All right. Good morning. And I think you can hear me. So, good morning. And, hey, Mike, thank you for inviting me. I really appreciate it. The faculty is really just phenomenal faculty, so I'm honored to be part of that. And with that, we're going to talk about something I think is problematical, at least in my practice. This is my disclosure in Finite Academy. So, this is a 17-year-old right-hand dominant volleyball player with chronic shoulder pain. She's a year-round competitor, as you might anticipate, elite level. She's had pain and problems for over two years. She didn't really have instability as my shoulder pops out, but she's got early fatigue. She's got dead arm, not much strength, not much accuracy. And on the Winn-Davies, you know, you're baiting, you know, whatever you like to use, she's got three of five. She's thumb to forearm, elbow and knee recruvotum. And let's remember that laxity is not synonymous with MDI. Laxity is laxity. Symptomatic laxity is consistent with an MDI diagnosis. Here you're going to see a sulcus sign on this young lady. Here we simply just pull down a little bit and she opens up. This is CHL-SGHL, and we'll go in and externally rotate her. And in that process, you'll notice that her, we externally rotate here and she still opens up a bit. So, we know there's some leg lax going on. We turn around and we look at her scapula and you see right away that right scapula is sticking out a bit. And this is despite a lot of rehab. You can see the dyskinetic pattern here. And this is something that Ben Kibler, I'm sure, can shed light on, but this is a sort of a common problem or pattern we see here. And she's been through rehab. So, the question is, is this causing it or is it the result of? And I'm sure we'll have that discussion. Imaging, she's got a passive capsule, as you can see, with contrast. And so, she's had PT. She's been a very good program. She's been a very good patient and the benefits have been very limited. She's had a steroid injection with, again, limited benefit, and she can't compete. So, she's kind of out of the game despite all of this rest and all of this rehab. And so, for the treatment alternatives that start at the table, there's more conservative treatment, doing an open capsular shift, an orthoscopic limited thermal, prolotherapy, orthobiologics, even the pacemaker that Marota's talked about. And with that, I'll ask you all to get started with your table discussions and then we'll go from there. Thank you. Probably as much as, yes. Okay. So, she's very weak. She's got pain, obviously, but she's weak. Fatigue's early. She can get her arm overhead, but she's weak. She fatigues early. She kind of loses accuracy. So, I'd say probably pain and early fatigue are the two big ones. No. No. So, no clicking, no popping, no subluxation type episodes, just weak. And again, fatigue's really early. Like, you know, she's in and then suddenly after like, you know, five minutes, she just, you know, can't hit with any power. Okay. We'll get started, Mike. We're good? Okay. So, we're going to go in again. So, on your way up, I'll throw out some interesting, we'll get into all these conversations, but just before you jump into exactly what you did, a little more depth on the conservative management. Okay. Well, Buddy's going to ask me a question I can't answer. So, go ahead, Buddy. So, I'll tell you. So, yeah. So, she did not go through one straight ear rehab. So, she probably has been through rehab. I mean, saw the rehab for probably out of two years, a couple of sessions of three months. I mean, really good rehab. And then she, in that three month period, one time for two months, she didn't play at all. So, the longest time she was off was two months in a three month period of really good rehab. She wore a scab shirt or, you know, Intelliskin type shirt, but she did not do taping in the truest sense. And that was, that's pretty much it. But she had several sessions over a two year period, but not one year straight. I would say, you know, I'll be honest with you. Yeah, no, no, no. Well, the answer is, I'll be honest with you. I don't think I even looked at that. I wouldn't say her pain was more, I'll tell you, more anterior biceps region primarily and some posterior, but I wouldn't say around the coracoid or in that region. And with that, so I think the tables may be, how do you want to do this? So, you know, let's ask, we'll start with this table here. And so, what's your decision? What are we going to do? Can you stand and can you just face everyone? Because I think they hear you better. If you'd like, you can come to the microphone if you'd like and just tell us what your table wants to do. My guess is you'll probably be in concert with a number of the tables. So, we talked about first doing some non-op stuff, continuing to try and diagnose other problems. Talked about different kind of ultrasound guided injections to see if there's another area of concern like suprascapular nerve before jumping in, especially because she didn't have a labral tear. It was really just the capsule and before jumping into surgery. And then we kind of were talking about going the arthroscopic route and doing a capsular shift with the rotator interval closure if we decided to do that after the injections. Thank you. Great job. And so the next table, anything different? Steve, your table, anything different? So, you talked about a lot of the same stuff. We actually talked a little bit about background stuff. So, you know, there's some discussions about, you know, pathological accidents like EDS. We talked about that. We talked about some mental components for some of the catheters and some of the conditions. And then we talked about treatment and literally the