstring tendon grafts [273]. Knee brace in full extension with partial weightbearing is prescribed for 0-2 weeks post-ACL reconstruction [273]. Gradual range of motion (ROM) up to 120° and full weightbearing are prescribed for 2-6 weeks post-ACL reconstruction [273]. Progressive strengthening is prescribed for 6-12 weeks post-ACL reconstruction [273]. Jogging is permitted at 3-6 months post-ACL reconstruction [273]. Return to pivoting sports is permitted at 6-9 months post-ACL reconstruction if quadriceps strength is ≥90% of contralateral side [273].

The rehabilitation protocol for Type V SLAP tears involved placing the shoulder in a sling for 3 weeks, while allowing non-resisted activities of daily living without elevation of the shoulder [238]. Patients immediately began physiotherapy after Type V SLAP tear repair, which continuously increased in intensity over the next nine weeks [238]. Return to contact in training was allowed after twelve weeks following Type V SLAP tear repair [238]. Return to full contact and competition usually would follow within the next three months after Type V SLAP tear repair, depending on progress of physiotherapy [238].

Foot and Ankle

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 [18].

Groin and Core

Surgery is indicated for athletes who fail nonsurgical management to allow return to sport for core muscle injury producing groin pain [13]. Return to sport after treatment of athletic pubalgia should involve a multifaceted assessment process [265]. Conservative treatment is classically recommended before surgery is performed for athletic pubalgia [265]. The length of conservative management before failure of such modality is declared is undefined for athletic pubalgia [265]. Even if successful, conservative management of pubalgia resulted in slower return to sport compared with operative treatment [265]. 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 [265].

Spine

Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes [154]. Direct surgical repair can yield high rates of pain relief in recalcitrant cases of spondylolysis [154].

Soft Tissue and Other

Conservative treatment leads to significant strength loss and prevents return to competitive sports for pectoralis major rupture in athletes [107]. 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]. Non-operative management of isolated LCL injuries is associated with high return to pre-injury level of sport (100%), reasonable recovery times, and no significant residual varus instability [146]. A broad arm sling for a week aided comfort after surgical treatment of acute type V acromioclavicular joint dislocations, after which gradual mobilization was encouraged [268]. Physiotherapy was not usually necessary after surgical treatment of acute type V acromioclavicular joint dislocations, and full movement was gradually regained at 6 weeks [268]. Patients were informed not to exceed the prescribed activity levels or to overload the repair before the completion of 3 months after operation for acute type V acromioclavicular joint dislocations [268]. All mobilization and exercises were performed within the pain-free range of movement after surgical treatment of acute type V acromioclavicular joint dislocations [268]. A gradual buildup of strength during the next few months allowed return

Complications

Return to Sport and Performance Outcomes

Nonoperative management of ulnar collateral ligament injuries permits 42% of throwing athletes to return to their previous competitive level at an average of 24.5 weeks post-diagnosis [5]. In contrast, nearly 90% of adolescent baseball patients return to preinjury sport levels after ulnar collateral ligament reconstruction at a minimum of 2-year follow-up [48]. Arthroscopic Trillat technique for chronic anterior shoulder instability facilitates rapid return to sport at the previous level in the majority of cases [16]. Athletes undergoing meniscal allograft transplantation report significant improvements in most outcome measures [10], with return to competitive sport associated with excellent graft survival and superior long-term outcomes without increased failure rates [23]. Subtalar arthroscopy for sinus tarsi syndrome provides effective long-term outcomes regarding patient-reported measures, return-to-sport metrics, and safety in athletic populations [18]. Following arthroscopic decompression for femoroacetabular impingement, 78% of athletes (35 patients) remained active in professional sport at an average follow-up of 1.6 years [38]. Athletes with patellar tendinopathy receiving physical therapy generally experience an acceptable long-term prognosis [12]. However, subgroup analyses of return-to-sport outcomes after surgical treatment for high-grade acromioclavicular dislocation are not feasible due to low evidence levels and methodological heterogeneity [8]. Adolescent athletes undergoing revision anterior shoulder stabilization surgery face a high failure rate and modest functional outcomes at a mean of 5.5 years [19]. Strength deficits persist at 6 months following stabilization surgery for recurrent lateral patellar instability, particularly when concomitant tibial tubercle osteotomy is performed, which may delay return to sport [56]. Early unprotected return to contact sport after metacarpal fixation in professional athletes does not increase clinical complications or deteriorate sporting performance [221].

