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Interviewer: So a little bit of elbow pain if you're a pitcher in baseball is okay, but if it starts to get pretty severe, you're going to want to do something about that.

Dr. Chalmers, how much elbow pain for a pitcher is acceptable? And what's kind of the threshold that you maybe want to have somebody look at what's causing that pain?

Dr. Chalmers: Yeah, we've done some studies that have helped to inform of us of that. And I think one thing to understand that it's not a normal human motion to pitch a baseball. There's nothing we're evolved to that makes us good at pitching a baseball. And there's a lot of adaptations pitchers undergo, as they pitch through adolescence, that help them to become better at it for sure.

But we've done two studies that I think help and inform our thinking about this. We did a large study of youth baseball players, kind of youth and adolescent baseball players, where we asked them whether or not they have pain. And about 30% of kind of normal, uninjured players will say they have regular pain with play. Now this study we did, though, I think is even more informative is we took pitchers and we had them throw through a simulative game. So they threw 90 pitches kind of in simulated 15 pitch innings. And what happened is that . . . and we collected pain scores and fatigues scores, and what we found is that as pitchers get towards that sixth inning, pain scores start to creep up to somewhere around 1 or 2 out of 10, which just kind of still qualifies as minimal to mild amount of pain but not zero pain.

So I usually tell pitchers, if you're throwing and you're getting above a 2 or a 3 out of 10, that that's not normal, it's not expected, it's not something that can be just swept under the rug with the classic saying of, "There's no crying in baseball," and that it's something that probably you should look into. But if you're having a little bit of soreness, 1 or 2 out of 10 with heavy use six innings of pitching, that's probably very normal and something that you could expect with this particular sport.

Interviewer: How do you, when you do the 1 to 10 ranking, help somebody understanding like what a 1 what might be? Because somebody's 1 might be somebody else's 6.

Dr. Chalmers: Well, no, I think you're right. I mean, I think this is always the issue with pain is there's no objective measure of pain. We have no way to measure that in a way that can be comparable between patients. We have the subjective scale. Usually, the ways that we qualify that are, you know, the number, which can be hard, the words which to say mild, moderate, severe, mild being kind of a 0 to 3, moderate being 4 to 6, and severe being 7 to 10. And then the other way we use this is the scale called the Wong-Baker Scale. It has this . . . you know, starts with a smiley face at zero and like a very unhappy face at 10. I usually think of 2 out of 10 as being a place where there's still maybe a little bit of a smile if you have a really good game, but definitely there's some grimacing if things get bad. And if you start to get to the place where there's no longer a smile on your face, then probably it's too much.

Interviewer: And that's during. What about pain afterward? How long until that pain would go away for kind of the average player?

Dr. Chalmers: Well, usually what I tell people is that you should be able to do what you're doing in a reproducible way every other day. So if you feel like I could pitch like this every other day, then that's a right amount. If you feel like, "Ah, I need four days to recover from this pitching outing because it was so painful or took that much recovery," then what you're doing is too much.

Interviewer: And you said, you know, the saying is, "There's no crying in baseball," and sometimes pitchers tend to be a little tougher than the rest. If somebody is having elbow pain above the threshold you described, what are some of the downsides to not having that looked at?

Dr. Chalmers: Yeah, there are definitely downsides to just pitching through significant pain. The significant pain can be a sign of a substantial injury to the elbow. So, for instance, if you do have ligament tear and you're trying to just work through it, I've definitely seen players that years later have developed arthritis in their elbow or they have bones spurs that have worked to kind of help the elbow to stabilize even though the ligament is not functioning properly. So there's definitely a downside to thinking, "I'm just going to push through this."

Interviewer: And then, what about the repair? Some of these elbow surgeries can take a long time for patients to recover. Do you think that plays into why perhaps sometimes pitchers choose to play through it, because they don't want to be out of the game for any period of time?

Dr. Chalmers: Yeah, I think that's definitely part of it, is that pitchers think, "Oh, I can't afford to take 12 to 18 months off." So, if you know that there's a solution that can get you back in six months, that's the length of the offseason, and I don't think you need to worry so much about, "Oh, I'm going to lose next season." So it's definitely worth if you're having pain thinking, the very least get it looked at the end of the season, to see maybe if there is something that can be done that could still you get back in time for next year.

Interviewer: Yeah, and new procedures are coming along all the time that have shorter recovery periods. So even if you are of the opinion or if you've heard, "Well, if I get this done, I'm going to be out for 24 months," that might not be the case anymore.