indications for treatment that we discussed was focused pain, kind of more posteriorly and anteriorly. And then pain that was simply extended beyond volleyball into the brain and my cell. And I think there's fairly good consensus that we would operate on a good and likely arthroscopic procedure. You talked about injection and there was a little bit of back and forth there. I'm curious to get the faculty to weigh in on what the role of an injection may be to diagnostically if there are a few of these things in common. Okay. All right. Can I ask Albert, just to answer that question, do you use therapeutic injections at all in this situation or diagnostic? Okay, great. The one message I want to get through is that, still in my town, this patient often gets a subacromial decompression. And that is the worst thing in the world for a young athlete to ever have. So, you know, shoulder, cuff pain, they always come to me and they say, oh, my doctor says I have impingement, I need to have a bone spur removed. And it's like, kiss of death. Yeah. Well, so the reason you give the injection is so their rehab is more efficient. That's what I do, because they have that secondary pain, you know, to sort of prime the pump. But I never give the injection thinking that that's really the issue. But they just can't get started. And that injection helps them. It does, but, you know, we all know that that's not really the diagnosis. Do any of the tables have anything to add beyond sort of what you heard, which is sort of the general, you know, background of these patients that are difficult? And this is true MDI. And we're going to go through a couple slides here, but I think sometimes the literature confuses MDI with trauma superimposed on someone who's loose-jointed. And that's a very different group. Can you say just one other question? Does she have true apprehension in a push-pull test that's positive for reproduction of the symptoms? So she's got more than one direction of stability. No, no. I hear off in the back of my head saying, let's define our term. So she does not have apprehension in terms of true sense. She has pain. So I bring her back. It stops. It hurts. It's not that, oh, my shoulder's coming out. And push-pull, I'll be honest with you, I don't do push-pull because to me it's been a relatively ineffective test for me to make decisions with. Now, do you do that on a frequent basis? And does it actually help you? Maybe not in this particular patient. It's going to be laxative and positive. Yeah. Yeah. Professor Arciero. So even though she's not complaining of overt instability symptoms, the term dead arm syndrome actually developed by part of a group to describe painful self-decision. So the patient may not have overt apprehension. A labral tear, a superior portion of the labral tear might be needed to get on a syndrome. But it's, it's, it's, it's pointless way, especially when they, when they strike the ball, or they hit the ball, or they release the ball, then, and whether it's the top or the serratus isn't strong enough to break the shoulder, and they can get some more acquired capsular action and actually get a little transient shift of the head. Okay. I stand corrected, Bob, thank you. I appreciate that. One question on the relocation test. Does relocation test, is that a test for instability or is that a test for posterior impingement? Okay, all right. Ben. Yeah, the problem I'm making, you were talking about, there's a zillion things, everybody's talking about all these things. I don't know, I like to try to put things in buckets and try to figure out if we can look at each of the buckets. One of the zebras, like you're talking about, the EDS and the suprascapular nerve and those kind of things. But the thing that hits you in the face right here is she's weak and she's painful. And you can see it's, no matter what scapular rehabilitation she did, it's not effective because she's still got her serratus. It's not working by the position of the scapula. With that position, nothing's gonna work. You can't move your arm, you can't get your back on strength. You're gonna have the most comparative compression and all that stuff because of this position. So my first thing is let's really make sure that we've done everything for the right type of, if you're doing scapular exercise, but you're doing it this way and she's total, then she hasn't done it. She's not using the core, then you're not gonna get the best scapular rehabilitation. So that's one thing is the serratus and the low cap are not working. You gotta make it work. Make sure there's no EMG in that case. Second thing is why is she weak? I guess she's done EMGs and all that stuff's fine. She's got the nerves okay. And that's because the question is, is the shoulder driving the scapula or is the scapula driving the shoulder? This stage of the game, I can't tell, but if you've done a really good rehabilitation, that means something in the shoulder's doing the problem. In this situation, it's gonna be an instability. Probably gonna be some type of a crack in the ligament. I'm not gonna be completely clear of it. So I think you do a capsule or a shift, maybe a missing point if you don't fix it with a plate or a tendon, and this as well. We had this discussion about the rotator air and the closure of the EMG. See what we came against with rotator air. But I don't think we can do that. But I don't think that's gonna solve the problem by itself. So I think you need to break these down a little bit more and look at the things that you can try to handle and try to figure out. Thank you, Ben. I wanted to point out just one thing. One is that they never get a deacon. Number two is, and I learned this from Buddy, I learned this from Ben, you