So, now we're going to change the tone a little bit in terms of our baseball players to become very focused on the shoulder, and we're going to talk about the biceps and why the tenodesis may be the way to go in some of our overhead athletes. These are my disclosures, which are updated regularly at the American Academy of Orthopedic Surgery website. This is our symposium, Biceps and the Throwing Athlete, and so my focus will be on this group of individuals, and not all of this can be extrapolated to our workers or older patients that we deal with. In a recent study that we published looking at professional, both minor and major league baseball players, you see that there's over 100 shoulder surgeries per year, and the right-handed pitchers have by far the most amount of surgery, and that when you actually divide this up, you'll see that about 20% in major league and 80% in minor league, and the average age is right around 23 to 24. And most importantly, when looking specifically at the types of surgery that they have, the most common by far is labral surgery and mostly, more than two-thirds of the time, just a debridement, and it's very, very rare that bicep surgery is even reported, but that's what we're talking about now. We understand the labral pathology in our overhead throwers from the repetitive movements, from the activities that both Jim and Ben just talked to you about and how this can play a role in injuring and fraying this tissue. We've struggled to find out when this is actually pathologic versus adaptive. We know this position of abduction and external rotation is a very challenging position for our athletes to maintain perfectly, and so oftentimes, labral and biceps and rotator cuff pathology can occur. When we do have a labral injury, we try to treat it non-operatively. There's some success in this area, and when that doesn't work, we treat it surgically, and unfortunately, what we found is we're not as good as we'd like to be, with only about two-thirds of our athletes returning back to the play and only about half at the same level, not something that we're very proud about in these high-level athletes, and in a recent series that looked at all levels of these athletes, 133 baseball players, whether it was high school, college, or professional, again, only about two-thirds were getting back. We don't have many operations where we think they're successful, and only two-thirds are returning back to the same level. Why does this occur? Why do these surgeries not work? Is it the biceps that's the problem, which many people have felt is the culprit? We started looking at this years ago, and we found in those patients that we did a slap repair, an overhead athlete that didn't do well, the biceps tests were frequently quite positive, preoperatively, and we've learned from a number of authors that part of the problem is when we manage these all arthroscopically, much of the problem may be actually outside of the glenohumeral joint that we see. When it does fail, what do we do? We've learned from different patient populations, such as our military population and Matt Preventer's work, that you can do a biceps tenodesis, and many of them will get substantially better. So when do we cut the biceps as the first line of treatment and perform a tenodesis? Because this patient population, we're not going to do a tenotomy alone. And that's what we're trying to figure out. The biceps pathology can be proximal, it can be as it's exiting the glenohumeral joint, as you see here with the rotator cuff tear. It can go all the way down to the upper part of the pec. So how do we treat this and where do we put this? Many have suggested that if you don't put the biceps tendon down lower, you're not going to take care of all the pathology. And years ago, in fact, more than 20 years ago, we started putting them in the subpectral region and we reported our results. And we've done this in our overhead athletes. It's a cosmetic and very safe way to do this surgery. And it works extremely well in a variety of different individuals. See if this video will play. It played perfectly well before. Can you play that video for me, please? Just click on it. No? Okay. Well, there we go. So what are we talking about in terms of the surgery? We're talking about a very, very small incision, probably a little more than twice the size of your portal. We numb up the skin because the block doesn't get to this area. We go underneath the pec. There's really no dissection of any significant soft tissues. We're just spreading the tissues. We go underneath the pectoralis and you will always find the biceps tendon. It's always just medial to the tendon, the pec tendon. We can grab that tendon as we're looking here through an arthroscope and have that magnified. We can pull that out. We can put a nice safety stitch right at the musculotendous junction and we fix that just above the inferior border of the pectoralis. And we have the normal length, the normal contour, and it's a very secure surgery. Now that has worked very well for us, but the largest series in the literature is this series of 1,000 cases where their results were very low, but we haven't had this experience in baseball and overhead athletes, so I don't know if that procedure would work. What happens when you do a biceps tenodesis? Well, when you look at your throwers and you see what happens to them, you can look at a markerless system and follow them out. You can look at your slap repairs and your biceps tenodesis repairs and quite honestly, there wasn't much of a difference, but probably due to some residual stiffness, the actual biceps tenodesis patients had a smoother curve in terms of their pitching status. Now let's look right at the Major League Baseball and Minor League players. There was only a matter of 17 players over a four-year period that we looked at. We had two-year follow-up and a larger group will be looked at in the very near future, but the results overall are basically that in pitchers after a biceps tenodesis, only 17% got back to the same level. Position players, 80%. So this is not a home run. Most of these pitchers had had prior surgery, and this was being done as a salvage procedure. We looked at a group of patients that are just 25 years of age, and we had a relatively large group to try to compare that. These were college and high school players, and what we found that the majority of them a little more than two-thirds were able to return to their sport, and when we did this as a primary procedure, 83% were able to return to their sport. So in conclusion, in the overhead athlete, greater than 80% can actually get back, particularly if it's a primary procedure and it's their main problem. And a recent systematic review between tenodesis and a labor repair has shown in these forest plots that the tenodesis favors not only return to play, but the lack of reoperation. So in 2019, the recommendations from more of an expert point of view is that if you truly have a slap lesion in these overhead athletes, then you should fix that properly, and we prefer a knotless technique. If you have a slap that has failed, you should do a biceps tenodesis. If your patients have purely biceps symptoms, a biceps tenodesis is consistent with their ability to return back to a sport like baseball and to continue to compete. Thank you.

shoulder injuries

baseball players

labral injuries

biceps injuries

biceps tenodesis