I thank you all for coming here on a Saturday. I heard that is a challenge and I can understand why. So this is the inaugural meeting basically of an allied health slash PT session that we're starting at the Arthroscopy Association. And so, you know, we want to, we'll build on it every year, but the purpose is that when I ran my meeting, one of the best parts of it was getting basically involved with the physical therapy group. And so at ANNA, which is a nationwide group, we have 6,000 members. And so the purpose of what we've tried to structure is a membership that is cost effective. So it's $250 a year. But for that, you have access to the website. You can actually go on and see all kinds of procedures. You can get an understanding of what you're rehabbing. You'll have access to all of our journals, including our rehab journal. But most importantly, my goal is to build out a geographic referral network. And so that if I'm sitting here in Boston, a patient of mine's going to Texas and says, oh, who do you know in Houston? Well, I don't know anybody in Houston. So I can go to my network, I can plug in and look at who has joined ANNA physical therapy. Oh, this is what they're interested in. I can point my patient there. And that referral network does not exist, nowhere. And so that's one person. One referral pays your yearly dues. So spread the word. That's what we're going to do. And that's what we're trying to build on. And so anyway, today, very similar to what we used to do in Boston, we have a number of really good talks highlighting basically where we are in technique of knee and shoulder surgery so you can see what is cutting edge out there. And that way, it'll give you an idea of when you're counseling your patients or suggesting or looking at if they're not doing well, maybe you'll have a better understanding why. And we're going to start off with Matt Salser, and he's going to talk about anterior instability. All right, thanks, everybody. I'm coming from down the street at Tufts University. I don't have any disclosures. One sort of quasi-disclosure is this is a difficult talk to put together because we've got physical therapists, we have PAs, we have medical students, sort of a different allied health group than usual. So rather than the typical, you know, most advanced surgical techniques or going a really deep dive in the literature, I'm trying to put together a framework of anterior instability that I hope will kind of help everybody understand the way that we think about it and it'll allow you guys to understand the following talks that are coming up about some of the more complicated issues with this. So this is a general outline. We're going to talk about the way I think of instability, anatomy, pathoanatomy, and then how we decide who to operate on, when to operate, and then what surgeries we do. So we will talk a little bit about the different surgical techniques. So instability versus laxity, willful, non-willful, the direction, and acute versus chronic. All these things, they're minor subtle differences, but I just want to talk about them for a second. So instability involves a separation, either in part or complete, of the humeral head and the glenoid. It's non-willful, right? It's not intentional. There's some pain and or loss of function associated with it. So instability is different than laxity, right? So laxity is increased range of motion. Laxity is a physical exam finding. Instability is a functional symptom set. So people with increased laxity are more likely to have instability, but you can have laxity without instability, and you can have instability without laxity. It can be voluntary. All blacks play are clearly not voluntary there, so instability is not voluntary. It can be anterior. It can be posterior. 95% of the time, it's anterior. It can also be multidirectional, and it can be inferior. The main focus of this talk is going to be on the anterior dislocation. So AP radiographs, this is an example of what it looks like up on the top left, and then on the bottom left, what it would look like on an axillary lateral. So also the acuity of this. So a first-time dislocator we often think of very differently than a chronic dislocator. If you think of a river that has created a gorge, here's the Grand Canyon. So people who have more than one dislocation tend to lose bone over time, and it turns a small problem into a much bigger problem. And we'll talk about that a little bit when we get to surgical indications and the surgeries that we're going to use to address this. So acute or chronic, non-willful, it can be a subluxation or dislocation, painful with loss of function. So that's instability. That's what we're talking about. So what anatomy relates to this? So the shoulder has more range of motion than almost any joint in our body. It is a ball and socket joint, but very different than the hip. So the femoral acetabular joint is inside a deep socket. The humeral head is more like a golf ball sitting in a golf tee. We have a great range of motion, but we pay a price in stability for that. There are two types of things that help. There's the dynamic stabilizers that help to give us stability, and the static stabilizer. So if I'm going to run into somebody like this, and our arm's up like that, someone's shoulder's coming out, and it's not going to be his. So dynamic stabilizers are incredibly important. So the most important ones are going to be your rotator cuff. We have something called a concavity compression. So in the bottom picture there, you can see your supraordinary, if I have a forced couple, they're driving the humeral head into the glenoid. That way, when you get force pushing it, try to anterior or posterior, this kind of keeps it centered on the glenoid. The stratus and the deltoid also play a role in that, and then there's some debate about whether or not the biceps may contribute as well. So those are our dynamic stabilizers. Static stabilizers, so we have bony stabilizers. So in the picture on the left here, if you think about the golf ball golf tee model, if you're missing a portion of your golf tee, that ball's going to fall off a lot easier. On the right, we've got a Hillstack's lesion, so a big dent in the back of the humeral head. So if the golf ball is rolling around on the golf tee and there's a dent in it, it's going to roll off a little bit easier. In terms of soft tissue stabilizers, we've got the labrum. It's going to deepen the socket, function as a bumper. We've got all of our capsules and ligaments. So the ligaments are portions of the capsule, the inferior glenohumeral ligament. So that's what we're tensioning when we do our surgery. That's what we're bringing up. The inferior glenohumeral ligament complex is the most important. So looking here, you see this person, so in figure A, has the arm up like this, right? So the glenohumeral, inferior glenohumeral ligament is sitting kind of under the shoulder. And as you bring the arm up into abduction, external rotation, that ligament is going to roll up anteriorly. And so the inferior glenohumeral ligament, it's like the front part of the hammock that's going to be the most important contributor to stability. So we know this is an unstable joint, and there's a lot of dynamic and static factors that contribute to that. So what do we do as surgeons? So we're often dealing with a pathoanatomy here. So a lot of you have heard all these eponymous names, kind of like alphabet soup. You probably see them in notes, you see them in op reports, you see them in referrals. What is all this stuff? What does it mean? Well, understanding this anatomy, understanding this pathoanatomy helps to understand what we're doing, what we're fixing. And what we're trying to do typically is restore anatomy, at least as close as possible. So going through these, so we've got a bancarter. This is the most common traditional, hopefully if you get an isolation, right? So you've got, this is an example of an anterior tear of the bancart, so the labrum is pulled off in a rip of the inferior glenohumeral ligament. This is something that we routinely repair, and this is sort of what it looks like arthroscopically as well. A reverse bancart, so it's the same thing, only it's in the back, all right? So there's a talk coming up on posterior instability, so you'll see a lot more posterior stuff there. I just wanted to mention it here. A bony bancart, right? So again, if you've lost part of the golf tee, that's a huge problem. If it's acute, you can often repair it primarily, and not have to deal with some of the consequences that come from a bony instability from lost anterior glenoid. There's a Perthes lesion, right? So this is the bancart lesion plus, right? So you've got some stripping of your periosteum, it's a picture of what it looks like on the MRI. Often a Perthes lesion, a bancart, they kind of look fairly similar intraoperatively. That's an example of what it looks like there. An Alps lesion, this is, again, a similar concept, only the Alps lesions tend to pull back more medially. And so you can see this blue arrow pointing at this anterior labrum. Now it's kind of sitting, right, sitting medial. So this is a risk factor for recurrent instability. All of these things are bad, but this one is kind of a particularly bad one. You can see it on the MRI. You can think about the bumpers are really completely gone. Some of them, it's kind of in the right spot, ligaments a little bit loose, but in this one it's particularly bad. So a GLAD lesion, right, so the anterior humeral cartilage is going to flip off. So rather than the force just peeling that labrum off the bone, it actually comes through, shears off a little piece of cartilage and some of that cartilage comes with it. This is a good example. We've got asthma. This is our rehab journal. It's a great open access journal, a lot of good pictures there. So that is one of my disclosures. I'm involved with all these journals, but there's some great information there. So I encourage you all to look at that. There's a haggle, right, so humeral avulsion of the glenohumeral ligament. This is something that most people and I certainly will treat open in the front, because if you look in anatomy book, there's a lot of yellow, red, and blue structures right near there. Posteriorly, we often fix these arthroscopically, but anteriorly we often fix these open. This is an example of what that looks like when it's ripped off on the humeral side. So typically it disrupts the middle or comes off the glenoid side, but sometimes they come off the humeral side as well. And finally, the Hill Sachs lesion. So now we're back on the humeral side. This is what a defect looks like. You can see in the top, there's an MRI, you can see the defect in the back of the humeral head, and this is what it looks like arthroscopically. So there's a lot of different structures, they can be injured in a lot of different ways. They can be injured acutely, and certainly chronically, where you get some of these more sort of bad actors. So now I'm going to talk a little about clinical decision making. So what are we doing? What are the conversations I'm having with the patient? One we rehab, one we're in-season athlete very quickly, and then operative versus non-operative. And I'm not going to get into the surgical techniques until the next part. This is the clinical decision making. So the goal of rehab, obviously, in all ways, is to restore function and motion, but to really get that dynamic stability back. So a lot of these people, sometimes they'll actually have a nerve injury and they'll have a real weakness that you really can't get better until the nerve wakes back up. But a lot of them just have like a stunned muscle, and one week, two weeks out, you're testing their external rotation strength, and they're just not there yet, and it takes time to pull that dynamic stability back. But if you're going to go back and you don't have that dynamic stability, that shoulder is coming back out again. So rehab is obviously important. We often think of it for operative management, but it's also incredibly important for non-operative management as well. In terms of the in-season athlete, one of the things I tell our team all the time is, in order to play, you've got to be able to play, right? You have to have full strength, full motion, and you've got to be able to play at 100%. If you're not 100%, you're a danger to yourself, you're a danger to your teammates. The decision about whether or not to go back to play after an in-season dislocation, a lot of these athletes kind of know the conversation even before we have it, but some don't. And so I kind of oversimplified the rule of thirds, right? So there's a one-third chance for a contact sport that you're going to make it through your season no problems. Two-thirds chance you're going to have a problem, either you're going to have a subluxation or a dislocation. And so with that, I've had very intelligent, thoughtful athletes in different parts of their season, different parts of their careers, make very different decisions. And I think that's kind of a good example of a shared decision making. So then we're going to talk briefly about when we decide to operate. And so I'm not calling anything conservative management, because sometimes operative management may be the conservative management, and we'll see why in a little bit. So I Googled, or I looked into PubMed, and I put in operative shoulder instability indications. And so I got over 7,000 results. So it can be very easy to miss the forest for the trees here. And so I'm going to try to kind of give a broad overview to help you guys understand how we think about when to operate on these patients. So one, the most common indication would be chronic instability, right? So someone's had multiple dislocations, dislocations plus subluxations, or just multiple like frank episodes of instability where they haven't actually gone to the hospital. Maybe it's a subluxation with automatic dislocation, maybe it's just lots of subluxations. So that's one. The other would be an acute fracture, right? So acute glenoid fracture or bony vanguard, where if you leave it, that bone's going to dissolve and then they're going to be left with a big problem, whereas acutely you could go in and fix it. And then high-risk first-time dislocators. And so that's in quotation marks, because it's possible that almost everybody's a high-risk first-time dislocator. And so I have a slide coming up that'll kind of show you how I think about first-time dislocators. So there are certain things that definitely make you high-risk, okay? So it's your activity, right? So if you're a rugby player, you're a basketball player, you're a wide receiver, those things are very high-risk, right? Your arm's up in this position, they're overhead sports, they're contact sports. There's a few other ones too, right? So military, firefighter, rock climber. And so in those times, the high-risk isn't always because of the sport that you're doing or the activity that you're doing, but it could be the consequences of what happens if your shoulder dislocates, right? If you're rock climbing and your shoulder dislocates, that's bad, right? So the activity that you do, even though the activity itself may not be the problem, it could be what happens when you're doing that activity. And then patient path anatomy, right? So some of those things are worse than others, right? So glenoid bone loss, Hillsock's lesion, you're losing some of that golf ball, you're losing some of that golf tee, that's a big problem. Soft tissue stabilizers, we know that being hyperlaxed, right? That's a risk factor. The Alps lesions, we talked about that, Haag lesions, if you have a rotator cuff tear, so your muscles aren't going to function normally, you're not going to have that concavity compression stability. And then younger patients as well, they're going to be at higher risk. So this is when I say, what really is conservative management? So the recurrence rate of non-operative management. So this is all comers. The studies are kind of all over the place, but in the range of 50 to 90%. That's high. And there are some people who would say, you know what? I just want to have surgery. And one of the reasons why they'll do that, so successful surgical management of a first time dislocator has better results than surgical management of multiple dislocations. And so maybe conservative management is operating on a lot more of these people on the first time. Maybe it's not, but that's a good conversation to have with your patients. So the goal of rehab early on, restore the dynamic stabilizers. You've got the rule of thirds for the in-season athlete, and then the operative indications, they're complex. It's not straightforward. And then I think a shared decision-making is really important for a lot of these athletes. They're going to be sort of on the fence in terms of what they want to do. So this is kind of the fun stuff for me, the surgical decision. How do we decide what surgery we're going to do? And there's a ton of data out there, and I want to sort of present a framework that could help you guys understand this. So the main thing I think about is you want to restore anatomy, or at least as closely as possible. So I'm going to kind of go through some of these, but rather than looking at them sort of individually, I try to group them in a way that will help. So we're in the Boston area now, so Thoreau said simplify, simplify, simplify. So I'm trying to break this down into a couple different boxes, right? So it's glenoid-based pathology and humeral-based pathology, soft tissue alone, soft tissue plus bony involvement. Now one thing to be aware of is bony involvement is a lot more common than we think. We know it's bad, but it's a lot more common than we think. And if you just get x-rays, you're often going to miss it. So MRI, possibly even CT, are going to be needed. Recurrent instability, there's almost always bone loss. So we're going to start off with the easy part first, right? So glenoid-based, all soft tissue problems. That's simple, right? So your Bankart tear, Perthes, Alpsa, Glottalis things. So capsulography, you're going to re-tension the capsule, you're going to fix the labrum. You can do it arthroscopic, you can do it open. It's typically done arthroscopically now, but it opens a great procedure. Humerus-based, all soft tissue, open arthroscopic, you're going to fix the haggle. So that's the easy part. So now it gets more complicated. So what do you do when it gets bony, right? So whether it's a bony Bankart that's acute, or you've got some attritional glenoid bone loss, what do you do on the humeral side? Now almost all the talks you're seeing here are not about the stuff I've talked about already. They only talk about how we deal with these things, whether it's in the primary setting or in the revision setting. And so I'm going to do my best to not necessarily tell you what to do, but tell you how we think about what we're going to do. So in order to think about how we're going to do it, you have to understand how much loss there is, or how much bone loss there is on the humeral side, how much on the glenoid side. There's all these really complex equations, and it looks really scary, but if you just stop and think about it for a second, and you don't look at the equation, you just think about it, it's actually not that hard, right? So you take a 3D CT scan of the glenoid, and you look at it, and then you see there I drew out 7 millimeters, that's how much bone's missing, and you see how much bone there's supposed to be. You take the missing bone, divide the one that's supposed to be there, and you get a percent, 24%, right? So 7 millimeters doesn't sound like a whole lot, it's not even a centimeter, right? That's not much bone. That's 25% of the glenoid. That's pretty significant. So a few millimeters is relevant. So if you hear about something, oh, I just had a few millimeters bone loss, well that does have some substantial relevance. I think that this slide, to me, is incredibly important. So how do we decide what to do with this? So leave it alone, right? So you leave the glenoid alone. Maybe there's 1%, maybe it's 5%, 10%, 15%. So the threshold at which we don't do anything for the glenoid is unknown, right? So I've got this graph here, and I just kind of made this up. So first of all, we don't have perfect data that are going to show us what the failure rate is if we leave it alone, and we don't know how much glenoid bone loss leads to that failure. But let's say we have perfect data. We know exactly what the failure rate is at 1% bone loss, 2, 3, 4, 5. Well, the surgeries that we do all have complications, all have risks. So things that we're doing, so maybe somebody will say, well, the surgery to address the glenoid bone loss has a risk of like 3% to 4% higher risk of complication, or 4% to 5% higher risk of arthritis. So reasonable minds may have different opinions on what to do about that, right? And so I think that over time, as our surgeries have gotten better, we have started to lower that threshold more and more. The surgeries have gotten easier. The complications have gone down. And so I remember when I was first in meetings, we were talking like 25% was the reason to do something. And now you're hearing like 10%. You've got somebody like Ivan Wong who can do this stuff arthroscopically so easily. Some people are pushing that threshold even lower, and that may make sense. But that's where there's a lot of debate going on in the current literature. So you can leave it alone, or you can add bone, okay? So how do you add bone? There's a lot of different ways to add bone, right? So you can do it open. You can do arthroscopic. You can do autograft, or you can do allograft. Autograft, you'll hear about Latter-Jay and Bristow. Those are different ways to take a piece of the coracoid and to put it on top of the glenoid, right? You can do distal clavicle. You can do Iliac crest. You can also do allograft, right? So distal tibia. So I don't do these arthroscopically. I'm not that talented yet. Ivan Wong. So here's another example, another plug for our arthroscopy journals, right? So this is a picture from one of Ivan Wong's surgeries from arthroscopy techniques, part of the same family of arthroscopy journals. Similar to the glenoid side, we also have these problems coming on the humeral side. So this is an example of an on-track, off-track concept, right? So if you look here on the far left, you've got an on-track. So you've got the ball riding on the socket. It moves around. It doesn't fall off. And then it can go off-track, right? It falls off, right? That golf ball, the dent in the back of the golf ball engages with the edge of the tee, and that's going to come off. That's called an off-track lesion. Albert Lin showed us recently, there's something called a near-track too, right? And so again, there's all these complicated equations. But if you just think about the concept, it makes sense, right? So you can just see the actual, if you ever want to know the real math, so it's 83% of the glenoid width diameter. And then you take a look at the distance from the medial hillsacks to the cuff insertion. But these things are, in my mind, you can think of it as similar to our idea of glenoid bone loss, right? So there's a certain amount at which we're going to leave it alone, and there's a certain amount that we're going to do something about it. What that threshold is where there's a lot of debate. I remember 15 years ago, there was this concept of replisage, and everybody said, oh, that's terrible. You're going to be so stiff. You're going to lose all this motion. Horrible idea. And well, we've learned how to do it better. We've learned how to make it easier. We've learned that you don't really get all that stiff if you do a good rehab. And so that threshold has come way down. And people are even talking about, you know, a president here was saying, you know, just put a little, rough up a little bit of the edge, and you can do a replisage on almost anybody. So this is what it looks like here. So you've got your hillsacks lesion in the bottom. So the replisage technique, you basically put a few suture anchors in, and you basically tie down some of the posterior capsule and a little bit of the infraspadus and pull it down onto the bone there. That's by far the most common surgery. The rest of the surgeries they're doing are fairly anatomic, other than the Latter-day. This is a non-anatomic procedure, but it has some pretty good outcomes. There are also bone grafts and bow tamps and bone balloons, which are very rarely done. So in terms of summary, so basically you want to think about the glenoid humeral anatomy and pathology. Treat all the soft tissue pathology anatomically if possible. And then really where all these debates are, are what's your threshold, right? When are you going to treat the glenoid side? When are you going to treat the humeral side? And so that was going to be my whole talk, and Alan asked me to talk a little bit about the rehab. I'm a little bit over my time, I think, but I just want to say, so in general, we're making these patients stiffer, right? We want to tighten them up. So I don't want them in rehab in the first couple of weeks. They can do some pendulums. They're mostly in the sling. No rotation. If I'm not doing a replisage, I'm limiting their external rotation for six weeks, and then we're slowly adding external rotation. If I'm doing a replisage, I'm T and D'ing the back of their cuff, right? So I want to avoid internal rotation, too. So with replisage, we're going to limit rotation fully. Weeks four to six, again, now we're starting to get into the PT, trying to keep people from getting stiff. You're seeing who's really getting stuck, right? At this point, they should have near full forward elevation. Starting some light strengthening in the seven to nine week range. My slides are all available if you guys want them. And then nine to 12 is when I start telling patients, this is the time where you don't think of yourself as strengthening, but we're waking up your muscles, we're getting your scapular thoracic rhythm back. We're doing this stuff now that if you don't do now, you won't be able to do at the 12 week mark, which is when the strengthening really starts. And then return to sport. So good neuromuscular control, good strength, good motion, good scapular thoracic rhythm. So overall conclusion, right? So instability is acute or chronic, it's non-willful, it's painful, loss of function. If you think about the anatomy, the path of anatomy that causes it, you can think of how to understand it. In terms of the treatment, right? so we're going to operate typically on chronic ones, on high-risk, which may be a lot of people. We know who's high-risk. We don't know who isn't, possibly all first-time dislocators, and then consider addressing all soft tissue pathology and think about addressing the bony pathology on the humerus and on the glenoid side. Thank you. So, Anna, we have a pretty good relationship with SOMOS, which is the Society of Orthopedic Military Surgeons. And so the next two speakers, John Dickens and Travis Decker, both have their background in the military. Travis is actually the team physician for the Air Force Academy. And so one of the most common operations they do is instability in the shoulder because that's incredibly common in that population. So both are going to share their thoughts. John on revisions, and Travis on posterior. All right, so that's actually perfect because we're going to kind of take that tour through anterior instability, but then in a little bit more kind of nuanced path as we talk about revision surgery as well as bone loss options in the anterior setting. So nothing's relevant to this in terms of disclosures. I think overall what we know is that arthroscopic Bancart repair has a high recurrence rate when we're doing it alone and we're following those patients up for longer and longer periods. And as we mentioned, a lot of it has to do with kind of optimizing the timing of when we fix these or when we approach these patients because we know that even just after one dislocation, that capsule, that inferior glenohumeral ligament lengthens. It doesn't recover, but we can fix that and recover that length tension relationship with an arthroscopic Bancart repair. We can't do this very effectively in the revision setting. So we looked at our military folks and the take-home point here is that doing this surgery in the revision setting, extremely high failure rate of up to 44%. And that's kind of in line with what we would expect to some extent because just our primaries have a failure rate of 26%, so a revision setting doing the same thing, 44%. And interestingly, from a rehab perspective, a lot of these failures occur earlier on than you might expect. In our series, almost half of them were in the first year and in others, 35% more of them were in years one through three than in the later years. So JT has commented on this and he keeps saying, you know, it's like the sad country song, we just can't quit. It's because we are so used to going back and doing things arthroscopically that it's kind of our default when we're looking at something thinking maybe we can do it better. But I think the take-home point is whatever we do, the discussion really has to be what's the best thing that we're only going to do one surgery because no matter what the revision surgery is, it's not as good as the primary surgery, whether it's a revision of an arthroscopic procedure or that corcoid or Latter Jay transfer both have significantly worse recurrence rates and outcomes. I don't want to lose the open Bancart and so I just thought like this is something maybe worth touching on because one of the things that I think is a great indication for revision surgery or for the open Bancart is revision surgery and I'll consider it in many of these cases but the revision or failed arthroscopic Bancart is a great operation, one that's been around for a long period of time and when we look at the outcomes, we know that after a failed arthroscopic Bancart, if you do an open Bancart, recurrence rates of around 11% which compares favorably to 44% for the revision arthroscopic Bancart, still a challenging population and even when we compare these side to side against open versus arthroscopic, we see better outcomes, lower recurrence rates in the open Bancart compared to the arthroscopic Bancart and then maybe kind of the gold standard, this is a lot of open Bancarts in high demand, a lot of football players, only 2% recurrence rates and that doesn't include the fact that a lot of these patients had kind of challenging bone loss on the humeral side or the glenoid side so certainly a very high quality operation and the best study we have that looks at this in a randomized control trial in Canada, better outcomes, lower recurrence rates in the open group compared to the arthroscopic group. Interestingly for this group, we talk a lot about the open Bancart being a concern for changing range of motion afterwards in their study, it did not change range of motion. So I thought I'd just kind of share a couple pictures of this. This is, you know, we don't see it as much as we used to but this is an open axillary based incision. That's the short head of the biceps, that kind of red fleshy fibers that you see there and so we enter that and then we can expose the subscap and you can see we're splitting the subscap here so leaving it intact in this technique and that's the capsule beneath it and then we can expose the capsule next and then there's a number of different ways to do this so once we have that kind of capsule started, it gets a little bit tighter as we work laterally and so this is continuing to mobilize the subscapularis tendon now and we'll put some sutures in there to help peel that subscapularis tendon off and then retract that superiorly and inferiorly so it's through a subscapularis split. This is how, there's a number of different ways that you can do this capsulotomy so to speak but I kind of take it across horizontally and then down peeling off the labrum so we've done now our kind of horizontal limb and then we're doing kind of the peeled now portion so we're just taking, that's the labrum there that we now have a suture through and then we'll come through that labrum and then peel everything as one sleeve down and that allows us really what we're doing in this kind of Bankart repair now which is an open Bankart repair is we're going to shift that whole Bankart or that whole anterior inferior labrum from inferior to superior and from medial to lateral and you can kind of see here or appreciate it's probably easier to do that open than we can do arthroscopically in terms of the degree of that shift and then so we'll place our anchors and this is, you know, there's kind of very similar to how we might do a arthroscopic but just maybe different instruments in a different look. So this is kind of what it looks like afterwards and then we can just close our subscapularis back up on top of that just down the way out and those are our tagging sutures. In terms of bone grafts, there's a lot of different bone graft options. There's more now and we've kind of had an explosion of this in part because of the indications changing as Matt mentioned and when we might do this in smaller amounts of bone loss, different sort of patient factors, high-risk patients. We might be considering this more and more and a lot of this is coming from our European colleagues too who kind of favor this. The Latter Jay, this is one of the most common or the most common bone block procedures that we'll see. The Bristow was the original description. The Latter Jay is really taking that horizontal surface of the coracoid. We're placing it on the glenoid two-screws fixation and then the other version that we may see and maybe a little less common is congruent arc so we're just taking the medial surface of the coracoid and using that against the glenoid surface. But regardless, excellent in terms of outcomes and our French colleagues probably use this a whole lot more than us but even still, very low rate of recurrent instability with this group. It's theorized that maybe one of the reasons for this, it has three reasons. One, it's adding bone so it's expanding the glenoid track. The conjoined tendon serves as a sling that helps in that abducted externally rotated position to prevent recurrence and then you're able to use or repair the capsule in the ligament with the attached CA ligament. It has great healing potential and this has been evaluated in biomechanics studies. You can imagine testing the effect of the sling in a cadaveric study is kind of difficult and so there's been some variable reports but most saying that it is the main stabilizing effect of the latter J. Interestingly, when we look at this clinically, we've compared a free bone block procedure so it doesn't have the sling coming from the iliac crest and we compare that to the latter J, there's actually no difference in clinically how they behave in terms of recurrence or outcomes and so maybe calling into effect a little bit of the need for the sling and then another study more recently just looking at overall in the literature systematic review, outcomes not significantly different in terms of recurrence or return to sport between the two and in fact maybe better improvement in outcomes or change in outcomes with the free bone block versus the latter J. There's a number of different complications that you can have as you can imagine with a bone block type procedure and there's been a movement to maybe use some other bone blocks. I mentioned the iliac crest so taking a component of the iliac crest and either doing this open or arthroscopically, it's nice because you can for large bone graft needs, you can take larger sizes but taking that iliac crest has donor site morbidity and there's concerns for osteoarthritis and graft resorption, in other words osteolysis is another way to describe that. JT has described using the distal clavicle as well. Looking at this biomechanically from a size perspective it can match in some ways the size of a latter J in terms of reconstructing the amount of bone needed. It does have kind of an osteoarticular component which is nice, it's obviously right there and it's autograft but there's a lot of challenges with this, the size, the variability in anatomy and the arthritis that may be at baseline can kind of limit its use and then one thing that we're seeing a whole lot more of recently is the distal tibia so an osteoarticular graft that has a similar concavity and surface that matches the native glenoid and so when we look at this, it has great joint congruity and then it follow up clinically seems to behave with at least encouraging initial results compared to a latter J. Also with this, a lot of these are being considered as more opportunities especially with free bone blocks to do these procedures arthroscopically. We mentioned some of the ability to do that, there's a number of different ways to do it but arthroscopic distal tibia allograft can be performed a little bit faster than latter J's arthroscopically, it's certainly easier to use and improve graft position with these arthroscopic approaches so I think we'll see more and more of these especially as arthroscopic approaches become more and more common and we know from Ivan's work who has probably a larger series of these distal tibias even at four and a half, five years of follow up, excellent outcomes in terms of good graft union and minimal screw removal and no neurovascular injuries at least in his series. So in summary, in terms of revision procedures and bone grafting, open latter J still remains the go-to as the primary procedure but I think we're seeing a whole lot more free bone blocks, distal tibia allografts and we'll see those probably performed both open and arthroscopically more and more as we move forward, thank you. What a meeting, what a cool session to integrate into the large meeting. This is a quick, I just am curious with who the audience is, how many like PAs, therapists, how many PAs do we have in the room, sweet, therapists, okay, so lots of therapists and then surgeons, I see Dr. Killer so that goes with that same, cool, all right, so PAs, therapists are the majority of this crowd and so I think that we're talking about a lot of surgical aspects and I know the PAs oftentimes get to go into the OR and see what's going on, I would encourage the therapists to go into the OR every once in a while just to see kind of some of the anatomy of what you all are treating because for me and it's probably because I'm still the younger guy of the bunch, I think that what I'm doing sometimes doesn't really matter and a lot of what you guys are doing is ultimately what actually makes the patient better, so that's just a quick aside but I'm going to be talking about the posterior side of the glenoid aspect of this and I am supremely biased based off of my training and I'll have, I'll go through this a little bit, I actually came from where John is now an instructor and he's faculty so I went to Duke and then I was at Stedman and then from there going into the military, you quickly learn about things that work and things that don't work and I pray to God that a lot of the people early on in your career, you always are questioning and wondering, looking at your outcomes, hoping that you're making people better and this is where I've been blessed with great physical therapists. So I started my journey in practice down in Florida where I was working on a lot of special forces operators. It's awesome and they're a great patient population but they will quickly ignore everything that you ask them to do and they are quite challenging and so I relied very heavily upon the athletic trainers and the PTs who know them and work with them on a constant basis to really reign them in because for me, I didn't know what they were doing until I got pictures with them like giving me the middle finger three weeks later doing dips and it just is what it is and so you try your best and then you rehab them to the best of their ability but man, it was a challenging population and it was fun. So posterior instability, it's more of an umbrella of what you're looking at. I think that their anterior instability is something that we've classically have understood as mechanical symptoms of the shoulder, essentially feeling the sensation of falling out of the joint or it's sliding. Posterior instability, a lot of it, what we're taught at least in boards is that it's pain driven but there is true posterior instability too. People laying on extended arms, they will pop out posteriorly and so for me, I had to really create my own algorithm and how I was evaluating these patients because they were so different across the spectrum of what we were doing and why we were doing it. So I'll go a little bit through our algorithm and kind of at least my thought process through this and take us through a case example. For any of the formatting stuff, I'm sorry, I'm one of those Apple users and so some of the words may get jumbled up here but this was a patient that I was seeing consistently for the first five years of my career and still see it somewhat. But this was a guy that was in the prime of his career for it being in the Army. These Army Rangers, they're in their peak athletic performance between 35 and 45. They're on these teams, they're getting deployed in high cycle, high volume, in and out and these guys are jacked, they're huge and they're very challenging and like I said, they won't do what you ask them to do. So I kind of, I ask them what they're limiting and what their goals are and ultimately, these guys just want to keep up with the young guys that are able to kind of bust down doors and rip people out of cars if they need to. And oftentimes, it's a challenge because their life depends on it at that point. And so they'll give you these short windows, they'll say, hey, I'm going to South America in six months, you've got, this is your time frame so fix me. And so we will try the non-operative route and we'll see how well they do and they're definitely, there's papers to support that non-operative care can occur both in atraumatic and traumatic instability patients. So physical therapy with adjuncts at BFR, I found very useful. Dry needling with some of these guys help loosen them up and get their scapula kind of in the right position and moving correctly. Injections, steroid, I've started to shy away from, but Toradol, platelet-rich plasma, that's something that we've been looking at and evaluating in our military patients with early good results. Now, whenever you talk to these guys that all of them look like bodybuilders, they say, hey, I've got a slap tear, which is you have to explain the biceps complex and what's going on. And so I'm in the room with Dr. Kibler right now and so I'm going to be very cognizant of how I approach this, but this is part of my training. And so I came from a background, whereas Dr. Dickens will know, I came from a background of biceps killers. We saw biceps and there wasn't a biceps west of the Mississippi that we weren't cutting. I got into practice and John Kelly, who's going to be the president here in a couple of years, he saves every biceps, it doesn't matter what it looks like and that biceps is being repaired or fixed. And so I have this vast spectrum of how I'm evaluating this and this complex of what we're looking at in sheer injuries versus traumatic and loading injuries. So my hope is that as I've looked at it and tried to be a little bit more critical about it, that I'm taking a fair and balanced approach. So surgically, this was this 38-year-old guy, he has a little early wear with a slap tear that extends down the back. And what we do is we go in, we clean it up, we prepare it, so we rasp it in order to get a bleeding surface, and then I utilize the lateral decubitus position in order to really get down low in this percutaneous portal, which is my main workhorse in order to get low and extend all the way down to the bottom, placing anchors, and there's a variety of suture configurations that you can do, and people that are very dogmatic about what type of suture and how you place these. For me, that ends up being a four-to-five-anchor label repair for isolated posterior instability. So this is an outline of what I'll talk, and we had already mentioned what type of patient this is. We're taught for our boards that this is typically a loading-type patient, so big offensive linemen, heavy bench pressers, they come in, they're talking about, I've got this deep pain, but man, when I start doing a lot of push-ups, it starts to refer to the anterior part of the shoulder. There's a lot of interesting studies, and I think more in the future that will be coming out about how this is more of a micro-instability that we're dealing with instead of these people that are popping out. So I like taking them and asking them, going through, what series of exercises is this hurting you on? I think I'm critical in looking at, it's interesting to hear that if they're hurting in an inclined bench press versus an overhead press versus a bench press, where the tear actually is on the glenoid clock face. And so it does kind of give you an idea of what they're doing and how limited they are. Posterior instability is much more rare on an overall spectrum compared to anterior instability, but in the military we still see it significantly just because there's a lot of guys that are still lifting heavily well into their 30s and 40s. What about those traumatic dislocators and the folks that you will see in your first time posterior instability patients, and what are we looking at with patients that are at higher risk of recurrence? So we know that seizures put patients at higher risk for recurrent instability, but also age, so younger patients. And then for us, we have imaging studies that retroversion, which can be a very natural consequence of just either how you're born with glenoid and slight glenoid dysplasia can lead to higher risk of instability. I did an anatomy study with Dr. Perventura up in Vail where we looked at all the stabilizers of the shoulder. It was definitely, it was kind of my ultimate work during my fellowship, and it was really interesting to see this really is a complex, and they've discussed and described the ring complex back into the 80s out of HSS that they're looking at. You can't just crack one end of the ring without it affecting the other side of the ring. And so there's very few static and a lot of dynamic stabilizers, which is where you all come in and I think plays a big part into why patients improve and do better with rehabilitation in a lot of ways. And so getting that cuff worked out