That's what it looked like. And she was treated MRI at an outside facility, actually. But here, there actually is something to see off the humeral side, as you can see. And she's young, right? So what to do in this young thrower, softball player, young age? So nothing. And so she was just treated nonoperatively. But she continued to have pain with use, pain with valgus stress testing when she came to see me eight months, I guess, later after her initial injury. And I think the question, the reason they sent her up was, now you can see there's a calcification that's formed on the medial side. And gosh, what do you do with that? Some open growth plates. She's now approaching 12 years old. That's really not a huge issue at that age in a female. But what to do? So I guess any thoughts? Again, she's having pain with valgus stress testing. I can't actually get her to open up. We did floral her. I maybe thought it maybe opened up on the humeral side. But the parents, particularly the mom, was concerned that she's having pain. She can't throw without pain. So she's 12 now, I guess, eight months after initial injury, some calcification there. Any thoughts? Anybody have any thoughts of? Has she had to give up sports because of this? Yes, yes. Did she have ulnar nerve symptoms? She did not have. That's an excellent question. She did not have ulnar nerve symptoms, Josh. And her pain seems to be medial instability. It's not like olecranon pain or anything like that. Correct. Good point. When you have open growth plates, some of these kids have a stress fracture or a fissile injury. But we did not get a bone scan. But on the MRI, those cuts did not light up at the fissile. But these are all important things to think about, the ulnar nerve, fissiles, young patient. But she continues with pain on the medial side and calcification. Anybody from the panel, any thoughts of Michael? Yeah, I'd probably get an MRI arthrogram to see what's left and what her UCL looks like. I did get an MRI at that point. I don't think I have it here. I'm trying to buy time here, because I don't want anything to do with this case. Who wants a 12-year-old with two parents attached to them? I can't take it myself. And she's also a Greco-Roman wrestler, whatever that is in a 12-year-old, right? Professional, actually. No, I'm just kidding. So what we did do, and I had the, I assumed, and based on the MRI, that the calcification was these young patients, everything calcifies as they try and heal. And so the calcification was just the ligament. It was not a bony avulsion. And I did a suture bridge technique of repairing the ligament back to the humeral side in a technique that has been published by others, Jeff Douglas, a very similar technique. I ignored the calcification, the soft tissues. I didn't want to cause taking that out, I think, would have left a defect. And there was still some soft tissue in that area that allowed for healing. And so I really just, it was a fairly straightforward operation once I decided. And I put the anchors in, kind of thinking of not affecting the growth plates, even though I don't really think we need to care at that age. Very close to fusing in a female anyway. Did you do, like with your suture bridge technique, did you do an internal brace and span it? Yes. Yeah. Yeah. I think that's a key thing is in, well, I don't know. In a 12-year-old, they heal like chameleons or whatever. Possibly just the repair. But I also, using the three or five anchors, I think that most of us use in the throwers, just repaired that back. But did have the brace going across. And I think that because I did that, I was able to be a little bit more enthusiastic. But something I don't normally do, I spun it for six weeks. I had her in a cast for six weeks. And I wasn't too concerned about that. But that's a fairly long time, at least for me, to spun someone. I just didn't trust this professional Greco-Roman wrestler to not to start doing handstands and that kind of stuff right away. But afterwards, she noticed the x-ray, still showing the calcified soft tissue there. But her range of motion is usually the case because we're doing an isometric operation. We're not going anterior. We're not going posterior. We're going sort of an isometric axis of the elbow joint. So usually don't get stiff. And I think I had her range of motion here. So there's an incision. So she's straight, you know, whatever. And she did fine. She got back to softball and Greco-Roman wrestling. I think that's outstanding because, you know, I think you look at that calcification. And one thought is, well, that thing's contracted. I have to reconstruct it and do a full Tommy John. But at 11, like, her healing potential is so good, you know? So just a primary repair in those young athletes, I think, is a great option. That's outstanding. I think not confusing the calcified part. Like, I peeled it off with the 15 blade and just not trying to put that piece of bone that really isn't a piece of bone back off of the humerus. Yeah, that wasn't an avulsion. That was a calcification within the ligament as a subsequent