Dr. Chalmers: Oh absolutely. And not only that but if you're listening to this and it's two years from now, let me tell you, it's going to be even better, because we've got all sorts of things coming down the line that will help to bring down recovery periods for pitchers in the future.

Interviewer: Yeah. So, if you have some elbow pain while you're pitching, there is something you can do about it and actually something you should do about it. And there's a new procedure that might be the thing that you need.

Dr. Peter Chalmers is an orthopedic surgeon. He's an elbow specialist. He's also the current team physician for University of Utah baseball and Salt Lake City Bees Triple-A baseball. So if somebody does have elbow pain while they're pitching, where do you start with that diagnosis, Dr. Chalmers?

Dr. Chalmers: Yeah. Absolutely. So elbow pain during pitching, it's not normal to have really, really a sore elbow with pitching. And there can be a couple of different causes, and some of them can be problematic for the future for a pitcher. So, definitely, I think it's worth, after a period of rest, if the pain doesn't go away, seeing someone to be fully evaluated with, you know, having someone take a look at the elbow, and then potentially getting an MRI to take a look at the cartilage and the ligaments within the elbow.

Interviewer: All right. And if the condition happens to be something called an ulnar collateral ligament injury, then there's a procedure that's been used for a long time called Tommy John surgery. Tell me a little bit about that, and then we're going to talk about the alternative, which could be better for some patients.

Dr. Chalmers: Yeah. Absolutely. So, for a long period of time, if you tore your ulnar collateral ligament, the ligament on the inside of the elbow that basically holds the upper arm and the lower bones together when you pitch a baseball, if you don't have that ligament, those bones try and fall apart, and it's basically not possible to pitch a baseball. If you tore that ligament, historically, then your career was just over.

And there was a pitcher named Tommy John, who had that injury, and he went to a surgeon who said, "Well, there's got to be something we can do," and they invented this procedure to reconstruct or rebuild the ligament using a tendon graft. And that actually works pretty well, but it has a very long recovery. It takes about a year to get back to play because the new tendon has to become a ligament over the top of the old ligament. And that process is very slow.

So that was the historic way that we would treat ulnar collateral ligament injuries, and the pitcher that first underwent it, his name was Tommy John. So they're commonly referred to as the Tommy John ligament or Tommy John surgery.

Interviewer: And now there's a new procedure. So I've heard that considered called reconstruction, and now there's a new procedure that actually just repairs the ligament and has some better outcomes. So tell me a little bit about that.

Dr. Chalmers: The good thing about many of these ligament tears is often the ligament is torn right off of either the upper arm bone or lower arm bone side. And the ligament itself is still good quality tissue. So, historically, we would replace that whole ligament with a new tendon graft.

The new procedure is to repair the patient's own ligament and allow their own ligament to serve as their ligament going forward. That has a much quicker recovery and can get pitchers back to play in six months. So that's been a huge advance in our treatment for this injury and has certainly, for a lot of our players, granted them ability to get back to another season or even sometimes to get two seasons in depending on the timing.

Interviewer: So, when you're working with a pitcher, how do you determine which one of these two that you're going to use?

Dr. Chalmers: So there's a number of factors that go into that. Certainly, the appearance of the ligament on the MRI and the location of the tear play a role, but often during surgery, we'll also assess the quality of the tissue. And if the tissue is robust enough, then we can use the patient's own tissue to do the repair.

Interviewer: If it is an option, then is it just as good as the Tommy John surgery? You said, definitely, you could get back to playing faster. Is it as a robust of a repair?

Dr. Chalmers: It may be better.

Interviewer: Oh.

Dr. Chalmers: Some of our early data suggests that the rates of return to play may be higher after repair than they are after reconstruction.

Interviewer: And I understand another advantage of the ligament repair is if you have a younger athlete, that this would be an option where Tommy John surgery would not be an option. Tell me about that.

Dr. Chalmers: Yeah. Definitely, younger athletes have the highest capacity for healing. And so, in a younger athlete, this surgery can work very, very well, and that's who it's been performed in mostly to date. But in someone who's really young, if they have open growth plates, you may be concerned about performing a surgery with a ligament graft, where we may have to drill tunnels in the bone that may disrupt the growth in the future. So this is a nice option for that patient population.

Interviewer: And what does the recovery look like then? You said that the recovery is faster. You know, Tommy John surgery could take up to a year. How fast is this recovery, and what's the rehabilitation process like?

Dr. Chalmers: So as early as two weeks out from surgery, the patient begins moving their elbow. About a month from surgery, they begin strengthening. And the whole goal here is that you have to start strengthening early because as early as three months out from surgery, the pitchers will start throwing again.

Interviewer: Wow.