and recentering the head and taking tension off the biceps oftentimes can take away from pain if pain is their primary complaint. Evaluating these patients, once again, pain typically tends to be the primary complaint. They have an acute dislocation that's totally different, and then we do have to assess the volitional aspect. A lot of people can come in with a diagnosis of multidirectional instability, and that we're rehabbing as much as we can. It's very different than these traumatic and even these chronic dislocators or instability patients. So recurrent instability, specifically posterior, they oftentimes are vague. They can have associated pain and weakness with it. They can describe this anterior bicipital type pain versus a deep pain with loading exercises. And then on physical exam, you've got to get the shirt off. We have to see if there's any scapular dyskinesis that's occurring, see how they're mobilizing their scapula. And then ultimately for us, we're looking at if they're ligamentously lax and how that can have any implications in how we treat them. Certain exam maneuvers, the ones that I tend to use are the Kim and Jerk test. I also use shear type tests and throwing type maneuvers. Now the Kim and Jerk tend to, with an abducted and loaded arm, providing a posterior base force, you can see this pretty reproducibly cause pain and symptoms. And it is also interesting to examine both shoulders because there can be some laxity and one can cause pain and the other one not, but just to know baseline, kind of what you're looking at in order to adequately assess these individuals. Imaging, we always start out with radiographs and the key image for this is the axillary lateral. You have to make sure this is, we always had this beaten to our heads as residents, this is the number one reason to get sued is the patient comes in, they have this light bulb sign, but nobody gets this axillary lateral and they've actually been sitting out the back for weeks to sometimes months, I've seen a couple months type of procedures. This obviously has huge consequences if we're missing this and should be put back in and reduced as soon as they can. MRI versus MRA, I think that we have multiple studies looking at 3T versus MRA about to be equivalent and that can be mainly access driven. And then if you are worried about bone loss, what are we doing, still 3DCT is our gold standard, it allows for that volumetric analysis and evaluation of the glenoid bone stock. But does glenoid bone loss posteriorly matter? As we had just heard, anteriorly it definitely does, so Dr. Tokish when he was at Tripler looked at his outcomes and interestingly he found that no degree of bone loss within these military patients had implications on their clinical outcomes. But clinical outcomes may not be as sensitive because ultimately what we want to do is get our patients back to the fight, back to duty, and with this, similar to his work anteriorly, 13.5% was this threshold that if patients had more bone loss than that, they weren't able to return to duty. So although our clinical outcome scores were equivalent, they couldn't get back to the fight and so for us that does make a difference. So then we start looking at these biomechanically and does this actually matter? And what Dr. Owens, who is another military surgeon, evaluated was this anterior base model posteriorly and what they found is that they sequentially cut it, cut the bone, that 20% was this magic threshold to where you no longer could restore it just through a soft tissue procedure. But when we were looking at this, everybody's always beating in my head, anterior's not posterior, anterior's not posterior. So we started looking at the 3DCT scans and started noting that this isn't actually parallel to the glenoid axis. And so looking at this being off tilt, which is about 30 degrees off axis, we're able to more accurately identify where the bone loss is occurring. And so for us, helps us surgically to where we need to be aware and where to put the bone. But also, our biomechanical studies from the past, are they equivalent? This 30 degree axis is not the same as having a vertical inline axis with the long axis of the glenoid. And so these are not the same. Traumatic posterior instability. There's a, they have so many algorithms along these lines and we do try to rehab them. Oftentimes, we've talked about the first time anterior dislocator, we still can rehab a lot of these guys through posteriorly, depending on their symptoms. And at three months, that's kind of my threshold to kind of see if they're able to proceed forward with non-operative care. Both volitional and traumatic instability patients can receive rehabilitation and return back with excellent subjective improvements, despite maybe having some subjective instability in terms of subluxation. Gold standard for actual repairs and as a labor repair, as I'd shown earlier in the talk, I do utilize lateral decubitus position. I feel like it gives me the best view. It does allow for the best visualization down below. I think that six o'clock anchor is essential to be able to really imbricate the posterior inferior glenocumeral ligament, getting low and hitting that six o'clock position. And that Dr. Bradley, as he should, has really published the most on this and how are we doing arthroscopically and what factors do we have and can improve upon. And so there are risk factors for recurrence, but the patients do really well. His almost 300 patients, minimum two-year follow-up, had less than a 10% need for further surgery, which is excellent. Those are better than anterior instability patients. But what he saw within that 6.5% of patients is that if you're treating these patients with less spot welds, so for us, modifiable factors of at least using three anchors to be able to encompass the entirety of the tear does have an implication in how well they do. And there's other patients that we just know that they just don't do as well if it's their dominant shoulder or if they're female. They have a higher risk of needing a revision. Now, this patient that I had showed earlier in the case, what do you do when the biceps anchor is intact and they're older? And I think that we could, with, you get 10 surgeons in the room, five people will say one thing and five people will say the next. But for me, with these big bodybuilder-type patients that are in their late 30s, these type SLAP8 tears, these are the same patients that they were seeing out of El Paso. They presented on their patients where they showed that patients were able to return to duty reliably and get back to the point that not only are they at their job, but they're able to deploy with these types like that type 8 SLAP tears with a labor repair as well as a biceps tenodesis. So for me, chronic and degenerative, these atraumatic shear-type injuries with loading-type pain, I've been doing posterior labor repairs with biceps tenodesis and they've been doing quite well. And so to conclude this, I'll just briefly go into rehabilitation considerations. And this is our head athletic trainer at the Air Force Academy. He's a New Mexico brother of mine. And I trust this guy just innately with just doing pretty much whatever with my patients. I trust him and we're able to talk. We're very open about protocols, very open about how patients are doing. And we continue to modify trying to get better every patient every week, trying to see what and how we can tailor to the best of our abilities. So we take these guys through a variety and a litmus of tests. Sorry, I know these all flipped around, but we start out slow, but we do progress to early bench press-type progression in terms of motion early. We're able to put a PVC pipe and limit their humeral extension in order to not load the posterior shoulder, but allow for early mobilization. And then getting patients to return to sport is on average five to six months with greater than 90% return of strength. We do a closed kinetic chain upper extremity tests and make sure that they're within the 10% difference of their opposite side, as well as wide balance tests. And so these patients, we do talk about the use of harnesses in our athletes. We just base that up to the individual. We don't make them go back to sport with that for up to a year. We base it off of their confidence and their return of strength. And so I really appreciate your time. And I hope through this that we do realize that posterior and anterior aren't the same, that Dr. Kibler, I try to be very careful about what I do with the biceps. And then last but not least, find a trainer or a therapist that you really trust and have an open relationship with that you can critically evaluate and talk about your patients in order to best treat them. So thank you. Thank you. Thank you. So hopefully, so Kevin Wilk, who was supposed to be here, had some family issues. So he taped all his talks, which was great, as long as they work. So let's see if a rehabilitation talk comes up. God love him. Speaking about the post-operative treatment, the rehabilitation bowel and shoulder stabilization. And I'll allude to the elite athlete, as well as the weekend warrior that suffers a shoulder dislocation and has surgery. First, I'd like to say thank you to the organizing committee, particularly Dr. Alan Curtis. Alan's done such a fantastic job organizing the program on sports rehabilitation today in Boston in conjunction with the Anna 24 meeting in Boston. I wish I could be there in person and see you all. It's a fantastic meeting. I've had the opportunity to go to the Anna meeting before. It's just great. It typifies what we're all about as far as a team approach to the treatment. So thank you so much, Dr. Curtis, for putting this together and your thoughts about trying to bring physical therapists, athletic trainers, and physicians together in a nice organized manner. You know, when we talk about shoulder stabilization and we talk about different surgeries, obviously things have evolved. And we've had the opportunity to write several papers on this particular topic, which I appreciate. My goal is to talk strictly about the post-op, give some keys of treatment, if you will, some clinical tips and insights. Surgery today is a little bit different than what it was before. There's really only a few surgical procedures. Obviously, you've heard about that already from the excellent talks by Dr. Tokish and Dr. Dickens and so forth when they've talked about bone loss, bladder jays perhaps, and bank cards, and even doing plications of some sort. But, you know, the point is the rehab has to match the surgery and the individual. This is a unique case I had. He's back in college now, but rehabbed him about a year ago, so he's got one year follow-up. He had bilateral bladder jays done, college wrestler. They were done six weeks apart, and he did wrestle this year and did very well. So pretty pleased with that. Years ago, I've been around a few years, so I've seen putty plats and magnuson stacks and Bristow procedures. So obviously, these surgeries evolve. And speaking of historical, I thought I'd throw this in for some of the physicians in the audience. This is a thermal heat probe. I found it when I was going through a few of the talks preparing, and you can see here, this is Dr. Andrews striping the capsule, as you see here. And obviously, this is a procedure that was done. It was done on a routine basis by some surgeons, but nowadays, obviously not being done because of tissue necrosis and basically cooking the capsule like a bacon strip, as you see here. And obviously, shrinkage was the game plan, but it basically weakened the tissue. And it weakened the tissue for a long period of time and actually caused tissue necrosis, unfortunately. I know Mike Reinhold is there, Mike and I, when Mike was a fellow here and our staff member did an excellent job back in 02 presenting on this and actually wrote a paper on this that in overhead athletes, we had an 87% return to competition after a thermal. But everyone needs to realize, when Dr. Andrews did the thermal, he barely touched the capsule. I mean, it was just a couple stripes and a lot of rehab. Certainly, depending on who dislocates their shoulder and what they're going back to dictates the rate. And obviously, we have a high-level quarterback here who dislocates his shoulder inferiorly, tears his rotator cuff, has surgery, goes through very aggressive rehab at the right timeframe, and was able to play a very successful, continue a very successful career and win a Super Bowl. You've seen people dislocate here, one running back making a tackle, and he dislocates his shoulder. He was treated non-operatively, returned to play in about 10 to 14 days, and actually did very well and had surgery at the end of the year. Here's a young lady who just actually retired last week after, I believe, 14 or 16 years in the WNBA. But this was when she was in college. She dislocated, semi-finals game, NCAA, went back in the game after it was reduced and actually sustained a second dislocation in the same game, actually in the same quarter. Came back in the game with a brace on her shoulder and actually played that game and played several years before she actually had it reconstructed and repaired, as you can see here. Many times these injuries occur, as I mentioned, and depending on what the patient is going back to, what their makeup is from a tissue standpoint is what we determine the rate of rehab. So it's, is it a traumatic? Is it a congenital person that's having some type of stabilization? Is it acquired laxity like a thrower? We've got collision athletes, like you see here, dislocating, we have overhead athletes that dislocate. Numerous, numerous surgical procedures. I'm gonna say numerous, it's really about four. Here's a young lady, high school athlete, swimmer, tissue laxity, sustained a small tear in her capsule, couldn't swim, had it fixed. The rate of recovery is a little bit slower because of the laxity, I'm not concerned about motion. Here's a young man, football player, interior line member, plays third base, also high school, dislocates his throwing shoulder. His goal is really baseball at the next level in college. He's hypomobile, so therefore I have to err more on the range of motion side. So all that's determined with the physician at the time of surgery and immediately post-op. But we also can pivot along the way of our rehab depending on how the rate of recovery has gone. So what do we do with bank cards? Well, you know, the vast majority of bank cards we all see are obviously arthroscopic. And obviously being at the ANA meeting, we're talking arthroscopic procedures. But I do see two or three a year that are done open. Either it's a revision or horrible injury. But we do see one or two, maybe three open bank cards. Our program is really a four over to five phase approach. We think we have pretty good outcomes, but we'd love to improve that. There's a study by Dr. Andrews published in Arthroscopy in 2016. Had basically an 83% return to the same level of sports. We'd love to get that into the 90s, and we think we can 90, 95%. So what do we do post-op? Well, we put people in a sling, usually some type of little pillow. So there's a little bit of abduction, but not much. And they're instructed to sleep in that as well. We may move them right away, or we may hold them for a couple weeks for motion. It really depends on the individual, the physician, what they're going back to, and what type of tissue they had at the time of repair, and do they have congenital laxity. We don't allow anything above 90 degrees for a good four weeks, no matter who they are. Elite football player, wide receiver, runs back kicks, we're gonna move him relatively quick. High school cheerleader, gymnast, super hypermobile, we're not gonna move her. We're not gonna move her for several weeks. We're gonna work on neuromuscular control, posture, scapula position. 45-year-old gentleman with a traumatic injury, not an athlete, we're gonna err on the conservative side. So when we say we move people right away, it really depends on who they are. Most athletes here in Birmingham, we do move somewhat right away, but probably the majority of people, non-athlete, they will not get any range of motion for several weeks. We start them close to their body at 30 degrees of abduction, just light IR, ER, and they're not really even going into ER very much. Flexion, 70 the first week, 90 degrees for the next three weeks. Nothing above 90 degrees where it's putting stress on the capsule for four weeks at least. Four weeks and a day, we start bringing you up to 90 degrees of abduction, and we'll do some IR, ER up there, as well as allowing you to gradually gain your flexion back. At eight weeks, we expect you to have, it says full motion here, eight to 10 weeks, but if you're a little bit on the tight side, we're okay with that. Early on, we'll do some muscle activation where we ask the person to hold a static position here. There's a gentleman with an anterior arthroscopic Bankart procedure in a throwing shoulder, and he's about six, seven weeks post-op in that video. As I mentioned, if you're a thrower and you had a Bankart, we worry about you being too tight. So at eight weeks, we want 180 roughly. We want 90 degrees of external rotation at 90 degrees of abduction, and then from eight weeks to three months, so two months to three months, we start pushing you beyond 90 degrees. Early motion is super easy. It's not really stretching, and I can't emphasize that enough. We want the capsule to heal. It's light motion. It's not stretching. We're really not doing any type of stretching for a good six, eight weeks post-op. Some patients, as I mentioned before, they don't move right away. Maybe it's the physician's choice. It's not that important if they get a little tight, especially early. We know that they may loosen up later, and sometimes immobilization is very beneficial for those people. Reducing pain after surgery, ice, motion, laser. We even use shockwave occasionally, but we think motion can help with that. As I mentioned before, strengthening exercise is more muscle activation right away, and no aggressive strengthening for a good 10 to 12 weeks. We do a lot of dynamic stabilization exercises like you see here, and we gradually work the person up into an abductive position. A lot of manual with tubing exercises, a lot of proprioceptive training as well. So we wanna challenge the athlete. We wanna train them. We wanna get their scapula strong, their cuff strong. So we'll even do some scapula training still in the brace as you see here. That's a way of working on posture and kind of resetting the whole neck musculature. Once they get out of ways, maybe around that six, eight, probably closer to eight weeks, we'll put them in a side-lying position and do some scapula. We'll also get their arm up against the wall. But we're always working on perturbation-type training. We want them to become a neuromuscular machine, if you will. Maybe even work on some stabilization exercises, working the shoulder, working endurance, really, really important. They're not going back to collision sports for a good six, seven months. In overhead throwers, it's position-dependent, but it's probably gonna be between seven months and nine months. What about open procedures? Just real quick, open bank cards, obviously they have a 10 times greater occurrence of getting stiff than an arthroscopic. And there's numerous reasons for that. There's obviously the dissection, the exposure, the potential immobilization afterwards. So it's a totally different game, as you see here. There's an open bank card, and by seven days, I'm fortunate to even get the person to neutral. So it's a slower progression. We expect somewhere around eight weeks, maybe having 75 degrees of external rotation, and then gradually increase that. The good part about opens, it usually slows the patient down, like you see here in this professional wrestler. They're usually not in a big hurry to get motion going and push you as far as what exercise they can do. So they're pretty controlled. Collision athletes can still go back at about six, seven months. Throwing won't even start for a good four months before they get enough motion. Posture bank cards, it's a little bit different scenario. We see it a lot in interior alignment in football. We see it in hitters, batter instability as well. We're slower than we do with anterior. The capsule's thinner. Many times, just functional activities like pushing and going across the body. You put stress on the posterior capsule. So we use a sling that has a bigger pillow. So you're in a neutral position. You'll be in that for a good six weeks. You sleep in it as well. And we don't really do a lot of early motion. We tell the person no horizontal adduction, ADduction, no internal rotation, no pushing, nothing behind your back for a good six weeks. So it's pretty slow, six to eight weeks actually. It's a pretty slow progression. As I mentioned before, we work on scapula. We work on your rotator cuff. By eight weeks, obviously you have some decent motion. Matter of fact, I have three high school baseball players right now, ironically, that I'm rehabbing posterior bank cards. By about six months, you're in pretty good shape. No bench pressing. I know this says 12 weeks. That's in a football player who's pushing it. If it's a baseball player, I'm holding for a good 14 to 16 weeks. Last couple things to mention as my time runs out. Lattregeres. Lattregeres go in a sling. They're done arthroscopically. This gentleman had one done open. It's an older slide. It's a brace that they wear for four weeks. We hold on motion initially. Then we probably start your movement about two weeks post-op. Get some early bone healing. Nothing above 90 degrees for four weeks. Somewhere around that six to eight week time frame, you have pretty decent motion. Bone to bone healing is an eight week proposition, roughly. So we gradually increase range of motion at eight weeks, approximately being full motion at 12 weeks. And we expect you to return to sports at about four to five months once that bone heals. I mentioned my gentleman wrestler, bilateral. Obviously, that slowed things down a little bit. Rempellage, last procedure. I know you've all talked about that at the meeting already. The procedure usually is performed with something else in our center. We're cautious with internal rotation, horizontal adduction, pushing motions, bench pressing, range of motion. Slower in the beginning. The idea of the rempellage is not to engage that Hill Sachs lesion. So we're a little bit slow in the beginning, but by six to eight weeks, you have pretty good motion going. Expect full range of motion about eight to 12. Return to play criteria. Here's our criteria. I don't have time to get into all these parameters, but we have published that in the International Journal of Sports Physical Therapy for the collision athlete, but also for the overhead thrower. So in conclusion, a team approach is critical. Surgery has to, or the rehab has to match the surgery. Good communications between the surgeon and the rehab team. We try to avoid stiffness in real active individuals because we know that that can lead to poor results and osteoarthritic changes. Thank you very much for your kind attention. I know you're enjoying all the presentations at the Sports Medicine Symposium and the GANA meeting. And thank you very much for the kind invitation. Yeah, Kevin just texted me that he's sorry he's not here and that he will absolutely be in Washington DC next year. Okay, we're gonna shift into the overhead athlete as we have some pretty good experts here. So Mike O'Brien is the team physician for Tulane and then Mike Reinhold, you know well, is an expert in this area. So the next three talks can be on the overhead athlete. Mike's gonna lay it out. Mike Reinhold's gonna talk about his approach and then Kevin's also gonna come back once again. So the next three talks should be, one after another should be pretty good. Well, that's not good. The orange cone sign, that's like an F right off the bat, right? Oh, boy. Thanks to Alan for the invitation to be here with you today. So as he mentioned, I'm down at Tulane University in New Orleans. So we're going to talk mostly about the evaluation of the young throwers that come in, focusing more on your younger athletes, high school and college age. Thank you. These are my disclosures. So as you all know, these are very challenging patients to treat. And when someone like this comes into our clinic, you kind of sigh a little bit, because you know this is going to be a 20-minute, 30-minute visit going over this with parents, because they all expect their son or daughter to be the next great thing. There's been a huge increase in this, mostly due to year-round sports. It's a highly discussed topic, as you can see by the audience today. There's many textbooks that have been written on this. And so we're going to try and touch on some of these highlights. Part of the problem, especially in pitchers, is it's such a fast, violent motion. So the acceleration is 7,000 degrees per second that can cause repetitive microtrauma, tissue damage, adaptive changes to the humerus, adaptive changes to the labrum and the rotator cuff. And our goal in these athletes is non-operative management. So surgery is the last resort. I heard Chris Ahmad say yesterday, who takes care of the Yankees, he said our job is to get out of the way so the physical therapists can make these people better. So we don't want to get in there and screw anything up, because surgery can always make things worse. Injuries are in a huge rise, so especially in our adolescent athletes. And it's due to year-round baseball, multiple leagues, pitching showcases. So a huge increase in UCL tears, as well as shoulder injuries. So surgery is not great for these problems, you know? And so I love to discuss this data with people, because someone gets referred in to us, and they have an MRI that shows a slap tear, and they're already convinced they need surgery. So it's a 20-minute discussion telling them why they don't need surgery. And I like to quote this study, and if you look at the bottom right, return to previous performance for pitcher, 60% after shoulder surgery. So I tell them surgery's the last resort, and we only go to surgery if you cannot throw. Because the chance of you getting back to pitching after a slap repair or a labral repair is 50%. And once you get them to understand that, then they're like, oh, okay, surgery might be bad. Maybe I should do the rehab first. And it gets worse from collegiate up to professional, but especially in the pitchers. So our take-home point is try not to operate. Surgery's the last resort. So my job in the clinic is trying to figure out what is causing your pain. So this is a busy slide, but as you all know, like with year-round baseball, it creates overuse injuries. Too many innings, too many pitches, pitching on consecutive days, not enough rest, playing for multiple teams, multiple leagues, pitching through injuries, not following proper strength and conditioning routines. And it's the showcases and the radar guns which are killing us. You know, everybody's trying to get that velo. And so I try and discourage athletes from throwing at showcases because they try and throw as hard as they can to get that velo, and that's where a lot of injuries occur. This is a slide that I love, or this study. So what this showed is that most of the professional pitchers at the highest level played four sports in high school because they weren't just the best pitcher at their school, they were the best athlete at their school. And so they got rest, you know? And so rest from pitching at least because they ran track, they played baseball, they played football, basketball. So they weren't throwing year-round. So they have a lower rate of upper and lower extremity injuries, which is amazing. It's hard now because in New Orleans, in the South, as in many places, if they're not playing baseball year-round, their coaches tell them, oh, you gotta be dedicated, you gotta come out and play, you're not gonna make the team. So they're forced in sixth grade, maybe eighth grade, you know, to choose baseball over all sports. And then when they get cut from the high school team, it's devastating. So it's really hard, and I don't know that we can change this, but I think it's important to at least educate our patients about this and encourage them to play other sports so that when they're just working on being an athlete, their arms getting a rest. It's all about the kinetic chain. So our job is to evaluate them from head to toe, you know? You guys probably know better than me. The first muscle that activates with a pitching motion is the gastroc. The first muscle that fatigues is the glute. So the lower extremity evaluation is hugely important, especially for these athletes. And any break in that chain is gonna cause down-chain injuries. That can be muscle strains, can be tendinitis, can be tears. We're mostly gonna talk today about the non-traumatic injuries. So not where a pitcher's throwing and feels a pop and then their arm goes dead. We're talking about this slow development of pain over time. So it's usually a gradual onset, not an acute injury in most of these throwers. They might remember a specific game, but if they have a specific pitch where they felt a pop, then we're probably gonna jump right to an MRI. When somebody comes into clinic, the things I ask them to try, I learned this from Jimmy Andrews, is he has them write down on a dry erase board the number of teams they play for, the number of leagues they play for, how many pitches they're throwing a game, how many days a week they're pitching, how many days rest they get. And they're proud because they have this big list. And then he says, you're doing way too much. So especially in the spring and summer, try and get an idea of how much they're throwing, how much they're resting, when it hurts, if it hurts at late cocking, early acceleration, or ball release, have them try and point to where it hurts to give you a little idea of what's causing the issues. Communication is key. And so especially at the higher levels, some in high school, certainly college, I don't take care of a lot of professional athletes, but it just, even at the next level, gets even higher. You gotta communicate with the athletic trainers, you gotta communicate with the coaches, you gotta communicate with the parents. And so once the parents start to understand that their son, their daughter's elbow or shoulder is hurting, that's a sign they need to rest, not pitch through it. And once they understand that, then they start to get buy-in. And so once the patient, the athlete, and the family buys in then it's a little bit easier. So this is a very rough timeline, you know, for a non-acute injury, is immediately we will shut them down. So we wanna control the inflammation, usually with anti-inflammatories, occasionally a guided injection, but that's pretty rare, and immediately get them into physical therapy so they can maintain their flexibility. And while they're resting their arm, we want them to work on core strength, leg strength. At four weeks usually, once they're pain-free and have full motion, we'll begin shoulder strengthening, really hammering the scapula. So working a lot on scapula retraction and posture training. And then maybe around eight weeks, we'll start some more plyometric exercises, which Mike Reinhold's gonna go into much better detail than I can, and potentially a re-entry throwing program. And hopefully by 12 weeks, they're ready to be back playing. And so I kind of line out with them when they come in. This is gonna be a three-month process. Like this isn't, you sit out for two weeks and you go right back. We have to shut you down, your body needs to heal. You're young and healthy, we can get you better in order to get you back. So as they're starting out with resting their shoulder, maintaining that mobility, doing some scapular work, that's when we really kind of hammer the legs. So especially the core, the glutes, work on dynamic stabilization, neuromuscular control. You guys know all of this better than I do. So in the office exam, we start from the ground up. And so we wanna look at their hip rotation. This study showed that when you have a hip internal rotation contracture, especially in the lead leg, that that can lead to shoulder and elbow injuries. And so this is a 16-year-old guy. He was referred in for a slap tear, thought he needed surgery. He's a lefty. And when we get to his right leg, you can see he's got decreased internal rotation on this right hip here, very tight. And it turns out that when he was little, he had a skiffy and he's always had a tight hip. And that has affected him as he's gotten into high school and throwing more. So we put him in rehab, got some better motion in his hip, and he never needed surgery. The best test, I think, in the office is the single leg squat. So this is, guys, it's terrible. This is a good test of core strength, glute strength. Like you can see, he has to push himself up from the ground. And when you get them to do this in front of their parents and you say, your legs are so weak, like 50% of your power is coming from your core and your trunk, then they start to get it. Like, oh, maybe I do need to go to physical therapy. In high school athletes, I kind of want to see them be able to do this. I used to try and demonstrate this, but as I'm older and weaker, I can't now. So I just go down a little bit, you know. I do like a mini squat. But head up, shoulders back, good control, very little wobble. You want to see that that knee is pointing forward and the knee is not collapsing in. So when the knee collapses in, you're like, oh, I got to strengthen your glutes. College and higher level players, if they can do the pistol squat, which I cannot demonstrate, then you know that they have good core control or good core strength. And so again, head forward. You can tell them, take your time with this, but to try and be able to drop all the way down in a pistol squat and come back up, they've got strong glutes. I think that's probably the best test we can do in the office to show them that their glutes and their core is weak. We used to talk a lot about glenohumeral internal rotation deficit, and now we've learned that it's really the total arc of motion. So I usually lay them down and to try and stabilize the scapula and then check their total arc of motion. And the throwing shoulder will likely have more external rotation, less internal rotation, adaptive changes, but as long as that total arc is symmetric, then we think that they're not too tight posteriorly. When they are tight posterior, the two stretches I like to show them are the sleeper stretch and the cross body stretch. And I tell them they can do this sitting up, but if you lay them on their back and just bring their arm across and show them where their hand gets in relation to the contralateral shoulder, the uninjured shoulder will come all the way across, the injured one will come to about midline, and you show them your posterior capsule's tight, so that's giving you trouble. The scapular exam, I've learned so much from Ben Kibler, who is the scapula guru. And I put this video in here because this is just wild. This girl came in and she's hypermobile, so she just needs rehab, rehab, rehab. But I mean, you could argue that's good scapular control, but a lot of scapular laxity. So as you work your way up to the shoulder, the first thing I do, which I learned from Ben, is you gotta look at them from the back. And so Ben taught me that if you get them to raise their arms up and down about five or six times, you can start to look for asymmetry in that scapula. So I'll put my fingers on the medial border of the scapula, and I'm looking if one scapula's down and out, if it starts to wing up a little bit, if they get some dynamic winging. I have them do it in forward flexion, and then I also have them do it in full abduction, just to see if there's any difference. So I'm just looking side to side to see if it's nice and symmetric, which his is. But I've learned so much from Ben. If they start to wing, then we do the scapular assist test, where we hold the scapula down as they raise their arm up and see if that helps eliminate some of their pain. The Whipple test I learned from Buddy Savoie. So this is a test of scapular dyskinesis. And basically, when their scapula is protracted, it puts their rotator cuff at a mechanical disadvantage, because the whole scapula's tilting forward and it's decreasing that subacromial clearance space. And when you teach them, once they sit up, they become much, much stronger. And so that's a good test to show that if that helps with their pain, and when you teach them to keep their shoulder back, then it's not a pathologic lesion that needs surgery. It needs rehab. And so it's a scapular problem. This young woman is a softball player, and she still has her shirt on, but you can see her scapula moving pretty well. And as she starts to raise her arms up and down, if you watch her right scapula, it starts kicking out just a little bit. So as she does that a few times, her scapula's still kicking out. It's a little bit down and out compared to her left one. And there, with her normal posture, where she's protracted and slouched forward with two fingers, I can push her arm down. And then I teach her, pull your shoulders back, sit up straight, and then she's much, much stronger. So she gets better motion. We're getting that scapula out of the way. And then I can show her, your strength is much better here. So this, in the office, also helps people buy into the fact that you need to strengthen. You're weak right now. The provocative tests that we'll do. So we start with a lot of palpation. So a lot of throwers can get biceps pain. Sometimes it's biceps tendonitis. Sometimes it is secondary to a posterior superior labral tear. The clinically significant labral instability, as Dr. Kibler has coined. And, sorry, I was talking through it. The dynamic labral shear test, which Ben has also taught me, I think is one of the best tests to look for labral pathology. So what we do there is we bring them into full extension, full external rotation, and then you bring them up and down. So here's the apprehension test. Here's the dynamic labral shear test. Sean O'Driscoll described it laying down. Kibler's modification is sitting up. So we're gonna check their rotator cuff strength, check the supraspinatus in a couple different planes, check the infraspinatus, check their subscapularis. We'll do our instability exam looking for any apprehension. And for a pathologic posterior superior labral tear, I really like to do the dynamic labral shear test, O'Brien's active compression test, which is not mine, Steve O'Brien from New York, and a simple speeds test to see if that creates biceps pain. The elbow, we're not gonna spend as much time on. I think palpation for this is key. And really, they're gonna tell you the story if you just ask them what happened. And if it's a little bit of vague pain that has developed over time, or maybe some numbness and tingling, it could just be a flexor pronator strain with a little ulnar nerve irritation. Usually with a UCL tear, there's one pitch, they feel a pop, their arm goes dead, and then they come in and they say, I can't get the velocity, I can't get the control. That is a UCL tear until proven otherwise. So those guys get an immediate MR arthrogram. Just by palpating the elbow, you can learn a lot. So you palpate the ulnar nerve, the flexor pronator, palpate the proximal and distal ulnar collateral ligament, feel in the back, if they point to the back, they might have an olecranon bone spur. Younger athletes, 14 to 16, might have osteochondritis desiccans. They're gonna have lateral-sided pain with swelling in the lateral gutter. That one, you bring them into full extension and grind it, load it, as you rotate their forearm, and you're grinding on that OCD lesion to create the pain. Stress radiographs we can get. The one on the right there, that's a complete UCL tear, so that is kind of uncommon to see that amount of instability. And in-office ultrasound has been very nice for us. So you can, in the shoulder, you can look for inflammation, you can look for partial rotator cuff tears. It's hard to see the labrum in the shoulder, but it's great to look at the ulnar collateral ligament in the elbow. The best test I think that we can do in the office to reproduce elbow medial instability is the moving valgus stress test. So you put them at valgus stress and you kind of crank on them, and you go from about 70 to 120, and that should reproduce their pain. And I think that's the best way in the office we can try and reproduce the amount of force that goes on the throwing elbow during pitching. So the best treatment is prevention. Like I said, we want to train athletes, not pitchers. They need periods of planned rest at the professional level. It's easier because they have a whole team helping them. When they're in high school, they need a lot of education on how to do that. Younger patients, I make sure that they or their parents are watching their pitch counts. I refer them to this, so MLB.com has pitch counts, Stop Injury Prevention, Jimmy Andrews' website has pitch counts. So someone's got to be watching their pitches. Tell them not to throw curve balls and sliders at a young age. And then they should do year-round rehab. So we have a sheet called the Throwers 10, which you're probably familiar with. And as they finish out the rehab, we make sure they all go home with that. And we say, this is now your year-long rehab if you're playing baseball. So in summary, most of these injuries occur from breaking the kinetic chain that's gonna cause downfield problems, downchain problems. So it's gonna affect their trunk rotation, their arm position, they drop their elbow, they start to get problems. So we wanna diagnose that, and then we send them to y'all to make them better. The last thing we wanna do is surgery on these folks because it might end their throwing career. And some need it, and if they can't throw because of pain in a certain joint, then we will take them to surgery. But that should be after at least three months of non-operative management, probably closer to six. Thank you so much. I want to start by echoing what Kevin mentioned earlier and send a big thanks to Dr. Alan Curtis for putting this together, for creating this opportunity for us, you know, as physical therapists, rehab providers. This is a pretty unique experience, right, and I hope you got to attend some of ANA for this week and learn from the physicians, saw their perspectives, saw some of their techniques, and don't forget, you have access now, you're a member of ANA for the year. So go to the website, take advantage of the resources that you have as a member. It's a really impressive opportunity for us in the rehab field. So big thank you to Dr. Curtis for doing this. He approached me, I don't even know, six months ago with this vision and we've been talking about it for several months and it's really cool to see this happen. So there's no doubt this is going to grow bigger and bigger. So continue to spread the word. I'm going to talk about rehab to the throat or shoulder. It's May in Boston. It's a very lucrative time to own a sports physical therapy clinic that specializes in baseball injuries. Last week I had three post-op Tommy Johns and college pitchers. I had two high school, one high school, one college kid that are doing a weighted ball program and can't understand why their velocity's down even though their rotator cuff strength looks like a rotator cuff repair patient's post-operatively. We had two 13, 14-year-olds pop their elbow last week and walk around in a guarded position. It's a great, great time of year for us. So I don't have any relevant disclosures for this presentation, but as we know, overhead athletes are pretty unique. So if you work with overhead athletes, you know that they're a little bit different and some of the things that they can do with their bodies is unique, right? So you have to have an understanding of this. You have to appreciate that the uniqueness that they have does have some implications for what we're going to do in our rehab setting, right? Because not only do we have to understand what they have, but we have to treat them differently. So to really maximize how well we can work with our overhead athletes, you have to understand the shoulder, obviously, but you have to understand the unique characteristics of baseball players. And I learned this over my career, but I started essentially working probably in most of your settings in a clinic. And I worked with a lot of injured athletes and I thought I had a good sense of what an injured baseball player looked like. And then I started working within professional baseball and then I realized that all the healthy patients also looked like that, right? So it's very interesting and there's a lot of assumptions that can be made when you only see injured people, but you have to understand some of the uniqueness of these athletes. So obviously a tremendous amount of force, end range motion with angular velocity that is unique to the overhead athlete. So very common, what we see is we teach our athletes that throwing a baseball is essentially not good for you. And we teach them this. This is the first thing that we do in our evaluations. And what we tend to say is you get tight and you get tired, right? So you have mobility restrictions that occur from the cumulative eccentric effects of throwing and you have some fatigue for the dynamic stabilizers that we have to address. And those are the two big things we talk about. When we break down our principles of how to rehab these people, I try to just break it down into four quick and easy principles. And the more I've been doing this, the more I realize that the more simple we can make this, it's actually probably the most effective. The first principle that we'll go over is really just decreasing their acute pain and inflammation. But then after that, it's getting their motion back, getting their strength and dynamic stability back and then gradually returning. Pretty basic. But let's hit each one real quick. The first thing we have to talk about is reducing that pain and inflammation. We all know that any pain and inflammation is going to have reciprocal inhibition of the rotator cuff. And if you don't have a rotator cuff, it's very hard to throw a ball, right? So depending on what they have, we'll abstain from throwing. Typically anywhere from two to six weeks, postoperative obviously is a bit of a different beast depending on the surgery. But what we're trying to