All right, up next, we're going to have five questions for Dr. Morgan. All right, my name is Steve Lemus from Detroit. All right. Okay, question one for Dr. Morgan. In 1987, you published results from an arthroscopic Bankart technique. Probably it's safe to say that most people were doing Bankart repairs open at that time. What made you think of it? Well, there's an article in JBGS in 1952 from a military base where they actually showed the transglenoid technique with a suture pin. I joined Ward Cassell's practice in 1982, and I was there two weeks, and I told Ward I wanted to start scoping shoulders, and he thought I was crazy. But it occurred to me that this could easily be done transglenoid under arthroscopic control. How do you do it today? I use suture anchors. Yeah, and why lateral decubitus? What? Why lateral decubitus? The beach chair position for instability is the worst thing that ever happened to the shoulder. Literally. I remember I was at the academy, and Lanny Johnson ran a symposium in the big room, beach chair versus lateral decubitus. This was back before PowerPoint. I had two projectors, and on the left one I had a 480-pound lady in a beach chair on the beach at Cape May, and on the other slide I had Cheryl Teague's swimsuit issue, lateral decubitus. And I said, you can do this either way, but I like the Cheryl Teague's picture, and I got written up by 10 female orthopedists for being a sexist. But in reality, lateral decubitus, you can see better, you can put a bolster in the armpit and lever the humerus out so you can really get down to the 5 o'clock position. Great, thanks. So question two, sick scapula. Has it evolved or stayed the same? Well, it's always been there. It was there probably for centuries before we recognized what was going on. In a thrower, this is caused by repetitive overuse, muscular fatigue, and that's the first domino that falls in the pathologic cascade. If you continue to throw with weak scapula muscles, you're going to get a glenohumeral interontation deficit. The reason you get that is at ball release, there's a violent contracture of all the scapula muscles in the posterior cuff that counteract the distractive force generated during acceleration, which is about one and a half times body weight. And if you have 18% of the distractive force counteraction is the cuff. The other 82% is from the scapula. So if you have scapular dyskinesis at ball release, you're not going to counteract that completely. And the posterior band is pointing right at home plate, and the forces that aren't counteracting get transferred right onto that. And then it's Wolff's Law of Collagen. You get a contracture and a shortening of the posterior band, which then creates all this other evil stuff like slap lesions and the lesion that Kibler talked about. Is there one new treatment or exercise routine that helps prevent it? Yeah. In a throwing athlete, if you do maintenance scapular exercises to prevent weakness and you do sleeper stretches to prevent posterior capsular contracture, you'll be successful in preventing shoulder and elbow injuries in the thrower. Several years ago, I was a consultant with Ben Kibler for the Kansas City Royals, and we examined every patient at spring training and then put them on maintenance sleeper stretches and scapular exercises, and we lowered their injury rate by 92%. That's great. I think the Tigers might need something like that. Anyway, the overhead athletes, so pitchers, for example, do not need their biceps, long head, tendon to throw. True or false? That's absolutely false. You know, in my practice, I've seen, I think, eight throwers that have had biceps tenodesis. Four of them were pros. They're all out of baseball and they're doing crappy. And a lot of these had interval lesions, and even if you do a biceps tenodesis, they can still have pain due to their interval lesion, and you need to close that. That kind of answers this next question. So at the time of surgery, a pitcher has a 50% biceps, long head, tendon tear inter-articulately. What do you do? Do you tenonymize it, tenodesis it, or debride it? Tell them to retire. There you go. Okay. Question four, can you get all pitchers back surgically if they have failed non-op measures with a slap tear? Yeah, if you can give them religion on scapular exercises, sleeper stretches, and you appreciate that the lesion goes all the way down like Ben Kibler shows. You can fix the slap, but if you don't fix the lower part, they're in trouble. And then if you can't correct GERD or scapular dyskinesis, they're also in trouble. You know, the first successful slap repair that I did was Curt Schilling, and he got three World Series rings. And the reason he did so well is prior to this, all he did was go to Burger King in the park and go back home. We taught him scapular strengthening and proper posterior capsular stretching. Great. So how about the same thing? So someone with GERD can't get back. Can you get them better surgically? Yeah, 10% of throwers that present with significant GERD, which is greater than 20%, are what I call stretch non-responders. They're usually older veteran pitchers, and their posterior band is so contracted and so thick you have to use electric. I do a posterior inferior quadrant capsulotomy just off the labrum. Excuse me. The capsule is so thick there you have to use electrocautery because a basket forcep won't open up enough to get the job done. So what about the same for a pitcher with a rotator cuff tear? Don Drysdale once said that a pitcher with a rotator cuff tear, it's a career-ending problem, and that's true. Okay. And the last fifth question, let me just see if I can get this other one to pull up. Could you just click on that to my right? Yeah, that one is fine, but there's also another one over here. So there's two rotator cuff tears. One's full thickness. I don't know why it's not playing. One's full thickness like this one, but there's another one that's retracted to the glenoid. I use suture anchors to fix these. Why shouldn't I? Because there's between a 50% and a 79% failure rate if you use suture anchors. What they do is they strangulate the blood supply of the cuff. This appears as a U-shaped tear, but it's not a U-shaped tear. It's an L or a reverse L. And what you need to do is put a suture here and bring it all the way over to the corner here, and then the supraspinous and the infraspinous that are here will actually lay right on the footprint. Steve Schneider showed us years ago if you just lay that tissue on there and create a crimson duvet, God will fill it in. Don't mess with God. You always have to leave something for God to do. Otherwise, this tear will never heal. I actually have a prospective study that I'm going to present next year, 200 cases of suture anchor repair with a 50% failure rate, and then I have another 200 with just margin convergence and then the proper anatomic way and lay it on the footprint with no defects. This is both MRI and high-resolution ultrasound proven. Great. Well, thank you very much. Thank you.

shoulder injuries

surgical interventions

arthroscopic Bankart technique

suture anchors

scapular dyskinesis