Dr. Chalmers: And the goal then is to get back to full play with full velocity, pitching full games by six months.

Interviewer: That sounds pretty amazing. Is that pretty amazing from your perspective as an orthopedic surgeon?

Dr. Chalmers: It's a huge advance. It's a huge change over the year, sometimes 18-month recovery we saw historically with reconstruction surgery.

Interviewer: Are there downsides to this type of repair?

Dr. Chalmers: Well, it's a relatively new option, and so we don't have 5 or 10-year outcomes with it so far. But so far, it appears to have few downsides as compared to the reconstruction. There had been some concern that if you do this surgery, it may make another surgery in the future more difficult. And so far, those have not appeared to be true, but there have been very few of those performed because it works so well.

Interviewer: And it sounds like this is a very specialized procedure still at this point. What advice would you have for somebody choosing an orthopedic surgeon to do this type of procedure?

Dr. Chalmers: Well, I think that one of the most important things patients need to understand is that surgery itself is a technical skill, and it's important to find a surgeon that you feel like performs enough of those procedures to feel competent at it. So, as a result, I think when you look for a procedure that's less common like this, you need to find a surgeon that feels comfortable and performs enough of them, that they'll have already worked through the kinks and make sure that they're not going to have any problems performing this procedure for you.

That's one of the benefits of coming to a place like the University of Utah, where you have specialists in a large variety of areas. It allows each of us doctors to find a smaller niche and then, as a result, to be better at what we do.

Interviewer: I want to talk a little bit about this procedure. So what is, in your mind, the youngest patient that you would do this type of a procedure on?

Dr. Chalmers: One of the things that is unique about this area of the elbow is that right above the ligament is a growth plate. So for people who are skeletally immature, it's very rare to have the ligament be injured. And the vast majority of those that are skeletally immature, the growth plate itself sees most of the injury, if there is an injury. As a result, we very rarely perform this procedure for anyone under the age of 14 really.

Interviewer: Is there anything else about this procedure that you feel that a patient or a patient's parents would be interested in hearing that I missed?

Dr. Chalmers: One of the things that I think is really interesting about this procedure and really important for people to understand is that we've talked historically about the reconstruction and the tissue within the reconstruction as though we can make you a new ligament. But I will tell you that the tissue that we bring in from somewhere else is not the same as what you were born with. It doesn't have the same nerve fibers. It doesn't have the same pressure fibers.

And we demonstrated that actually pretty elegantly recently in a study we did with the Angels, where we looked at the changes in reconstructed ligaments as compared to non-reconstructed ligaments over the course of a single season or off-season on ultrasound, and found actually that the ligaments that had undergone a prior reconstruction respond differently to stress than native ligaments. And I think that's probably because they don't have all of their normal sensors within them.

So one of the big benefits of this procedure is that it preserves all that. It preserves all the normal pressure sensors and nerve fibers within your own ligament and allows it to respond normally to stress in the future. So that's a real benefit of this procedure over the reconstruction, and one reason why I think we're probably going to head more and more in this direction in probably a lot of areas of our field in the future.

Dr. Miller: Shoulder instability - how do you get that, and what can you do about it? We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm here with Dr. Pat Greis. Pat's a professor of orthopedic surgery in the Department of Orthopedics here at the University of Utah. Pat, what the heck is shoulder instability and how does somebody get that?

Dr. Greis: Well, shoulder instability is when the shoulder actually comes out of the joint. And often when it does that, it stays there.

Dr. Miller: Is that another fancy name for dislocated shoulder?

Dr. Greis: That is what it's called. Dislocated shoulder, often see it in our skiers and our football players and others.

Dr. Miller: Skiing, that's right, I've had it myself from a good fall on hard snow. Do you see it mostly in sports-related injuries?

Dr. Greis: Yeah, it's a common injury for athletes, and then other people who are just unlucky, falling off ladders, other injuries. Certainly does happen that way too.

Dr. Miller: Tell me a little bit about . . . are there degrees of shoulder instability, and how do you know if you have shoulder instability? Is it just pain?

Dr. Greis: Shoulder instability, the classic would be the dislocation, where the shoulder actually comes all the way out of the joint. There are some who injure their shoulder and then have subluxations, where the shoulder just slides a little bit but doesn't come all the way out. So you can have either. Obviously, both can cause symptoms that people find difficult to live with.

Dr. Miller: Primarily pain or function?

Dr. Greis: It's a little bit of both. Obviously function, when the shoulder comes out, that's usually the end of the day for whatever athletic event you're participating in. Like in our football players, they dislocate their shoulder . . .

Dr. Miller: That's game over.