do in this early phase is to take the ball away and allow them to heal. And what we tend to find is it's often a workload versus a capacity issue. So it's usually one of these three things, oftentimes several of them, but they may have high chronic workload. So maybe their innings count, their amount of outings so far they've had in the year are very high. They can have an acute spike in their workload. They had two outings this week or, you know, they had a couple of innings with 30 pitches per inning. They're walking everybody. And then obviously you can have a reduced physical capacity on top of that. So it all comes down to, again, to me, it's just an equation of workload and capacity. Our job is to build their capacity, right? And then to help guide them a little bit with their workload afterwards. But in this phase, really it's about normalizing motion. And again, we just learned about this, but the total motion concept is very important for me. Most of these people with shoulder injuries were cautious going into external rotation because that's usually what's annoying with them. But for us, it's going to be more of a focus on their soft tissue, which we'll talk about. So I always say this. I want to restore your motion, but not more. And that's an important thing. I would say earlier in my career, we would literally say everybody needs to have this much motion because this Hall of Fame pitcher had this much motion. And we would try to emulate that in everybody, but that's not the case. So GERD's a big topic. We talked about it a little bit in the last conversation. GERD is still a hot topic for me within baseball. Very popular. We use the diagnosis a lot as a physical therapist in your clinic, right? Leads to a lot of things, right? Anger, depression, sometimes confusion, right? Lots of things. Too soon? Too late? I don't even know. To me, I want you to realize this. I want you to realize this. This is a normal adaptation. When total rotation motion on both sides is equal, I don't care what the number is, I'm okay with it. And here's what I'm finding over the last 20 years. The window is getting bigger. We used to say 180 degrees, but high school kids now are closer to 200. I think the last mean we did in the people that we looked at was almost 195, right? So it's crazy. We're getting these big windows. And sometimes you'll see people that have a 30 degree more arc, so 30 degrees more external rotation and 30 degrees less internal rotation. For me, I think if it's the same, I'm okay with it, right? That doesn't mean I necessarily love it. But we used to say that that 25 degree loss of internal rotation was a probable cause for their injury. I actually think it's the opposite. I think that 25 degree gain in external rotation is probably what's more predictive of their injury than anything else. So for me, I want to be careful, and I urge us all to stop saying GERD anytime. It's just a normal adaptation, and reserve it to something like this. When you actually have a limitation in their total range of motion, then you can attribute it to internal rotation. Then we'll call that GERD. Because when you label it GERD, then you assume that we have to label posterior capsule and sleeper stretch. Right? Those are the two big things that happen. So very familiar with the sleeper stretch. I've actually started to do this less and less each year. And to this point, I've actually stopped doing sleeper stretch. Very aggravating to people. I don't like doing exercises that simulate special tests that provoke rotator cuff inflammation or pain. But for me, we've actually found it to be more of an addition by subtraction type thing, where we actually take it away from people when they come to us. So sometimes they'll come to us and say, I've had persistent pain for two, three months. I don't know why. I have GERD. I'm doing sleeper stretch. We take it away, and we actually think that's one of the things that helps them get over the hump a little bit, is that they stop torquing it. If you're going to do it, right, do it in the scapular plane. That's important. But again, I really don't do it that much. So for me, I don't use it that much. If we look at what we've done over the years, and this is speaking with humble experience with this, we've analyzed this and even followed our pitchers over the course of the season. And with 20 Major League Baseball players that averaged over 122 innings pitched, which that's combining our starters and relievers, and nowadays that's a starting average, but we did no sleeper stretch, no posterior capsule, no internal rotation focus at all, and nobody lost motion. Okay? We actually gained external rotation about five degrees, but we didn't have a loss of internal rotation. Now, that doesn't mean we didn't work on things, but we worked on more with more posterior shoulder, right, and soft tissue of that posterior shoulder. And what I actually see more than anything else now is this, right? To me, this is the number one barometer that somebody has a workload capacity issue, right? That they are not doing a good job either recovering, right, restoring their range of motion or whatever it may be, but it's more this than anything else. And we spend time working on their lat, their teres major, and that opens up everything. Their external rotation range of motion improves. Everything feels a lot better over time. So I actually urge you to look for this, this loss of overhead elevation, more than anything else. I'll use this to dictate my treatments more than internal and external rotation the majority of the time. And then really focus on things, specifically teres major, a lot of people, it's lat too. There are little variations depending on your arm slot, but teres major seems to be a big one for me. Don't forget too, to increase internal rotation has been shown in JOSPT in 2007, that horizontal adduction stretching and contract relax in 2011 for horizontal adduction was better at restoring internal rotation than actually stretching into internal rotation. So again, look at that picture of John Lester that I showed earlier here. It's that traction, that distraction, that cross body motion of it is probably why they lose that internal rotation if it is above and beyond those bony changes. So once we have our motion going, then we really want to emphasize a balance in strength. This is very common for me. This is three sessions, you can see May a couple of years ago, and then June and August what we looked at. And we see this all the time. Somebody comes to us with an asymmetrical rotator cuff strength. This is external rotation. And you can see in my two slides over here, we started throwing in June after about five weeks of rehab because we got that orange bar back up, right? We got that increase of about 10% in their external rotation in the next five weeks, but we continue to work on that, right? You can see over time, he actually had about a 25% increase in his external rotation strength over the course of their rehab program. That is somebody that's going to do well. We have to focus on that strength. So what do we use while pitching? Well, it's posterior, right? It's external rotation, it's the scap stabilizers, it's working on the basics, right? Everybody wants to frost the cake before we actually bake it, right? We want to get it nice and strong before we start getting those cool Instagram videos that we all see, right? Work on the basics. It's important. The scapula has to be positioned well. You have to have a strong base, right? You can see the glenoid and the humeral head up here. Little tip on that, by the way, that's all my bicep contraction holding it up, by the way. He's really not doing anything. But you have to have that balance. You have to have that stable scapular position over time. So posterior cuff. The thing that I do different than I think that some people do is we linear load this. Lots of people stop four or five pounds. We still say that. We still say that in Major League Baseball, that more than three pounds will get the wrong muscles going. It's completely untrue. All my people are doing anywhere from 10 to 20 pounds over the course of their rehab progression. Then we get them on a cable column, we get them on flywheels for eccentric training, and my guys are animals, right? And that's what we do is we say this is your moneymaker into external rotation, scap stabilizers, all the basics that you need to get over time. So again, we're trying to restore that asymmetry, and I actually want it to be stronger. I want that orange bar to be more than the blue bar, because I want that right side to be a little bit stronger over time. Because we now need to use this strength to restore their dynamic humeral head control. Remember, we have to stabilize in this position. That's challenging. It's a very aggressive position. We have college and lax people, those unique athletes that can do these crazy things. We need a combination of strength and dynamic stability. So keep that in mind. Balance those net forces of the rotator cuff and put it all together. So how do we do that? Well, there's lots of exercise, right? And we'll put that together, but I'm going to pose it as questions, and we'll kind of go backwards. So is strength important for dynamic stabilization? Well, you know, we had this movement about 10, 15 years ago about functional training, right? And everyone said, you know, is functional training enough? Literally well-known physical therapists would say doing isolated external rotation was not a good idea, right? They were doing a bad idea. You know, we had to be more functional than just doing isolated strengthening of the rotator cuff. Yes, I think you need to do both, right? But just like anything else, peanut butter, chocolate, way better together than just doing them in isolation. So for me, a weak muscle can't stabilize, right? This is never going to win the battle. It doesn't matter how well you can have neuromuscular control if that's your strength line, right? So don't forget, after a game, we have a 6 to 18% loss of rotator cuff strength, and over the course of the season, it goes down about 3, 4%. They're going to get weak from throwing, right? Because throwing a baseball is, we talked about this earlier, bad for you, right? Exactly. That's what we tell everybody, right? So we know that you're going to lose strength over the course of the season. We want to fill up that tank as much as we can, because that 3, 4% is going to have a loss of dynamic humeral head control. Okay, so strength, obvious. That's checked. That's easy. What about endurance? Well, we know some of the models, mostly in the knee, ankle, that weakness and fatigue go hand in hand. But you can have a change in humeral head position by almost two times in a post-fatigue setting. So keep that in mind, that fatiguing out the rotator cuff will have an increase in superior humeral head migration. That's not what we want in these athletes. What about posture? We talk about that a lot, too. But I actually think this is a great image, right? Everything works together, right? So you can't look at the glenohumeral joint without looking at the humerus, right? You can't look at the scapulothoracic joint without looking at the thorax, and you can't look at that without looking lumbopelvic. They kind of all go together. So we have to put that together. What we do is we call that local and global dynamic stability. So a lot of our exercises are for local dynamic stability of the shoulder, but then we start putting it together to try to get them into the best position as possible. This right here, what do you think? What's that look like to you? How's that posture look to you? What does that look like to you? That dude's made well over $100 million, no hitters, rings, crazy, right? That's what a professional athlete looks like. That's impressive, right? We know that scapular position changes things, right? Chuck and I did this a lot earlier in our career. Chuck had hair. I had bad vision before LASIKs, and everything has changed, I think, since then, right? But we know that the position of the scapula changes, and we know it's different in baseball players, and we know this has a correlation to decreasing the ability for them to use their muscles. That's how we'll call it. So we'll have to put that together, right? So posture matters. Well, how do we enhance dynamic stability? Well, let's reverse-hack what we just talked about, strength, endurance, right? Put these together with posture, dynamic stability. There's tons of exercises that you can do, right? So numerous tricks that we use for dynamic stability. I love compression, right? So we'll do ball-against-the-wall, rhythmic stabilizations, perturbations. We'll include them with our shoulder and our isolated shoulder exercises. But I want to go back to the point where we said local and global dynamic stabilization, right? So as we start to progress, we'll start doing these in, like, side planks, half planks, full planks, like in this position. Think about what that's doing to his left side oblique, right? So he's locking down his left oblique in a side plank. That stabilizes his thorax, which is going to stabilize his scapular position, and then I want to produce strength in that. I want to increase that torque in that position. Now be careful. All of you are going to want to do this Monday in the clinic. They have to be strong to do this, right? Otherwise, you're working on the frosting and not the cake. Bake the cake, then you can frost it with these pitchers, right? Perturbations again in various positions. There's so many things we can do, right? To me, these are just the options that we have. There's lots you can do. We have tons of videos online that you can see for these things, but you really have to understand that, okay? So to summarize again, you have to understand why the injuries occur, and that's why meetings like this with the physicians are so awesome, right? You get to see the surgical procedures, you get to see the anatomical things that happen on the inside. You have to understand why they occur. But for me, again, take the ball away, reduce their pain and inflammation, otherwise nothing else is going to matter. Get their mobility back, specifically, again, I'd say lat, teres major, maybe a touch subscap. Get their baseline strength up and resist the urge to get too fancy until they are rock solid strong, right? Then get fancy with their dynamic stability, gradually return them back to play. Thank you very much. Next talk, we're going to have Kevin come back up. This is going to be great because he's going to show some exercise variations, which is great. He's going to be talking about neurocognitive training for the upper extremity. And as they load that, this is the last talk before break. We'll take about a 20-minute break when we get there and come on back, but Kevin. invitation and I know Mike Reinhold just spoke before me and Mike obviously does a great job with the rehabilitation the overhead athlete so I'll try to I'll try to enhance what Mike talked about a little bit or dovetail on on the points that he brought out for those of you in Boston or Boston Red Sox fans sorry about that Yankee pitcher there but he has a lot of motion so we talked about neurocognitive I want to mention why is it important to incorporate in your rehab what are some examples of upper extremity neurocognitive exercises and what are some of the tests we do from a neurocognitive standpoint so what is neurocognitive rehab and testing well it encompasses a lot of things and I think for me personally I think it's changed the way I think about rehab the most I don't have anything when I think about rehabilitation I know there's talks on lower extremity this afternoon I think one of the things that's changed my rehab dramatically is blood flow restriction for ACL patients I think in addition of what's changed the way my patients do it's perturbation training and neuromuscular training and then lastly I would say the neurocognitive and a lot's been written of recent and neurocognitive basically talks about challenges of any task which includes mental visual auditory verbal kinesthetic that occupies the athletes or patients cognitive attention partially or whole as they're simultaneously doing some type of either traditional exercise or sport and you'll see some examples of that so catching a ball while you're touching lights or throwing a ball as you're catching lights those are all examples of neurocognitive here's an example of lower extremity football player actually coached for the Patriots the last couple years standing on a rocker board played in the NFL and as I mentioned coach no he's out west and I'm tapping the platform as he catches the ball after his ACL so he's doing multiple things simultaneously we know that neuroplasticity happens with ACL patients and we think that some of this happens in patients who have shoulder instability per se who's an ACL patient right show right knee excuse me he's doing a ladder drill and I call out which direction to go in as I flip a ball to him but what you may not hear is he's actually counting backwards by sevens from a hundred while he's doing all this so there's a lot going on simultaneously and we've written a couple papers on the return to sport related to this but when you look at return to sport articles there's over 2,000 probably today on the knee and there's only maybe 700 at best on the shoulder so we wrote a paper on neurocognitive reactive testing for that return to play for the overhead athlete and that was published in the International Journal of Sports Physical Therapy last year and the reason for that is not only just for the overhead athlete but also for the basketball player the football player the lacrosse player the soccer player who dislocates their shoulder like I showed you earlier with this gentleman now he's a high level athlete she's a high level athlete he's a high level athlete that dislocates his shoulder but when they dislocate their shoulder and the capsule is injured proprioceptive deficits occur where you recognize where your joint is in space is compromised for the longest time we thought that happened locally because the proprioceptive fibers of the injured area were traumatized or injured or the capsule was torn maybe tension on the capsule what's been shown with the knee literature is it's not so much what's happening at the injury site at the periphery but how you're interpreting that information in your brain and what areas of your brain you're interpreting but also responding from is what where the alteration comes in and there's some great work on ACLs in particular by grooms and others this is a study looking at shoulders recurrent shoulder instability comparing to healthy individuals and what they found was differences in brain activity between the two groups abnormal motor control and activation in the recurrent shoulder instability group not only do they respond differently with passive range of motion but also with active excuse me with active range of motion as well so we know that when you're interpreting the information differently in the brain and those centers your response will be different and your response may not be advantageous and what I would call to your attention would be the ACL patient who just can't contract their quads that muscle shutdown they're experiencing neuroplasticity and that neuroplasticity results into rewiring unfortunately that rewiring how you think about a response has a negative effect on how you walk how your range of motion at your knee is and how fast you can get muscle to return the same thing is true in my opinion with shoulders as these people get more and more lax or become unstable because of a traumatic injury the way you respond to that is different so we see traumatic injuries of the shoulder in baseball so we see micro traumatic and macro traumatic injuries we know laxity decreases proprioception that decrease in proprioception may also be perceived by how you're interpreting the information and how you just can't contract so I would bring to your attention perhaps not the overhead thrower the highly skilled person but the MDI patient with capsular laxity elasticity and that's throughout their body they have poor proprioception but they're not quite recruiting at the same type of level or proficiency more importantly than somebody else also fatigue plays a role when you fatigue proprioception goes down now we certainly have elite athletes like this gentleman who has hypermobility and does well and wins gold medals but we have people like this with big sulcuses hypermobility or people like this who have injured their capsule and they know it just doesn't feel quite the same so neurocognitive training has represented significant change in what I'm doing in rehab there's a gentleman that's simulating a throwing motion that's a two-pound ball he's throwing up against the wall and he's tapping blaze pot so target lights yes identify the target color which is blue while while he throws the ball and in this case while I'm doing a rhythmic stabilization at n range so we have a lot going on I'm not sure you can hear him or not but he's actually counting backwards again from 100 by 7 really really tough exercise to so we try to get people to do neurocognitive type exercises and where we're trying to do with these exercises is recruit the proper centers of your brain this is some MRI work done by Dustin grooms dr. grooms from Ohio University done some fantastic work as far as ACL patients the ACL patient neuroplasticity is represented with the red that you see here the ones that have good activation normal activation is the blue scatter points and all it is a simple knee extension exercise and those of you interested in neuroplasticity with ACL patients obviously I would ask you to look up grooms and others they published extensively let's get back to the shoulder if you will so we do a lot of shoulder type work here is one of the exercises that I like a lot these are called ball drops with a sustained hold he's dropping a two-pound ball and he locates the target light and basically just taps it then we can add in some ball drops with the stabilization like you see here so I'm stabilizing doing a rhythmic stabilization so it's all on my verbal commands gymnasts here doing a step over exercise locating the target lights and the reason we like the lights because there's a target color but there's also distraction colors as well which makes it much more difficult for the patient same thing a gymnast elite gymnast on a BOSU ball excellent plank good good stabilization as she's doing it locating the target color we can even ask people to move through space as she does this lateral sliding type of maneuver we also have tests that we encompass as far as neurocognitive so we use the lights for a series of testing as well we've gone to schools we've gone to high schools and colleges to perform this testing mode and this has been published as I mentioned before so our return to play criteria after a shoulder injury or after elbow injury like a UCL is obviously we're looking at range of motion for the entire extremity and even spine so we record all the range of motion and we've talked about this at meetings at length we look at strength as well most of the time for us it's a handheld dynamometer where it's just basically a way of measuring objectively the strength we have strength parameters for the overhead thrower we'll do a ball drop test as you see here where the person drops and catches a ball the number of catches they drop the test is repeated to the opposite side we'll also do some ball throws up against the wall with a two-pound ball it's a 30 second bout and we count the number of throws and catches and compare it to the opposite side there has been some reproducibility studies performed this one by Davies and myself showed excellent reproducibility with these overhead tests then we have you back up and throw into a rebounder with a one-pound ball we don't count accuracy we just look at your mechanics and then we'll do something like this this is with a 350 gram ball that this guy is throwing here he's working just mechanically we're looking at his arm slot we're looking to see how he throws if he has any soreness any pain during the activity itself we also look at lower extremity even though we're having a shoulder we'll have them do a single leg squat especially with your younger people your high school little leaguers and things of that nature we want to see what their hip and their core is doing we want to make sure they're strong in their core posterior chain so we like that single leg squat and also look at a plank as I mentioned we've done these testing this is the upper extremity test by Davies that you're all familiar with instead of doing it no lights we've also incorporated lights as you see here stabilize on one side as he locates we like this test a lot red light he hits with his right hand blue light he hits with his left hand really really tough drill but also very very rewarding to say the least this is a NFL wide receiver with a shoulder subluxation so he's got to be able to stabilize this brings both arms into the equation instead of just working on one at a time this forces him to kind of juggle one side to the other we talked about the ball throws already so we've done it with pitchers catchers high school athletes like you see here as well as well as as gymnasts and so forth this has all been reported it is in a paper in the International Journal of Sports Physical Therapy so there are data points as well those exercises by the way that I shared are all on my Instagram it's just my name Wilk underscore Kevin collision athletes return to play let me just I have a minute or two left I mentioned this in the previous talk about shoulder stabilization clinical exam by the physician we look at range of motion strength and special tests the the functional tests that we do is a unilateral chest press on a machine we start out at 50% of your body weight and we count the number of repetitions and then we have you do it on your injured or or reconstructed side operative side and we want 85 to 90 percent we do do a quote we do a closed kinetic chain upper extremity stability test by Davies but we'll do it with the lights as I mentioned before and then we'll do our unilateral ball drop test we'll also do the neurocognitive with the lights as you see here we do three tests there are other tests available but those are the ones that we advocate so to summarize injuries to the physical structure of the shoulder does compromise stability and muscle activation but there is something going on in many individuals from a neuroplasticity standpoint we think by encompassing and including neurocognitive training and testing that will enhance your rehab it improves dynamic stabilization it improves confidence and it also improves functional abilities and lastly what we're trying to do if we're an injured athlete or injured individual by encompassing neurocognitive training is actually making you better than you were before thank you very much for your kind attention and enjoy the rest of the conference Nothing exciting, I'm just here to tell you to see you in 20 minutes. So we'll say whatever 20 minutes is. See you around 10 of, right? Yeah, give or take. We're all set stage right, correct? Okay. All right, you ready, Mark? Yeah. Okay. All right, if I could have everybody's attention, it's my honor to... My name is Brian Biscone, just didn't sleep at a Holiday Inn, I don't know as much as Mike does, but I did train Mike at one point in time, so... The next session is Management of Rotator Cuff and Biceps Pathology 2024. Very fortunate to have here a past president of the Arthroscopy Association of North America, someone who I've known for 25 years, to talk about complex rotator cuffs and how he manages the biceps tips for success, Dr. Mark Edelman. Thanks, Mark. Thanks, Brian. And it's an honor to be in this session, and I think this is a new frontier for our meeting, and having you here, I've had the privilege of speaking at Dr. Curtis's meeting in Boston in the past, and so some of you are familiar to me, and hopefully I can provide some insight in terms of what we're talking about. My disclosures are available. So when you think about the rotator cuff, there's a lot of things that you have to understand conceptually on why it becomes a problem. There's this avascular area that exists basically in all rotator cuff tendons, and that's where rotator cuff breakdown takes place. And it's this avascular zone that leads to the problem. And so even before the degeneration begins, you have an area that's predisposed to it, and there's nothing we can do to change that. And we've known about this for 50 years. And then once the rotator cuff does fail, even before the patient sometimes becomes symptomatic, there's changes in this muscle penation angle that is irreversible when you have chronic tears. And so you guys take care of these patients after we fixed them, and you look at the op reports, and it may say how it was done, or it may not say whether it was a single row or a double row or it was an augment or, you know, and it just says rotator cuff repair, and now you have to figure out what you can do and what can't you do based on the quality of the repair and the quality of the tissue. There's a lot of industry pressure and peer pressure driving our colleagues in terms of how they fix the rotator cuff. And a lot of them choose to do these, quote, double row repairs. For me, it's done rarely. And that's because it puts the repair under tension. And when you have tension on a repair, it can lead to failure. So when I tend to see this is in an acute traumatic tear that has no tissue loss in a young individual, and that's not who tears their rotator cuff, right? The rotator cuff tears are the 70-year-old who's playing pickleball four days a week now, or somebody who has a traumatic fall off a ladder hanging Christmas lights. These are not the people that have normal tissue quality. And so if I happen to have a high-level athlete or a heavy laborer who has an injury, then I'll do the double row. But a lot of times, they have this concurrent critical zone damage. And so we still use single row repair, and it doesn't mean that it's a weaker repair. Not all the single rows that you see are created equal. But there's a difference in how they're done. How many sutures are in the anchor that you're using? Where is the anchor placed? And we've actually developed a very specific technique called a SCOE row, which really is understood by my colleagues as to what that repair looks like. We've learned from Scott Rodeo at Special Surgery that it's really the number of stitches that you put through every centimeter of tear that you have, and it really doesn't matter how many rows you've put in there. And it wasn't until 2016 that the, quote, SCOE row-style repair was actually reported in the literature, and that's only eight years ago. And I've been doing arthroscopic rotator cuff close to 30 years now. And so there's a difference in tension. And so what we did here is we developed this tensiometer, and if you look at the rotator cuff up on the right, if you just let it sit where it lies there medially or you pull it out laterally, there's force that's required to do that. And in this case, it's a five-fold increase in force to pull that rotator cuff tissue laterally over the tuberosity. And so you have to think about that when you're doing your repair. Bone quality is a big issue. If you look at the people who tear their rotator cuff, it's the 70-year-old on the right side of your screen, not the 30-year-old. And look at what the difference in bone is. This isn't, you know, the graphics. This is the difference in bone. And you want your anchors here where there's still good bone, the white. The black is basically a deep hole, and there's no cancellous bone. And so you're relying only on the very edge of the cortex to hold that suture anchor to give you your fixation. So what we've coined is what we call a SCOE row, which is where I practice. We use strong anchors and the best bone, and we maximize the passes per centimeter. We use high-strength suture, and we try to create the best environment for healing. So we're doing an in-situ repair. We basically just put it right down where it's torn from. And then we microfracture the tuberosity, right, because it's all about biology, and we need biology for healing. And that's where your biology is coming from. So this is what it looks like. This is a right shoulder. We're looking from a lateral viewing portal. I'm looking directly in, and then I use my devices here to pass our suture. And so we use retrograde passing. So basically I use that purple monofilament to transport these colored sutures through. And then we're using these bioresorbable anchors that are going into the tuberosity. And then once we've done that now, in this case, we're passing six stitches. If you do a double row, you're making two poke holes through that same size tear, and this way we're getting more fixation. So there's still value in this technique. And then we go ahead and just tie knots, right, and if you're capable of tying good knots, you can get a secure repair. Guys who don't like to tie knots do a double row because you don't have to. You pull the anchor into the lateral row, and then this is the key right here, is microfracturing the tuberosity. And by doing that, we release the bone marrow elements and the stem cells, and there's my completed repair. And then we turn off the flow, and look what happens. You see all these blood products leaking up into the repair, and that's giving you the healing elements you need, your stem cells, your platelets, your vascular buds. And this is what it looks like after surgery. This is a radiologist who got on the MRI scanner every four weeks after his surgery to drive us crazy, but we got to assess what happens to the rotator cuff, and that's all new tissue that's forming by eight weeks post-op. We've biopsied this tissue, and it shows us that it's good quality tissue, and it looks like rotator cuff. We've studied this so that the world can understand what we're talking about, and what we found is when we looked at 100 patients, only five re-tears. We had a 92% healing rate, which is still today the best results reported ever in the world's literature for rotator cuff repair. This technique works with excellent healing, and we get good, satisfied patients, because if the patients heal their rotator cuff, they're going to have a better outcome. It's taken off around the world. This is a paper that was done in Guangzhou, China, and they talk about it in their abstract using the SCOE-RO technique. We've made our mark in terms of how we look at this. When do you need to augment? If your tissue quality is poor, you better think about an augmentation. This is a study that we participated in. If you add augmentation, this is a dermal allograft augment, you can double the healing rate of these large, tough tears. My indications for an augmentation are revisions, massive tears, or what we call tears at risk, those that have prior trauma, have fatty infiltration, and aren't healthy. This is a 66-year-old woman, and here's her rotator cuff. What you'll see here is as I try to pull on it, it's under too much tension, so I can't get it back to the bone. In this case, what I'm going to do is do what we call a side-to-side or margin convergence type repair, and I can get it repaired. You can see here I've got tissue now back to the bone. I'll microfracture that tuberosity, but in this case, I'm going to bring in a dermal graft over the top to try to secure that repair, and give me an augmentation to try to double my healing rate in this 66-year-old patient. There's times when this is necessary, and if you have good tissue quality, then just do a standard repair. So in 2024, we think a lot about this, and if it's a repairable tear, but poor quality, then I'll either add the biceps tendon or add a dermal graft. If there's really bad tissue, I'll even sew the graft into the rotator cuff and use it to lengthen it, but that's an off-label use by the FDA. We have the SCR that you hear about, superior capsular reconstruction. If the biceps is intact, I use the biceps to do my SCR. If the biceps is ruptured, then I may do an SCR, but if they have a lag sign out in here, that's where I do a lower trap transfer, augmenting that as well. Well, what about the biceps? The biceps is an important structure, right? Up until the last two years, everybody just said, cut it, do a tenotomy, it doesn't matter. But patients aren't happy with tenotomy. They don't want the Popeye deformity, they don't like the cramping. It's a real hassle for us, and I gave an instructional course lecture yesterday for an hour and a half just on uses of the biceps tendon, and the room was packed. So we have to think about this differently. I leave it alone a lot. I don't just routinely say the biceps is a problem and cut it. But if it's frayed, if it's damaged, if it's red, if it's angry, then you have to do something to the biceps. And so if it looks bad, then take it. If they're unhappy, deal with it. If there's a subscap tear, deal with it. But for complex tears, it's a great source of collagen, so we use it a lot in that case now. And so there's lots of different techniques. What about tenotomy? Tenotomy is easy, and sometimes surgeons just like easy, right? It takes two seconds to just cut it and let it fly, and it's cheap. But 23% of patients who do that have an obvious Popeye deformity. Another 20% have continued cramping if they're using a screwdriver or they're a laborer. That means 43% of your patients are potentially unhappy, so this isn't the right answer. So for me, I almost never do a tenotomy. But talking about informed consent in the office, right? If you're going to tell a patient, I'm either going to cut your biceps or I'm going to fix your biceps, there's not a single patient in this world who's going to say, please just cut my biceps, right? It just doesn't exist. And so if you're really going to have informed consent, you've got to tell them that they're going to have a Popeye. In LA, where I live, people go for fillers every two days. They're not going to tolerate having their biceps cut and floating down their arm. And so everyone will say, after 20 minutes of a talk, can't you just do something? Well, yeah, I can do a tenodesis, and it takes me 20 minutes to have that conversation. And my office is busy. Now I've got negative Google ratings for the next patient. I've wasted all this time. Just do a tenodesis. Don't do a tenotomy, because everybody wants a tenodesis. So when we think about this, in the past, we used to do a lot of open subpecs. We've now switched to doing arthroscopic suprapec, and there's risk factors when you do that. If you use an interference screw, you can fracture the humerus, and that's a disaster. So again, it can't be benign, so you need to think about different ways to do this. There's inlay techniques, where you make a hole in the bone, or an onlay technique, where you just attach it to the surface of the bone. And so we've studied this in our institution, looking at it, and the outcomes are the same, whether you do it suprapec or subpec, but your risk factor is lower. So I actually developed this technique called the suprapectral tenodesis, where we didn't use an implant, and you can see on the cadaver specimen there, we make a tunnel, and we just tie the biceps down. We've validated it biomechanically, and this is what it looks like. So we make two little holes at the bottom where the stitches are, we then put a whip stitch in the biceps, we pull it in, and we dunk it into the hole, and secure it in place. Great technique, but really hard to teach, and so we kind of had to do something a little bit differently. And so we studied it biomechanically, it worked great. We didn't have failures, and when you think about the biceps, you have to think about how you're doing it, and how it fails. If you use an interference screw, and it fails, you get a Popeye deformity. If you do an onlay technique, it's harder to get healing, and the tendon can cheese wire through, and you get a Popeye deformity. If you do an intraosseous technique, you may get some tendon elongation, but when it fails, there's no Popeye, so you have a happier patient. But again, it was hard to teach, so we actually developed this. So this is what I call like the space shuttle, so it has this big nose, and the bicep sits in there with a half sheath design, and so this is what we do today. So I basically mark the bone, and then I mark the tendon to assure my resting length relationship is correct. And then when I do this, I can then exteriorize the biceps the same way, and what we'll do is we'll pull these sutures out, and then I can pull up on the biceps, and you can do a tenosynovectomy, so you can release the angry red tissue that is what's causing the pain in the biceps groove. And once you do that, you can get a little bit more length on the biceps. We then size it, we create a tunnel in the bone, and the bone hole is placed in the groove, and so by putting it in the groove, we are able to be protected, so the risk of fracture is very small. We size the tendon, we drill a tunnel unicortically, so we're just making one hole between the uprights of the bicipital groove, so the risk of fracture is very low, as opposed to the risk of fracture. And here's the device, and this is what it looks like when we bang it in. So the biceps is sewed to it on the inferior margin, we go ahead and implant the device into the bone, and that's it. It takes five minutes to do this operation. So this is the newest thing that is out on the market. I have to disclose I am one of the developers of it, but I think it's exciting new technology, and that's where we are today in 2024. So the clinical results do what's best for your patient. The SCOE row works really well. We don't get what we call type 2 failures, which can be a disaster. Double rows make sense if there's no tension. We add a graft if it's a high-risk patient, and think about doing that superpectinal adhesives. Thank you very much. I appreciate your attention. Hold on, Mark. Is this on? Yeah, hold on, Mark. One second, Alan. So, group of therapists in the room. Three questions. Yeah. Ready? One. Rotator cuff repair. How long are you on a sling? When can you begin passive? When can you begin active motion? So six weeks in a sling, I don't waste a single PT visit, because in California, at best, I get 24 visits. So they don't come to therapy. They don't see you for six weeks. I have them basically do passive exercises at home. And I do table slides. And I let them do passive, you know, I have them do pendulums. And then I do passive supine external rotation for the first six weeks. At six weeks, they come out of the sling. They start with you. We do active range of motion. At 12 weeks, I see them back. I do an ultrasound. At ultrasound, if I see healing and you have gotten their motion back, then they can start to strengthen. Subacromial decompression with a biceps tenodesis. How long are they in a sling? And when do you start elbow motion? So isolated decompression and biceps tenodesis. So the subacromial decompression has no bearing on therapy. I'll let them start the next day. If I'm doing a tenodesis isolated, I will tell them two weeks full time in a sling, two weeks out of the house in a sling. And I start therapy at four weeks. Perfect. Thank you. Yeah. Thank you, guys. Thank you. All right, next up is Alan Curtis. He will be the new incoming president of the Arthroscopy Association of North America. Known Alan for a long period of time. He has dedicated a tremendous amount of efforts in the field of the rotator cuff. Some of the original papers and pictures that we all put up on our slides came out of Alan's hard work within the lab. It's an honor to have Alan here speaking about rotator cuff pathology. Thanks, Brian. And Mark was the last president of Anna. So I'm honored to be next to him. Anyway, so Mark was so kind to show you success. And so I'm going to talk about failure. And so this is what I do outside of other things. So rotator cuff repair. Well, the enemy of success is tension too much. So if you over-repair and over-pull on that tendon, you can do triple row, and it's not going to hold. Technique too little. And you see this all the time. And I do too in the office, because I see a lot of revisions, is that some people need five or six portals to fix a simple cuff. And for the last probably four or five years now, I do 90% through just two. And I think that makes a difference, because there's less holes in the deltoid. And certainly, I don't touch the anterior deltoid unless the subscap is involved. Soft tissue care is really important to the post-operative course. As far as tissue goes, loss or quality, well, it's hard to deal with that. We could talk about allografts and augmentation. And capacity to heal, that's a big area of research right now. We can put the tendon to bone. How can we ask it and help it heal? So what is failure? So to me, failure is not the existence of a non-complete healing of a tendon, because I think that happens a lot. I think that you take a big four or five centimeter tear. You repair it. And there's probably areas that are just scar or a centimeter or so that didn't always heal all the way back. But if they have full motion and no pain, that's still a success. And vice versa, you could have a guy who's completely healed and is miserable, because they're still in a lot of pain, or they have a frozen shoulder, or they just didn't get their strength back. So that's really loss of function is really, to me, the definition of failure if someone's sick, someone's out and still struggling. So post-op pain factors. Well, too much done at the original surgery. Some people, unfortunately, just shotgun it. Everybody, you should never do labral surgery in association with rotator cuff surgery. You might as well just schedule the manipulation at the first surgery. You don't need to take out the AC joint in everybody. There's actually a good paper that came out last year saying that in symptomatic AC joint and rotator cuff repairs, the people that the AC joint was ignored and the cuff repaired did better than the people that had their AC joint and cuff taken out. So that's interesting. It might have been that the stress of utilizing the AC joint in the shoulder not functioning properly actually exacerbated the pain in the AC joint. Stiffness is the biggest problem after rotator cuff repair. I'm sure you all see that. Why does it happen? Well, I think it's the most common problem. It started off with, again, soft tissue care. So if there's