Injury Risk and Recurrence

Early sport specialization is an independent risk factor for chronic overuse lower extremity injuries in youth athletes, and high school athletes who specialized earlier recalled higher injury incidence attributed to specialization [52, 53]. Training more than 8 months per year in a single sport is associated with sports-related concussion and prior concussion history [63]. Prior injury or surgery is a known risk factor for reinjury, with 31% of athletes with a prior knee injury sustaining an additional significant knee injury in the following season [64]. In the 24 months following ACL reconstruction and return to sport, patients face a greater risk of subsequent ACL injury compared to young athletes without such history [55]. Patellar tendinopathy in elite male soccer players exhibits a high recurrence rate of 12%–27% [233]. Athletes with a history of core muscle surgery at NFL Combines achieve comparable selection and performance outcomes to others, and residual postoperative MRI findings are common but may lack clinical significance [67]. The pitch clock has not increased short-term injury risk in Major League Baseball, though long-term effects require ongoing research [141]. Increased caution is recommended when returning to play after prolonged restrictions, as injury rates in NCAA student-athletes increased following COVID-19 lockdowns [236]. Future prospective research is needed to define injury risks for young athletes participating in early sport specialization [11].

Concussion and Neurological Complications

Second-impact syndrome is a repeat injury occurring when an athlete has not fully recovered from a previous head injury, resulting in diffuse cerebral swelling, delayed catastrophic deterioration, and occasional brain stem herniation [234]. This condition has been documented in 14- to 18-year-olds, where death occurs from diffuse cerebral edema and possible herniation as the brain loses autoregulation of intracranial and cerebral perfusion pressure [234]. Concerns exist for adolescent athletes returning to sports while symptomatic from concussions, as the National Center for Catastrophic Injury Research identifies recent head injury as a possible risk factor for catastrophic injury [234]. Adolescent athletes with a concussion history who sustain a lower extremity musculoskeletal injury exhibit a relatively suppressed acoustic startle reflex compared to injury-free peers [59]. Players with concussion do not experience reductions in short- or long-term performance metrics when compared with matched controls [51].

Prevention and Screening

Periodic health evaluations screen for injuries early and implement interventions for at-risk athletes, particularly in the off-season to provide medical clearance [62]. Specific sports are identified with distinct injury patterns, such as acute injuries in team or high-speed sports and overuse injuries in technical or repetitive-motion sports, guiding the development of sport-specific evaluations [62]. An 8-week neuromuscular training program after concussion reduces 1-year subsequent injury risk, with similar sports participation between groups during the monitoring period [47]. High-intensity and prolonged training and competition load is associated with increased risk of subclinical immunological changes and actual illness symptoms [235]. Frequent and prolonged international travel, inherent to the modern congested sports calendar, may be related to increased illness risk in athletes [235]. The majority of variability between studies on ice hockey injuries is explained by differences in definitions of injury and athlete exposure [49]. Incidence of season-ending shoulder injuries in the National Collegiate Athletic Association varies widely by sport and injury type, with multiple associated risk factors [61].

Epidemiology and Definitions

A considerable number of high school athletes specialize in one sport during their underclass years [25]. Participation in sports is considered part of a healthy lifestyle encompassing physical and emotional well-being, with the benefits of physical activity believed to outweigh injury risk [21]. Early sport specialization is a modifiable risk factor addressable through a multifaceted approach [21]. Annual injury rates in specific high school sports include 41–46% for football, 40–46% for wrestling/gymnastics, 31–37% for basketball, and 7–18% for others such as volleyball, baseball, soccer, cross-country, softball, and track [66]. Bone injury in children often occurs through the epiphyseal plate, the weakest point of the traumatized region [66]. Salter-Harris type I and II fractures have a more favorable prognosis after anatomic reduction and often can be managed nonsurgically [66]. Salter-Harris type III and IV injuries usually require open reduction with anatomic restoration of the joint surface [66]. All proximal adductor avulsion injuries in high-performance athletes occurred during matches [4]. Five of the six proximal adductor avulsion injuries (83%) occurred on the dominant leg [4]. Four of the six proximal adductor avulsion injuries (67%) were due to overstretch [4]. Three of the six proximal adductor avulsion injuries (50%) occurred while kicking a ball [4]. One of the six proximal adductor avulsion injuries (17%) occurred while sprinting [4]. Data on injuries suffered while performing specific styles or tricks in skateboarding do not exist [227]. The literature on alpine skiing and snowboarding examines the current state of injury data, common injuries from beginners to experts, and strategies to minimize risks [228].