response later. So that's why it was floating still. But yet you had continuity with the humeral end to its insertion point. Exactly. Excellent point. So we had the whole ligament. One point on calcification. So if you have a pitcher that has a calcification of the ligament and they have a UCL tear, as you excise that calcification, you'll have tissue deficit. And so that is an indication in our practice to do a hybrid with a reconstruction of the internal brace. Thank you. The question for the room is, when you have a weight-bearing upper extremity athlete like this, a gymnast, and female wrestlers are now becoming more and more prominent. I'm sure you guys are seeing them more in your office. With an acute UCL tear, is this you guys treating these non-surgically first and they have to fail with symptomatic instability? Combatant athletes, or are you going to repair or reconstruction? What's your first line of treatment when they walk in your office and they're 17 years old and they're going to be a college wrestler and they've just incurred an acute traumatic UCL injury, assuming the lateral side's intact? So in that scenario, how many of you are going to try and brace them and rehab them? 17-year-olds, collision athlete with an acute avulsion. Who's going to brace and rehab? I think about Glenn Ross. I think he's here somewhere at the Naval Academy. Why don't you stand or talk about your study, Glenn? Yeah, for most simple dislocations in younger patients, you want to see them, prove to them that they're going to be, prove to you they'll be unstable. The majority of them, especially the non-throwers, are going to be. I think that I totally agree. I think the throwers and the gymnasts, I've become more aggressive with fixing it early. Because a lot of times they won't, if it's their throwing arm or a gymnast, they probably are going to stay unstable after an injury like that. But if they're not a thrower, it's their non-dominant arm, I think those can be treated really well, non-operatively. And they'll be fine, even if they're a little bit loose, like it won't affect their sport. Do you want to pull up that other side deck for us, guys? The problem with the combatant athlete, though, is you can't really put him in a brace to compete, because if they're wrestling, that's going to be their target. So in my experience, I tend to be more aggressive and proactive. I could be wrong with the repair early on these group of patients, but that's a picture. So a couple other additional cases. First off, just to set the stage, how many people take care of elbows across the entire room? And keep that hand up, how many people do shoulders as well? OK, so we got a pretty good mix. For any that take care of elbows, this is what I've often termed humble pie. I've never had somebody where I've immobilized them six weeks in a splint and not have just a catastrophic result. So my applause to you on being able to execute that and have the faith that you could get it back. So we had a little bit of a mixed bag of shoulder and elbow cases. This is case one. So a 22-year-old male, first baseman. He had a swing-related injury, onset of pain, and was unable to resume physical activity. He's our starter. He's a pretty high-performance athlete. These are his range of motion parameters you can see here. Josh, what do you think about his physical exam? I'm trying to see how you're looking at that, but his motion looks, he's got a posterior labral tear with a batting injury. Yeah, so pretty classic presentation for a batter's shoulder. Mike, you've seen this in your office? Yeah, definitely. I think that story is great. And so when somebody comes in complaining of posterior shoulder pain, especially if it's their lead shoulder and they're swinging, and you ask them, did you take a really hard cut at the ball? Did you notice it after a swing? And that's usually what happens. So for those of you that don't know what batter's shoulder is, it's a posterior labral tear, usually in the lead shoulder when they follow through, and the shoulder goes right out the back. And a lot of times, they'll recall swinging really hard at one. Maybe they miss, and then they get this posterior shoulder pain. Yeah, so pretty classic. You don't really see much on radiographs here. Dr. Rosano, what's been your success with managing these non-operatively? Not great. Not great. I mean, it depends what happens. Obviously, if it happens in the middle of the season, we'll try to get them through the season, but most of these, they still have pain, discomfort, as they try to swing. And obviously, the amount of swings that they take at the collegiate and professional level are quite high. Thanks. Yeah, I'll stick with you for a minute then. What do you think of these axial sequences on the MRI there? Can you describe where you think the zone of injury might be? So he has the posterior labral tear. Trying to see where on the coronal here. Sorry for the fuzziness on the screen. That's all right. Pretty classic posterior. No major curveballs. Obviously, we were looking for any cystic change, any associated