a lot of bleeding into the region early on, it sets up this blood and this goo and if the patient doesn't move, it really just, within the first week or two, the dye is cast, I think. If they're diabetic or they're stiff preoperatively, it is gonna be a problem postoperatively and these are the people probably we do wanna get in to your hands a little bit earlier. Passive range of motion, they don't move and they should, and pillow use. So I don't routinely any longer make a patient stay in a pillow. They can if they want, but I don't encourage it because I want them to do some writing and typing so that they rotate below the acromion a little bit and they don't scar to it because that's a very common cause of failure, I think, and I'll show an example of that. On MRI, I just use a regular MRI, don't need genital anemia. I wanna know where the tissue is, where their problem is, and then I go from there. And also, there's no reason to cause more pain in these situations. This is a good example here of what I was talking about. Whoops. Okay. So on, here's just another, on the top corner there where the arrow is. So there's an example of, so that's the supraspinatus muscle tendon unit and you can see it's scarred completely to the overlying acromion and there's nothing on the head where those two anchors are. It actually never healed. And why did that happen? Well, someone does a subacromial decompression, so it's raw bone on the acromion, and then they fix the tendon to the tuberosity and they go home in a pillow. And so then they don't move because it hurt a little too much or they just didn't move. And so the tendon heals to exposed bone. So it heals to the acromion and it heals to the tuberosity. And then at that six-week point, when it's like, okay, let's move them, whatever interface is stronger wins. So in this situation, the acromial interface was stronger, unfortunately. And so I'll show you what that looks like too. So what do I do? Well, if I have someone who's not doing well postoperatively, at three months, I'll give them a MedDol dose pack, and at four months, I'll give them a cortisone shot, mostly just to break down the scar tissue, have them take a week off from PT and then go back. And then at that point, I'm sure you've seen this, is that they usually see a jump in motion, a decrease in pain. It works pretty good. We do them under ultrasound. Cortisone shots are important, and in the literature, you don't just stick them in somewhere. I mean, they should pretty much always be guided, whether by arthrogram, floral, or by ultrasound. We do them all by ultrasound now because it's an important step in treatment. You don't want to waste that opportunity. And then I'll alter the PT and work regimen back to just working on motion. Motion's everything here. Surgery, if they fail that, the goal is to save the deltoid because that's all you need. You need a deltoid to do a reverse shoulder replacement. And so no matter what, as long as someone has a deltoid, we have a thing we can do for them if they do poorly. So you don't want to make a bad situation worse, and so we try to stay arthroscopically as much as possible. So this is a subacromial revision here. So this is what it looks like when the cuff scars to the overlying acromion. There's no subacromial space anymore. You can't see a damn thing. And so what I do is I come in right on the bone of the acromion laterally, and then just staying on the bone, I skeletonize it, and that allows everything to drop away, as you can see there on the bottom. And so the acromion's above, the cuff's below. You can see some sutures and things like that on top of the cuff. But although not pretty, it's intact. So in this case, this person was pretty miserable and stiff in the overhead. We released all the scar tissue. The nice thing is they can move the next day, so we're not going back to square one. If they're having problems in the joint itself, it's usually, again, stiffness or loose material, foreign material. Here's an interesting case. So this was a double row repair somebody did, and the bridge actually broke off and scarred into the, it's in the joint floating around, yet the cuff still healed over it. As Mark showed, I do a lot similar to him, more single than double rows, because I think the body has the capability to heal from the outside in. So if you prepare the tuberosity and create the crimson duvet type of situation and go look at that, it recreates the cuff. And so you don't have to drag the cuff over that. It'll do it on its own. And this is a prime example here. The whole bridge aspect failed and the cuff still healed. So cuff repair options. So I'll accept partial or scar repairs, but I have to fix full thickness tears. And so that's an example there on the top where, again, a bridge technique, everything healed except for the tissue under the bridge is a type two failure. And here we did a side to side repair and then repair to the base again. And so what I'll do in these revision situations is that I'll use different anchors if I can. So if there were plastic, peak, or metal before, I'll use suture base the second time and sometime reverse depending on the quality of the bone. And the biceps is really critical now. The first thing I look at, actually, when someone comes in with a big tear, huge, I don't know what I'm gonna do with it, is to see do they still have a biceps. And if they do, I know no matter what I can do something to help them. And so my goal is sometimes when I don't have enough tissue just to balance partial repair to restore the force balance in the shoulder so the deltoid can work. Other options are an SCR, lat transfer, reverse shoulder. If going down the line, if I don't have a biceps to work with, if they're young and they don't have arthritis, of course, they do have arthritis, maybe lean more toward the reverse. So here's an example here of a orthopedic surgeon that I took care of, actually, someone you probably all know. And anyway, he thinks he's a stud skier and he retore his cuff right there. And he had a big cuff tear. And so he comes in and on the MRI, I was a little worried that we'd be able to fix this because we couldn't even see cuff, it was all retracted well beyond the glenoid rim. So there's a left shoulder, I'm looking for the back to the front, that's the biceps to the left, that's a probe about the size of a pencil that I'm pointing to things. And that's the edge of his rotator cuff, the red point right there. And what we found though, and this is what's key, is that the MRI predicts the size of the tear, but it doesn't predict the repairability of a tear because that all depends on the quality of the tissue and how well it moves. And so that's what we found here. It's like a window shade. So once we found his cuff and put a stitch in or traction stitch, the whole thing rolled back. And so then it just became fix the interval split and it takes all the tension off the anchor. So you don't need a ton of anchors to actually do the job. And so we fixed it and then repaired the tissue back to the tuberosity. And he actually was doing knee scopes five days later despite his surgeon's recommendations. And so here that you can see there, just the side to side component, understanding how cuffs tear is critical because if you can repair that aspect, it makes the job of the anchor basically just to hold tissue in place while it heals for six weeks. So this is the real problem. This is the tough one that no one has the absolute answer to and you'll see, if you go in the other room, you'll see a dozen different options. But the real problem is the massive retracted cuff tear with tissue loss. So we don't have enough to cover the whole head, but they don't have arthritis and they're usually younger. So you hate to put a reverse in there, but I can't tell you how many people I see on Tuesdays for second opinion who come in and they've been told they need a reverse shoulder replacement. So you have to think out of the box. So they have a biceps, it's a free graft, it's very strong tissue and there's various ways that you can use it to really augment this problem or solve this problem. So this is what I do now. I do an in-situ biceps tenodesis. And so what that means is, I don't know if this works. Oh, well, I can't point to it. Oh, nevermind. So that's the biceps tendon right there. It goes from posterior superior on the glenoid rim and it goes anteriorly down the biceps groove from separating supraspinatus and subscapularis. So it's ideally positioned. If you put an anchor right there, this tethers the biceps. So it's ideally positioned to prevent anterior superior escape, which gives your deltoid a chance to work. And that it also is parallel to the strongest portion of the supraspinatus. And so if you don't have a supraspinatus to work with, there is usually something here that I can use and I'll tie it to the biceps and use it as a bridge graft. And then I'll do whatever I can posteriorly. And that gives me a balanced repair. So if I can do that, I can actually turn someone who doesn't have a function into someone who does because there's enough cuff to depress the head that the deltoid will work. And so here's an example here. This is a big tear, right shoulder. So it was infraspinatus and supraspinatus are torn, biceps tendon is intact, and the tissue is way over here beyond the glenoid rim. And so there's no way it was gonna go all the way back to where it belonged. So what we did is we tinnitus the biceps in situ right here. So we put one anchor right behind the biceps, put a stitch behind it, through it, and then one up through the interval tissue to create this construct. And it's pretty darn strong. We do this with the arm only abducted about 15 degrees so we don't over constrain it. And then from there, I'll tie the remnant of the supraspinatus right here to the biceps because that's as far as it would go is halfway across the rim. But I've actually taken power and restored it to the tuberosity via the biceps. And then I actually posteriorly was able to fix some infraspinatus. So we have this balance repair. And so we did a lot of these back probably starting about five, six years ago. So we looked up the first 40 and we did have significant decreases in pain and improvements in function, yet we never even covered the whole head. So obviously you don't have to have complete coverage of the humeral head to have good results. So now fast forward and the same thing. And this is a scar failure that I was talking about, but we've added one more piece to the puzzle that seems to help at least in the last couple of years here. So here's a scar failure where here's the supraspinatus and it's scarred to the acromion, not to the head where it belongs, double row repair. And so when you look inside, this is the suture bridge just sitting in the breeze. And then down below here is what we found when we went in. And so the cuff is right here and it's healed to the top and not to where it belongs. So we have to release it from that wrong attachment, so to say above, because we're going to try to put it back on the bottom where it belongs. So this is what it looks like when we freed up the tissue, we got to get rid of all that foreign material at some point but now we have a sleeve of tissue here that hopefully we can do something with. And this is what we did basically is that, he had a little bit of a biceps beat up and I just incorporated it, had a little supraspinatus we could work with and I incorporated that. So I got something in the front and then didn't look like initially much to work with in the back, but we kind of worked for a little bit and we actually found some. And so here's a remnant of the infraspinatus that we're bringing up here. And so we fixed that and we have now this balance repair. So basically we could stop there and these patients did pretty well. But there's this newer device, it's a little saline filled absorbable balloon that has the indication actually is to put it in when you have nothing else to do, but we found that it works quite well to prevent subacromial scarring and also prevents what do you call it, really pain in the first three to four months because it separates the healed, sorry, the healing cuff from rubbing against the acromion. So the acromion doesn't ebernate against it and it's impossible for it to scar the acromion. So we've done a lot of these in the last couple of years and we're following the results very carefully. So we've done about 110 and that's just my practice. I have a lot of weird cases, I guess. But this is what it looks like when you put it in. You put it in and you fill it with saline and it just keeps this surface from rubbing against that surface. And then it dissipates and it absorbs at about three to four months out. And just it's interesting because a lot of these people are revision. So they've been through this before. And so to hear their comparisons between their first operation and the second operation is really interesting. And I don't know if any of you have been taking care of some of these people, but they progress quite nicely at those early two to three month points. And then there's still the role of the SCR. And I did quite a few of these. And again, when I did them, I incorporated the biceps in situ and I tied the graft to that. And so for the young active person, usually under 50 or so, no arthritis, this still is a good viable option. So in summary, from our standpoint, we have to avoid treating the MRI report because there's a lot wrong on it. Anytime anybody has surgery on shoulder or knee. So if they have a meniscal resection at some point, they need to understand the MRI will never be read as normal the rest of their life. Because you get a repeat MRI, you get a repeat MRI of the shoulders, not normal. It's gonna be read as thin tissue, question re-tear, it looks okay, whatever. Because things heal with scar and then they kind of thicken up over time, but it's never normal. And then, I mean, that's probably as good as it gets right there. And then you wanna, but also as Mark said, look how the footprint reconstituted all the way to where it belongs in the tuberosity. It's a single row repair. And so tension is the enemy. So from a surgeon standpoint, we have to do our best not to overload these constructs. Soft tissue care is vital to the perioperative period and to make your job easier. Preserve the deltoid and hopefully we can come up with better and better ways to enhance healing. And also you just have to be a cheerleader. As you are every day, we only have to do it every six weeks when we see the patient. You come in and they've been dealing with this also. If it's a revision, they haven't been normal in a year or two. And so they come in and they've got 110 at two and a half months out or whatever. And I'm like, that's unbelievable. I mean, you had 60 for a year and a half. So it's gonna take a year to plateau. And so that's, you're doing great. You're on the way to recovery. And often that's all they need to hear. Anyway, thank you. All right. Great. Thanks. Thanks, Alan. I'm gonna ask a couple of similar questions, but salient points, I think, for our rehab specialists here. So one, how long are you in a sling for your standard rotator cuff repair? Single row, non-tensioned, perfect repair. So usually average is five weeks. During that period, I let them type and write immediately. If they're not crazy, everybody drives anyway. So I tell them just keep the elbow at their side and use their other arm. Mostly keep the hand down low. And then I start passive range of motion at two weeks. Usually I will have them go see therapy at two weeks. I mean, if they're doing great and they wanna go and they can do it on their own, great. But it just identifies some of the people that can't do it are the people that are stiff. And so then we'll go from there. And then after they come out, second month is active assisted. And then I don't really start strengthening till 10 to 12 weeks. All right, so here's the key thing. So you're seeing the patient if you do it one week. Most of us are seen by PAs and so on, right? Irene takes the stitches out. God love her. At six weeks is your first visit with the patient. They have 110 degrees of flexion. You're doing your cheerleading activities, okay? And the therapist is seeing them and now they're at 10 weeks and they're still at 110 degrees of flexion. At what point time are our rehab group hitting the panic button to talk to you? Like, when is it that you wanna hear from them? Hey, you know what? This is not progressing. We need to move to another. Is it time? Is it just the overall feeling? I mean, because we're not touching the shoulder as you indicated at six weeks and 12 weeks, but that 10 week mark, everybody's getting a little anxiety. The patient's like, I'm not sleeping at night. Things aren't going well. When's the panic button for you? Well, I don't really panic, but I would say it's three months and I'm gonna do a medial dose pack at that point. And what's your degree of acceptance for that now? Like 110 degrees, 120 degrees, 150 degrees? I think it takes three months to get your motion back. And as long as there's progression. Get your motion back to? Oh, I would say that, you know, if they're like 130 or so and they're a little stiff there, that's probably normal. I mean, there are some people that get it back, but you know, in Europe, if you're not stiff, you didn't heal. That's their belief. It's like, if you don't have an element of adhesive capsulitis, you didn't heal. And so, yeah, it's interesting. It is partly true that, you know, you lay more scar tissue down. The other thing that's very interesting is that those people that 10 weeks out that are stiff, and sometimes I don't even know this ahead of time, being an orthopod, you know, we don't do medical histories. And so they are the folks that can't take an anti-inflammatory. So they're either on a blood thinner, they have a GI issue, or they're allergic. And so, like I'll say, you know, have you been taking ibuprofen? Well, I can't. And it's very interesting how often that is the patient that is stiff. And so, you know, then the medevial dose packs, the first anti-inflammatory they take, and then a cortisone shot at four months. But I can't tell you how often that is, and it almost sets them apart, where the rest of us, you know, you just suck down Advil. And, you know, if it hurts, you take Advil. All right, great. Thank you, Alan. Appreciate it. President has to take phone calls, so we're gonna let him go. Thanks, Alan. Yeah. So, it looks like we don't have much time. We haven't been too fast. Should we just play Kevin's thing? Yeah, no, no. Yeah, we're gonna do Kevin's, and then Mike and Julie will hit the stage. Okay. Yeah, I think we'll be good. All right, okay. We're gonna have a bunch of blaze pods here for our 70-year-old. It's a pleasure to talk to you about rehabilitation following rotator cuff repair surgery. It's really an honor to speak at the Anna Sports Medicine Symposium. I hope I see you all next year. It's also a real honor and privilege to speak after Alan Curtis. Dr. Curtis has been a mentor to me. I've enjoyed his conference up in Boston for numerous years. I love listening to him as a presenter and also learn from him as a clinician as well. So Dr. Curtis, thanks so much for organizing this and I hope we can do it again next year. So rotator cuff repair rehab for us is one really bottom line, is one rehab program doesn't fit all patients. And the way that's dictated is through the physician. The physician's the captain of the team and the physician basically dictates the rate of recovery following a repair. So we'll talk about how that all works. So probably the most important parts of my presentation are right here, that all cuff tiers are not the same. Rehab has to match the patient variables. A team approach, surgeon, PT, patient, all have to be on the same page. And slower many, many times is better. We have precautions after surgery. So I'd like to talk about range of motion, strengthening, and return to activity. The variables that we need to know as rehabilitation specialists are size of the tear, location, meaning what tendons are involved and to what degree, tissue quality once it's repaired, tear pattern, which is maybe not that critical, the type of surgical technique, single row, double row, suture, bridge, and anything concomitant. And then right now, degenerative joint disease, spurs, AC joint problems, big factors. Also patient variables, smokers, insurance. Recent paper just came out of Rush, Dr. Verma and others on that paper found the risk factors for failure after rotator cuff surgery is type of insurance, workman's comp, higher rate, interesting to say the least. So the types of tears, not that we want to turn therapists into experts as far as tear patterns, but it's an interesting thing to note. And also the bigger the tear pattern, L-shapes and big crescents where there's a lot of retraction and the physician has to mobilize creates a big problem. Here's a gentleman which is unique. He's got bilateral massive rotator cuff tears. His right is worse than his left according to his physician and he also is encouraged to get a reverse total shoulder. He's actually my neighbor and I've rehabbed him for that right there, his quad tendon repair which he fell and by the way has a torn rotator cuff. This is another gentleman. He's 94 years old. Dr. Curtis, he still plays tennis. I know you're a tennis advocate. It's funny because he says to me, I play tennis but I don't play singles anymore, I just play doubles. And I'm like, great, I'm pleased that you can even play doubles. 94, still works, still drives, comes in, he can only come in certain times because of his work schedule. When we see someone post-op, obviously it's important for that physician to communicate what type of repair and many times, at least down here in Birmingham, we see people that get a biceps tenodesis. I don't want to say routinely but quite frequently. At our center, most of the repairs if not all are suture bridges but sometimes there's unique suturing or repair techniques as well. The other factor is, who are you rehabbing? Here's a gentleman here in his 70s, second rotator cuff repair. I'm going to be ultra-conservative with him. I mean, I don't even need to see him for a good four to six weeks. This gentleman tears his rotator cuff acutely, a traumatic injury, acute rotator cuff repair. I would say I need to see him right away because of his occupation. When this gentleman tore his rotator cuff, he does CrossFit and Agent Orange or whatever those workout places are called, wants to get back into it as fast as possible. I need to see him relatively soon, really to convey the precautions and saying, don't do this, what can you do and so forth. Not being super aggressive in his rehab but more patient education, which I think is critical. As I mentioned before, the rehab has to match the patient. What we have is three rotator cuff repair rehabilitation programs, type one, type two and type three. The physician, the surgeon who's doing the case dictates which protocol we follow at the time of surgery. Type ones are small tears. You're talking about a centimeter, one anchor perhaps put in, maybe two at best but probably one anchor, really good tissue. We use an abduction sling for four weeks and we expect you to get moving and get your arm up overhead at probably about eight weeks post-op. Type twos are medium to large tears, two to four centimeters, pretty decent tissue, sling for six weeks, maybe eight if they're on the large side and you're not going to raise your arm up for a double digit weeks, probably closer to 10, 12 weeks. Type threes, large to massive, four centimeters or greater, those are the ones we worry about the most. It's retracted, big mobilization by the physician and we don't expect you to raise your arm up overhead for about three months. Team approach, surgeon, patient, physical therapist, all on the same page. These are what we like to see at the end result, shoulders that can raise their arm up, no pain, happy, not stiff, and an intact rotator cuff. And you can see, I only see right shoulders by the way, oh there's a left shoulder, how did that happen? But I also see athletes and that's a different type of rehab. A thrower with a cuff repair, a quarterback with a cuff repair, pro wrestler, football player, that's a different rehabilitation program. A guy like this, a Bostonian, torn his rotator cuff a few years ago, he's not going to comply. We have to modify the rehab accordingly. Tissue healing constraints, why is slower better? Slower is better because it takes a long time for these tendons to heal. You're talking about generally older patients, which is a big factor for me, if you're older, if you have a bigger tear, if it's retracted, we're going to go slower in our rehab. For a good six to eight weeks, the strength is really subpar, as you can see here by the study by Dr. Scott Rodeo from HSS. So it doesn't really get much stronger until we get five, six months post-op where it may increase and that's why the surgeons often do some type of enhancement as far as trying to enhance the repair site. And again, I know Dr. Curtis has gotten into all that. Tensile strength, stiffness, you can see that first six to eight weeks, when people are getting rambunctious, it's not very strong. The difference between three months and six weeks is pretty significant, but it's still not that great. So it's really slow and at 12 weeks, it's only 25% the normal tendon strength. At 26 weeks, it's 85% the strength and even then I would question that based on the age and the general health of the patient. Many times these patients are smokers, which really results into horrible, horrible outcomes. I mentioned the study by out of rush looking at insurance factors. All these factor into the equation. Our rehab program protections are important. So I believe in a sling with a pillow, not a big pillow, but a 20 to 30 degree pillow. A study out of Japan pointed out that with the arm at about 30 degrees of abduction, there is no strain on your supraspinatus repair site for a medium sized tear. At 15 degrees of abduction and at zero degrees, strain goes up about two to three times greater than at 30 degrees. So we like that pillow. When I start people moving, we start people at about 30 to 45 degrees of abduction and it's easy motion. This guy is way far post-op. I really need to change that picture because it's misleading. He is not just starting out. I would never move a rotator cuff repair that far first week or two of range of motion. They're moving 10, 15 degrees at best. Somewhere around that six week time frame, we bring them up to 90 and start working IRER and then maybe later we'll bring it down to zero. Pillows are beneficial. When you're working on flexion, again a study out of Japan with a strain gauge in the repair site showed you're better off working passive range of motion in the scapular plane than in the sagittal plane. So stay away from cardinal plane flexion early on. The group out of LA, Dr. Elitrash and Dr. Park and Dr. Lee pointed out that even with external rotation, just the 30 degrees, you can cause enough stress on the repair site to cause gapping. So stay away from excessive external internal rotation. You can move a little bit, but it's all based on the tissue quality, size of the tear and so forth. Controlled stress can be good, but too much stress is bad. There is no passive range of motion. Let me say that again. There is no passive range of motion. CPM is not passive. The therapist moving the arm is not passive. At least it's somewhat closer than a patient doing pendulums and pulleys and things of that nature. Table slides are beneficial. Nice study by Huell, Tim Huell out of Kentucky showed low EMG if the table slide is done right. Dr. Burkhardt showed us that if we do table slides, we can decrease our rate of stiffness in patients by about 50%. Nice study in arthroscopy. Caution with long lever. When I get someone moving actively, I usually start them in sideline for arm elevation and I do it with a bent elbow. I hate this here where a person is trying to raise their arm against gravity and they have this big shrug. If you have a shrug, I'm not having you do it. No working through shrugs, we work around shrugs. Range of assisted motion is difficult, so there has to be speed limits in your range of motion progression. As I mentioned, here's a gentleman four weeks after a pretty small borderline medium tear and that's as high as he goes. The big question I ask him is, does it hurt? But more importantly, do you have any residual soreness afterwards? Here's a gentleman eight weeks after his rotator cuff repair, about 80, 85 degrees of ER, solid end point. We do work on scapular muscles, really important. This is using some biofeedback on low trap as well as upper trapezius muscles. We do a lot of rhythmic stabilization, trying to capture that humeral head at the appropriate time frame. These are light force, easy exercises, completely pain free at the time of doing them, but equally as important, they have no residual soreness later. We want a good outcome two years, three years, five years later, ten years later. As I mentioned, Dr. Burkhardt showed that by doing some easy exercises, a table slide, you can reduce your rate of post-op stiffness and that was published in 2011. What about some studies looking at motion? This is a systematic review and meta-analysis by Dr. Les Besson from Buffalo and what they basically did is show that passive range of motion had no significant difference in re-tear rate between early versus delayed passive range of motion, but we have to question what is early and how much motion were they moving? Size of the tear may influence re-tear rate, so when in doubt, don't move or don't move much. Another study by our friends at Rush said basically the same thing. What about active motion associated with risk of re-tear or structural defect? There is a correlation. There is a correlation between early active motion and rotator cuff healing and failure. Last couple of points, we try to work on balance of muscle forces. We've done some research in this particular area looking at the amount of force generated by the external rotators and the anterior rotators, so the external rotators and the internal rotators. We want that ratio to be 52% or better. If your ER is generating 52% or more of your internal rotation torque, you'll be able to raise your arm without a shrug. We do a lot of what we call rhythmic stabilization exercises. We try to use the deltoid as a compressor. These are some force vector data points from the Mayo Clinic, Dr. Ahn, a biomechanist there. We bring the arm up 100 degrees of flexion, and we ask the person to hold that static position, and we do a rhythmic stabilization. We don't work into a shrug, so if they have a shrug up there, we try to find an angle where the shrug is not occurring. From there, we'll go into the side lung, as I mentioned before. Really slow in muscle return. Sometimes we may use muscle stimulation, especially if we think there's something going on with the suprascapular nerve. Don't forget the scapular muscles. They can do this in a sling. We can do it out of the sling with a pillow or a towel roll underneath their arm. Very slow with muscle training. I couldn't say that enough. The last point is the pool is a great medium to do exercises in. We like aquatic rehab. We wait for the incisions to close. I don't just rely on tachyderm patches and the patient putting it on their own shoulder. I'm a little bit cautious, but I think the pool can be a great medium for a rotator cuff repair patient. The key to success is a gradual return to function. Sometimes slower is better. Depends on the functional demands. Depends on who they are. Overhead athlete might have to go a little quicker, and not quicker day one, but quicker at the appropriate time frame. Slower with your general ortho patient, especially the older, especially the big retracted tears, the tissue that's not great. By all means, a team approach, again, is so important to successful outcomes. Thank you very much for your kind attention. I know you're going to enjoy the rest of the program. I wish I were there. I apologize. Again, Dr. Curtis, thank you so much for the kind invitation. You're awesome. I hope to see you real soon. Take care, everybody, and good luck. It's really a wonderful thing to have Kevin speak. He's really been a mentor to all of us. I think we just need to send him a quick thing saying, do people fix rotator cuffs above the age of 60 in Alabama? Because I didn't see one person that was above 60 there. We have listened to four hours of didactic lectures. I'm not going to put up any more slides. It's time to get into a Socriatic discussion. I want to hear from you guys, points that you want to hear. I have a fantastic panel up here, Julie and Mike have given up their time or sacrificed themselves to be up here. We have out here Mike, who talked about the rehab throwing shoulder. We have JT for instability, and Alan Curtis. We have some experts that you've listened to. If nobody has any dying questions, which I'm going to ask, then what will happen is I unfortunately will ask questions, which tends to increase the squirm factor in the room. Does anybody have any questions at all, all things shoulder? Go ahead, Kevin. or effect repairs in a negative fashion, healing-wise. So I'm just curious, what is all of your take on the use of anti-inflammatories? And are you talking about all surgery, Kev, or are you just talking about a specific rotator cuff world? I mean, since we are talking mostly rotator cuff, we can just stay in that world. I mean, my world is rotator cuffs from 20s to 80s. We do see athletes, but not professional athletes. But we're dealing with those people that sometimes have significant past medical history that lead them to have pain still. You know, they're in that four, six, eight weeks, they're still having some discomfort with various activities. What's their next step? Okay, so let's do that. I'll pose a question. JT, you've got a young athlete has had a bony allograft transfer to his glenoid for bone loss. We're struggling mightily in therapy with an external rotation of about 20 to 25 degrees. How far out? He's eight weeks out, and his forward flexion is about 110. So it's sort of at that point where we're feeling okay with it still, but yet, you know, he's having difficulty sleeping at night. You know, where are you going with your pain management to help out the therapists in terms of getting over that instability point? Yeah, I mean, eight weeks is starting to get a little concerning. Fortunately, I have Julie in my life, and so that almost never happens with it. The nice thing about eight weeks is that I'm pretty comfortable that the bone is, you know, it's not finished remodeling, certainly, but it's probably healed, and so she can push it at that point. If we're, you know, I'm patient with those things because a 25-year-old almost never doesn't get their motion back, right? I think that they get it back pretty well. I often think that external rotation passively, if they'll get that back, then they almost always will get their forward elevation back too. So if it is a major problem, then we just talk to them about getting a little bit more aggressive and all the things that you guys know from, you know, from heating it up and ice training and some of those modalities I think really work. A lot of deep tissue kind of work in their active release I think can be very helpful too. So I think I don't get too worried. I have, maybe on two occasions in my life, taken a patient back after instability surgery and released them. I don't like to do it because now we're back to square one potentially, and they can re-dislocate. But this person's miserable, like can't sleep at night, is unable to focus at school, just is not doing, he needs, or she needs something else. Because of pain, pain issues kind of stuff, yeah. Yeah, I think eight weeks out after something like that, you could consider a steroid injection inter-articulately if you think it's coming from that place. I'm not a huge lover of that, but if we're more than six weeks out, we're okay. As far as the anti-inflammatory issue, you know, for a while that was all, Scott Rodeo got us because he released that paper showing that the MMPs and, you know, metalloproteinases would kick up, and that if you took the anti-inflammatory, that that would inhibit healing of the cuff with higher retail rates. Other studies have now shown that that is not the case. And so most would say, you know, sort of down the middle of the fairway, anti-inflammatories are fine. I'm still nervous about them, so we don't use them as a routine part of our thing, unless, if I'm asking for something to heal, because why, you know, why take the chance? But if they come back at two weeks and they're miserable or three weeks and we're struggling, then we'll definitely put them on one. All right, so Mike, you've taken an overhead-throwing athlete and you've, you know, it's their 14th opinion, they have a posterior superior labral tear, definitely has impingement, the therapists are tired of looking at them. You know, they're in your office, you do a posterior superior slap repair on this overhead-throwing athlete, and we're at eight weeks, same scenario. Very common after slap repairs to have some tightness and some difficulties. Using anti-inflamms, what are you doing to consult that patient? Yeah, and I agree with JT that in the first four weeks, I try and stay away from anti-inflammatories. At four weeks, I'll start them, and I usually do something long-acting like Celebrex or Mobic. If at eight weeks, similar to what JT said, I think the labrum should be healed, so they should have a ton of inflammation. So I would start at eight weeks with like a five-day course of Tordol, so put them on a strong anti-inflammatory, get them on some topical stuff, continue heat, ice, try and get them in a pool to do some gentle stretching. So I would try and do multimodal stuff with a strong anti-inflammatory, topical anti-inflammatories, heat, ice, try the pool, stuff like that. Maybe I'll even put them on a Valium at bedtime so they can maybe get some sleep, because if they can't sleep, they're super miserable. I try and hold off on a cortisone shot until about 12 weeks. And there's some data that at six weeks, it's safe. Like JT said, we know at 12 weeks, it's safe with no increased retear rates. That's more rotator cuff than labrum. Yeah, you know, it's interesting, no hearingness of Medrol DosePak. So, Alan, that's sort of your go-to. Well, just at three months, I try Medrol DosePak before I get shot. Yeah, and any thought process of Toradol versus Medrol versus everything all? You know, Medrol's well-tolerated and it works well. I tell them it's a cortisone shot to the body. It's gonna make them feel good all over. All right, so Mike and Julie, you guys have enough experience that even though we all say, JT says, I've only had two people ever be stiff in all my surgeries, okay? You know, you're actually seeing these people. What are you saying? How are you talking to the patient to get them over that psychological hurdle? You know, this is just miserable in my life right now. Yeah, I think you gotta have that conversation where it's like, are they doing too much? Are they doing too little? Like, what are they doing during the day? Are they out of the sling? Are they letting their arm hang? So you gotta really get a big picture of what that person's doing. And then you also, it's just a lot of education and talking to them about, you know, this is the goal of the surgery. This is where we are at. This is what I would typically expect to see. We're a little ahead. Maybe we're a little behind the curve. You know, what do we think our barriers are? If it's pain, I really do try and manage their pain. At least heat them up, soft tissue, do some scap work. And usually for the instabilities, they'll come around. The cuffs are a little bit different. Okay, you know, Mike, I can't fix one of these athletes while they're coming in looking like they have 51,000 cups everywhere. And I know it's more than what you guys are doing because the placement of some of this cupping stuff is all over the place. You know, where are you with cups? And you know, one thing I didn't see in any of the talks was, you know, BFR and things like that. So any new modalities that you have for these people going home, managing their pain? That's a big question. I like it. I mean, we use a lot of different tools, right? A cup is an instrument-assisted tool, just like a Grosten tool or a knockoff or a spoon, right? I mean, there's so many things you can use. What we do with our manual therapy techniques with tools is we do try to hit it from a bunch of different avenues. So we'll use our hands, we'll use our tools, and we actually use cups too, but we don't leave them there for the petechiae. We don't need to cause a bruise. But if you really look at the different nerve fibers that you have, right, they're all susceptible to different sensations, right? Deep pressure, light pressure, friction, you know, traction, right? So the more we can neuromodulate and bombard the body, the more we get. So we put them all together and get a great outcome. BFR, we use all the time in the lower extremity. Not a big fan in the upper extremity. With my overhead athletes, I think it's contraindicated. We don't use it just because brachial plexus, neurovascular structures, I think are a huge problem in overhead athletes that are underdiagnosed. With the legs, we use it all the time. But, you know, with the arm, we don't, you know, the proximal effects, like on the cuff and scap, just aren't really there. I don't know if I think the research is there just yet. And I don't have trouble getting forearm strong, so I don't use it as much in the upper extremity. For me, it's more lower extremity. But the systemic effect is great. So I'll take that back. In my post-op Tommy Johns, they use BFR in their legs week two. Yep. Right. Okay, you know, Mike, we had a great discussion about the throwing overhead, oh, by the way, any other questions, instability? Go ahead, go. It was, thanks everybody for their comments. And just a question, for the patients, you were just talking about the younger athletes and anti-inflammatories, because the aging athlete is coming, is still, you know, people are really wanting to continue to play higher level sports over the age of, say, 60. How would you handle, I know, I know, you can't say they can't play either. I'm there, sis. But how would you handle the anti-inflammatory scenario, the same kind of scenarios you were just talking about, the younger overhead athlete? I'm on an anti-inflammatory omelet every day just to walk around. So, you know, I think as long as you're working with your general medical doctor, I don't have an issue with it at all. It's, you know, we as orthopedic surgeons and therapists, you know, don't do a good job of understanding what the effects of anti-inflammatories with liver as people getting older. You know, it's funny when you listen to Alan's talk, you know, blood thinners become very important in that 60 to 70-year-old group because stroke risk and many other things that have happened in their lives. You can't just willy-nilly start giving anti-inflammants while they're on the blood thinners. So, you know, I think having an understanding from their primary care doctor and the orthopedic surgeon has a significant effect as to what you're gonna do with those people. Again, I will tell you that the MedDRAW dose pack is sort of the, is the one with which escapes a lot of purview. You know, you ask a primary care doctor, hey, can I give somebody a Sunday course of, and I'm not a MedDRAW dose guy, I'm a prednisone guy, so I like to go, you know, 30, 25. I don't like, the MedDRAW dose pack is made for poison ivy people. It really is not all that strong. So, you know, if you coordinate that with that, I think you can be very successful with your management of pain and anti-inflammatory with those agents. That's what I've gone to also. People that have heart disease or blood thinners and they're not supposed to take NSAIDs, I'll go straight to prednisone and have them clear it with their doc first, but just do, we'll do five or 10 milligrams a day for 10 days and then maybe taper it from there. And the killer thing is they'll come back and say, I've never felt this good in my life, you know, I can't see. Their whole body. Yeah. Can I have another one of those? So, how often can you do that? A lot of people have recurring pain, a lot of issues, like how often will you do this prednisone course and just asking for a friend. Just asking for a friend. Until they stop calling at all. Yeah. If I do it for a prolonged course, like a 30 day course, then I'll make them take a three month holiday before doing it again. I'm usually a 10 day person. I'll tell you 80% of the people get better after 10 days on a Meddrel steroid taper, but a real one, not a, you know, Meddrel Dose Pack is sort of the generic wimpy thing. Any other questions? Yep, go ahead. Please, this is good, right? This is what we want. I had a question about strength. So, I know in the lower extremity, they're looking at body weight ratios for strength testing. I wondered if you're looking at extra rotation and if you're checking that down by the side or looking at that for like the IR ratio as well, which brings me to another point, too. Follow up question on, do you put a lot of emphasis on 75% ER to IR, or is there such a thing as too high? Like if someone's 95%, is that actually meaning something else is going else? This is great. We actually just had a conversation like this in between the sessions here. So, we do do that. So, the first thing I'll start with, if you're not using a handheld dynamometer, you're guessing, right? So, that's the first thing. We did an internal study with the Red Sox that we never published, that you have to have about a 15% deficit in rotator cuff strength to get a four out of five on a manual muscle test. So, 13%, 12%, you're missing it on exam, and that's not satisfactory to me. So, yes, we do that. Body weight ratios are important, right? Because me versus a professional athlete, not a fair fight, right? So, we have to have two different things. The numbers are different. I think 16% body weight is my minimum for external rotation that I'd like. I'd rather be 18 to 20. That's pretty big. So, a 200-pound guy in the 40s is kind of what I'm looking for. That's what an all-star looks like. Your numbers in ERIR, I'd say, are a little bit off, but I'd like IR to be stronger, and that might be why. So, I'm usually about 