Recovery

General Principles & Return-to-Play 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]. For athletes with stress fractures, both the location of the injury and the severity determined by imaging should be considered for prediction of return-to-sports-time [14].

Upper Extremity & Shoulder: At a minimum of 2-year follow-up, nearly 90% of adolescent baseball players returned to their preinjury level of sport after ulnar collateral ligament reconstruction [48]. In contrast, the postoperative course for elbow 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 [270]. 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 [241]. All competitive contact athletes returned to athletic activity at a level similar to the preintervention period after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation [262]. 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 [19]. Extended follow-up is needed to definitively assess the success of arthroscopic intratendinous repair of the delaminated partial-thickness rotator cuff tear in returning high-caliber overhead athletes to their previous level of competition [184]. An early return to sports is possible after plate fixation of displaced midshaft clavicle fractures, although the time to return is highly variable [224].

Lower Extremity & Hip: 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]. 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 study population [276]. Fifty-three point six percent 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 [54]. 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 [208]. Strength deficits persist at 6 months following stabilization surgery for recurrent lateral patellar instability, especially in those undergoing concomitant TTO, which may delay return to sport [56]. Athletes with patellar tendinopathy after physical therapy can expect a generally acceptable long-term prognosis at 5-year follow-up [12]. Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic populations with sinus tarsi syndrome, with favorable return to sport level, return to sport time, clinical outcomes, and safety outcome measures [18]. 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].

Knee & Meniscus: Athletes who returned to high-level sport after meniscal allograft transplantation had significant improvements in most outcome measures [10].

Concussion & Neurological: The diagnosis of sport-related concussion remains a challenge due to non-specific symptoms and lack of objective biomarkers [26]. Mean recovery time across all groups for concussion was 29.4 days, which is considerably longer than the most commonly cited concussion recovery time window of 7-10 days for collegiate athletes [274]. 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 [51]. 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 [47].