fluid collection that might lead to impingement on the neurovascular structures. But this is a pretty classic badder shoulder. So what would you do for this gentleman? Josh? Well, to me, this is a surgical procedure. So get in there, fix him, and see what else is wrong. Take care of the cartilage that's probably associated with this as well. So he says, and his advisor would like to know when he's going to be able to play, and what should we declare to the teams that might or might not be interested in him about the morbidity of this? I would say six months is probably a return to play reasonable, assuming an uneventful postoperative course. And I would not necessarily say this is the perfect injury, but I would expect robust repair with this tissue and a high rate of success. Mike, do you have any numbers that you lean on when you talk about success rates with these types of athletes and being able to resume unrestricted play? Yeah, I tell them five or six months. I can tell them they can start some gentle swings at three months, but nothing hard. But by five or six months, they should be back playing. And I think Jim Bradley has shown a high degree of success with this. So I tell them 90%, which is upper end of Bradley's numbers, but I think Bradley showed 85% to 90% success with his post-sure labral repairs. Justin, mark that. That's five minutes in. That's the first Jim Bradley reference. I thought it was going to go much shorter than that. Any words of wisdom to contribute from? Ask him how they do it 10 years, though. Don't ruin our shine here, OK? Yes, please. 1.2 is, I think, Andy Sheehan mentioned it in our session. When you do these, you want to make sure not to grab too much of that posterior capsule because that's when they get stiff. So you really just want to grab the labrum. Can you talk a little bit about how you're getting this guy through the season? Because you're probably not trying to fix this guy in season, potentially. You're injecting cortisone once, PRP. What are you doing to adjust, perhaps, his swing or something to avoid that outside pitch, move up in the box, crowd the play a little bit? What are you telling your guy? In terms of swing, there's not really a ton we can do. There's not a lot of bracing options. I think you've got a couple things you can emphasize. One is focusing on optimized scapular mechanics. Two, I think trying to work on some overall cuff backup stability. But mostly, it's maintaining your safety net options. For me, that's MedDRAW Doseback. That's a routine anti-inflammatory. It's trying to avoid him laying out for any ground balls. And then, truthfully, just trying to get him to the offseason, unless he's just not able to do it. In which case, we pull his card and operate early so that we can get started early in the fall. But everything's seasonality, right? No head first diving for base. So they shouldn't try and dive for a base when they're running the bases. We talked a little bit about 360 degree access. I think that's an important learning point. We're just going to run through a little bit of this technique, most of which is redundant for the shoulder session. But for those in the elbow, you can see this is a lateral cubitus position. This is a right shoulder. You can see that drop off there posteriorly with this stair stepping sign. Once you do a mobilization, I like to do that from the anterior superior quadrant. Then it's really you want to get to a nice bleeding surface, remove some of the fibrillations and segmental tissue. I like taking that rasp and creating that nice bleeding surface. And then, ultimately, it's establishing your 7 o'clock portal. I agree with what Andy alluded to in his session, which is that you want to make sure that you get access around the shoulder. But make these percutaneous portals so you can instrument and access all the areas where you need. My preferences for using knotless constructs and then using this long 8-2-5 cannula because that allows you to get through this fairly muscular and stout tissue. So you can see dual portals there in the back. Then you can see we are just going to just plug and play. This is the standard knotless approach. You can see us struggling to get that repair suture and then standard shuttling. I think probably more importantly is seeing where you grasp that tissue. And you can see you can just advance that. You want to get about an hour lower on the clock face and advance it up. And then, to Mike's point and Andy's, you want to make sure that you titrate your capsular repair to your athlete, to their activity, and what their baseline is. If it's a thrower, you definitely want to scale that back a little bit. So I'm going to skip forward a little bit in the interest of time and just show our final construct. This is a case where definitely we look at re-tensioning that. You want to remove all those twists. And then the final construct you can see is shown here. We get at least three or four anchors below the equator. And in this case, we had a pretty good functional result with resuming batting activities in the fourth