70% ERIR, so 35, 50, give or take, just like making up numbers for you, just as those ratios, but I think to answer your question is, yes, and that's next level. You now become a therapist that are gonna have very good outcomes with your people because you're nitpicking that minutia. That's how you get people over the hump. So, Mike, what degree do in your external rotations? Zero degrees. So, I've tested everything. We used to do 90. I didn't have any, we didn't find any weakness at 90 that we wouldn't have found at zero, and zero is just so much easier to replicate. Handheld dynamometry is almost as much art as it is science. You could really do it poorly and have bad data. So, get a dynamometer, and for the first six months, take it all with a grain of salt as you're getting practice with it, right, because you have to make sure everything's stabilized and things are going well with that. So, zero degrees, nice and easy. It's a huge bang for your buck. Same with IR. 90 degrees, there's so much stabilization going on, so much compensating, so much cheating. It's just hard. I've been doing, we just do zero now. We don't even do 90. I mean, I think it's another thing, too. We have a handheld dynamometer, and we also, we had to force frame for a while, but that takes forever to actually use. But, you know, also looking at timing of when you're gonna do, start doing your testing. I was just looking at a study, because the latter day came up, and we don't really see that much where I'm at, and so I was just trying to look and see what was out there. But when they did the, I mean, most of the stuff, like when you say back to sport, right, it's range of motion and strength or time. So, when you look at the studies and you look at strength, most of them are still saying five out of five, four out of five, and I think that's on us to make sure that we are helping in that area, that we can give valid numbers, and we can use the handheld dynamometer. And I agree, too. Like, it definitely, like, I do it in sitting. I still do it at 90-90 for certain things, but I'll do it supine with things. But it does take some practice with it and stabilizing, so they're not using their body, or you'll get these weird numbers, and you're like, yeah, I probably didn't set it up right. But it's pretty cheap. We have the vault one. I'm not a vault rep, but you can get it on your phone. You can show it to them right away, and it's objective data. People like, it's a data society, so people like that data. But, you know, if I have a stability surgery, I'm always like, hmm, when should I start testing with the dynamometer versus what I feel comfortable with my hand, and on a rotator cuff, I'm gonna wait even longer. You know, I'm not gonna test my cuff, especially if it's a medium or large at three months. Do I even need to do that? But I do think we need to kind of get some, it's a very objective way to get data, but then we also have to figure out when it's the safest way to do it post-surgery. Yeah, and, you know, as we're moving along, what you're hearing is sort of an outpatient setting. You know, where we are with the Red Sox, I work with them, you know, we're doing force plate stuff now. So I think that as these force plate things start getting smaller and more, I think that some of this stuff will get into therapy clinics in terms of being able to measure your external rotation. But for now, get very good with the dynamometer and your external rotation strengths. Mike, you've done yours in supine or seated? Seated, it's just so much easier to replicate. But, you know, I mean, there's always like, you know, to Julie's point, there's always somebody that might benefit from a different position, maybe a wrestler or something like that. You wanna test them in a different position, like for sure. But our standard battery is ERIR zero, scaption, abduction, it gives me so much information from there. And I would just add, symmetry index and being symmetrical, especially in an asymmetrical athlete, which is oftentimes what we're dealing with, is not the right thing to be looking at. Because their left stinks, right? Or excuse me, their non-throwing side stinks, right? So there, you wanna have that difference. So IR, we wanna have about five to 10% stronger on the other side. I'd like it for ER, nobody is until they're done with me. But at the beginning, they usually come in five, 10% weaker and we want them five to 10% higher. So a quick question for the two of you. Absolutely, Mike, agree with the GERD thing. Of course, we grew up together with that. And the fact that if you're going to challenge somebody that they have GERD, you have to recognize that you just can't, you don't know what their baseline is. You're just evaluating them saying you've got GERD. Well, that may be where they've lived their entire existence and changing that may totally change their overhead throwing mechanics. So you don't wanna be that person that changes that. However, the one thing I didn't hear and I want your opinions on is the pectoralis minor tendon and where you guys think that that is affecting the overhead throwing athlete in today's med ball strengthening and analytics. So go, Jules. Well, I think the pec minor gets pretty dang tight. So, and then you have an unstable athlete. So you're trying to figure out how to get to release that pec without stressing the anterior capsule. So I probably do more soft tissue work with the pec minor really trying to make sure that it's not. And it really starts to take over for things, especially, I think even in like a chronic instability person who hasn't undergone surgery, they're using their pec for everything. I mean, people figure out really fast how not to make their shoulder unstable, they move different and that pec major and minor just get on fire. So for me, it's more soft tissue. Yeah, I agree 100% and I see TOS in the clinic almost daily if you work with baseball players, I think you see it daily or just sometimes don't realize it, but there's this like transient neurogenic and neurovascular, even you could call it like that happens from throwing a baseball, right? You come off the mound, your EMG and your blood pressure is different, right? So things change just from like one session. So back to the pec minor now, if you look at the biomechanics of some of the things that the kids are doing, so let's talk weighted balls, for example. When you throw with a weighted ball, it changes your kinematics, right? So it changes kinetics too, to a certain extent, but it changes your kinematics. And they actually have less layback, right? So if you have less layback, what are you doing with these weighted balls? You're doing this like push, right? And what happens is I think what they're doing is they're training with it so much that they've become very anterior dominant, that pec minor comes in, subclavius. There's a lot that happens to these people because these weighted balls like require you to almost throw more anterior dominant than getting that layback. So, huge, huge topic with weighted balls with what we're dealing with kids, that there's so many layers to this onion that we're still unraveling that it's different every day. Questions about rotator cuff? We still have Dr. Curtis here. Any questions at all? Everybody, oh, there we go. Lay it on us. I hate to steal the mic the whole time here, but when you do strength test interrotation, do you cue it in a certain way? Like, for instance, I found if I coach them to retract and then interrotate, they feel their scapula tensing up versus uncued. They sometimes, it's to me, pec dominant interrotation versus subscapular. Just wonder if you cue it in a certain way. Yeah, absolutely. So we have very specific cues that we do all the time. So feel free to grab me in the hallway. We can talk a little bit more, but like, yes, right? So we use a towel roll, we squeeze a towel roll. We have to make sure that we're not compensating. And it's all about motivation too. So we studied this actually, Brad Pearson versus Mike Reinold. My guys were 7% stronger than Brad's because Brad's a quiet guy, a little monotone, right? And he'd say, push, push, push, push. And we'd yell at him, we'd punch him. We'd say, let's go. Is that all you got? Push, push, push, right? And we'd get different numbers. So you have to have motivation. You have to have the same cue. So we have the same positioning, the same phrases, the same cueing, the same ramp up. You have to be precise. And again, it goes back to the art of dynamometry to make sure that you're not getting bad numbers. Same, I usually tell them to sit tall. I don't want them hyper retracting or anything like that. But it's like, same thing, right? Your feet on the ground, I put them on the corner of the table. Like, you're trying to do the same thing every time. And then I'll manually do it on them because I feel like I can tell whether they're pulling their pack or they're actually doing internal rotation before I put the dynamometer on them. So I feel like I have a better feel of what they're doing. So if they are, then I can cue them. And then I'll do two to three trials, 50, 75%, 90%. And then I'll go into the test and I probably don't yell as much as you, but I am loud. We yell. We yell, yeah. All right, last question. Last question, rotator cuff repairs. You know, a lot of them are going in already with poor scapular mechanics. We, as surgeons, fix the rotator cuff. But they've still been lagging for eight months with poor scapular mechanics. When's your go-to time to stimulate that scapula? What do you do as a therapy tool in that eight to 12-week period of time where everybody's saying, okay, well, Kevin says there's no such thing as passive motion, but we are going to begin active motion. How do you cue in that scapula when you're doing that? Mike or Julie, go. Well, I'm a big short-lever person, and I'm a big, like, different positions of gravity, so if I think if they've got a shrug or they've got anything that's icy, any superior migration, they don't get gravity privileges. So I'll put them on the table. I'll make sure, and they don't have stiffness, because a lot of times it might be scapula mechanics beforehand, but then afterwards they're stiff, and so then they also, you know, have crappy mechanics. So I'll do a lot in sideline. You know, I start that pretty early, because you can get them pretty early in those range times, and you can kind of see what they're doing with their scapula, and then that way when you get to that point where you do start moving them, you can tell, is it the stiffness that's limiting them? Is it just neuromuscular control? And then that helps guide my transition, and they have to, like, get privileges to get on the pulleys, because there's nothing. It just drives me crazy. Like, you know, they start pulling, and you're like, okay, we're going back to the table. Yeah. I like that gravity privilege. I'm gonna use that. I like that. Actually, that's a great phrase. That's a great phrase. You haven't earned the right to bear gravity. I would agree. I would just say, like, it's, remember, this person's been in pain for a long time, and they're in significant pain now. The body takes the path of least resistance, and it's not the most biomechanically efficient. It's probably the most energy efficient, which sometimes isn't biomechanically advantageous, right? So what I want you to think about is, just in their life, they're trying to reach the sink. They're trying to do things. They're gonna take the path of least resistance. So a lot of what we do in early rehab is actually just, like, teaching them, again, the movement patterns, how to use the scapula and the humerus together to bring them back. And I think just that's, it's the cuing, it's the educational part. It's not just sending them in the corner to do their exercises in the clinic without you. It's about actually talking about the quality of it, too, and not just the quantity. Perfect. Any last questions? I know we're a little bit older, but this is, like, a great time. Yeah. Dr. Kibler, what's up? Speaking of scapula dyskinesia. Yeah. Just to reiterate that point, and I've forever worked on these patients, I used to always work on strength. It's all about cuing and activation and getting that going. You can pull all day long, and they'll be pulling their own way. Pull down, they'll do this. It's got to be activation. It's got to be cuing. Even in the post-operative thing, they didn't have cuing. They were bad to start off with. The pain is such a disorganizational activation thing for proprioception. So you've got to get proprioception. So don't try to pull stuff, but put them in the right position, side-lying, table. I like standing because now you're facilitating from your hip and trunk all the way up. But it's all about cuing. And some of the most frustrated patients are the ones that you try to put on strength. You don't have enough strength. No, they just don't have the activation. And it's all cuing. Great. All right. Any other questions? Well, listen, thank you very much. Again, great job, everybody. Great discussions. And everybody from the panel will be around if you have any further questions. Again, we have some expert orthopedic surgeons here also that may be able to help. So unbelievably, if you like scapula dyskinesis, it's the first talk in the afternoon, and Ben's giving it. So about one o'clock for that. I mean, downside to this place is the food is a track. So you're going to get your steps in. But back at one, there's a few good shoulder talks and some really good knee talks, and the opportunity to ask a lot of questions again. And there'll be beer and wine provided to loosen up everybody's tongues at that point. So all right, we'll see you in a little while. Well, he had another meeting. So hopefully everybody's gotten some food, but hopefully you won't go to sleep here. So thank you for all coming. And this morning's session is very good. And I just want to talk a little bit about the scapula, my favorite bone in the body, as you all know. And I do make a plea for calling this dyskinesis, because that's what it is, an alteration of motion. Dyskinesia is a neurologic problem. And so there's two different things. And I'm a purist about that. So let's talk a little bit about diagnosis and treatment. Once again, in the throwing shoulder, let's talk about the kinesis versus dyskinesis and what the evaluation pathway can look like. And then maybe it's a few guidelines for treatment. So we've talked about scapular dyskinesis for a long time. I think it's a very important finding that we're talking about the throwing shoulder here, but in any shoulder. And so you'll see on the left, you've got kinesis, which allows retraction for a term, and dyskinesis, which is an alteration of motion. And you can see very definitely that there's an alteration in the motion. And the reason this is important, because it affects the two things that the scapula has to do with our motion. The first is that it has to work in what's called the shoulder girdle mechanism, where the scapula and the clavicle, which are linked together as what we call the claviscapula, the three-dimensional motions, constrained motions, around the SC and the AC and thoracoscapular joints, to place the arm and the scapula in a position to do the work. So you've got to get the arm up here. And then the way you get the arm up there is to have it delivered by, because you don't have something on the end of it pulling it, so you've got to deliver the arm into this position, this 3D position right here. So it has to deliver it to perform whatever task it is. The second thing is that once it gets there, then it has to follow the arm as the arm does its thing. So there's this position and this motion. Now, you know this for a fact, what's the worst problem to be unable to raise your arm? It's a serratus anterior palsy. Every other muscle, every other joint in your body is normal. You can't raise your arm higher than this, because the serratus will not deliver the arm to the position to let you do it. You can do stuff down here all day long. You just can't do stuff overhead. So it has to deliver the arm in the position, then has to move with the arm to maintain the dynamic glenohumeral stability. So there's talk about golf ball on a tee. Well, we're here about function, and so we really want to talk about the ball on a sea lion's nose. Can you hit that and play that? So in other words, to maintain that stability, the humeral head is the green, and the glenoid's the nose, and the body of the scapula is the sea lion. It's got to move to maintain that stability. So altered kinematics, whether it's unilateral or compared side to side, either you measure it or you observe it, this is called dyskinesis. It's alteration in these roles. Now, it's not a diagnosis. It's only an impairment of this mechanical function. That's all there is to it. Now, it can be incidental, where you just see it, whatever, no big deal. Adaptive, sometimes like the throwers, got a little bit of adaptive anterior tilt. That helps them throw. They got to do a little bit more posterior rotation because they've got to get their arm back this way. But mainly, we can see disruptive, where it alters the forces. And we see this very commonly as a prodrome to injury. And I think you need to watch this to make sure. And of course, then there's pathology, which is really associated with symptoms. It's creating a problem. Most of the time, it's the result of the problem, but it then exacerbates the problem, the functional problems you have. So we decided, well, if we can understand this a little bit, let's talk about this disruptive pathological situation. And can we evaluate the scapula? So we looked at, first of all, is it present? Second, how does this affect the clinical presentation? And third, what are the causative factors for this alteration in motion, which is what we call dyskinesis? So we start off with the presence or absence. And you say, it's either there or it's not. So we originally classified this into type 1, type 2, type 3. Type 1 is inframedial border prominence. Type 2 is the entire medial border. Type 3 is a shrug with upward rotation. It turns out that very rarely is this a pure thing. It's usually a mix of these. But there are specific muscle activations, inactivations that are associated with this. Most prominently, type 1 is the low trap. The serratus is just not working at all. Type 2, it's a low trap rhomboid as well as serratus. Type 3 is a lot of tightness. And the levator is very commonly involved in this. Upper trap is very commonly involved. So we use what's called the scapular dyskinesis test to really see about the presence or absence. It's the go-to test. You ought to do this test. It's easy to do to say, is it there or is it not there? That's all you can say. You do dynamic motion, three to five motions in about 30 degrees forward flexion. That puts the most tensile load strain on the scapular stabilizing muscles. And you start seeing the loss of this control as a prominence of the medial scapular border. You say yes or no. We eventually got down to we collapsed those three types into one. Just is it there? Is it prominent or is it not? Turns out, I'll show you in a minute, it's pretty good as a screening. So modifications, you add 10 repetitions to make it a little bit more tired. It's amazing how weak those muscles are. After about three to five reps, that scapula starts sticking out. These muscles are really, really weak in a symptomatic individual. So yes, no. It turns out it has specificity of 0.64, sensitivity of 0.82, compared to mechanical testing with bone pins. So therefore, if you see it, it's there and you can count on it. Now, we can also measure it quantitatively. This is a thing called show motion. I was one of the help to develop it. And you see that you have the three different motions, anterior posterior tilt, internal external rotation, up or down rotation. And you see that in this individual who has throwing pain overhead, that as the arm gets up toward 90 degrees, you see that on the injured side, you get an anterior tilt of the acromion and you get internal rotation. So the thing's going this way compared to the other side. And so this is a quantification of our visual capability of seeing that. So if it's there, go to the next step. Can you do something to alter the symptoms? How does this affect the symptoms? So we have two go-to tests here. One's the scapular assistance test, where you assist scapular upper rotation and posterior tilt. And a positive test is relief of symptoms, increasing range of motion, and better capabilities. So can you hit that one too there for me? Not this one, that one right there. Yeah. You see, so you have them go overhead and they'll, I'm sorry, go back. That's scapular attraction test. We want to go this one right here. Yeah. Scapular assistance test, you have them move and they'll get an impingement, decreased range of motion and forward flexion. So you stay, it's really assistance. You don't push on them hard. It's inferior medial border. Just help it go up. You'll see it goes up higher, symptoms are less. And they say, what'd you do? I'm feeling better. That's the way it's supposed to feel. So they know, they can't see this, but you did something that helped them and their symptoms. So it tells you that indeed some of this motion impairment, some of this impingement is due to the scapula itself. Then we do what's called scapular attraction test. That's where we manually stabilize the scapula in a position of retraction. Positive test there is you improve the demonstrated strength that you have in forward flexion or external rotation as well. And then if you're looking for a labral injury and have a dynamic labral shear test that's positive, by moving the glenoid back, you've changed those symptoms as well. So hit that button there for me, if you don't mind. So you give them a little test of the strength. It's hurt, it's painful and it's weak. So you can pull the scapula back. Your forearm fits very nicely over the medial border of the scapula. Test them again, they're strong and they don't have pain. So once again, this helps you understand, helps them understand and also helps them, oh, if I got to do something to my shoulder blade back there, then I feel better. So that will help. So then if that's positive, then you have to go and this is the grouping of all the factors that can create scapular dyskinesis. Now it's a whole bunch, yeah. But it's a pretty straightforward algorithm of how to evaluate it. You've got some serratus anterior weakness and insufficiency. You've got hip and core weakness. Fifty percent of the patients will have hip and core weakness. All your shoulder muscle tests that you normally would do to look for these things. Muscle tightness, pectoralis minor, lat, very, very commonly involved. This thing of loss of conscious control that we were talking about just before the last session, this is a real thing. Inhibition of that activation occurs about six weeks after pain starts. It's very, very common and you've got to treat it. And then there's an anatomic thing called scapular muscle detachment, which is a traumatic injury. It's very rare, but it does occur. Then you've got your fractures. The fracture of the clavicle or the AC joint injury shortens, you know, messes up the strut in the front, which then allows the scapula to be prominent posteriorly. You can use that as an identifier of the mechanical problems of the fracture or the AC separation as well. And then look at the AC joints, SC joints. Look for instability. Labral injuries very commonly create muscle inhibition, which causes scapular dyskinesis. Sometimes treating the dyskinesis will eliminate the labral symptoms. Sometimes it won't, and therefore you have to fix it. And if you fix the labrum, then the muscles start working better. And then you've got all the neurological problems, all the long thoracic nerve and everything. So there's progression. We start with hip and core. Then we have them do one leg stability. We look at the scapular muscle detachment about palpation along the medial border. We do all your muscle testing. You look for all the tightness just about palpation. There's a test where you can put your hand on the wall in this position right here, have them try to retract their scapula back. A lot, if they have loss of voluntary control, they cannot pull the scapula back into retraction. You do it on the uninjured side first. Do this right, and they'll do, am I doing it? They do not have any clue how they, whether they're getting their scapula back or not. That tells you right there that that's where you have to start with your cueing and your activation. Then your joint exam, look at fractures, and then do your neurologic exam. Whole thing takes, if you're doing well, it takes about 10 minutes to do this whole screening exam. So when we did that, we looked at a whole bunch of patients with scapulodiskinesis. We found that the pathoanatomical factors, the labral injury, fractures, one third of the cases. However, the causative factors that are pathophysiology, muscle weakness, muscle imbalance, tightness, things like that, two thirds of those patients. So you guys need to fix all those, but you need to understand that some of the third need surgery or need anatomic restoration, and the other two thirds are all really getting into the physical therapy component. So what are you going to do? These are the strategies we use. First of all, you've got to optimize scapular border control in retraction, which means you've got to have core stability, integrated core scapula. So we start everything standing. We have the core hip extension, scapular retraction as a unit. That's how the body works. As I mentioned this morning, first muscle that works in the body when you raise your arm is the gastroc on the opposite side. You get a facilitation up the glute and then over to the other side straight through. So once again, kind of reimagine the actual way that the body works. Second, get your glenohumeral range of motion. It's very commonly tight and it's just going to wind up the scapula and make it tight. So internal experimentation, very important, lat, very important to loosen that up. And then eccentrics, that's the way the body works, eccentrics, scapular muscle control. You've really got eccentric control. And then finally, you get into strength and endurance. That's the last thing. Then this voluntary control, very common, where it's altered muscle activation. It shows as decreased force production. Therefore, you think it's a weakness, but it's not. The muscle itself is okay. It's just not activated. It's not driven. And it happens between four and eight weeks of the onset of symptoms. And it's a lot of times the reason for your failure of your PT. You do this all day long to try to get your serratus working, but because it has no idea how to work, they'll do one of these numbers or, you know, whatever. And so you stand them up, get them closed chain, get them right here, and cue them to do that. I'll show you. So we always have a rehab approach first. If you have a positive scapular dyskinesis test and corrective, positive corrective maneuvers, but no negative signs of pathoanatomy, such as labral tear or AC separation, rehabilitation is by far the number one thing to do. If you have a positive scapular dyskinesis test and corrective maneuvers and signs of pathoanatomy, you still try rehabilitation, because a lot of times you can get the scapula to lay back down and kind of get everything in a better position. And about half the labral tears will get better. We just talked a minute ago, a lot of AC separations can get better with this approach, but you try it first for four to eight weeks. Our studies on throwers, if they're not better in six weeks, then that means they need surgery. And remember that if they need surgery, then you're really setting them up for afterwards. All your arthritis patients, all your total shoulders, their scapulas are terrible pre-op, and they don't automatically go better when they put the total shoulder in. So you can try as much as you can to get them going with these exercises, get some of that pec minor tightness off, do a lot of that serratus work, so that when you do, can move your arm, then you're at least started on those patterning again. So pearls, kinetic chain's the base. We have almost all of our patients, when they can, stand. We may have to start them when they're real weak on the table or sideline, but we love standing because it facilitates the way you're supposed to do it. Address muscle tightness in our common, it's upper trap, pec minor, and lat, very common, usually is a trifecta right there. You really have to get all those loosened up. Emphasize this voluntary control. If they cannot do this, put their scapula into a retracted position voluntarily, then your PT capabilities are reduced huge, until they understand perperceptively that that's what they have to do. And that takes a while. Sometimes it'll take you three or four weeks to really get this muscle re-kind of tuned up, because they'll still need to be in these patterns they've always done. We always do closed chain, somebody was talking about short lever arm, yeah, we do all closed chain, hand on the wall, hand on the ball, something like that, and short lever arms start off with below shoulder to above shoulder. So what we do, that's a wrong pattern right there, so we can use a cell phone or iPad or double mirrors to have them show that they need to retract that scapula back the way it's supposed to be. Trunk rotation improves scapula external rotation capability, and therefore you want to do as much as you can with rotation when you get ready to, so you drive from the hip and core and do rotation, and then get the scapula in a three-dimensional pattern. So it's just a lot better to try to do rotation as part of this facilitation. Controlling medial scapular border, there's all kinds of different ways we do this, so we do bands, we'll do step backs, we'll do all these things, and you say, well, that's not controlling medial scapular border. It is, because you start with your core first, and then you work into the scapular retraction position out of that. There's this thing called a scapular stability series, where they're isometric and dynamic, and you can do these early because they, you're not overhead, and you can really get your scapula working very quickly, and it's below the impingement. So you can do the isometric exercise, inferior glide, you just push straight down and have them pull the scapula back while you're doing that. This low row is our go-to exercise. It's basically pushing back, once again, standing with hip trunk extension, arm back this way, push. You don't push with your triceps, you pull with your arm going backwards right there. Cheating is that you're using your, you're doing one of these right here. The exercise should be in this fashion right here. And so, we have two dynamic exercises. We love this lawnmower with all its variations. Start somewhere into protraction and trunk rotation, and then you go somewhere with your arm back in this position. You start here first, maybe even in the sling, then you go farther down and farther back and farther down, and then eventually you step up on something and you get back in this position right there. So, all kinds of different progressions off of that one. And then the robbery, this is a bilateral one, once again. This is the 38, this is the 44, caliber guns. But the idea, and once again, all these exercises are where you, you see where your elbows are? Your elbows are in the back pocket. You always end your exercise with your elbow in the back pocket. That gets scapular retraction, trunk extension. Optimized glenohumeral range of motion, the one on the bottom right, where's Mike? Here's our exercise for pronation, using the ranger, it's a great exercise right there for that. Eccentric muscle control, posterior shoulder tightness, biceps tightness, biceps always gets tight, you've got to loosen that up. So these are a couple we do. Hit that first, let's see. We call this the accruva, it's an eccentric with different weighted balls. Our trainer made this up, listened to ACDC, Motley Crue, and Van Halen when he called it accruva. If I'd have done it, it would be Beborow, Beatles, Beach Boys, and Rolling Stones. The idea is you have an eccentric load, and then you come back the other way. This is a great one, it's called old school, it's fantastic eccentric control of not only posterior shoulder, but also the scapula. Very good exercise, it controls, you get eccentric control. In this, we've written this up, posterior shoulder eccentric test, it's a very good test to, once again, do abduction, extramutation, extension to failure. So the scapula is a very key link in the kinetic chain. It has important positions and motions in scapular humer rhythm, and you get adaptations and dyskinesis as a result of repetitive exposure that may be adaptive, it may be incidental, it also can be disruptive or pathologic as well, and therefore you need to identify the disruptive is that you've got a baseball player, and he's starting into the season, maybe he's got a little bit of slowness of motion, maybe his location's a little bit bad, scapula's starting to look a little bit bad. That means that he's in trouble in his kinematics. The worker who has to do the, we've got a big Toyota plant over there, they do this all day long, and they say, oh, it's starting to hurt, it kind of ached toward the end of the day, you know, kind of a little weakness. The scapula's bad. That's disruptive, that's not normal. And then I had one guy, he's an arthroscopist, he said, Kibler, look at my scapula, it's all winged out, but I don't have any symptoms. And I said, well, what do you do? He said, well, I surf and I fish, and I said, well, that's not, but I said, what do you do in scoping on your fourth scope at the end of the day, and you're out here like this? He said, it's just kind of tight, I have to kind of, so that's disruptive, and you start going to have some trouble right there. So that also means in throwers you need to do episodic evaluations throughout the season because this will progress, this is an adaptive change, so you need to look at that. And early interventions will minimize this loss of control. To me, that's the hardest thing that we ever have to deal with, is that loss of control. Once you have it, it's hard to get back, but if you get it early, then you don't lose that, so you can start with your rehabilitation like you want to. And then there's maintenance of conditioning. Thank you very much. Thank you. I've got to go catch a plane. Any questions real quick before I go? Okay, great. Everybody knows it. Great. Fantastic. All right. Now we're going to delve away from the sexy throwing shoulder to this adhesive capsulitis. These are my disclosures. So 10 things as I prepared this talk for you guys that I thought I knew and I learned. So diagnose as early as possible. Literature does show that early corticosteroid injection may decrease the length. We still do not agree on what the underlying pathology is. Frozen shoulder or primary is different from secondary frozen shoulder caused by trauma, surgery, other aspects, neurological. Be aware of that. And comparing all treatments, time and natural resolution is the most reliable. That's the kicker. Injection, intra-articular, subacromial are both. Physical therapy, if it hurts, don't do it. Hydrodilation can help, but not always. Manipulation under anesthesia, kind of an older technique with some complications. Arthroscopic release. Since we're surgeons, most of that surgical literature shows that it's very good, but I would say around 85% success. And there's great variability in the presentation and treatment. So when I started to prepare for this talk, this is the Dunning-Kruger effect, where when you just start, you think you know everything. And then as you start looking at it, you realize you're in the valley of despair. So clinical presentation, painful stage, that's the stage that I think is a bigger stage. I would say stage two and stage three, which we all know about, are minor. So the painful stage is really the thing that I try to concentrate on the most. I think people with decreased range of motion can really compensate a lot for that over time. But when they're in horrible pain, waking up every night, anytime they move they're in pain, that's the big problem. Physical exam, I think sometimes we miss a lot of this in our office. For me right now, some type of variation of adhesive capsulitis comes if people have pain at the end range of motion. So they have decreased range of motion and then pain, especially pain below shoulder level. So if we're doing external rotation, they have pain, yeah, we know that. But also abduction, forward elevation, pain at the end range of motion, there's some type of capsulitis going on. Imaging, really normal x-rays generally. In this town a lot of people have MRIs already. But I will say that we've been really looking at this thickened inferior capsule. We try to look at that on the coronal images. You can see and that can kind of make the diagnosis a little bit more for you. I would also say that a lot of time these MRIs come back with tendinosis, partial thickness rotator cuff tear. I get a lot of referrals for partial thickness rotator cuff tear where nobody seems to read the word partial. And they all think they have a rotator cuff tear. So that can help you. All right, pathophysiology, inflammatory mediated, myofibroblast mediated. This is all kinds of like what's going on? Why does that capsule all of a sudden start hurting? Is it the capsule that's hurting? Is it inflammation inside the glenohumeral joint? Is there something intrinsic in the capsule? And that only is worthwhile to hear for us because it kind of can dictate the type of treatment that we want to do. Here's inflammatory mediated. This is the slide that really talks about this hypermetabolic state where myofibroblast mediated contractile and will form scars. So this is where this whole myofibroblast or variant of a fibroblast, which is just a cell that makes collagen. This is kind of some histology from this and a picture, like a cartoon picture, just to see what a myofibroblast is. So when we talk about it, you kind of have a better idea. And you can imagine, or as I imagine, that as you have these cells that can then contract, that's kind of how you get into this. So we had a big international congress 10 years ago, and we produced this book, but I would say not a lot has changed. The stiff shoulder is not always adhesive capsulitis. And in fact, at that consensus conference, we thought adhesive capsulitis was not really a name. However, not a lot of people read this book, so everybody keeps calling it adhesive capsulitis. So don't get stuck on that, but just make sure that when you're evaluating people, you want to see really the difference between primary and secondary. And secondary, you need to ask what else has happened. Did they have trauma? Did they have surgery? What's going on? All right, so this is kind of what we're looking at. You're either looking at the blue, which is the glenohumeral joint, or the yellow, which is the surfaces around. So the difference between inside the joint and outside the joint in the subacromial space, posteriorly and anterior. Also, this shoulder injury related to vaccine administration. These patients are sticking around. They also come in with terrible pain and blame it on the vaccine. We don't know really a lot about this, but this is probably stuck into that kind of painful shoulder with no motion. Epidemiology, ubiquitous in the world. 20%, 30% of these patients may have contralateral shoulder involvement eventually. 