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)
• [L4] Nonoperative treatment allowed 42% of athletes to return to their previous level of competition at an average of 24.5 weeks after diagnosis. [5] (10.1177/03635465010290010601)
• [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)
• [L1] There is an urgent need for more robust, operationalized, and sport-specific return to performance criteria to support clinical decision-making. [9] (10.1002/ksa.70180)
• [L4] These athletes also had significant improvements in most outcome measures. [10] (10.1016/j.arthro.2012.10.027)
• [L5] Future prospective research is needed to define the risk of injury for young athletes who participate in early sport specialization. [11] (10.1177/0363546515576899)
• [L3] Athletes with PT after physical therapy can expect a generally acceptable long-term prognosis. [12] (10.1177/03635465251336466)
• [L5] Surgery is indicated for athletes who fail nonsurgical management to allow return to sport. [13] (10.5435/jaaos-d-22-00739)
• [L3] Both location of the injury and severity determined by imaging should therefore be considered for prediction of return-to-sports-time. [14] (10.1186/1471-2474-13-139)
• [L5] Ultimately, this statement provides guidelines that best serve the health care needs of athletes and teams. [15] (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. [16] (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. [17] (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. [18] (10.1007/s00167-020-06385-8)
• [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. [19] (10.1016/j.arthro.2014.05.037)
• [L1] Level I Evidence and RCTs comprise 10% and 6% of contemporary sports medicine literature, respectively. [20] (10.1016/j.arthro.2013.11.015)
• [L5] [21] (10.2106/jbjs.21.00018)
• [L3] [22] (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. [23] (10.1002/ksa.70137)
• [Paper] [24] (10.1136/bjsports-2025-109904)
• [L2] A considerable number of high school athletes specialize in one sport during their underclass years. [25] (10.1177/2325967119s00408)
• [L5] The diagnosis of sport-related concussion (SRC) remains a challenge due to non-specific symptoms and lack of objective biomarkers. [26] (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. [27] (10.1007/s00167-015-3600-1)
• [L5] Sport-related concussions are heterogeneous and require an individualized clinical approach. [28] (10.1007/s00167-013-2791-6)
• [L3] Sports injuries in young males and females differed by injury type, diagnosis, and body area. [29] (10.1177/0363546514522393)
• [L3] The significant injuries and diagnoses appear congruent with the position-specific demands placed on the athletes. [31] (10.1177/0363546508329542)
• [L2] Symptomatic FAI causes substantial reductions in athletic performance compared to healthy competitors placing these athletes at a distinct performance disadvantage. [32] (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. [34] (10.1177/2325967117732516)
• [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. [36] (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. [37] (10.1177/03635465020300012501)
• [L4] Thirty-five athletes (78%) remain active in professional sport at an average follow-up of 1.6 years. [38] (10.1007/s00167-007-0332-x)
• [L4] The technique demonstrated a high rate of return to sport (82.6%) and good functional outcomes. [39] (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. [40] (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. [41] (10.1016/j.arthro.2025.07.032)
• [L2] [42] (10.1177/23259671251403160)
• [L5] Olecranon stress fracture is an overuse injury primarily affecting throwing athletes, with MRI serving as the gold standard for detection. [44] (10.1016/j.csm.2020.02.005)
• [Paper] Rehabilitation of the upper extremity athlete differs from other patients due to high functional demands and reinjury risk, requiring sport-specific protocols. [45] (10.1016/j.hcl.2016.08.016)
• [L5] Despite these benefits, ongoing barriers for inclusion of all athletes in sport still lead to reduced rates of para sport participation. [46] (10.1136/bjsports-2022-106192)
• [L1] Sports participation was similar between groups during the year-long monitoring period. [47] (10.1177/03635465211069372)
• [L4] At a minimum of 2-year follow-up, nearly 90% of patients returned to their preinjury level of sport. [48] (10.1177/2325967118769328)
• [L4] The majority of variability between studies is explained by differences in the definitions of both injury and athlete exposure. [49] (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. [51] (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. [52] (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. [53] (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. [54] (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. [55] (10.1177/0363546514530088)
• [L4] However, strength deficits persist at 6 months, especially in those undergoing concomitant TTO, which may delay return to sport. [56] (10.1007/s00167-016-4409-2)
• [L5] [57] (10.1136/bjsports-2014-093551)
• [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. [59] (10.1177/2325967126s00184)
• [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)
• [L5] [62] (10.2106/jbjs.19.01245)
• [L3] Training >8 months out of the year in a single sport is associated with sports-related concussion and prior history of concussion. [63] (10.1177/2325967121s00537)
• [L5] [64] (10.1177/0363546515598994)
• [L2] [65] (10.1177/2325967120922764)
• [L5] [66] (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. [67] (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. [68] (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. [70] (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. [71] (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. [73] (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. [74] (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. [76] (10.1177/2325967120932306)
• [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. [77] (10.1016/j.jse.2023.09.001)
• [L4] Arthroscopic repair in athletes with symptomatic MDI appears to be an effective, reproducible treatment option. [78] (10.1177/0363546509335464)
• [L2] The findings in this sample of collegiate athletes suggest that incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion. [80] (10.1177/03635465211072261)
• [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. [81] (10.1177/0363546513486768)
• [Paper] Screening athletes for conditions associated with sudden death varies by country, competition level, and physician opinion. [84] (10.1016/j.csm.2015.03.002)
• [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. [86] (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. [89] (10.1016/j.jse.2010.05.020)
• [L5] Athletes are at particular risk of neurovascular compromise distal to the brachial plexus; when diagnosed properly and in a timely fashion, function of the limb can be preserved. [90] (10.5435/00124635-200705000-00006)
• [L3] Bracing is not effective as an adjunct to standard nonoperative management in allowing athletes to return and complete a subsequent season. [91] (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. [93] (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. [94] (10.1177/0363546507305454)
• [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. [100] (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. [102] (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. [103] (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. [105] (10.1177/0363546518776638)