Dr. Greis: That's game over for them. So it's either the docs or the trainers have to pop it back in, and then pretty sore shoulder for the next couple weeks.

Dr. Miller: Well now, if you have a state where the shoulder's out or dislocated and doesn't come back in, you treat that acutely, right? So they can . . . I guess maybe on the sidelines, or do you have to go to an ED to have the shoulder put back in? I know everybody talks about using a towel in the locker room, a lot of screaming, and is that true, or?

Dr. Greis: You can watch movies and see Mel Gibson hit his shoulder against the wall, but that's not recommended. Clearly if the shoulder's out and stays out, that usually results in a trip to the emergency room. There are some techniques that don't require sedation, where people can get their shoulder slid back in. But often in the emergency room with some pain medication, the medical maneuvers of the shoulder, they can get the shoulder to be popped back in, at which point we then have to decide what to do over the next couple weeks.

Dr. Miller: And what generally do you do?

Dr. Greis: For the first time dislocator, it's common that we treat them non-surgically. You do a period of immobility while they're real sore, do a rehabilitation program.

Dr. Miller: You put them in a sling?

Dr. Greis: Sling for a while, realizing that after the first dislocation there's a chance that it'll happen again. And it's a bit of an odds game depending on age and activity, whether or not that risk is high or low.

Dr. Miller: So I suspect that physical therapy probably comes into the treatment.

Dr. Greis: It does, unfortunately a therapy program probably doesn't eliminate the chance that it's going to redislocate. In a young, active, athletic individual, there's still a pretty high chance that if they return to those activities, they can redislocate their shoulder down the road.

Dr. Miller: So this brings to mind a question: if you have a shoulder dislocation, let's say it's treated in the emergency department acutely and the pain goes away and you are an athlete, you're a student athlete or even a professional athlete. Should you seek treatment from someone like yourself, or evaluation from an orthopedic surgeon or a sports medicine physician because of this potential for recurrent injury?

Dr. Greis: I think that's important. I think the discussion on options is a very reasonable thing. We treat many people non-operatively, but on occasion we will treat an athlete or certain individuals after their first time dislocation. And that can be to prevent recurrence, perhaps during the next season, which is coming up in six or nine months, so treating it now decreases the odds they would have a problem down the road. And there's times where with the dislocation there may be a fracture of the front of the socket, that fixing it early would be advantageous.

Dr. Miller: What would you say the percent of time this requires surgery, dislocation or instability requires surgery?

Dr. Greis: That's a tough question because it really does depend on the patient's age and activity. A young individual, 16 to 18-years-old who's very active might have a 70, 80% chance that they'll have a recurrent dislocation. So we can be very aggressive with those folks. Someone in their 40s who dislocates and doesn't have any other major damage to the rotator cuff may only have a 10% chance. And so, you know, same injury doesn't always get the same treatment, it depends on the person, their desires, their activities. So there's a lot of factors that play a role.

Dr. Miller: How do you advise an athlete on what to do after a shoulder injury if they are prone to recurrence, separation or instability? And you mentioned a minute ago that you're sort of counseling them on the fact that this can happen again. I mean, are you also telling them to avoid certain things that they're doing as an athlete? Or just tell them, "Look, this may happen again, so beware."

Dr. Greis: Yeah, I think I try to educate them, counsel them, you know, it's not realistic to think that an 18-year-old's going to modify their life. I just think that's something that's not going to happen.

Dr. Miller: I'd agree with that.

Dr. Greis: Right. So you have to educate them. If we were to say an 18-year-old football player has an 80% chance that over the next 2 years they'll redislocate, and they're nine months away from their football season, well you might say, "Surgery now might make that risk only 5 or 10% down the road." So an acute surgery might be in the cards for that kid. In-season, it's another issue. If it's the start of the football season and they want to play, then we have to talk about how do we manage potential shoulder instability during the football season to try to get them through, realizing that if they have recurrences we may have to pull the plug and have them miss the rest of the season.

Dr. Miller: So in summary, student athletes, athletes, professional athletes tend to have, especially in contact sports, run a higher risk of developing acute shoulder instability to the point that it's painful and not functional, might need to be manipulated back into place. But also I think you mentioned that there's an important piece in that athlete being seen by a professional who deals with sports problems in terms of anticipating what might happen in the future.

Dr. Greis: Yeah, I think that's the important thing, is educating them, trying to give them the options, because at the end of the day it really is about what their wishes are. There's pluses and minuses of being more or less aggressive with this type of an injury. And jumping in early might be right for one but might not be right for everybody.

Dr. Miller: Individualized care. That's what we do.

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