2% to 5% of the population, really associated, not necessarily everybody with diabetes or thyroid disease has it, but generally if you have a person that hasn't been diagnosed with diabetes or thyroid, it's kind of good to have them be checked out by their primary care doctor. Interestingly, type 2 diabetes more prevalent, and don't forget about the hypothyroid. That's actually more common than hyperthyroid. This is just kind of giving you a picture of what it looks like inside, why we think it's kind of inflammatory mediated because of this capsulitis. Dr. Warner wrote this article where he looks at the same type of picture I was trying to show you before, where not only do you have the capsule inside the joint, but you also have adhesions outside the joint, subacromial and in the area underneath the deltoid. These are just different pictures showing idiopathic, post-surgical, diabetic, impingement, post-traumatic. Really the purpose of this is that inside the joint it really doesn't look that much different. Natural history, this seems long to me. I usually quote people around 12 to 14 months, which also really doesn't help them. They're coming into you with this terrible pain, they can't move, and you look at them and be like, no problem, it'll go away in two years, good luck. That's really where this problem kind of comes. Proposed treatment, anti-inflammatories, oral steroids, people debate that back and forth because of the pathophysiology. If it's not mediated by inflammation, how are the NSAIDs and the oral steroids going to help? It does seem to help with the pain. Many surgeons, as I prepare for this talk, really now not only inject the glenohumeral joint, but they'll inject the glenohumeral joint and the subacromial space. Therapeutic studies, when you're looking at the literature, these are difficult to review due to the tremendous variation in all the different patients that are involved in these. Cortisone injections, we do recommend with ultrasound guidance now, that way we know we get into that area. And like we said before, we also go in the subacromial space. These are some articles looking at some of the potential biases that are in them, and that there's really no significant difference. But I do believe it can help pain, and at least you're doing something. Physical therapy, something near and dear to all your hearts here. It's your profession. We go back and forth on this. This was an older study, but pretty effective, where they looked at the constant score at time 0, 3, 6, 9, 12, 15, and really in a group of prospective successive cohort, no real difference between the constant scores for all of those. So really we come with, if it hurts, don't do it. There is a new study out there on this adjunct physical therapy kind of method, where they have a kind of passive stretch, and that did show some improvement. Hydrodilatation, I bring this up because people will talk about it, where you just inject a little bit more lidocaine and steroid. They did feel that at six weeks, adding more saline kind of helps. So the idea here is that you're stretching out that capsule. Manipulation under anesthesia is more of an older issue, where we used to put people to sleep a little bit and then manipulate them. It did have some complications. Fracture would be one of the big ones that we were worried about. Arthroscopic capsule release, most people wait until about six to 12 months afterwards, kind of a last-ditch effort. I'd have to say that in my series of patients, I haven't had great success with this. Arthroscopic procedure, but it may be because I was waiting too long. So a lot of surgeons that I was speaking with in preparing for this talk, think around six to eight months afterwards may be the sweet spot for this, and me waiting until 12 or 15 months when it's really contracted may not be the best. If you're doing post-traumatic arthroscopic, you really want to get into the subacromial space, and then you want to also release all those adhesions underneath the deltoid. So is arthroscopic capsule release more effective in pain relief than conservative treatment in patients with frozen shoulder? This study showed maybe. You can see here on the X-axis, pre-therapy, NSAIDs, interarticular physiotherapy, and then surgery. But if you look at residual pain was observed in more than half of the patients, so 51 percent, and then you can see right here. So 24 percent still had some level of pain after that procedure. Arthroscopic versus manipulation under anesthesia, really no difference found in pain or range of motion. So as far as evidence-based approach, diagnose early. Ultrasound or fluoroscopic guidance on corticosteroid injections, above and below I think is probably pretty good. PT during any phase but may be painful and try to avoid painful activities. And then arthroscopic capsule release at around the six- to eight-month mark may be better. And then just back to our original slide, the ten things here, and I would say really in comparing all the treatments that the patient can hang on, it'll resolve. Thank you. Well, that was daunting. Awesome, what's up? Awesome. All right, so this is the fun stuff, right? This is what we get to do afterwards, right? It's the rehab of the stiff shoulder. We all know this is a pretty challenging patient, right? Oftentimes a long process. Sometimes we feel like we're banging our heads against the wall and we're not making any progress, and sometimes we take a step back. I think that's the ones that you go home at night and think about, right? You're laying in bed in the morning feeling bad that somebody's kind of taking a step back sometimes. The first thing you have to realize with the stiff shoulders is there are different types of stiff shoulders, and we have to identify which that is that's in front of you if we're going to treat this well, right? So the three I like to basically categorize them as is the acute chronic adaptations to activity. So even the baseball player that we talked about this morning, right, they have changes to their lat, their terries. Those are adaptations to the sport that they do, right? We could all go outside right now and run 10 sprints down Boylston Street, and our hamstrings will be pretty tight and sore tomorrow. We don't have frozen hamstrings, right? So there's different things that we have to keep in mind. Post-injury or surgery, oftentimes what we have is we'll have a unidirectional or maybe not quite a global restriction in the range of motion. That's different too. In this talk, we're going to be talking more about adhesive capsulitis to just go with this afternoon's session, that more global limitation. But you do have to understand that the different treatments that we perform will vary depending on what you have in front of you that day. So we don't need to go over this too much. Gus just did a great job going over exactly what adhesive capsulitis is, who it occurs in, that type of thing. We know that, but I wanted to spend a little time talking about the four stages of classification and then how that is going to impact our treatment because each of these phases has some unique characteristics that you'll see in the patients when you work with them in this phase that are going to change what we do with the rehab dramatically. So it's pretty important to understand these. So pre-adhesive, again, that's where we have the synovial inflammation but a minimal loss of range of motion. That's the angry shoulder, but they're not quite tight yet. We're going to talk about that a little bit more in detail. Acute is when we start getting some more synovitis, early adhesions, and then finally maturation when we start to actually have a loss of the axillary fold, which you can kind of see here in the diagram over here on the right. So you have to understand the beginning of those phases and how that kind of comes into play and eventually over time results in this loss of the axillary fold because that's when we're frozen now. That's when we have the most restrictions of the maturation of the tissue that we're dealing with, and that has significant implications. So we all know we talked about the circle concept of stability this morning when we talked about instability. Well, it's the same thing when we talk about stiffness. Tightness in the inferior capsule is going to have a global implication in range of motion throughout the whole shoulder, the hammock effect that we see with this joint. So these tend to correlate well to what we consider our four stages of classification when we talk about their clinical presentation. But essentially I call the pre-adhesive phase and then freezing, frozen, thawing. When you look at these phases and you see how they interact, I think we're all familiar with that phase and how that tends to overlap with the different findings that they've done histologically and also with some of their photos that we showed from intraoperative procedures. So let's talk a little bit about the principles of treatment. You can check out a CPG and JOSPT from 2013. I actually think they're working on updating that as we speak right now. It takes a long time to do a clinical practice guideline, but they have a lot of information there. But I want you to be wary of this. We're collecting information when it comes out there with adhesive capsulitis and stiff shoulders. It's very hard to do a randomized control trial on this. We literally have people trying to study, does manual therapy work for adhesive capsulitis? What does that mean? So is it a 40-year-old, a 60-year-old? Is it a diabetic, a non-diabetic? Are they in the freezing phase or the frozen phase? What does manual therapy mean? Was it an experienced person, an inexperienced person? Was it 6 sessions, was it 12 sessions? So be careful when you go on Instagram and you hear people say nothing works or these things don't work. It's very hard to do these controlled studies. It always comes back down to we often find if you really look deep or you really muddy the water with a systematic review, nothing is better than supervised neglect. But I think all of our patients would disagree. None of them want to have supervised neglect. They want to try to maximize their function as much as we can in those early phases. So that's what it's about for me. I don't want to see two to even five-year outcome studies where everybody is the same. To me, it's how do you fail them on 3, 6, 9, 12, right? And I think there's a big difference when we do this. So we have to understand this. We have to understand the type of motion loss. We have to see these phases. And remember, assess, don't assume, especially with the pre-adhesive. This photo right here, that could be adhesive capsulitis. That could be a rotator cuff repair or not repair, a tear. So we have to make sure that we're doing a good, thorough assessment and not assuming. I've seen lots of people with complete full range of motion come to me with a diagnosis of frozen shoulder, but they had a huge cuff repair, cuff tear, right? So keep that in mind. That's just some of the things that we see over time. So let's talk about the stages because I want to dig in deep a little bit here. And I'll be honest and I'll be humble with you about this too. I care more about the recipe than the ingredients. So I'm going to show you my recipe. But you guys can change the ingredients, right? If you like active release and you like instrument-assisted or dry needling or whatever it may be, that's fine. But we're going to talk about how those ingredients all kind of play together with the recipe because that's really what matters. So the first stage is the pre-adhesive stage. This is the shoulder pain patient, right? Inflammation, minimal loss of motion, they tend to have pain within range. Sometimes these people will have no pain with elevation, like where you'd almost expect with like an impingement type person, but they'll have some pain with external rotation. Usually they're pretty strong too, right? I think the key characteristic for this one in me though, and you have to look deep with this, is there's just a smidge of inferior capsule tightness, okay, you gotta document that smidge, right? But it's just, you can see there's a little bit tightness of that inferior capsule, and their pain doesn't seem to correlate, like it's a negative near, maybe it's a negative Hawkins, but they have it with external rotation. This is the type of person that we probably see more than we think. These might be more impingement people than we think. So I'm on top of these people at the beginning because I would like to think maybe there's a chance we can prevent this from going further along in the pathology. Maybe they won't freeze, maybe they won't become frozen over time if we can address this right away in this pre-adhesive stage. But unfortunately, we probably don't see them here enough. So the keys to this phase to me is education. It's breaking that cycle, right? That pain, that guarding, that immobilization that they'll do, that self-guarding, we wanna break that cycle, and that's through education. Hey, this looks like an inflammatory response that you're having here, not just rotator cuff symptoms. So we're not gonna just exercise ourself out of this. We need to work on your range of motion, and we have to make sure we're staying on top of that. So we educate, we educate them what to do, but also what to look for, so that way they don't advance, right? And for me, it's really just preventing this disuse, right? But I hate to say it, but I wish we saw more people in this phase, right? We don't see people oftentimes until they're freezing or even frozen, and that's when it becomes even more problematic. So that's phase one. Phase two, the painful phase or the freezing phase, right? For me, I think what differentiates this than the other phases here, obviously they're in a lot more discomfort, but they have a spastic end field, okay? So that spasm end field, where you actually get them to that external rotation end point, and they guard, they spasm in there. To me, that is the number one characteristic of this phase, in addition to pain, obviously. But that becomes the center of our treatment focus, then, is that spastic end field, right? Because that is gonna be your gauge. That's gonna be your barometer of how hard you can push or how hard you need to push, right? So the whole purpose of our treatment, in my mind, is to get somebody to progress from a spastic end field to a capsular end field. And sometimes that'll just happen with time, but we can also make that worse. You can have somebody that's transitioning, theoretically, from freezing to frozen, that starts getting stiff, that if you get too aggressive with, will revert back to a spastic end field. That's a sign that we're doing too much. So spasm end field with pain is a big one with this. Careful, it's not always a capsular pattern. I know they teach you this in school because they like to get you to memorize things. It's not always a capsular pattern. It's often not, right? So just keep this in mind. It's not always as simple as they say in the textbooks. This is that characteristic there. Oftentimes, I see people with internal rotation being their greatest limitation, not external, right? So again, recipe-wise, right? We can mix the ingredients a little bit, but I actually listed this slide out. I usually don't make slides like this, but I listed this out because this is what a session with me would look like. We'd use some moist heat because, again, what do I want him to do? I want him to relax. I want him to settle down a little bit. We'll use modalities because, yes, modalities like laser ultrasound and e-stem have been shown to be effective in adhesive capsulitis. Careful what you read on Instagram, right? Soft tissue mobilization obviously is big for me here. I wanna work on a lot of soft tissue because they're very guarded, right? They're compensating. They're holding their arm in a painful position. That's gonna be the key to getting them to relax and moving more. And that gentle range of motion, gentle joint mobilizations, and again, getting them to just do this throughout the day. Strength's not my primary concern. I say that too when we talk. We say like, look, you're pretty strong. I wouldn't really worry about that. We're just gonna focus. We're gonna put my energy, my physical energy, your mental energy are gonna go into your range of motion, not your strength. We'll deal with your strength. That's easy. We can get that back, right? So break that pain, spasm, and mobilization cycle. That's important, okay? So a couple of tips. A lot of people throw a hot pack on like this, right? Or you have the tech throw the hot pack on like that. We can probably do a little bit better job with these people, right? So I like to use positional release. We'll get them at their end point. You could argue this is like a precursor to a low load, long duration stretch, but just get them to that barrier and strap the moist heat on in that position and let them sit there for 10 minutes. That's a great beginning for a stretch for that person. So we'll do that in external rotation, overhead elevation. Sometimes it's more comfortable to lay off the edge of the table. But I think the concept here is get them to that barrier, right? Now, again, you can be overaggressive and they'll start spasming. You'll see the moist heat start to almost shake a little bit when we're in there. That's not the goal of this phase. It's just to neuromodulate. Lots of soft tissue, posterior shoulder, again, posterior cuff, Terry's major, big ones for me. Anteriorly on the subscap, that thing is gonna get locked down, right? If they haven't externally rotated in six months, that subscap is gonna be a problem, right? So dig in there, start working it. And what I do, if this was a video, is I'll move them a lot. A lot of like rhythmic oscillations with this, just in and out of internal, external rotation, flexion, elevation, while I'm just doing just like a sustained pressure on that subscap, right? I'm not trying to kill them, not trying to cause pain because that's gonna not break that pain, inflammatory spasm cycle, right, with immobilization. So the key is to decrease that, okay? We really wanna be careful with that. Joint mobs in this phase are basic, right? Long axis distraction, just some real basic things for them, just neuromodulating pain, trying to get them to relax. I'll often just do some gentle traction, just like this, like nice and simple. We can do some lateral mobilizations as well, just some lateral distractions. Again, all we're trying to do now is neuromodulate pain, right? We don't wanna work through a spastic infield. So this is just real basic grade one, grade two mobs. I'm not picking up the capsule or slack. I'm not putting them at end range. I'm just trying to neuromodulate that pain, okay? We'll do single plane joint mobs, grade one, grade two in this phase. So inferior, anterior, posterior, single plane basics, right? I'll show you the progression next phase because that's where it gets more fun, but that's the basics of this. One key note here, remember this, when you're laying on the table, remember this in school again, the body is not set up to be perpendicular to the ground like the table is, we think it is. The glenoid faces at a acute angle, right? It's the scapular plane for a reason. So if we're doing our mobs in this direction, it's probably not the most advantageous position. This is where a lot of people think, like even in a baseball player, you might have a tight posterior capsule, but if you're just gliding into the posterior rim of the glenoid, then yeah, it'll be tight, right? So make sure that we're doing our glides that's specific to the plane of the glenoid. Be real careful with that. That's a good basic here. So if you're doing grade one, grade two mobs, like even posterior, for example, or inferior, and the person doesn't feel great, make sure you're in the right scapular plane. I bet you that'll help a lot, okay? So that's a little bit with all of our mobs. Lots of active assisted range of motion. We wanna teach them to do these things because they're gonna have to do that at home. I do like to dry needle and yeast them again here, neuromodulating pain, get them to do just relaxation, get them to settle down. Again, whatever you like. There's some nice devices you can send them home with nowadays. I think heat and vibration are great to neuromodulate pain and tone and get them to relax and move more. Hyperice does a great job. This Venom device here is heat and vibration. They have like stickers that do it now, and they even have this nice head on a massage gun. Everybody has a massage gun nowadays, but they have a head now that heats up too, which is kind of a cool combination with them. So again, anything to throw the kitchen sink at these people. The key to this phase, again, is don't push through the spasm and feel, that's it. That's the basic key for this, but you have to teach them frequent light motion throughout the day, hourly. Every time you're awake, you gotta do something. You don't have to do 15 minutes every hour, but you're gonna do something every hour. So we give them a lot of things. Do the golf club one hour, do rope and pulley the next hour, do a pendulum the next hour. Whatever it may be for that person, get them to keep it moving throughout the phase, okay? But again, spasm and feel, that's our thing, right? Change that spasm and feel to a capsular and feel. That's when we start entering this progressive stiffness or frozen phase. So less pain, plateau of progress, right? And they have this hard capsular-like and feel. These are the fun ones, right? These are the ones. You ever do a joint mob in a frozen person? It's literally like pushing the wall for 15 minutes. It's terrible, right? So it's exhausting for us. It's a great person for your students to practice on, right? But really work that person over time. We can start getting more aggressive. So again, recipe for this one, same thing. Moisty, we're more at the end range. Soft tissue, active and passive range again, but now we're gonna progress our joint mobs. Grade threes, grade fours, multi-plane, end range mobs, contract, relax, low load, long duration. This is where we start to throw kind of our techniques into this phase, okay? So here's a good example here for me. I like to do multi-plane mobs in this phase here. So here's an inferior capsular glide you should do all the time, right? Nice, simple inferior capsular glide. The progression for me to this is to pick up the slack of that hammock, that capsule, bring them into external rotation and repeat that inferior glide, right? Very effective on that person. If you did this last phase, you probably wouldn't even be able to get them in that position, to be honest with you, but very effective in getting them to do that joint mob, okay? You can do that anterior and posterior as well. So again, same thing. I'm a close access mobber. Is that a word? I like to mobilize. Let me rephrase that more intelligently. I like to mobilize the joint with a close access more. For me, I wanna feel the motion in my hands. I don't like pushing my body weight into the person. I like to use my hands. But again, spiral them into external rotation, perform that mob. Same thing, posterior again. I'm going posterior lateral, so you could argue in the video, it almost looks like I'm going inferior, right? But I'm shooting towards my foot, right? Going off the table, posterior lateral with that, okay? Interesting thing on posterior, by the way, and posterior band of the inferior glenohumeral ligament is often involved here. If you actually look at the strain of the posterior band, it's better that you perform it in the sagittal plane than you do in the scapular plane. The anterior capsule is better mobbed in the scapular plane, but with posterior, you actually wanna get them more sagittal. So I kinda do this like scoop technique where we get them up where they're straight plane sagittal, and I'm doing almost like this posterior inferior glide. And I really like this. You gotta obviously like your patient and have an Altoid mint in your mouth, but you can manipulate the range of motion that the shoulder's in. You can internally, externally rotate them. You can move them around. I think that's a good technique. Contracts relax is great in here. You know, the original methodology of contract relax, or if you can go back and it's like a Leon Chateau or somebody that really used to master this sort of thing, it's at most 10% effort, right? You can do this too aggressively. If you do it too aggressively, it's gonna be bad. So 10% effort, get them to relax, and you'll see so much range of motion gain just in this one session by doing that. And then finally, low load, long duration stretching. You know, and it's funny, if you look at this slide, I have references from the 80s and the 90s. There's no new information on this, which is mind blowing to me. I was shocked. I thought maybe I missed it. Unless Chuck, Julie, I don't know that I miss anything. We're gonna do a new study on this, Chuck. But it showed that low load, long duration was better than the opposite, right? High load, short duration, which is aggressive stretching, right? So we wanna do that. And then if you add heat, you actually add ice too, but if you add heat, it increases as well. You have a much bigger gain in range of motion. So again, we'll do this low load, long duration stretch. Red band, not very tight. You can manipulate that. That's her end range of her resistance. I just took that photo to show you, but do it with a hot pack on, right? So do that same position. So you can do that external rotation. You could do that overhead elevation. You know, we even have people set up and do that at home sometimes with like a family member to help them a little bit. There's ways to do it. Very, very effective, good way of doing it. There are devices out there that you can do. I do think we should probably get these on people before we usually do. We usually wait till it's way too late and then give them these devices. But jazz braces are great. You just kind of dial it in and slowly go back. DynaSplint has like a little resistance to it. So sometimes if you're battling between that spastic or capsular Enfield, that's kind of aggressive for them. And then this new Erme device, it's gigantic, unfortunately. I cut it off. I didn't even show you the whole thing. It's pretty cool though. It does a good job. So, you know, talk to your physician if you're struggling to do that. Get a script for one of these things is pretty helpful to send them home with. And for some reason, they tend to do it more if they have this. If you just say, do your golf club exercise at home, they forget, right? But then if they have this contraption in their living room, just sitting there, they tend to do it a little bit more, right? And then we do a lot of self stretching type things. I'm not a big shoulder stretcher in general, but for these people, I just want to move, right? So external rotation, horizontal motions, both direction, just keeping them moving is the way to go in this phase. So what's the key to phase three? Again, we're doing exercises all day, but our progression is based on the Enfield, right? More aggressive mobs, multi-planar mobs, low load, long duration stretching. That's the beginning here. This is the phase for that, right? Our key though is to avoid that regression back to spasm. It can happen, right? So that means we either went too far or they went too far, but we took a step back. And then finally, we're thawing out. We're in the fourth phase. It's pretty good. This is our slow gain in motion. Clinical exams finally getting better. We're seeing some light of the tunnel. You're sleeping better at night. It's a good spot to be in. This to me is where we just get into homework, right? They just have to keep going with this, but again, it's education. 20, 30%, depending on the study you see, are gonna get it in the other side. So what we're gonna try to do is mitigate that by educating them that we have to stay on top of that, okay? So we continue to progress the aggressiveness of our techniques, but it's really about maintenance for them, okay? Making sure they're compliant, they don't overdo it, okay? So again, challenging complex patient, right? I don't think any of us love working with somebody that's frozen, especially that's in that frozen phase. Sometimes it seems like nothing can help. Small, baby step gains. Avoid the roller coaster of spasm and capsular infield, just baby steps each session, right? It's gonna take a while, but if they're not compliant, they're not gonna help either, okay? Make sure you're using the right treatments for the right phase. Make sure you're progressing from that spasm infield, and really the key here is this frequent low load motion, slow, gradual progression. Thank you. We're finally gonna switch gears to the lower extremity. Dr. Brian McKeon is gonna be talking about meniscal surgery, and then Chuck Thigpen will follow with rehabilitation. Hey, sir, it's good to see you. All right, good, good. All right, I'm running late today, so hopefully these videos come up. Mike, that was excellent. That was excellent. I feel bad for you, therapist. Oh, my wife did make it, hey, all right. All right, shoot, no swearing. Am I supposed to upload this? And I feel bad for the therapist. I mean, you guys get paid like nine bucks probably to do all that work, and man, let me tell you, patients blame so much on you guys. But boy, they love it when you guys touch them and dig in, and that's probably the number one concern or complaint. I switched gears, I went to a different therapist, they were so much better, and taking the time to get in there and dig in, like Mike said, was just so important. But many do complain of Mike's breath, so I'm glad you said the mint, Mike. Just got a pointer here, too. And so the same thing what he was saying about the shoulder, and I'm sorry, do I pass, does it go with this? There you go. Same thing you were saying about the shoulder, the same damn thing with the infrapatellar joint. It just seems like more and more every surgery, that damn kneecap gets trapped no matter what you do, a meniscectomy or anything. And so, and getting these people on a home exercise program is amazing. Is Alan here? No, Alan's my partner for 26 years, and I realize why now I had to carry his overhead for 26 years, became the president of ANA, so I wanna congratulate him. And in fact, Dr. Richmond, who was in our practice, was the past president of ANA three years ago, so I'm the head of our garden club, so I've done something right. This is the case, I've videoed always, every surgery I've done since I was a rook, 26 years ago, my poor PA Jason had to carry around all these discs, but this is the patient I cleaned out her meniscus tear 25 years ago, and these are the patients that are miserable, because that's what we call root tear, which is just a radial tear, and the knee with that radial tear up top, that's the time of arthroscopy, so I cleaned it out and tried to balance it so it wasn't bothering her, and these are the patients that go to bone-on-bone so fast, and these are the most miserable patients in the world, and I'll come back to that in a second, but ever since then, I've always been thinking, and I always thought it was a cartilage problem, and in 1994, I finished my training in 1958, not 1998, and in 1994, this article came out, and I thought it was transformative, this is growing cartilage out of Sweden, and I became so interested in it, and I was just a resident at the time, so much so that when I finally finished my practice and had some time freed up, I went there, I went and spent three months in Gothenburg, Sweden, and Lars Peterson, the gentleman on the lower, was kind of my hero, he was there doing all these transplant and they printed that landmark article, in fact, the Boston Globe printed it in the front page, and says, this is it, we're gonna cure cartilage, and so, my whole career, and I took care of the Celtics for 20 years, a professional athlete can play without a meniscus, but they can't play without cartilage, that will get them the team option in one year and then the quick trade, and so, but the whole goal was that we're trying to preserve this shiny stuff, right? My whole career, my whole life, that's my goal, it's like, not go here, and I thought we maybe had a solution, but articular cartilage and meniscus has such a detailed macromolecular organization that we've not been able to replicate it, really haven't, even I tell patients, like, even like, you know, I tell people when you're cold, you know, you don't do this, you do this, right? And the knee can't stand that, because the articular cartilage doesn't like it either, it goes, but even if the articular cartilage could callus, like I would do here if I did this all day, if you're a bad golfer like me, and you get these calluses, it finds a way to protect itself, and articular cartilage does not do that. So I really went on this long run, and ultimately, I mean, it's amazing to me, even today, that if you look at the curve of, you know, knee replacements in America, around the world, and hip replacements as well, it's unbelievable how many of you are done, like, you know, and you know, surgeons say, I think the American Academy of Orthopedic Surgeons says, tell patients, you know, 15, 20 years, how long it's gonna last, but revision knee replacement is like life-altering, you know, and if they're doing these people and 48, 50-year-olds, and I see it every day, it's kind of a concern, and so I've really come to realize that it really is the meniscus. It really is the most important structure in the knee, according, you know, in my opinion, and it's amazing what it does, and I think the biggest thing it does is the load transmission, right, and the top of the lateral compartment is basically convex, and so the way that the knee works on a medial pivot, so the outside of the knee, the tibial geometry, which is so variable, is almost like the top of a ball, and so that meniscus moves like crazy, and there's a lot of work to do, but both meniscus are concave to house the femur, and the meniscus, I tell patients, is a tibial phenomenon. They're on the shinbone, and they're attached in different ways, but it's amazing, you go back and look at the literature, it's been standing right in front of us, and, you know, and I'm gonna give kudos to the hip guys, because the hip arthroscopists, you know, I met when I first, when I was a fellow in 1998, we had one, Dr. McCarthy, if anybody remembers him, he started doing it, but he was one of the first hip arthroscopists in America, and they didn't really see anything, they're just in there cleaning things out, but they've gone so quick, they have progressed way faster than we have, and we started 30, you know, 25 years before them, so they know you gotta fix the labrum, they know you gotta fix everything, and they know that it's important. Now, the hip's a ball and a socket joint, so it's got one degree of freedom, so it's quite easy, fair enough to them, fair enough to us, and the knee, as you know, has got six degree of freedom, so it's incredible, but Dr. Fairbanks, this is one of the classic articles that was published, but you've heard of this hoop stress, and basically, when you walk, right, you lower the meniscus, and the meniscus wants to spread out, and that's what it does, so when you walk around one leg, go to the other leg, the meniscus spreads out, then it dynamically returns, and the ability to do that is because of these longitudinal fibers right here, oh, these longitudinal fibers, they are everything. Go back here, oh. Yeah, so right here, this is probably the most important picture of this whole talk, these longitudinal fibers, which are not immediately in the inner part of the meniscus, they're in the periphery, so if you have a little tear right here, and patients ask me all the time, how much did you take out, how much was torn, And you can take a pair of scissors and just go snip right there, and that'd be 1% tear. That's the whole name, meniscus. So if you're going to, you know, take a dog and do an arthritis model, because they got a fancy medicine and they want you to prepare them, you don't need to take the meniscus out. You just give them a deep radial tear, and they get arthritis in a month. And so I still love dogs, so maybe I should say cat. But what these longitudinal fibers do, it's like this is the belt, you know. So the wine people noticed early on, a long time ago, right, that they got to put a tension band around the wine. Otherwise, the wine, the weight of it, will blow out the barrel, right? And so this was like my belt after Thanksgiving. It's the same damn thing, right? Containing the force, right? And so this picture is another critical one. This is just a chronal shot of the men. This is somebody walking or a diagram of one. And you see the meniscus right here. So the meniscus doesn't have a direct compressive force because the meniscus is at an angle. And so if you blow it up here, so these are the compressive forces you're walking. And so the ground or the tibia responds with a direct force up. But there's an oblique force coming into the meniscus as this is. So the meniscus, if you have an oblique force, you have to break it into two forces, a horizontal component and a vertical component. This horizontal component is everything. This is every time you walk, get out of bed, whatever. So that meniscus wants to, by virtue of these forces that are put on it, wants to spring out regularly, right? These are tensile forces. These are compression forces, okay? And so that's supposed to be a video here, I think. Can you hit that video for me, the lower right one? Yeah, there it is. Hope you had it for a second. There, kind of going, I think, hopefully. And so what I tell people is it's those longitudinal fibers of the meniscus that really prevents the meniscus from keep going. Oh, shit. Sorry, I got to hang on. Okay, here we go. So I tell people that the thigh bone or the femur basically dances with the meniscus, right? So it's very dynamic. As you know, a lot of meniscus moves, you know, we think maybe 17, 15 millimeters in the middle meniscus, moves about two to four because of the MCL, it's tethered. But no matter what, if you break it down right to this one area, the meniscus is jiving and moving, and it's responding. So these longitudinal collagen fibers are preventing the meniscus from going to the other room. And the menisciotibial ligaments add to that. So these are called the coronary ligaments as well. And, you know, in orthopedics, it's kind of funny. You always get these buzzwords. It's all the same things. Anything new in orthopedics or new concepts, it's just we know the anatomy better. That's the only way to really for me to describe it. If the knee is unstable, the meniscus is under more load and it's going to tear. This is a bucket-handle tear down here because there's no ACL. All right? And so you've heard of a ramp lesion, and that's just another fancy word, you know, it becomes a hot name or hot topic, it's published for a few years. All a ramp lesion is, can you play that video up here for me? I'm sorry. All a ramp lesion is, is that, you know, this knee is deficient in its ACL. And so the posterior horn of the meniscus right there just gets beat up and eventually it slides around so much, it tears in the back of the capsule. And so that's called a ramp lesion, and they talk about how it's missed 18, 20% of the time. And you just got to look for it. So nothing should be missed because you're looking for it. So we all learn in our textbooks, the meniscus are secondary. Stabilizers. And so another big word here is, it's funny, I was just down at a company recently, like extrusion. Extrusion is a hot topic. All extrusion means is all those mechanisms don't work anymore. And so once the meniscus extrudes or leaves the knee, this is an MRI where you're non-weight bearing, because every time you walk in real life, and they've done this in ultrasound studies, but you don't even need that, you know that's what happens. When you walk, the meniscus has a gasket, extrudes, and then springs back. So that ability to handle those compressive flows and redistribute them protects the cartilage. Right? And so once you have a tear, that's all altered. I don't know if you've heard this word, sunk, before. It became a big hot topic, but this is a patient, you know, it's usually a post-menopausal woman, has a meniscus tear. And, you know, I remember I had one case. You never forget these patients. And, you know, you do a scope, and all of a sudden their knee goes to shit. And then you say, I don't know what happened. You know, I blame it on the therapist, you blame it on me. And when we both talk, we blame it on the patient. But basically, the bottom line is, you know, that was coming. We knew that was coming. And that's why there's some joint replacement doctors that are actually getting smart. They'll take an x-ray like this with somebody that has an extruded meniscus and say, you need a total knee replacement. And, you know, most of us are like, wow, that's so radical. But that's the guaranteed, you know, answer that's going to give you the best result. So, because fixing these meniscus can be very, very challenging. And so, through my career, you know, always follow these key articles. And I should get this article to you. There's a paper published, the top 50 meniscus articles printed in the last 50 years. And it's kind of, you can see some of these you think it's almost political, like the way they're responding and talking. But this was a major turning point. This helped us, but screw it, this article. This is Dr. Mosley. And I believe it was in Dallas. I remember I was in the OR the day it came out. It's basically because, you know, he took all these patients and put them all to sleep and made sham incisions on a third of them, just poke holes, woke them up. And they thought they had surgery. And then he just cleaned out patients with like a hose, just flushed them out. The other ones he cleaned up. And you can imagine. No different, right? No different. And so when insurance companies got a hold of that article, holy crap. And so, you know, I mean, you are getting inundated with prior authorizations or more authorizations, peer-to-peer reviews. And it is like ridiculous. I mean, you know, the last week I had, not me, my PA had five of them. So it's like every single day now, any meniscus there, insurance companies say it doesn't work. And you have to fight. And, you know, and time is money on some of these type of tears. And then, you know, the New York Times got involved. And there's been other papers that have validated it saying, look, it doesn't work. But this was, and I'm missing one of these New York Times editorial, but it was fascinating. 2008 was the first one. I couldn't find it. It basically said, hey, what are we doing with meniscus? And then 2013, it's like, hey, you know, we're not sure what it is. And then this one, 2016, why is this useless? This surgery. And they related it to spine surgery, you know, spinal fusions don't work either. So, you know, they pick select articles. And once the media gets a hold of it, that's pretty breaking news. So, you know, who the hell is going to get an arthroscopy if, you know, you're recommending that? Because this is what they're armed with, the insurance companies, the primary care doctors. And many people, they just don't really understand. And so we failed. We have definitely failed as a whole discipline. And there's an article in 17 which said, hey, Dr. Mosley, 15 years ago, printed this landmark article. Did it work? Are people listening? Do people understand it? Or has it had some type of impact, right? That's when it's relative. In fact, our journals now have, you know, impact factor. And again, it's all down to the anatomy. It should be impactful if we're not understanding the anatomy, because that's whatever the hell it is, knee, shoulder, whatever. And so basically what they concluded, and this is a follow-up 17 years later, looking at their own database, is that, okay, doctors are not doing arthroscopy as much for arthritis. And this is just a couple of papers. And so it was really heavy, right? So, you know, do publicized, really well-blinded, perfectly designed, level one trials, do they influence us, right? So this one article said possibly, but arthroscopies have increased overall. And so if you, you know, you try to get a subset out the patients. And so, and it got, it was really kind of interesting. Like we know that, you know, you can't take the old man meniscus out, right? And Fairbanks told us that 30, you know, 78 years ago or so. So it seems like this group was like, hey, let's go back to the basics. You know, partial meniscectomy is way better than a total, right? We're kind of lowering the bar a little bit. And these are all things that make so damn sense, right? But the pendulum is swinging. If you look at kids that are taking their boards, when you graduate from your fellowship or general residency, you don't have to do fellowship. For two years, you collect your cases. And then you go to Chicago and they try to, you know, rough you up and pass your boards, right? That's when you're finally a real doctor. And so, you know, that's sort of a good pulse on what's happening in America. Cause these guys are on, you know, they're being trained by us. And so, meniscus tear repairs are definitely going, increasing, definitely. All data suggests that. Because why? Because at 10 years, right, it's not perfect, but at 10 years you have a better result, right? If you don't clean, if you clean it out, 20% of the people are coming back mad at you. And the other 10% are still not happy with you if you repair them. So it's very, very difficult. And then you get these other articles get thrown in. It's another big one, right? Cause what we're saying is like, look, if you clean it out, this is a long-term study, right? This was 40 year follow-up. One of the great article, 40 years, it says, look, if you take it out, 40 years later, you're in trouble. Right? And you know, that would make a lot of sense cause that's how important the meniscus is. So even NFL players, if you take out 10% of the meniscus, they're gonna have function alterations in their gait. They've done gait studies. If you take out more than this is, the rest of the knee is normal, right? You take out half the meniscus, you're gonna start getting more increased translation, right? And an athlete that's cutting and pivoting, even though everything's normal, except for the meniscus loss, there's gonna be some alterations. And you know, this is the kind of stuff that makes some people retire, even though I'm talking about pro athletes, even though, you know, there's always some rookie that gets there quicker. And so tibial slope, another additive factor, but we don't put all these together. And we've not been able to really put this whole thing together. And I put this slide together. So meniscectomy, it's still the easiest to do, right? From a doctor's standpoint, you just clean it out, you can do it quickly. It's not hard, clearly, right? Fast rehab, it's got low complication rates, but you know, we're still not looking at it closely enough. I mean, that's the problem. So the insurance companies are all over us. I mean, I have a case from 2020 from Aetna, and we have a separate billing company. They still won't pay for it because it was a degenerative meniscus tear. We don't pay for degenerative meniscus tears. And I should have sent that one to Dr. Midhoffer. He just got here, one of my partners. And so, can you get that other video to play, the one on the right? If you could, far right, yeah. And so, you know, I would say in the last seven, eight, but probably 10 years, I went to Italy. I went to Rome, Rome in 2013. I went over, I did nine ACLs, one of the Celtics owners owned a soccer team. So I knew you over there for a long story, but I jumped in and watched one of these surgeries. And this, you know, kudos to this older surgeon. He was fixing meniscus in ways that I'd never seen. And it was fascinating to me. And I came home and I would say in the last 11, 12 years, I've done everything I can to really do everything I can. Because if you look at it, you know, we're still, even though we're fixing them, we're still not doing a great job, right? Because even meniscectomy, follow-up long-term, and meniscus repair, follow-up long-term, there's not a whole, there's not a whole difference, right? And so, you know, if you take care, if you have the opportunity to take care of a team, and you look at the athlete in the center, these are all the, you know, stuff you got to deal with, right? And especially the owners, they should be up there, owners. And so, I mean, there's a lot of people, right? And sometimes you just wish it was just you and the athlete, it'd be so much easier, right? So I changed it to meniscus, right? And so, and when we look at the meniscus, yeah, 200 meniscus, like, what do you mean? I kept the lawyer in there. And so, all the stuff, what they do for a living, you know, smokers are like, you know, smokers don't heal as well. This is all proven literature. Smokers don't heal as well as, like, just like fractures, right, same thing. Where's the meniscus, right? You know, I did 100 meniscus repairs, and, you know, only half worked. Well, I mean, you know, you need a lot more information, right down to all of this, how long it was, was it running along arthritis? What are the comorbidities, you know, was there an ACL at the same time? What type of tear was it, right? Back to my little example, if you have a meniscus, you just snip it with the scissors, which could be an extension mechanism for, you know, an ACL injury with a hyperextender, they just basically just snip their meniscus or transect it. And, you know, and so it's only small amounts torn, right? But that tear is way different. You know, I'd rather take out a 40% of the internal portion of the meniscus, and that patient's gonna do a lot better. What's their alignment? You know, some people are just born really, really varus, or noxious, so you gotta take that into account. But if all this stuff is looked at and often addressed, you know, you're gonna get much better results. Even heavy people, right? BMI 25 and less or over, there's no real difference, right, in patients. Gotta have a stable knee. Anything you do inside the knee, if it's not stable, it's not gonna work. The radial tears are the big ones, right? Those are the big problems. Why? Because they cut through the longitudinal fibers. And that's why, if there's one patient that I'm like trying to drag them in there, okay? Because MRIs is getting much better. We get these frontal coronal fagile images. I love the axial images. Most MRI companies, four millimeters, three and a half millimeters, and you miss it. So often I'll send the patient back to the MRI, or if I order it, I'll ask for one millimeter slices. Now, it takes longer, because MRI companies now get more prouder. We can do it in 12 minutes, get the patient in and out. But, you know, we gotta get the important part. So here's a good video. Shit, bro, can you play that again, man? Sorry, yeah, that was right here. Okay, so that's a radial tear right here, guys, right? Oh, no, that one's the right here. Yeah, so if you look here, okay, this is, you know, this is what, oh, shit. Sorry. All right, here we go, good. So if you look here, this is just a coronal section. This is one slice through the whole knee, right? But you see that, this guy's loaded his knee. That meniscus is out of there. So you can have 1% of your meniscus torn. That's it, right? The primary care doctor's gonna see that and go, you don't need surgery, Christ. That knee's in trouble. That knee's gonna go. So if I get a patient that looks like this, right? It only hurts when I cross my knees, doc. Like, I'm like, that's the guy you gotta get right in immediately. But it sounds radical, because you're like, gee, why? Because that guy's gonna get a great result, because that's not gonna get through those longitudinal fibers and overload the meniscal tibial ligaments and get that meniscus to leave you, okay? And so we have this new hot topic. All our hot topics are just, because we understand the anatomy better. This is a spine rep, 48-year-old female from Rhode Island, came up to see me. She had three surgeries. She had an OATS procedure, which is just a plug of bone from one area in cartilage, and they moved it over. They put it in here. And she was miserable. And so she saw three doctors in Rhode Island, and I won't give them credit, because her x-rays aren't awful, right? And they said, total knee replacement. You know, 48-year-old female, spine rep. I mean, that's, you know, you gotta try to do what you can. But no doubt, another scope would be worthless, right? That would make her worse, more frustrated. And so that image, that's supposed to be a video, but we'll just, oh, now it's going. And so here you can just see her meniscus is extruded. It left the knee. And this is non-lapar. So when the meniscus leaves the knee, it ain't ever coming back, okay? Only with a procedure, right? And so, but the patient's got arthritis. She's had three arthroscopies over the last, you know, four or five years. She's a spine rep, so they, you know, they think they know everything. And these are the patients that are tough, right? And so we have this centralization procedure now where we, this is what her scope looked like. And so that was an axial of her MRI, but this is what her scope looked like. There you go. All right, cool. So this is me