• [L4] Conservative treatment leads to significant strength loss and prevents return to competitive sports. [107] (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. [108] (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. [111] (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. [112] (10.1016/j.arthro.2015.04.087)
• [L1] [114] (10.1371/journal.pone.0188410)
• [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. [117] (10.1007/s00167-017-4463-4)
• [L4] UCL repair is an effective procedure in helping female athletes return to sport with low complication rates. [118] (10.1016/j.xrrt.2025.02.007)
• [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. [119] (10.1016/j.jseint.2023.01.001)
• [L4] A positive trend for return to sport was observed with respect to rehabilitation protocols favoring earlier active mobility. [123] (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. [125] (10.1177/2325967116682211)
• [L5] Return to play is a challenging metric to define and is not always correlated with the outcome of the procedure; consensus needs to be established in exactly how to define return to play, and primary biceps tenodesis as the best surgical option remains difficult to recommend. [127] (10.1016/j.arthro.2022.09.003)
• [L4] [129] (10.1177/03635465211027946)
• [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. [141] (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. [142] (10.1177/03635465030310032601)
• [L4] Non-operative management of isolated LCL injuries is associated with high return to pre-injury level of sport (100%), reasonable recovery times, and no significant residual varus instability. [146] (10.1177/2325967126s00022)
• [L4] Athletes conservatively managed returned 40% faster than those with surgery, though this appears to be associated with the severity and complexity of fractures treated surgically. [147] (10.1016/j.jse.2021.04.006)
• [L3] Players have a 62% rate of return to sport, which is lower than expected for this nonreconstruction or repair procedure. [150] (10.1177/0363546519829159)
• [L3] MRI evidence suggests that CAM impingement is more common in the elite ice hockey athlete in comparison with non-athletes. [151] (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. [153] (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. [154] (10.2106/00004623-200402000-00027)
• [L3] UCL injuries in high school baseball players can be successfully treated nonoperatively in most cases. [159] (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. [160] (10.1016/j.jhsa.2014.04.011)
• [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)
• [L3] Elbow and shoulder kinetics increase with time, particularly after age 13. [171] (10.1177/0363546517732034)
• [L2] Despite similar outcome measures to nonthrowers, throwing athletes are less likely to return to their preinjury levels of sport. [172] (10.1177/0363546508314426)
• [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)
• [L3] Nonoperative management of MRI-documented isolated grade III lateral collateral ligament injuries in NFL athletes results in more rapid return to play without subjecting the player to the risks of surgery, while achieving an equal likelihood of return to play at the professional level. [182] (10.1177/0363546509344075)
• [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] Early orthopaedic referral and early MRI may help prevent delay in diagnosis and allow expedient surgical intervention in appropriate candidates. [194] (10.1177/0363546509351559)
• [L4] We recommend systematic radiological examination of the lumbar spine in athletes considered to be at greater risk of developing spondylolysis. [197] (10.1177/03635465000280012101)
• [L2] The MRI findings in asymptomatic MLB pitchers do not appear to be related to near future placement on the DL. [203] (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. [204] (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. [205] (10.1177/03635465251339773)
• [L4] This study demonstrates a high rate of abnormal magnetic resonance imaging findings in asymptomatic throwers' elbows. [206] (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. [208] (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. [209] (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. [210] (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. [211] (10.5435/00124635-200704000-00008)
• [L4] Valgus torque at the elbow during baseball pitching is associated with 6 biomechanical variables of sequential body motion. [213] (10.1177/0363546509336721)
• [L4] The study demonstrated a high prevalence of both acute and chronic shoulder injuries in the Olympic athletes receiving shoulder MRI. [214] (10.1186/s12891-018-2224-2)
• [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. [216] (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. [217] (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. [219] (10.1177/0363546508324965)
• [L4] There was no appreciable increase in clinical complications or deterioration in sporting performance. [221] (10.1302/0301-620x.99b10.bjj-2016-0686.r3)
• [L2] Increased medial elbow torque was associated with greater ball velocity regardless of the history of medial elbow injuries. [223] (10.1016/j.arthro.2022.07.016)
• [L4] An early return to sports is possible; however, the time to return is highly variable. [224] (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. [225] (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. [226] (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. [227] (10.1007/978-3-319-28265-7_14)
• [Textbook] This chapter explores the current state of literature about skiing and snowboarding injuries, examines the most common injuries typically seen in beginners to experts, and addresses potential strategies to minimize the risks associated with these sports. [228] (10.1007/978-3-319-28265-7_11)
• [L4] Early diagnosis using MRI and consistent conservative treatment are recommended. [229] (10.1007/s00167-005-0003-8)
• [L3] [231] (10.1177/03635465010290051101)
• [L4] Evaluation with radiographic examination or bone scan is indicated, and reduction of training load may prevent acute fracture. [232] (10.1177/03635465010290021901)
• [L2] [233] (10.1177/0363546511408877)
• [Paper] [235] (10.1136/bjsports-2016-096572)
• [L4] [236] (10.1177/2325967123s00339)
• [L3] [238] (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. [241] (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. [242] (10.1016/j.jse.2018.06.023)
• [L5] Additionally, both elbow varus torque and swing velocity were greatest when swinging to the outside location. [243] (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. [245] (10.1177/0363546517719047)
• [L5] Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. [256] (10.1016/j.jse.2023.11.001)
• [L3] [259] (10.1177/0363546515597485)
• [L3] [260] (10.1186/s13018-025-05935-5)
• [L4] [261] (10.4085/1062-6050-239-17)
• [L4] All athletes returned to athletic activity at a level similar to the preintervention period. [262] (10.1016/j.jse.2024.05.047)
• [L2] [265] (10.1186/s13018-022-03376-y)
• [L3] [266] (10.1177/17585732241235631)
• [L5] [267] (10.5435/jaaos-20-08-518)
• [L4] [268] (10.1016/j.jse.2017.05.032)
• [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. [270] (10.1177/0363546511422350)
• [L4] [272] (10.1177/0363546508331205)
• [L3] [273] (10.1177/23259671261421598)
• [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. [274] (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. [276] (10.1177/0363546516632743)