month, doing some throwing progression about four and a half months. But this is not just another bank art. You need to get this person into a gunslinger position. You need to make sure you're getting scabs activated early and just try to keep them patient throughout the entirety. One little technical tip that on Brian's video, he hadn't cut all of his sutures. So you can leave the one anchor before, because once you put the subsequent anchor in, you can re-tension the one before it a little bit. And it always tensions up another millimeter or two. So with those knotless type anchors, I think it's helpful to not cinch it down and cut it. But cinch it, leave it, put in your next anchor, and then go back and re-cinch the first one before you cut it, because it's always going to tighten up a little bit more. So he had a pretty good result. And case two, so we'll go south, right? We'll go to this athlete. You can see javelin thrower at a rival university in our area. And he sustains, he's probably got a couple of years of prodromal symptoms. And then all of a sudden has a pop, onset of pain, unable to compete. Josh, what do you think about with this athlete? I mean, this is UCL written all over it. So the question is, what's the history? And you said it predated for a while. What's the UCL tissue and quality look like? So those are my considerations. Could you advance that for me? All right, so here is his imaging. Are you getting contrast on these routinely, Josh? We talked about that in the other room. And some people are turning towards no contrast. I typically still get contrast. I like contrast for the purpose of seeing the sublime tubercle. It'll elevate off. And I know those prognostically are a little bit worse treating when they're partial injuries. So I still get contrast in my UCLs acutely. Yeah, Mike, any difference? Acutely, no. But if it's been over six weeks, then yes. Anthony? There's been a big push for a lot of the MLB to go away from contrast. We still do contrast on everyone. We get a fever view as well. Yeah, yeah, great, great. Some specialized sequencing. And I can't get imaging within two weeks where I am. So that's just the pace of where we practice. So I'm sorry. I can't get them right away. But I do agree within two weeks, you do not need contrast typically. Yeah, Dr. Steinman, what's been your experience? Kind of moving away from contrast, but I understand in individual players, how is Potter at the HSS is really with the newer machines, really don't need contrast in the elbow now. But I guess each patient's individual. Yeah, I think the one circumstance where I've thought about it is where the MRI is equivocal. And maybe if I want to see if there's any delamination or T sign, those are probably more subtle injuries. And Chris Ahmad would call that kind of a failure in development or continuity. So that's probably been the only case where I've done that routinely. So options. Here's our panel, our menu of options. Dr. Rosano, what do you think? Is this a guy that you're going to get your special sauce of PRP and pray? No. So if you look at UCLs, anything distal on a UCL doesn't do well with. Obviously, biologics is the full thing to stare. There's fluid, diastereosides. The repairs have been in vogue now. And I think there's definitely a role for them. We still do a lot of reconstructions and a lot of hybrids. I think when you're looking at athletes that are collegiate or professional athletes, it's about time. And we could predictably say with a reconstruction, this is when you'll be back throwing. And that's mostly baseball players. So I think when you look at that, the repairs are great. I think they're doing well. I don't know how they'll do long term. Revisions are a little harder because now you have an anchor there. So I think we've done very well with our reconstructions and our hybrids. Mike, this is a junior. He's a javelin thrower. Mom says he's not going to do a fifth year, so no COVID year for him. He wants to go to business school afterwards. He'd like to compete next season. You saw his MRI. Are you offering him a repair or reconstruction based on that? Repair with internal brace. OK, Josh, anything different? Javelin throwers have a little bit more stress. And I don't know any data that would allow me to hang my hat and say repair brace. But repair brace is a nice option. Time-wise, I think it's the only option you have, though. So you kind of have to walk down that road. So yes. Yeah. And obviously, I think that's what you need to talk about, the seasonality, the timing, and then I think really the ultimate cost, mostly with UCL reconstruction. We know it's the gold standard, but it comes with some morbidity in terms of time and increasing rates of secondary operation or revision. So nothing fancy here. We do a repair as well. For those of you that are interested, Corey Edgar and the team at UConn have actually established a special javelin-specific return to play rehab protocol, which was awesome. We utilized with him. We actually made some of our additional modifications, but a standard tendon splitting