probing. When you get tibial wear, the knee's really in trouble, right? So that's a bipolar lesion, we call it, both sides, side bones, shin bones. All this is, is just you gotta actually precisely define the anatomy. Here's the O's plug I was, right there. So the guy plugged the doctor, you know, but that's gonna do nothing if you leave behind a tear like that. That's just gonna, again, that's another letdown for the patient. So we do all these knee procedures, but you gotta go the extra length and you gotta, you know, if you're gonna do it, you gotta do it. You can't just clean it out and see how you do because then people are gonna be miserable, right? And so the centralization procedure just means bring the meniscus back, okay? And it's, you know, you first do these, but these are the people that, by the way, these are the people that send you this shit, man. Because their uncle had it done and he was, you know, he climbed Mount Everest the next day, right? And so no shit, this is from her, right? Right to the heart. I'm like, can you hit my knee or something instead? You know, even though you're getting back golfing with an unloader brace, you know, and so, you know, this is her at one year. I had to go back in because of her kneecap joint. So, you know, to Mike's point, the kneecap joints get so trapped in this. And I have a form now, I even started to send people YouTube videos that get sent to them like day three. I'm like, hey, it's me talking to them. Are you moving your kneecap? You know, and so, and I tell them, you're gonna hate me for, you know, five, six months. And if you do this on a Muslim, I'm not kidding you, right? Because they, you know, pray like 12 times a day. Because you can't do flexion. So they're out praying with one leg. And so, you know, so why not just clean it out and have them do a total knee? So much easier from a doctor's standpoint. But, you know, if you saw her past MRI, I mean, I got the meniscus back, right? And she's actually doing okay, right? But it's a long time, it's a year. And I re-scoped her, but here's the, can you play the lower left one? Almost done here, guys. So, you know, you want the knee, the meniscus is supposed to get the hell out of the way where the knee bends, that's what I tell people, right? And so that's what's doing its job, right? And so here, she had failed a little bit of her radial part. With these, you know, I'm telling them all, look, 20% chance I'm coming back. But if you can heal, you know, the really important part, the rim, those collagen fibers, the longitudinal ones, if you can get those back, we have a chance. And, you know, I don't know if you saw her last MRI, if you remember, it had a lot of bone edema, right? It had a lot of bone edema. And so this is starting to respond. And you hear root tear, another hot topic. I've never heard of it. All a root tear is, is a radial tear. It's just, it just happened to tear there. And I do everything I can to fix these. And, you know, I did this on two of my partners. They didn't talk to me for two years. And so, because, you know, you got to be in the long haul. So if you say scope and see how you're going to do, and then, you know, if not, we'll do a knee implant. I mean, that conversation shouldn't happen, right? But these people need to be absolutely, you know, you got to spend an hour with them in the office. You got to spend a lot of time. But if you clean that out, it's a 80, you know, it's like 60% chance going on to a total knee if you do not try to fix it. And so I, and I've done it all, right? I've done meniscus allograft. Okay, many of them, hundreds of them. And, you know, if you, if you know about these, you know, you take someone, you match their knee up, put the meniscus in. It's not hard. None of these surgeries are really hard. The hardest part, you know, educating and getting the patient on board. But the long-term follow-up, a lot of these meniscus, when I started in residency, or, you know, in fellowship, the meniscus transplants was like, we're going to save your knee. You know, now you can get back to sports and all that. And then it started to change. Well, we're going to get 10 years out of it. And the reason why is because at follow-up, most of these meniscus end up extruding, right? So we don't recreate the anatomy appropriately, right? And that's why. So you have to now centralize these and add to that, right? This slide's out of order, but I've done, I did collagen scaffolds, right? People have a segmental loss. This is the follow-up showing that it failed. So you'll see the first video in a second, and I'm almost done here. So, you know, we talk about the vascularity, right? This is one of the most famous pictures, Dr. Aronofsky, right up here. In fact, Jason, one of my assistants, has a signed picture from him. You know, we got all these athletes and we got this. Because it's, you know, incredible picture. This guy figured out this is why meniscus don't heal, right, because the blood supply happens. But we know there's vascular channels. So yes, if you tear here, it's called a red-red. If you tear here, it's called a white-white. And if you tear here, you know, red-white, white-white, right, so all that means is blood supply. So we love it when they tear out here, because they heal much more predictably. And so, but that's not a reason not to do it, right? So this was the scaffold patient I was telling you about. She had a segmental defect. And so, you know, you sew these in, it's very tedious, right? And, you know, they actually got taken off the market. And so, and it was called a CMI. So we have not done a good enough job. I've put metal in, right? Because patients are always like, especially the guys, like, shit, doc, can't you just put a shim in there or something? And I said, that's not a bad idea. So I did five of these. It was a company called iFORMA, I did a whole trial. And they went in great, but they all dislocated, every one of them, right? Because it just wasn't balanced. Then I tried plastic. I just finished a big trial here called the New Surface Implant. It actually worked. It worked, but they break. Okay, the human body's powerful, right? But these things worked. I mean, I had people that should have been, you know, going on to bone-on-bone, but you put the implant in. I still have one guy that has it in there for seven years. And one guy had it in for six years, it broke. The trial was closed. So I had to do the Compassionate Care Act, you know, to go to the FDA, because he wanted another one. And so, and that's a nightmare. When they make it so hard on all of us, I mean, it wears you out. It won't wear me out, but it wears all of us out. And so, you know, sometimes you just say, just do a partial knee replacement. And so, so the whole concept and the whole idea is, this is a patient actually that, you know, 15 years ago, he evolved his root, and I just cleaned it out. He was in second basement in high school. I don't know if those are playing, but. So I brought him back, literally 10 years later, and I went back and fixed it. So I removed the root. This is a piece of bone. So I didn't know what, I mean, I knew what it was, but I didn't know really, okay, clean it out, meniscus there, right? I should have put that bone back, but I went and found this kid, because I know his father, and this is a long time later, 10 years later or so, he's having more, he's having some pain. He was having symptoms, by the way. It wasn't prophylactic. And I went back and repaired the damn root. Now, I couldn't do it quite anatomic, because, you know, he had lost some tissue, but I restored it, and this is now four, five years ago. I mean, I'm getting old. And he's doing unbelievable, right? And so we have all these fancy procedures, and if you get a guy like this that has a red, red tear, you know, they kind of like you. Otherwise, it's really, you know, we don't have anything really absolutely new, but the anatomy. So, you know, that's the thing you gotta learn. When I was in med school, you know, the kids would come to the anatomy class, they'd pull the body out, you know, and I'd be in it and be like, hey, guys, good morning. I slept with the body, man. I knew that damn thing, I did. I knew that so well, and I think that's what, so anytime a new procedure, a hot topic, anytime you hear that, it is the anatomy, and really understanding what it does, all right? Thank you, folks. Thank you so much. Thanks a lot. Thank you. That's because all the golf you were playing, you know. That's right. I see you. And you're coming up President, too. Yeah. Congratulations. Thanks. All right. So, we'll get going. I'm going to try to go fairly quickly for everybody here. My name is Kevin Bonner. I'm from Virginia Beach. I teach at the med school, as well. I actually have my team over here, Abby and Allison, who are a physician's assistant and athletic trainer, working with me, as well. So, thanks for coming, guys. Any questions during this, please don't hesitate to ask. I really don't have any relevant disclosures related to this. So, I'm going to just sort of go over the basics of ACL reconstruction. So, we'll talk about graph selection, a little bit about LET and ALL, and then some cases. And then, again, please don't hesitate to stop, and we'll try to bring up some different issues. So, graph selection, basically. We could talk about this for literally 45 minutes, and sometimes we will, but we're going to keep it brief. Basically, this is a shared decision-making process, and sort of I go over what influences selection. It's really the patient factors, right? And then, in terms of their assimilation of information, but certainly a big part of it is what the surgeon tells them. I sort of think of, like, graph selection, very similar to cartilage. It sort of depends on, you know, your religion, in terms of where you grew up. Like, if you grew up in a house that's Catholic, you're more likely to be Catholic. If you trained at a center that does all hamstring, guess what? You're going to come out doing hamstrings. And it's the same sort of thing with graph selection. And so, that's what we sort of call graph religion, very similar to other things, because all surgeons sort of give their spiel about what graphed, and now people do more, you know, research and everything. But they're very, very dependent, of course, on their physical therapist and everybody else to help decide. So, the autograph features, and I know, you know, you guys know this, but in general, for autographs, the patellar tendon, that, honestly, I've gone through this evolution. So, literally, Brian and I have been out 26 years, right? We've been doing this, so a long, long time. And I've personally gone through this evolution up and down. When I first came out, I was doing BTBs in everybody. And then, I sort of switched over, went to more hamstrings. Everybody was saying, oh, hamstrings are just as good. So, I probably went through about eight or nine years doing mostly hamstrings, did, like, 1,300 of those. And then, quite honestly, the results started coming out where our hamstrings, especially in high-level athletes, especially in these young soccer players, college pro athletes are just not doing as well. And so, we sort of went back. Personally, I've gone back to patellar tendon. So, patellar tendon, for me, personally, there is, in my mind, it has the lowest failure rate amongst all the graphs, if you go head-to-head. Yes, there are some studies, some of which are underpowered, that shows no difference. But when you really look at it, there's nothing that's better in terms of failure rate. Yes, could there be more morbidity? Yes. Quad tendon, clearly more popular now. I did a quad graph for revisions over the years, but not really as primaries until probably the last five years or so. And that's become more of my preference over hamstring, because if you look at the current data, the quads are probably doing a little bit better now than the hamstrings. And so, you can read lots of these studies. So, we used to say, oh, patellar tendon, one of the reasons we went away from it years ago, it's associated with more arthritis than hamstring graphs or soft tissue graphs. But if you really look at the higher level studies, that's probably not true. And Eric McCarty wrote this. Eric's actually here somewhere as well. So, quickly, patellar tendon harvest. So, everybody does a little bit different. So, typically, we take the middle third. It's a little bit smaller for smaller people, bigger if you're bigger athletes, of course. You have to minimize stress risers. You bone graft it. And there's little tricks in terms of shorten the tendon. So, there can be issues with it especially if people have patella alta, their tendon's long, there can be different issues. But that's the basics. That's Abby right there helping me over there. So, and this is us just doing a quad graft. So, again, there's different instrumentation for this. I will say that in terms of morbidity, it's probably in the middle between hamstring and patellar tendon. I will tell you that some of our quad tendon patients hurt just as much as our patellar tendon patients. So, it can be a little bit variable. I've had some of the quads actually hurt more than the patellar tendon, quite frankly. So, it's not quite the lower morbidity as a lot of people sort of advocate, just being realistic. I think it's maybe a little bit in the middle, but definitely closer towards BTB. But again, in my experience, some of them hurt worse. You can make small incisions and things like that, but it is a very nice, robust graft. And if you look at the current data, the failure rates seem to be definitely lower than hamstring. And some studies, some equivalence to patellar tendon, but some of those are probably underpowered. Now, if you look at, again, this is one of them that was just published a couple months ago. So, quad equal patellar tendon in the study, but less of a risk of revision. So, this is just one of the recent studies. So, there's no question that quads is becoming more popular. You guys, I bet, have seen that. If I have a kid with open growth plates where I want a soft tissue graft, this has become more of our go-to than a hamstring graft, but I would have given you a different answer eight years ago. So, hamstrings, you know, the issue, it was their size variability, it's multi-stranded. There is a higher infection rate, by the way. If you ever get asked, what graft has the highest infection rate? It actually is the hamstring graft. It's actually higher than allograft. Allografts actually have a very low infection rate. Hamstrings have the highest infection rate, significantly more than patellar tendon, for instance. That's why it's recommended we soak them in vancomycin. And allografts, what about allografts? We actually do a fair number of allografts, but we don't do them in young athletes. There's study after study that it is not a good idea to use allografts, and there's debate on irradiated versus not, et cetera, but we don't use allografts in young athletes. There's just a lot of data showing that they have higher failure rates relative to autografts. You know, then it comes to allografts. There's a lot of allografts that go in. I use a lot of allografts. I'm on the Board of LifeNet right now, and there's hundreds of thousands of allografts going in, people all over the world. Where, and if you look at the data, you can see this. This is based on the Moon data that was published. You know, there's a big difference in failure rates when you look at younger people, but as you get older and older, okay, sort of getting into that 35, 40 year range, it gets very close, the difference between autograft and allograft, and again, that's multifactorial. 40-year-olds are not playing soccer as much as younger kids, so there's various different reasons why, but the bottom line is that older people, you can have a cutoff of 30, 35, 40, whatever it may be, but a lot of it is how active they are, too. Allografts can be a good option in this group, and actually, if you look, okay, it's not only 18-year-olds getting ACLs in the United States. If you actually look at this study, over 40% of ACLs in the United States are over the age of 30, and 22, almost 23% are over the age of 40, so in my mind, that's the best group to use allografts if you like allografts, because they can do well. So basically, what I try to do is match the graft with the patient, okay? Do they have open growth plates? Are they a high-level athlete? I used to take care of the Navy SEALs, and I took care of my daughter's soccer team, and honestly, who had the higher risk of failing? It's not the Navy SEAL. It's the 16-year-old girl, okay? That plays a role as well. Do they have a medial-sided injury? I used to not like going to the hamstring, back when I did a lot of hamstrings, when they had a significant MCL injury, because that helps to stabilize it. Again, I've gone away from hamstrings, so it's not as much of an issue, and so there's lots of these different factors that go into matching the patient. I think if we're all honest, we all sort of go through what I call graft remorse, meaning that you, let's say, did an allograft in somebody. They sort of stretched out a little bit. They tore. Gee, should we have used an autograft? Then we come in, and Abby and Allison see it with me. Somebody comes in, their 38-year-old person, who said, I want a patellar tendon. I'm sure Abby's thinking the same person I am right now, this one woman we're taking care of. I want a patellar tendon. I'm still athletic. I know, I know, but I, and then they struggle and struggle after patellar tendon. Like Brian said, their kneecap gets socked in for months, months, months, and they're miserable, and so I think if you're honest, we all go through this graft remorse. So real quick, ACL reconstruction, when to add a lateral extraticular tenodesis, or ALL, and basically this has become more common. If you look, it's because with ACL instability, you get this anterolateral rotatory instability, and sort of the analogy to why try to augment an ACL reconstruction by putting another graft or doing a tenodesis further away from the central pivot, away from the knee. Adnan actually came up with this analogy. It's a good one. When you try to handle your car, is it easier? Do you have more stability of the wheel when you hold it in the middle, or when you hold it on the outside? That's somewhat analogous to putting a graft further away from the center of rotation. It tends to stabilize it more. So that's the general, general, simple principle of adding these LETs or ALL reconstructions, and there's a renewed interest in this. Believe it or not, this is way back, even before Brian and I ever practiced. This was the norm back in the 60s and 70s, before they actually did ACL reconstructions, actually, and I'm not gonna go through. There were about 12 different types of lateral extraticular tenodesis-type reconstructions that were done over the years, but what happened was in the 80s and 90s, this sort of went away. There were several studies done showing no difference. Jimmy Andrews then was quoted saying, listen, if you do a good ACL, you don't need an extraticular tenodesis. Basically, Alan Anderson, who was the president of AOSSM at one point, I remember being on a panel with him about eight years ago before he unfortunately passed away, asking him, he goes, listen, we did the study. You don't have to do a LET. When you look at it now, though, a lot of these studies were probably underpowered relative to some of the newer studies. This started coming out in the news in terms of the media got ahold of, oh, there's this new ligament that was discovered. It's not a new ligament. It's just that we sort of rediscovered it. So why even think about these? It's really the realization that many of our young athletes actually do have a relatively high failure rate, and up to about 25% of them come out of residual anterolateral rotatory instability, and that when you have this persistent pivot shift or pivot glide, that can be associated with negative outcomes and lead to meniscus pathology. And so we do know that there's non-modifiable risk factors, and I'm not gonna go into all of these regarding the posterior slope, narrow notches, malalignment, female versus male. Do they go into hyperextension? Do they have generalized ligamentous laxity? So we do know we have these non-modifiable risk factors for which some of these patients are at very high risk, especially with sports, playing soccer, that we're not gonna change, and should we augment their ACL reconstruction? And that's why this is our current debate amongst all of us about when should you add it and when do you not need it, and this is some of the podium stuff that we talk about now. There is certainly a lot of supportive biomechanical data that supports it, but there's a lot of conflicting biomechanical data saying that it's not always needed, hence the debate. So my sort of indications when to even consider it, it's sort of that high-risk knee, female, hyperextension, they have a lateral notch sign, higher posterior slopes. You may even hear about people starting to do tibial osteotomies to reduce their slope now, much greater morbidity with that, and especially in a primary, we certainly are not doing that. Most people are not doing that in a primary, but something to consider perhaps if you have a very high posterior slope, somebody has a high-grade pivot shift, et cetera. And for us, it's more of that revision patient, especially when the ones before were done well, and say, well, what's the definition of insanity? Am I going to do this again and have the different result? So when a prior ACL was done well, and you're going to redo it, sometimes in a high-risk patient, I think it's a good idea to consider doing this. But currently myself, I do not do it for most of our primary ACL reconstructions. So just sort of a case, this is one of our teams we took care of, this D1 basketball player, and just sort of going through the procedure. You guys have probably seen these, but sort of our typical case. Again, my go-to for our younger athletes is the patellar tendon graft, unless there's a reason not to. And if they say, I don't want to do it, we're not going to do it. We can show you can do shorter bone plugs. We just published a study this year that you actually don't even need a bone plug larger than 15. And we'll sort of mark out our starting spot. And then here we have the proximal ACL tear. Here we have the notch. And sort of just going through sort of our basic technique. I sort of like to mark out our optimal position. So not to get into the weeds, we used to do what's called trans-tibial ACLs, where we used to make our tunnels up through the tibia. We stopped doing that years ago, and we now go through the anteromedial portal. And so that's just something that we've changed over time. I tend to use flexible reamers. You don't have to do this. So there's lots of different techniques, but this is sort of our typical ACL, BTB, in one of our younger athletes, just going through, checking the back wall. I like to check everything, flush out all the bone, and then we're gonna deliver the graft. As we sort of go through, any questions at all so far? Are you guys seeing a lot of your surgeons using patellar tendon for most young athletes, or is it sort of across the board quads? And have you guys probably also seen going more towards quad relative to hamstrings in the last five years or so? I think that's sort of a big national trend, certainly, doing that when you have to do it. And again, quad is still not my first choice in young athletes, but especially with open growth plates, we'll use it. So another case, 20-year-old downhill skier, failed two ACLs before, redoing it. And so this is the case where we're gonna augment it with actually doing a lateral extraticular tenodesis. So we take a strip of biliotibial band, bring it under the LCL, and then we're gonna fix it. And again, she's had two prior ACLs. She was ranked in the top 25 or something for downhill skiers in the world. And I wasn't just gonna do another ACL and have it fail. Here's a 13-year-old, had a distal MCL, open growth plates. And so what we're gonna do here, we're gonna go distal to the growth plate. This is where I'm gonna use a quad tendon. You can see the incision. So in a kid like this, I'm not doing a patellar tendon. I'm using a soft tissue graft. And a stentor lesion is where your MCL flips over the pest tendon. These are the ones that absolutely should be fixed. So this is a good indication that I use for doing a quad graft. And then here's another one. Sometimes with these revisions, we need to stage it. This kid failed two ACLs, had an IT band before. So he already had his ITB used as a graft when he was like 10 years old. And then he failed the BTB, comes to me with a failure. So basically, what am I gonna do? So I did wanna augment him. I did a contralateral. So this is a case where I'll do contralateral BTB, go to his other knee to get the graft. Here's his BTB graft that I did using it from his other side. So this is a third time revision. And this is where we're gonna do an interlateral ligament reconstruction. So this is where I'm using a graft actually to do his ALL because I can't use his iliotibial band to do what's called a modified Lemaire. Remember guys, the graft fixation is initially the weak link. I have a very low threshold. This is a kid as Allison and Abby have seen who was literally like 10 weeks out after his ACL doing sprints. And unfortunately, this is what some of these kids do. So we have a very low threshold to back it up to augment our fixation. Here's another one. I'm not gonna go through this, but doing some of these revisions can get tricky. We tend to go slower on revisions. There's lots of little tricks in terms of doing a revision. Here's again, doing a contralateral BTB. We're filling the metal graft with a biocomposite screw and reaming it out. So lots of different tricks and certainly revisions are trickier. So we're a little bit behind, wanted to catch up. Anybody have any questions at all? I know we went through quickly, covered a lot of things. So ACL surgery is, I do it differently now than I did 26 years ago. Brian, you're probably the same way versus 20 years ago versus 15. And we'll probably be doing it different five years from now than now. But we've sort of evolved over time as you keep up with the literature and what's going on. Yes. Absolutely. Yep, absolutely. In fact, that's very, very common. There are a lot of people who say, listen, don't touch my other knee. Perfectly reasonable to leave your other knee alone. And that's actually a good indication. You get a very robust, thick quad graft. And I think a quad graft is a very reasonable, good revision graft for the patients who had a failed BTB before. Yeah, no, typically you don't limit their hyperextension basically. Now your graft, based on where you fix it, you can capture a need that they don't get their full extension back. That gets in little pearls about where do you tension it, how much tension you put in, but when you add a let or something like that, you don't limit their hyperextension. So all right, here's our program director for that, who by the way round of applause this is a phenomenal program so thank you dr. Rachel Frank I don't give her the stage so thank you everybody all right well good afternoon my name is Rachel Frank from the University of Colorado unfortunately I'm gonna have to run out immediately after just to get downstairs upstairs but I am available anytime my email is Rachel Frank MD at gmail.com happy to give anyone my cell phone if there's any questions you ACL surgeries most common surgery that I do in my practice we do a couple hundred every year I came from a BTB place in life and that's still about 50% of my practice but for my first five years in practice it was close to 100% now I'm about 50% quads so I found quad to be an incredible graft that reduces a lot of the challenges with BTB with equal outcomes but less morbidity but here we're gonna talk a little bit about repair I do have some disclosures none directly relevant to this talk so ACL injuries and ACL surgery are very common there are over 400,000 ACL surgeries performed in the United States annually ACL repair is actually not a new procedure but it's experienced renewed interest ACL repair was actually originally described in 1895 by Mayo Robson via a case report and then multiple other case reports came to fruition and then the great late John Fagan presented the results of his cohort at the Academy or American Academy of Orthopedic Surgeons in 1972 and had pretty good results 83% good to excellent at two years follow-up but then some other incredible surgeons Houston and Sandburg reported on their cohorts and they could not replicate those results so they found actually quite miserable results Houston found that 23% were unable to return to sport that's not acceptable and then Sandburg found that there was actually no difference between non-op and ACL suture repair so ACL reconstruction took over and experienced a revolution over the subsequent three decades with respect to autograft and then allograft and then now a variety of different techniques with drilling and fixation here's an example again of my my experience with the quad I started as a BTB surgeon that's where I trained and then I learned to appreciate quad several years ago and now it's about half my ACL practice and there's a lot of different advantages to quad over many of the other graphs when we talk about ACL reconstruction the important thing to know and you all know this is it's not perfect there's no free lunch as one of my mentors would say it's successful but it's not perfect so what can we do different what can we do better well when we look at return to sport rates if you really look at the literature we all like to quote our athletes we get back at 90 95 percent that just is not true when you look at athletes who are elite they get back at about 83 percent of the time but that's not even 90 percent that means you you can't tell your collegiate athlete who blows their knee you know here at CU soccer I'm gonna get you back nine out of ten times I say I'm gonna get you back at your level of play eight out of ten times four out of five chances are they've had five teammates with an ACL that really sobers the room up a little bit sobers the conversation with the parents it's not fun to have that conversation but if you're humble and you really look at the results this is what happens and then with the weekend warrior the non elite athlete it's even worse when you ask him did I get back yeah they got back did they get back at their same level of play no not all of the time and so you've really got to dive into the details when you look at the papers in addition donor site morbidity it's real there are plenty of surgeons including some of my mentors who say I have my patients never have anterior knee pain after an ACL you all know that that's a hundred percent not true and lots of patients have anterior knee pain after an ACL when you look at different graft choices the data is pretty clear BTB has the biggest amount of donor site morbidity after ACL reconstruction and that's followed by hamstrings so quad tendon actually has the least amount of donor site morbidity and in my experience we're tracking this very closely I've actually not seen any weakness in quad strength and I take a full thickness graft each and every time compared to BTB and I don't really do hamstrings so I don't have any compares it comparative data with respect to ACL reconstruction it represents a stable construct for sure high return to support rate relatively speaking it's reproducible and it's currently considered the standard of care but there is significant donor site morbidity there's potential muscle weakness potential reduction in proprioception it's not their own knee it doesn't feel quite normal and they don't necessarily return to sport at the same level I think the bottom line is like anything else in medicine you've got to treat the person in front of us not the MRI not the diagnosis but the person in front of us I would tell you these are two very different ACLs and before I thought about ACL repair I would just harvest every graft on every patient who has a pivot shift but now on patients that were their MRI suggests that they may have a repairable ACL tear and they fit into some of these categories which I'll get into in just a second I actually put the scope in the knee first and if it looks like the tissue on the right that's a repair every day of the week and twice on Sunday I can't make a graft look better than what that does look at that vascularity and that tissue even with a tear so if I can get that repaired a patient's going to be very happy treatment needs to be customized to the patient with respect to repair we're kind of going back to the future we've already done this we've been through this and it didn't work very well so what have we done differently well we've really understood the mechanics and the biologics with respect to marrying structure with function can the ACL heal you better believe it can especially if there's a proximal 1 3rd tear so those native blood vessels will continue to exist as long as that tear is clean and off the proximal aspect of the ACL so this is my technique in 2024 it's not my technique it's just a technique that others have done that I've stolen but basically we take a case like this we can drill a small tunnel in the femur with the knee hyperflexed white right where you would drill a femoral ACL socket and then you can put some high-strength non-absorbable sutures the ones I like to use are ringed sutures that are retention able I usually put in two in this particular case I put in three I think my implant company was really happy that day but in particular or not in particular in general I usually use two and then outside of the scope what you can do is you can load all of these retention able ringed high-strength non-absorbable suture devices onto a suspensory fixation device and many companies have suspensory fixation devices once all three of those are shuttled onto the suspensory fixation device we can now shuttle that suspensory fixation device into that femoral tunnel the femoral tunnel is either a four or four point five millimeter tunnel so you don't burn any bridges if for some reason this fails at a higher rate that's your ACL repair and then I like to augment my repairs with internal brace suture augmentation we can talk about that all day of the week every day of the week and twice on Sunday but internal brace suture augmentation is just that it's an augment it's not a synthetic it really is a mild part of the repair or reconstruction and it simply provides a seatbelt like safety mechanism for your early cyclical loading following ACL repair and reconstruction and then we do some marrow augmentation to try to help improve the biology so this is a patient six weeks after ACL primary repair and I rehab all of these patients the exact same way I do as a reconstruction we still need that tendon to heal tendon takes three to four months to fully heal and then we need their quad to come back from after all of that healing but this is a patient six weeks out and my challenge with these patients is they feel so good that I can't slow them down they don't want to wear a brace even if I did a meniscus repair they don't want to do anything they go through therapy for about a week or two and then they want to just do all their sports go bouldering go pickleball and go snowboarding so we really have to slow them down and I'm not faking this I'm trying to pull his knee off the table you can always fake an exam but not faking it there this is a four-month lady who's in her 20s one of my most controversial ones because I don't like doing repairs in younger patients but her repair pattern was so good and she came in begging for a repair so she's four months out from her primary ACL or a primary ACL repair and again you're gonna see her exam here full hyper extension great quad you can see she's a tall lanky female with excellent mobility zero pain and then again you're checking her Lachman you can't really make that up and so it's it's a great operation for the appropriately indicated patient here checking her anterior drawer which is arguably not the best test for ACL but I like to combine all of these tests when you look at the literature the literature shows that with modern conventional techniques ACL repair is much better than it ever has been and I'm going to show you some very recent literature to show that with the appropriate tear patterns it's actually comparable to ACL reconstruction this was a systematic review published by Greg de Felice and his group looking at a bunch of different studies with a bunch of different ACL primary repairs and they found that with all of these studies both animal and human that you get with early intervention suture repair stabilization you get good healing both from the radiographic and the biomechanical perspective this was Gordon McKay's group he's really popularized ACL repair from overseas with suture tape reinforcement 42 patients to your follow-up appropriately indicated proximal Sherman type 1 ruptures only on significant improvements in outcome scores decrease a decrease in their activity scale which was a good thing in this case and then an acceptable re rupture rate 5% in terms of other authors other authors have shown the same thing again you're getting the hint here appropriate indications makes for good results if these were blown out ACL as you obviously can't repair those but with these clean proximal tears you can get a really good outcome so the outcomes are if with you have good indications you can get a good result is there a role for internal bracing this is a big question both with repair and reconstruction and this short answer is yes there is as long as you do the technique rate so if I'm tensioning a repair or I'm tensioning a reconstruction the internal brace gets tensioned first with the joint and full hyperextension the graft or in this case the repair gets tension second so that the graft is the last thing to see load and that's how we eliminate stress shielding which is what many surgeons who don't like internal brace suture augmentation are concerned about you will not get stress shielding just from a physics perspective if you tension the internal brace first what about scaffolds or biologic augmentation the bridge enhanced ACL repair technique I'm not a big fan of this although it is in Boston so I don't want to offend anyone who is part of the development I think there's potential for this down the road but I don't think we've shown through the literature that we have superiority with this technique to any other technique and we're trying to bridge a gap and this piece of scaffold has not been shown to bridge that gap yet there's good data to compare to hamstring ACL reconstruction showing non-inferiority but in my practice hamstrings are inferior to BTBs and quads so I don't want something that's non-inferior to something that I think is inferior so good early data and Martha Marie and her team should be commended on the amount of work and effort that they put into this but I don't think this is the holy grail to ACL repair just yet and then finally what about timing of surgery some people wonder well if I tear my ACL but it's a proximal pattern and it's perfect for repair if I tear it can I get surgery three months later four months later do I need to get in right away like any other tendon rupture like a quad tendon rupture or distal biceps I used to think I needed to get my potential repairs in within a month good luck with that when you're booked out for six eight weeks it just doesn't work that way and good thing is Greg DeFelice and others have shown that you can actually do this greater than three months and as long as it's the right tear pattern they should do just fine so I do not use acuity as an indication for repair when you look at updated literature throughout 2022 2023 the outcomes are exactly what I've shown you and this paper is one of my favorite papers right now by Brett Frisch in Australia I had the opportunity to meet him when I went over to lecture there a couple years ago really good surgeon really honest guy with respect to how he does research and how he does surgery he looked at 20 consecutive primary ACL repairs compared them to age and sex max matched ACL reconstructions and assessed all the things this just got published this year and he found that the outcomes were essentially the same so for appropriately indicated patients ACL repair with modern conventional techniques is here to stay so in terms of ACL repair it's joint preserving they have less pain less morbidity better proprioception stable construct we're seeing a high return to support rate we don't know if it will match or be better than ACL reconstruction just yet we've got to follow the data but there is a potential higher failure rate in younger patients you've got to counsel your patients and every single repair that I consent I consent for possible reconstruction if I get in the OR and I don't like the quality of the tissue we're doing a reconstruction so you don't get my OR for a repair if you're not going to allow me to do a reconstruction because at the end of the day you got to do its best for your patient so a couple case examples this is actually that one that I showed you on the video already but this is what the MRI looks like this is a proximal 1 3rd Sherman type 1 ACL tear and a 38 year old mixed martial artist and I've already shown you this so for the sake of time I'm not going to go through the case again but this is a repairable pattern in this next case this is a 23 year old female skier you can see the ACL is again a proximal ACL rupture the tissue looks a little bit more gray though so this is a questionable one so I get in there and here's her ACL dr. Fulkerson what do you think repair or no repair so I put some sutures in and tried to repair it and I didn't like what I saw I'm gonna show you that here I'm putting these through I agree I thought this might be repairable and it's just not looking super healthy for me it's actually looking a little wimpy it's what the kids would say it looks mid looks us you know looking a little wimpy so what I ended up doing here was something totally uncost-effective I wasted probably $4,000 worth of implants trying to repair this ACL if I own my surgery center I'd be kicking myself and probably not even attempt it so if I didn't think it was a home run I probably wouldn't even attempt it because now I don't like what this looks like I wouldn't want that if it was my own knee so now what do I do I do what I also consented her for that's a quad ACL all inside reconstruction and you can see on the bottom right that's that's actually her graft so every case is unique with respect to ACL repair and reconstruction in 2024 my preferences these days are BTB or quad auto for really anyone who wants an ACL graft skeletally immature they're going quad auto history of history of anterior knee pain quad auto they prefer a soft tissue they're worried about anterior knee pain quad auto recreational athlete aloe or quad auto anyone under 25 no aloe but if it can be repaired I am looking for a reason to repair they just feel better and the outcomes seem to be the same with respect to repair if you appropriately select your patients you're going to have good outcomes but the key is indications staying humble under promising and over delivering thank you all very much you thanks dr. Frank I'm Chuck big pin I am going to combine a couple talks I'm gonna give you two stats while he's pulling this up 40 to 70 percent of ACL injuries have a meniscus tear 80 to 90 percent of ACL tears have a bone bruise so I think I want to put that in context I think dr. did a great job outlining all the mechanics of the knee and why saving the meniscus matters so I think what I want to kind of walk through is a little bit on the rehab standpoint of how I think about protecting and it gives me great joy and somewhere dr. Steadman is super happy that everybody's talking about the fat pad because that was his one of his you know just really key things and key to health I don't have any disclosures so one of the things I think it's important this Willis McGeaghy in the fiesta bowl I think tours ACL went back went on had a great career Adrian Peterson Jamal Lewis etc etc that's what our athletes and patients think about however this is actually more consistent what actually happens so Marcus Lattimore was it at South Carolina similar type college running back towards ACL was a little more than that but never really made it back and the point being is that I think we all remember the successes but we kind of try to push the failures back so I think dr. Frank hit it it's not a home run and so when I think about the importance of the meniscus that dr. out when we think about what it takes we have to understand these hoop stresses and what it takes to protect the knee and at the end of the day for me that's all this is about and so it's really about getting out getting out of the gate in a good way so we know that standing in extension seems to be okay and it's actually the shearing of the flexion he did such a good job describing the pivot we think about it it's like a hinge it's not a hinge not a hinge at all it's actually that rotation and pivoting at in range of flexion and loading in particular between 30 to 45 degrees if you don't control it you're not helping the meniscus so then when we think about it I think about when we let people weight bear and walk and what we're really responsible for in that early period and maybe why there's lack of alignment is knee excursion is decreased because knee moments controlled but when you take the quad out what happens you have no control at 0 to 30 degrees and you lose that control and then now what happens to the meniscus as you get into that 30 to 45 degree range where it's most at risk well it shears okay so nice mechanics lesson but I think when we look at the differences and outcomes there's not really any difference in the literature between weight-bearing and not and so if you think about it it's a I'm gonna try to repeat the term you said a micro a macro micro environment is that right close micro molecular because I think it the meniscus is a living organism it needs stress to remodel and so I think my concern is when you go completely no weight-bearing you've taken all the stress away so really our job is how do we give appropriate stress in the rehab so you've really got to get maxed expectations of surgery and rehab and so I think if we think about the