See Also

• Ligament Injuries

References

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[103] Osteochondral autograft plug transfer for treatment of osteochondritis dissecans of the capitellum in adolescent athletes. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.03.014

[105] High Rate of Return to High-Intensity Interval Training After Arthroscopic Management of Femoroacetabular Impingement Syndrome. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518776638

[106] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Annotated References.

[107] Surgical treatment of pectoralis major rupture in athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 1998. DOI: 10.1007/s001670050085

[108] 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

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

[112] Sporting Activity After Arthroscopic Bankart Repair for Chronic Glenohumeral Instability. Arthroscopy. 2015. DOI: 10.1016/j.arthro.2015.04.087

[113] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Biomechanics, Physical Examination, and Imaging of the Elbow > Anatomy > Bony Anatomy.

[114] Shoulder complaints in wheelchair athletes: A systematic review. PLOS ONE. 2017. DOI: 10.1371/journal.pone.0188410

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

[118] Female athletes have high return to sport and low complication rates following ulnar collateral ligament (UCL) repair or reconstruction: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.02.007

[119] 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

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

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

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

[127] Editorial Commentary: Return to Play in Overhead Athletes After Biceps Tenodesis for SLAP Lesions Is Inconsistent. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2022.09.003

[129] Do Sideline Tests of Vestibular and Oculomotor Function Accurately Diagnose Sports-Related Concussion in Adults? A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211027946

[132] Miller S Review Of Orthopaedics. ELBOW.

[141] 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

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

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

[146] Isolated Clinically Diagnosed Grade I-II Lateral Collateral Ligament Injuries in Elite Athletes Do Not Require Surgery. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967126s00022

[147] Factors influencing time to return to sport following clavicular fractures in adolescent athletes. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.04.006

[150] 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

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

[153] 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

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

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

[159] 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

[160] 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

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

[172] Arthroscopic Capsulolabral Repair for Posterior Shoulder Instability in Throwing Athletes Compared with Nonthrowing Athletes. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508314426

[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

[182] Treatment of Magnetic Resonance Imaging-Documented Isolated Grade III Lateral Collateral Ligament Injuries in National Football League Athletes. The American Journal of Sports Medicine. 2009. DOI: 10.1177/0363546509344075

[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

[192] Orthopaedic Knowledge Update. Osteochondritis Dissecans of the Knee and Elbow* > Summary.

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

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

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

[204] 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

[205] 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

[206] 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

[208] 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

[209] 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

[210] 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

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

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

[214] 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

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

[217] 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

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

[221] 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

[223] Increased Medial Elbow Torque Is Associated With Ball Velocity Rather Than a History of Medial Elbow Injuries in Youth Baseball Pitchers. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.07.016

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

[225] 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

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

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

[228] 11. Alpine Skiing and Snowboarding: Current Trends and Future Directions. Extreme Sports Medicine. 2017. DOI: 10.1007/978-3-319-28265-7_11

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

[231] 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

[232] Acute Transverse Patellar Fracture Associated with Weightlifting. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290021901

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

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

[235] 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

[236] 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

[238] 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

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

[242] 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

[243] 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

[245] 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

[256] 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

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

[260] 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

[261] 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

[262] 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

[265] 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

[266] A systematic review of the outcomes of partial ulnar collateral ligament tears of the elbow in athletes treated non-operatively with platelet-rich plasma injection. Shoulder & Elbow. 2024. DOI: 10.1177/17585732241235631

[267] 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

[268] Surgical treatment of acute type V acromioclavicular joint dislocations in professional athletes: an anatomic ligament reconstruction with synthetic implant augmentation. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.05.032

[270] 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

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

[273] Comparison of Braided and Nonbraided Hamstring Tendon Grafts in ACL Reconstruction: Impact on Graft Thickness, Rerupture Rates, and Clinical Outcomes. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261421598

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

[276] 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

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