approach. Fix the site that's damaged first, then go ahead and tension it. Josh, what are you doing for tensioning on this? Are you hogging on it? Are you placing a freer underneath it? What's your right level of tension for UCL repair with internal brace? Tiny mosquito, 45 degrees. That's my tension. I want a little space between it. It's not a load-bearing device, but it's got to mimic that of the ligament as well. So there should be something small and minute, but not loose. Mike, do you incorporate sutures in to bring the native ligament in with the tape, or do you leave those as separate entities? I do pretty standard technique. And on your video, you want the anchors 15 millimeters, so you want 16 millimeters of tape going in the tunnel. So if you put the tip of your anchor at your tunnel and then pull it up, you can mark it with a marking pen at that laser line, just proximal to the anchor. And then I put a freer underneath it, just like you're showing. And then once it's down, I take a Vicryl, and I do a mattress through the native ligament and through the tape. So pretty standard. Chris Ahmad has a video online showing that. And I pretty much do that technique. He's a pretty smart guy. Anthony? 45 degrees of flexion, supination, and close the joint down. We close the primary ligament down or repair it first, and then we tension it without a freer underneath. What do you think, Dr. Steinman? You've seen this evolve over time. Talk to me about what you're. I've made them too tight. On the lateral side, you can really make them too tight because you can just push the radial head up if you're doing instability there. So typically here, it'll hook in, but you can still make it too tight. The problem is make it too tight, and then start doing therapy, it'll pop. It'll pull the anchor out. So I do the exact same thing with the freer, just as Mike was saying. Great, that's two cases. Looks like Dr. Field here. Do you want to make some announcements or you want to stop it here? Well, I think just for everybody's benefit, we probably should kind of wrap it up in the next few minutes. Scott, did you have another you want to do quickly? Yeah, so I think so. That's OK. You can finish this case, and then I think we probably need to let everybody do their thing. Let's do it. All right, any final words of wisdom from Dr. Steinman? Maybe we can just run down the panel and just offer our one pearl about the throwing elbow. You can make it too tight, I guess, like I said. Yeah, which is interesting because we find a trend among certain subsets of throwing team physicians that are putting it to the max and then cycling it. And if it's not too tight, then they buy it. Maybe that's the counter-argument, what you're saying is. Because we've done, just as Jeff Dukas in the anatomy lab, and I have popped out the anchor, showing the fellows, look at this, see? Once it gets loose, you've lost the game. Yeah. Josh, return to play considerations, or maybe one other pearl from Kara, the UCL, or the throwing athlete? Return to play is depending what we do, but that's the compelling thing between brace and reconstruction. So I still have a hard time adapting Dukas' protocols with three to four weeks, throwers 10, six weeks, advanced throwers 10, and plyometrics. And then interval, typically, at 12 weeks. And they're back on the mound in six months, four to six months. I'm trying my best to follow the protocols when I do a repair and brace, but that's the big difference for me. And then the only other thing, too, is I find that these athletes have shoulder issues and postural issues and kinetic chain issues, flexibility issues with decreased frontal flexion or total range. You've got to look at these people holistically. And it's not just the ligament between two bones that are making the connection. And you have to have an excellent physical therapist and a team that works with these athletes. It's not our time in the OR that makes the difference them returning to play. It's a team approach. So that's my pearl. Mine's the same. It's make every thrower you see with an elbow injury do a single leg squat. And they can't, because it's a kinetic chain problem. And they've got weakness in their hips, weakness in their core, and the elbow's the last link in the chain. And that's why it fails. So if you get every thrower to do a single leg squat with mom and dad in the room, and they can't do it, and they wobble all over the place, and you prove to them whether they need surgery or not, they need to strengthen their hips and strengthen their core. That's exactly what I was going to say. I mean, I think the biggest thing, whenever we see an elbow, it's usually caused from the shoulder. They lack internal rotation. They have poor scapular control. And a majority of our rehab for Tommy Johns is based on their shoulder. Another thing is a throwing therapist is the best thing that's ever happened to us. Send your therapist down to Andrew's and let them train them up every year.

elbow injuries

surgical techniques

UCL repairs

physical therapy

young athletes

kinetic chain