discussions and really the really great description of the knee surgeries here's all the things we got to know surgeons gonna direct based on what they see what happens our job we don't have any way to look inside the knee at least not yet hey I'll do that soon I guess but we got to look at pain and swelling change in motion and changing quad function those are my indicators are my dashboard of how the knees doing and ultimately that allows me to match the expectations with it now this is actually my knee wish I had you in 2000 long time ago but when I had a big ACL tear and double bundle was all the rage and if you don't tension like Dr. Frank said it doesn't heal right and you get a cyclops it's really bad and you get a total knee when you're 45 no big deal but being able to understand what happens with the surgery so I think one of the things I appreciate about the opportunity for us to be here and build on this is understanding that allows us to understand the weight-bearing status for the surgeon patient and rehab team to be on the same page for us to understand our early expected knee range of motion and then what are the other concerns there's other things going on with most patients and in regard to their pain control postoperatively and how they manage that we may need to be able to deal with so we have criterion and we've got time and those are the two things that we used and I think of it like an accordion to either expand out or to compress ACL repair young healthy athlete not a lot of other comorbidities and injuries maybe not super high level pivoting cutting maybe I can pull it down pivoting cutting joint damage other things going on now it gets much longer and I think that's sometimes we put these absolutes out there and think oh in X I'll do Y and that's not really how it works the most important thing is to get out of the gate first and if you lose the first six weeks with any knee you're done you can forget it whatever goals you have you can just put them in the trash can because you it's completely unpredictable if you lose the first six weeks and so in this world of insurance and things where we're at if you have to choose where you're going to spend your time don't lose out of the gate because if you lose out of the gate you're done and so when I think about it we've got to control pain and swell and we know that pain and swelling limits quad function if you don't have quad function you can't control the knee so there's lots of things out there that's where the modalities matter and and I realize there's all the don't need modalities oh yeah you do because that's how you win in the first two to three weeks so you've got to get out of the gate do you brace I think it helps as much as anything it puts a some rains it's I grew up on a horse farm so it puts a bit in the mouth of your patient and slows them down now I hope if I could if I could make a brace go away it would be the big blue behemoth because if you see this come into your office you better get ready the knees gonna be stiff and it's gonna have a flexion contracture so I just get ready so just if you take a sock and put it inside the big blue and put them in hyperextension you can fight with it because there's still surgeons that that's what they want to do but if you can you want to be in one of the braces allows you to put them in about five degrees of hyperextension and actually have them live there make your life easier these are the core things that I tell every patient, this is what you owe me every day, twice a day. There's nothing hard. There's nothing complicated. But if they can do this, you'll win all day long. There's lots of other cool things that Mike puts on Instagram, and you can be like Mike. I'm just kidding, Mike. But I think he and I were talking like, those are all great, but you got to do this, and you don't miss this. And at the center, the reason I have at the center is the patella and tendon mobilization. If you get that right, and they understand to separate the fat pad from the tendon, from the patella, no problem. Knee motion comes back easy peasy. If they don't do it, you're screwed. We know that motion loss exists. There's abundant literature that shows when you have motion loss, bad things happen. And those two things go together. So then our job is, how do we keep that together to prevent the long-term degenerative changes? For me, it's simply a hilt. Every time a knee patient comes in, you're on the plinth, knees off the end, where are you at? And we're not starting until you're equal. And so it allows me to set the expectation of the patient, this is how you have to look before we go. Now, what's changed for me is probably 20 years ago, that's what I would do. I'd put you in whatever extension device, and I would crank, and I would hammer. And what I learned is, actually, by mobilizing the fat pad, you're actually able to change knee extension. I don't completely understand it all. Maybe if I understood mechanics as well as you do in anatomy, I'd get it. But because the fat pad gets sucked into the knee, you can't get extension. So actually, what you're doing is trying to get the fat pad out of the knee and to separate the tendon and the fat pad. And so really, it's grasping, as you can see there, I've kind of pinched the fat pad underneath and back and forth. It becomes really important, in particular, depending on where your portals are. So one of the reasons that going at several of the surgeons have offered to come and see is seeing where those portals are, in particular, the medial portal, if they get into the fat pad, no bueno. So you get patients that are super sore on the inside, it's just because they nicked the fat pad a little bit. And so when you have that, you've got to be able to understand how you're going to calm that down and get it. So I think that allows us then to get along. This is two really good papers that have shown really pain induction and really tie together where the portals are and the relationship to the fat pads, if you're interested in digging in. So when I get extension now, it's a much more dynamic, right? I can do that. I can do some easy mobilizations on a plant and get back and extension comes back. And it's much less aggressive than I was probably in my early days. So once I do that, now I can get muscle performance. And we know that at the end of the day, quads are king. It's amazing to me. I've been, well, a really long time, like 27 years now, and we still can't manage to get quads consistently strong. And I think it's because we miss the basics. And so really it starts with not allowing, that's not an acceptable straight leg raise. So I work for ATI, big clinic. I go all over the country. And it's amazing when I walk in, I'm like, really? This is really what we're doing today? And it's all of us. Because you get busy, the patient's not on it. So I think really making sure that this is not acceptable, right? You got to have equal heels and you got to have good straight leg raise. If that's not there, we're not getting off the plant. You want to get off the plant and do fun stuff? We can. You got to give me that. It's really this gating, or what did you call it earlier, Julie, earning gravity, right? You got to earn the right to get off the plant. And so there's lots of ways to do that, really progressively coming in. And I think ultimately clearly defining with your patient what a good straight leg raise is and what good quad function looks like. I will say there's a few things that have come along that I'm like, oh, this shiny object actually has got something to it. And so this has been both personally and professionally with blood flow. It's not overly complicated. I'm not going to go into the depths of it. You can gauge what the right one. We've kind of landed in the middle, you know, $5,000 is a lot per clinic. But I think there's good solutions in the middle. And what's amazing is in this non-operative limited weight bearing, you can get similar response. So there's several really good randomized controlled trials and some very complicated knee patients that are showing just almost unbelievable results. So I think it just really has changed the ability to strengthen the quad and get it back. So having this right early weight bearing pan, because remember, we said bone bruises are there, whether we do anything with them or we pay attention to them, they're there. So how do we manage that? And I think clinically, this is completely anecdotal. I don't know of any evidence that says this. I feel like these patients, that's when the quad shuts down. Bigger bone bruises, those patients seem to struggle with pain and swelling to get it back. So we have to make sure that we're getting that back and getting patients in a good spot because ultimately the ACL is the watchdog of the meniscus and the meniscus is the protector of the articular cartilage. So you've got to have A and B and C. So having that trifecta there allows for a healthy knee. And if we look at the changes that happen in gait, if I have good motion, I've got good quad control, I think sometimes we underappreciate just simple gait stuff. And it's not anything hard. It's just really simple exercises allowing people to learn how to walk again. They lose that. They've been on crutches. They've had injury. How are you going to retrain gait and get folks back? Then that sets us up for a progression to gradually get back. And I think at that point, we get here. We're finally at a spot that we can do fun stuff. But they're also back to life. They're back on their feet at work. They're back on their feet at school. And having had 14 knee surgeries, it swells. You get back on your feet and things swell. And so I think we have to be really conscientious of being able to, we're loading them, right? You're starting to crank up the load, but how many steps are they getting daily? What else are they doing in the rest of their life as they come back? So I think really helping them document. And however it is, most people have some sort of wearable something, right, that they're tracking steps and stuff. So really helping patients do that becomes really important as we progress them back. And just you can see here in a couple of these videos, the patient has BFR. So it's a really great way for me to increase load in a small amount of time without actually I get the effects of load without the load. So then as I transition from phase one to phase two, you can see asymmetrical loading. I'll do some of the things that Kevin talked about this morning with different neurocognitive engagement to really pull them along. Because ultimately what I'm trying to prepare for is what do they want to do? When can I run? I think sometimes, again, we're a little aggressive. Because guess what's still happening? If you're not checking later on as they get 8, 10, 12 weeks, you're missing extension lag because it shows back up. It's this nasty little thing all the way through that keeps showing its way up. And it matters because remember, when you don't have quad control, what happens to knee moment? Knee moment goes up and that's where you get into this cycle of really the knee struggling. So we think about trying to control the ACL and what's there. And I think this is really where we have to make sure we've got the quad control and dynamic controls. They start to load. Because this is where you get a little cyclical loading. This is where, for me, I'm interested in the bare and the other more accelerated pieces. Can we help the quad keep up for the loading that now the biology theoretically can take? And I think that's really our challenges to come into. So for us, it's really making sure we use isokinetics to really test strength. It's exactly what Mike was saying. You got to test, don't guess. George Davies would be proud somewhere. And really come back in a systematic way because these knee strength efforts will come back. My goal at 12 weeks is they can start this kind of stuff. They can start to do more athletic things. So once they begin that, now we're ready to really strengthen them. Not until 12 weeks are you really ready to start cranking up the load. And now they got to train. And from that three month to whatever spot that you're going to let them go back to sport is all about muscle building and being an athlete. It's a different type of training that most, in particular, adolescent athletes have done. So you've really got to come in and take them from maybe what I'll call more of a rehab focus, managing their symptoms and impairments, to shifting them to more of a performance mindset with lots of training. And so the two things that I come back and really ask is how hard are you working on a daily basis? When you get finished, where are you at? You need to be yellow or red every time you work. If you're not yellow or red, you didn't work hard enough today, go back and do some more. And then that allows us to gradually progress because guess what? Life's happening. They've got other things happening. So not only how hard are you working in rehab, but how are you feeling overall? And just literally put it in your phone, create a note, and just write it down every day and let's talk about that. And I think engaging patients in that way allows us then to begin to mimic in more controlled environments and professional environments where there's more staff to look, this very controlled ramp of how do we do that. So whether it's Garmin or Whoop or Apple Watch or Oura Ring, I'm not funded, unfortunately, by any of those, so it allows you to come along. I really like this progression that Darren Padua from UNC has published, and he says, really, I've got to take back relative to their training load they wanted to do before. So if you think about how hard were you working before you got hurt, and now how hard are you working week over week? And I like the way this kind of progresses out and begin to appreciate it as a long road. If we can progress 10 to 15 percent load over a week to two-week period, that starts to make sense why it's such a long journey to take somebody from post-operatively day one all the way back to return to sport. Ultimately, from a return to sport, it's a process. It's not a single point in time. We want to participate. We're going to play, and then you can perform. So you've got to set your expectations, range of motion, strength, movement quality, endurance and power in that order, and if you miss a level, you've got to go back. It's just like if you've got kids and you play board games, go back to jail? Nope. You've got to go back and start all over again. And so having that criterion plus the time really matters. What we've shown is similar to what's in the literature. If you go back to sport before seven months, 17 times more likely to re-tear your ACL. It's astounding. That's what people said. That's what Dr. Bonner said. It's pretty much seven plus months period, and I don't know that it's time. It's just hard to ramp back. If you think about getting all the criteria right, it's hard to get there in time. So ultimately, we have to have our patients exit with a good long-term health knee strategy that includes all the things we've been working on, at least my personal experience with knees and following patients for a really long time now. This is a forever thing. Once you've got it, you've got it, and you've got to be able to manage your knee over time to continue at the high level. So these are just some things. The slides are available, and I appreciate it and look forward to our other presenters. So this will be a super treat. I don't know if he invented patellofemoral, but he did for me. So Dr. Volkerson. I don't know about a super treat. Thanks. No, that's great. I appreciate it. Thanks. Yours is a super treat. So I'm going to go through this pretty quickly. It's getting late, but this is meant to be an update of where we are. Of course, it's more surgically focused because that's what I do and understand, but this is basically most of what I'm going to talk about because I think things have changed a lot. We have a team of 14 people, including engineers, orthopedic surgeons, one physical therapist, students who have been looking at this now for four years, okay? A lot of work. So this slide, I think, is, if you look at this and you look at where we were on the left and have been with two-dimensional images for a very complex four-dimensional problem, you guys are on to the fourth dimension. You're dealing with dynamic problems, complex anatomy. Truth is, it's very hard to appreciate in two dimensions. You take that jump into 3D, you can see and understand so much better what's going on. So for you who are therapists and surgeons, I just really want to suggest that this is the future. You can jump in now, but it's coming because we really need this to understand these problems. If you look at something like this, this is what we call the entry point all the way to the right side on the screen there. That's where the patella comes in. So our focus has gone very much to the entry point for the patella, which is a place where you guys can come in because you can adjust that. If you can rotate the femur back a little bit, or you can strengthen up it medially and you can, somehow it's what you do anyway, but just to show you the rationale, I mean, if you can get everything positioned so that the patella is a little better able to negotiate from the lateral side to get into the groove, that's really what I'm talking about here. We also know that surgically, if you put a graft in to stabilize the patella, that works very well in spite of trochlea dysplasia. I'm not a big fan of trochleoplasty. It does a lot of damage. And basically, what we're finding when we look at the structure is this study makes a lot of sense because if you can just keep the patella in the groove, that's the game, you know? I mean, we don't have to change the groove, we just need to help the patella to be there. So when do we do a tubercle transfer? That's changed now. We're looking at, we think in terms of positioning the patella, which you guys do in your own way too, to get it into that groove a little sooner. If we have a patella sitting too far laterally, we'll bring it over and just help it to get into the groove, that's it. So it's not real complicated when the patella remains lateral in a 30-degree axial view or when we see it lateral with a lateral entry point on 3D. Our goal is let's just help it a little bit, let's get it over and help it. And if there's an articular lesion, we may want to move it anteriorly a little bit to unload it. And if it's too high, we want to bring it down. So that's it, pure and simple. This is a deepening trochleoplasty. This was overdone elsewhere, you know, speaks for itself, but that can't possibly be good. It'll make it more stable, but I think we have better ways. Simple logic using 3D, limited proximal ridge recession. If you look at where that little tiny arrow is in the right-hand view, I mean, you just want to sand that down a little bit. You know, that's it, you know, let's get the patella to enter, stay in that groove. That's all we want. It's like a bobsled track. Think of it as a bobsled track. If you can take the bobsled and you can get it over a little bit so it gets into the track better, then game over, you know. Some people, you can't. One of the keys is, this is one of our studies by Brian Beitler. This is cartilage. We do 3D prints of cartilage. The joint is, even though it's just plastic, it's congruous. Just the fact that it's just plastic doesn't mean it's incongruous. It's just plastically congruous. We don't want to make it incongruous. If someone does a trochleoplasty, it makes it incongruous. Anyway, it's a simple concept, but basically, let's keep it congruous. Let's leave the joint alone. Let's get the patella where it needs to be to engage. This is some of the really cool stuff that we're just really starting to understand. These are contours. We can understand contours in these 3D replications with colors. In this case, the red is more concave, the blue is very convex, and the green is somewhere in between. It makes it easy to conceptualize exactly what's going, instead of taking a two-dimensional transverse image and trying to guess what's going on. Now we can look at the whole track and see what we're dealing with. I give this guy a lot of credit. He really was the one who described, and this was just published in the May Journal of Arthroscopy, the concept of the entry point. I mentioned about that. The other person I give a lot of credit is Johannes Sieberer, who's a PhD student in the Yale School of Engineering that works with us. He came up with this little diagram. It's as simple as that. It's great for you guys who do physical therapy. It's great for us as surgeons. He said, well, if you have a little ball in the top of a mountain, and it's a little bit goes a little too far this way, maybe it's going to get down the wrong side. That's kind of what we're dealing with. It looks that way over and over, particularly when we're dealing with a convex surface. What we want to do is get that little ball and help it to get down on the good side. Good rehab and surgery, if it becomes necessary, we can do that. That's all we have to do. We don't have to deepen anything and change the articular cartilage. Another measurement we do is the entry point transition point. That little green dot is where the patella comes in, the entry point. It's different for every person. You look at that medial ridge. You plot the midpoint between the tips of the medial and lateral ridges, right in between. That's what we call the entry point. That whole area where it comes in is the entry zone. There's a transition point in most people where the patella comes from lateral, and then it quickly goes from lateral to medial, and then it engages in the trochlea. There are different phases to that process. What we want to do is help it to get to that transition point without dislocating, just enabling it. This is kind of what these look like up close. I use the word delicate, but they are. These are very fine, beautiful anatomy here. The patella and this surface are congruous, and all we need to do is just help it. If it was a biopsy, I didn't want to help it get down that track. The rest of this is just, I mean, that's basically what we do, cut the bone and move it. You already know that. Resurfacing. None of this has changed. I think you're all familiar with this. No need to belabor that, but it is important to know that these are two knees, same patient. On one side, which is to our right, she had a tubercle anterior medialization 29 years before. The left side, she never had surgery. I mean, I think this tells a story. I noticed, I think it was Sabrina Strickland on Thursday showed a case like this. I think we know now that tibial tubercle transfers can prevent surgery done for the right purposes. If you get these patellas to articulate and stay congruous, we can preserve them long-term. We're talking about joint preservation. You can do that surgically with osteotomies. I'm personally not a big fan of a lot of complex osteotomies, even though anatomically it can make a lot of sense, but in general, we can do a lot by moving a tubercle. We can just kind of reposition that whole extensor mechanism and then turn them over to you. And usually these people can rehab pretty quickly if they have a good, stable osteotomy. This is just to point out just other aspects, you know, the understanding of anatomy has really improved. This is a medial complex, beautiful anatomy by Robert Smigielski, who's a Polish surgeon, but it's not just a medial patella femoral ligament. When you hear that, that's kind of old news at this point. It's really a medial patella femoral complex, and that's what Miho Tanaka here in Boston talks about, if any of you are in this community, and it's a complicated anatomy, but the reality is that there is sort of a midpoint where the patella goes in, and you can reconstruct that with a medial quad tendon femoral ligament. And again, just anatomy, the adductor tendon is archi-surgically, there's a point right between that and the medial collateral ligament origin, which is where this complex starts. So that's our surgical target for those of you who are interested in that. And then we just fix it there. This is what that surgery looks like. You find that sweet spot where the adductor tendon comes in, where the blue dot is, medial collateral ligament, red dot, and then go right there. Absolutely critical that this be in the right place, so it's important to use the anatomy for any surgeons who might be here, you probably already know that. The radiographic criteria are a little sketchy, they're good, they help, but they should only be used to augment the anatomical, you know, to know the anatomy. Use the radiographic for you to get you in the region, and then use the anatomy to pick the point. Just like an ACL, just like what Rachel was showing Frank, you know, you've got to get it in the right place. You put it in the right place, people generally do well. And that's what that is, just put it in there. And then the other thing that's maybe new to some of you in 2024 is there's a paper on this on Thursday, very low morbidity operation, which is what that paper was here on Thursday by Nancy Park. Put your graft in, bring it up under the VMO, which is that muscle you see on the lower left there. So we bring this up under the VMO. The patella is distal to the tip of that clamp over to the right. And so the graft actually is oriented right to the proximal pole of the patella, but it's all soft tissue fixation. So no risk of fracture. So these people rehabilitate. That's what it looks like. It goes in the same direction as an MPFL reconstruction, but it's just more benign. And it's actually easier to do technically too. This is what we're trying to avoid. So, you know, just tensioning is really important with these. That makes your life easier, our life easier. And of course, this is the goal that we're all looking for is that I think everybody here is familiar with. You know, that's the goal. And sometimes we need the tubercle transfer to accomplish that. Thank you. There's a lot of information on the Patella-Femoral Foundation website if you want to see some updates. And we connect directly to Helio and Slack Publishers. So they are very helpful in getting a lot of very current information out there if you want to kind of stay up on some of this patella-femoral stuff. Thank you. So, I guess, so my name is Tom Ward, so find, let's see the other slides, please. I guess the organizers have seen a few of my talks before, so I figured I'd bribe you with some booze and some food to stay here. Yeah, smart people, that's awesome. So Alan also titled my talk, Token Hipscope Talk. I wasn't quite sure what to make out of that, but, you know, so I figured we'll probably talk about hip arthroscopy, maybe some glute if we have time. First of all, I'm impressed, I mean, how many people are still here at this time? That's wonderful. And I'm thinking you're going to get a German double whammy, right? So first me, then Kai, so, exactly, hope it's the right beer. So yeah, thanks for having me here, it's great to be here, it's great to see so many familiar faces as well, and disclosures don't really count here in this setting for what I'm going to be talking about. So I'm going to talk about hip arthroscopy primarily, if we have time, maybe glute, I know we're running behind, so I don't want to run over. So let's see what we can get through here. So in my practice, I'm seeing primarily hip patients, almost exclusively now. And I just did a knee scope last week, which is very unusual, but that was a hip patient who had a knee problem, so, and I told her, I don't do knee scopes really a lot anymore, she said, no, let's just still do it. So anyhow, the problem, so for me, is when patients come in, they say they have hip pain, I have to figure out where is this coming from. The list of diagnosis here, that's just hip pain, hip specific. So now here, and that's frontal, side, and we can also have posterior pain, but there's also hip pain that's not hip pain, right, can be GI, urinary tract, pelvic floor, there's a lot I'm sure you see also in your daily lives. So it's really about finding out where is this coming from, where is the pain coming from. Patients come in, they got an MRI, there's a label tear, I said, listen, I don't care, and you figure out, is your pain you're experiencing really that label tear, is it the impingement, or is it something completely different. So I just showed you the different types of sources of hip pain, and then also we have different types of patient, right? You have Ron Burgundy here, weekend warrior, he thinks he's still an athlete, then we have high level athletes, military, special operations, ballet dancers, some of the most amazing athletes I've seen are ballet dancers. So you have to really understand your patient, and what are their goals, what the issue is. And in terms of hip pathology, I'm thinking about different layers, the osteochondral layer, dynamic layer with the muscles, tendons, neural layer, spine is close by. So diagnostic workout, okay, we have to put everything together, right, we have to put together the history. So you want to be efficient and good with your history taking. And it's great to see Dr. McKeon here, because I had the privilege once or twice to share a patient, we were in the room together, and the art of connecting with a person in a very efficient and effective way, that was very impressive. And really understanding where they're coming from, where they want to go, and how we get together on this journey together, and how hopefully I can help. So is there a history of trauma, what other sports they're doing, hockey, hockey hips don't lie, right? So, you know, the goalie with a big old cam, so obviously a physical exam, I want to make sure what's the range of motion, what are the positions of stress and discomfort? So a hockey player is very different than a ballet dancer, right? So when I see a ballet dancer, I'm worried about instability. When I'm seeing a hockey player, it's the impingement. Now impingement can also lead to instability, but you know, we don't want to get too much caught in the weeds here. And I also get x-rays, so I want to understand their bony anatomy. I want to see if there's impingement, if there's dysplasia, if there's osteoarthritis. And then a huge and important part of our practice also is image-guided injections, to understand, you know, intra-articular versus paraticular, where is the pain coming from? Dynamic ultrasound, to see, you know, MRIs and CT scans are wonderful, we need them, but an ultrasound can be so much more powerful at times, because in an MRI, you're just, you're laying in a tube, right? But you can take patients with positions of impingement dynamically with an ultrasound. So if you're good at that, it can be very powerful. Now injections, in my practice, I like to have them done in our office. Not just because we can bill for them, no. It is also because the exam after the injection is so powerful. You examine the patient before and then after, so you know the delta, what actually happened. If you tell a patient, hey, listen, go to the radiology department, hospital X, and then somebody's going to do that, they never examine them, they get an injection, and you see them three weeks later, they will not, even if you ask them to keep a pain diary, they will not really remember the details. And this is not about the cortisone necessarily, and we'll talk about cortisone in a different setting, but it's about the diagnostic part at the very beginning, and with an exam, so very powerful. And it's also a powerful tool to build a relationship with a patient right off the bat, because you're not sending them to somewhere else, to some anonymous hospital where some radiologists who never met them has gone to an injection. Now there are times where that is necessary, but overall I think that's an opportunity lost if you send them out for that. Okay, so labeled tear, primary focus of the talk, femorocytopenia impingement, hip pain. As you see, there's other reasons why people can have hip pain, obviously, and it can sometimes be a combination of things. So here, for this talk, chem impingement left, right, bottom, pincer impingement. What happens, that ball and socket joint doesn't articulate well, because it's out of shape, either the ball or the socket side. So what's around this socket, the gasket ring called the labrum, that's connected to articular cartilage, if that gets pinched and impinged and beat up over time, it tears and leads to deteriorating changes in the cartilage. How do we find out some of that? I mentioned the exam, the history, obviously still need imaging, MRI, MR arthrogram. I don't like MR arthrograms, patients hate them. I think we have good enough MRIs these days, so typically you don't need an arthrogram. So if somebody needs an injection, I'd rather have it in the office with the ultrasound. Arthrogram I only get in a revision setting if I'm worried about capsular defects, but I think that's also in the future going to go away, because we can leverage more and more the ultrasound. So and then we have, you know, talking about three-dimensional analysis, right? So in the hip as well, you need to understand that the impingement and x-rays are two-dimensional. So we get a bunch of different x-rays, but a CT scan like this can be very helpful, where we also have all the angles we need to understand the hip pathology or the anatomy. So there's different ways of doing that. This is just one example where you can look at the femur and the acetabulum separately. So label tear, let's say we confirm there's a label tear, and that's really what's causing the symptoms to a large extent. Well then, what does it look like, the labrum, once you're in there? If it's repairable, well, guess what? Repair it. If it's not repairable, two options, theoretically, in my mind, debridement or reconstruction or augmentation. Well, debridement, I think it's a little bit more historical now, I don't think anybody would do that anymore. Maybe a partial debridement at times, but overall, I think it's either repair or reconstruction. Now, if you would be living in Denver, Colorado, the pendulum swings always a little bit more towards reconstruction, it seems. Here and most other parts of the country, I think everybody would still try to maximize the options with regards to a labor repair, if feasible. Arthroscopic OR setup, so now you see all those big torture devices, that's what it looks like in the OR. Why is that? Because we need to get distraction. Hip is a ball and socket joint. We work in between, 10 millimeter space, camera, instrumentation, all this stuff. So we work in millimeters, basically. In order to do that, yeah, you have to pull it out. Traditionally, on the top right, you see a picture of a post between the legs. Just imagine, somebody puts a post and pulls against. Well, there's a lot of real estate that might be at risk here, right? So we might want to minimize the risk of that. Elective surgery is all about mitigating risk. So I switched six, seven years ago or something like that to postless. So use gravity, high friction to get that distraction without pulling against the groin. Portals, so it's arthroscopic surgery, typically have three portals. You see in the back, one more, that's just for very complex cases, typically it's just really three portals. And this is what it looks like. That burr, that ball that rotates and shaves away bone, that's 5.5 millimeters in size. So just to give you perspective, here we're repairing a labrum. So that's that, on the bottom right, you see that structure, it looks a little sausage-like. That is a labrum, believe it or not. I'm German, so sausage, right? And then you want to repair that so it's a nice sausage at the end and creates a suction seal. So that is what we're trying to achieve here. So that's what this looks like with a repair. And then, well, look at that labrum on the left. You saw the other one just now, well, that does not look like a sausage, right? So you can't repair it. You try passing sutures to that, good luck, nothing's going to happen. So in those cases, you could either traditionally or in the past, people would have said, hey, let's debride it. But on the right, you see a graft. So that is donor tissue that's fashioned like a sausage and put in there and fixated. So we're working through a little cannula, shuttle it in. There's a lot going on to make that happen. So you need to have a really good team. I have an amazing PA or two, and without them, I couldn't do this. We have also fellows and great surgical techs. But these are highly complex procedures, so you need to have a good team. It's all about the teamwork. This is what it looks like. And some of you from here, you have probably interacted with Stephen Wright and Alex Wolfe, my PAs, and they're really awesome. So here on the right, you see, it's difficult in this view to see, but you had to provide a little bit of force to get that distraction. So there is a suction seal where the labrum really seals the femoral head, which is that structure that pops out. So that's a labral reconstruction. Just a quick case. We talked about impingement, that asperity of the femoral head, that CAM impingement. So this is a 20-year-old hockey player, has this huge bump along the neck, the head-neck junction. So it's not round. That thing sticks out, right? So it should be nice and round, but it's not. So this is intraoperative. We take x-rays while we're burrowing away and making this thing round. So on the left, you see before. On the right, you see after. So this is 47, so 73 to 47. I typically aim nowadays to below 45, so a little bit more would, in this case, would have been gone. So this is what it looks afterwards. So remember this before, and this is after. So you want to have a nice, round shape, and you don't want to have a shark bite. You don't want to have a big hole in there. Now it should be nice and round. And that's ultimately then the art of doing this right, because if you resect too much, you create instability. The other thing you often hear patients talk about is just the capsule, the hip capsule. It's a confluence of different ligament. Ileofemoral ligament is the most important one. But these are hip stabilizers, right? So see, there's a knife going through a big wad of tissue that's called a capsulotomy. If you imagine there's something big in your body is cut through, guess what? It's probably important, right? So yeah. So you want to close that at the end. So for me, I mean, years ago, there was a discussion about do you close the caps or not? I think mostly that discussion is over, because we all agree that this is something that should be done. There's some cases in stiff hips where you might want to stay away from it. Here you see moving a hip throughout a range of motion after the impingement, that bony bump has been taken away, and then closing the capsule with sutures. Non-operative treatment, well, regarding the outcomes of that, there was some randomized control trials out of the UK where they looked at people only with focused PT and injections versus people with focused PT injections and surgery. All of the groups improved. The surgical group ultimately had a lot of crossover, but the surgical group ultimately did improve more. So I think we're dealing with a mechanical issue of bony abnormality where physical therapy is important pre-op, but I think it's not going to address the CAM, right? So there's only so much you can do. I mean, you saw that big, huge bump on the hockey player. That's not going to go away. So we need to address that ultimately. Again, injections are super important to get people maybe even also through the pre-op. But ultimately, a lot of these patients, so they come in, they've seen six, seven other providers. There's a bunch of different types of injections. Oh, you have a pelvic floor problem, oh no, it's bursitis, oh, all this stuff. And they deal with this and they're in pain the whole time. I mean, for me, the worst patient is somebody who's deconditioned, right? Because the surgery, the hip arthroscopy is a hard surgery not only to do, but for the patient to recover from. It takes a long time. And patients need to be patient. But they're often deconditioned. And so for me, the worst patient is 38-year-old female in a wheelchair with the service dog and the parents are there. And she tells me she has a high pain tolerance. And I say, okay, but she's taking five narcotics. So there's something not connecting here. And then I have to have a conversation. For me, the Gestalt of this patient is more of a dysplastic slash instability type. So I may not be able to help her with the surgery I do. So it's something to really understand. But ideally, deconditioned, reconditioned, strengthen the core, the hip, so they can have a better position to recover from surgery. Often patients say, why do I need PT? I was like, well, because you might get better and you don't need surgery, number one. Number two, if you have surgery, you're better positioned to recover from. Number three, the insurance will not pay for surgery unless you try it. But also, I mean, people come in and say, my hip hurts, my hip, okay. So hip for me is somewhere here. But it's front, side, back, different areas. But you can be deconditioned, have bursitis, or gluteal tendonitis might be the better term. So there's things you have to think about. You can actually improve some parts, maybe some you can't. But I think they will be better off to try. And it helps to actually build a relationship as well, as a therapist, being able to see them before, understand where they're coming from, then they have surgery, and then there's already a relationship ideally, hopefully a good one. So surgery, if non-arbor treatment failed, and I think we can kind of skip all of that. Label tears, I cannot, if there's arthritis, I cannot treat arthritis. I can treat label tear. I can treat impingement arthritis with arthroscopy, no. So total hip replacement. But there's obviously, that's nice, that's a little bit black and white here, but there's a lot of gray, so that makes it hard, right? But questions are asked, where is the pain? Front, side, back? Do you have any back pain? Numbness, tingling? Is there any pain prior to the injury? You know, often I have these athletes who have a big cam, and it's like, oh, it just started hurting. But I had groin pulls for years, and my hip was always stiff, and I couldn't really stretch well. That's been going on for a while, obviously. Red flags, night pain, starved stiffness pain, thinking osteoarthritis, hypermobility, dysplasia, Baton's score of nine, you know, these kind of things, EDS. These are hard. These are hard patients. They need help, but this is not just your run-of-the-mill hip scope. Yeah, wheelchair walker, pain out of proportion. So there's instability probably, not just the label tear. Summary, so again, only if it fails should you do surgery. Hip arthroscopy itself, as a surgical procedure, is one of the longest and steepest learning curves in orthopedic surgery. So you want to refer to a provider who does this day in, day out. As in other procedures, volume relates to outcome, so it's super important. And yeah, experience helps, obviously, and then it's a team sport. The patient, the therapist, and the surgeon, we all need to be on the same page. And if there's breakdowns in communication, that's where stuff goes wrong, and that's where we all need to just stick together. Return to work, desk job, 46, work from home, maybe seven to 10 days after hip scope. Physically demanding jobs, three to six months, work hardening, athletes, six to eight months, six to nine months. I always tell patients, listen, it's like an ACL tear. Recover from that surgery, reconstruction, not repair, I guess. Maximum medical improvement expected a year. I'm running out of time. I wish I could have talked about abductor tears, but basically, first try non-op, understand the pathology. What's important, people talk about fatty atrophy. If somebody has fatty atrophy, so on the right, stage four, that is a lot. It's more white. I say, I always compare it for patients. So the stage zero is just like a filet mignon, I love a good steak. Stage zero, filet mignon. Stage four, A5 Wagyu. There's a lot of fat and fatty degeneration, so you can't fix that, right? You cut right through, basically. So injections, PT as well. The other thing I want to say, corticosteroid injections, not great for this setting. Maybe buy a little bit of time, but I have people come in at six, seven, eight injections with corticosteroids. The tissue degenerates. That makes, ultimately, a surgery harder. So if you have a partial thickness tear, dutiltinitis, PRP is a great option. Dr. Walter Sussman back here, worked closely with him. He has a great team. He treats these people wonderfully. So we're going away. That's, I'd said, hey, keep the injection there, PRP with him. And Tenex. There's other things. I wish he could talk today as well, but there's so many things we work together. Corticosteroids, that's just only one thing, and it has its application, but I think it's shrinking. So failed non-arbitrary treatment. You want to leverage the injections. High-grade partial tear, you can do this endoscopic. Full thickness, large retractive tear, I would do open. And then chronic fatty degeneration. Maybe you'll allograft it. Maybe you do some augmentations or glute max transfer, but it's not a good position to be in. Here, a quick video. This is what you do when you do an endoscopic repair. Just like a rotator cuff repair, basically. So is Dr. Curtis here? No. Irene is here. So yeah, you know what that is, right? So prepare the footprint, like in a rotator cuff, and then pass the sutures, repair it. So good outcomes, comparable between open and endoscopic, just a little longer incision. But otherwise, recovery is the same. So thank you for your attention. Just a quick pitch, ISHA, International Society of Hip Arthroscopy, we're organizing a big meeting. We have a separate PT program as well. And advanced practice providers are also physical, for the PAs and NPs. In October, I know it's not around the corner, it's been an amazing meeting. So if you have time, want to come to D.C. in the fall, that's it, you can come. Thank you. I'll just put in a shout out, Mike Boyd and several other people.

Orthopedic surgery

Physical therapy

Rehabilitation techniques

Shoulder issues

Knee issues

ACL injuries

Hip issues

Referral network

Surgical techniques

Instability

Labral tears

Rehabilitation programs

Scapular dyskinesis

Meniscus function

ACL repair