gotta look at the back of the shoulder. Anyone that comes to you that's a thrower, if you're not having them take their shirt off, look at the back of their shoulder, their scapula, you have missed 90% of the pathology. And Ben's obviously the guru on the scapula. But I mean, routinely, if someone comes in, it's gonna be, you gotta look at their back of their shoulder always. George. So Ben, can you comment on, assume everything's done properly, there's no neurological disorders, so you do a capsule or a shift, certain things you have good outcome, she's feeling good, but she still has scapula weakness. Do you let her go back, or is that something that has to be corrected before you let her go back? I think sometimes if you fix the shoulder and the scapula kind of way down, normally. Right, but if it doesn't. If it doesn't, that means you still have these patterns that have been known, these muscle activations where the sprain is still moving, and if you let her go back through that, she'll probably not be able to do it. Great. But that's the time you're gonna, right from day one, you can start all the exercises that you need to do on your swing, with the hip and core, scapula, tricep, elbow, side, you can start working that right away, get that scapula laying down. Make sure she's not out here, because that's gonna tilt her every time, so get her back in place. And that, during that time, she's gonna be able to adjust to that. So if you let her, the way this happens, she had this, you know, she had this problem last week, she overdid it, she got something wrong with that, then all of a sudden her sprain shut down, and we'll press that down, and then we'll go down the road, and we'll have to put that back the other way. So I'm gonna go back and see if she's okay. You know, in the interest of time, George, we had to move along a little bit, if you don't mind, in the interest of time, so, you know, George and I know Ben will be available after this to chat, because the scapula itself is like a three-hour symposium, so we're gonna move on a little bit here, and Ben knows it all, and I'm sure George as well, and you can find them after the, so we're gonna come in here, and what we're gonna do is basically a capture application, and I had a discussion at my table about what you tell this young lady before in terms of the chance of it helping her, and we'll go through some numbers in just a little bit, but I'd be curious what the faculty says in advance of doing this. So you rasp all around, because this is gonna be basically a 360, and remember that for MDI, inferior is always a component, the one component is always part of an MDI, so we start inferiorly at the six o'clock position, we do a pinch tuck like Steve Snyder showed us, grab a nice pit of tissue here, in this case the labrum is intact, it's my belief that true MDI is capsular, and that labral is traumatic, and that you get some labral pathology late in the MDI process, but if it's a true MDI, and you're cascading at the right time, the labrum should be intact. So we're gonna basically retrograde a permanent suture through at the six o'clock position, we do a mattress suture, so we shorten and we increase the height of the labrum, we don't slide knots, we tie them because the tissue can be thin, we don't wanna fray it any more than it already is, and once we do the six o'clock knot, and we've taken care of the inferior part of the capsule, we then go in her case anteriorly, which I thought was more than posterior, so now we're gonna do the same thing in the front, and we'll balance this, and this is all balancing, and then once we've got the front sort of in place, you can see us here, we're now going to the back, and my goal is to decrease the drive-through sign by 50 to 75% is sort of what I use, and now we'll come to the back, and after I put these three in, I will sometimes use an absorbable suture to titrate, just depending on how well I've done this, and how well I've balanced, and here you see we have our sutures in place, and you'll see as we sort of lift up, you see the drive-through sign has been diminished by at least 75%, and then the question is, do you go and do a rotate interval closure, in this case I am, I'm not doing it the way Buddy does it, Buddy does a true closure where he gets a coracohumeral ligament, I'm just using his internal splint from SGHL to MGHL, and that's not the true rotate interval, and we can have a discussion about that, so the question is the answer, how long conservative and open verse arthroscopic, and I'm just gonna go through this quickly if we can, and laxity becomes a problem typically through progressive tissue compromise, and all your compensating mechanisms are overwhelmed, core, scapula, all the things you heard Ben mention, and then here, this is a great case, sometimes these patients come in, they're really in a lot of pain, and you see this MDI patient with a severe capsular inflammation throughout the joint, so they can be very painful in these situations, so the treatment goal is, you're just gonna try to restore the stability they had before they became symptomatic, so that the core, scap, concavity compression, once again can control that, but you're not gonna change your DNA, you're not gonna permanently tighten anything, so it just provides enough stability so the dynamic stabilizers can once again restore function, I wanna show this to you here, this is positional instability, I've had this guy elevate and lower his arm about 10 times and he's fatiguing, this is number nine, he's working hard, his scap is starting to fatigue, and what I'm gonna show you, this is positional instability, this is different than what I'm showing you because I wanna just talk about rehab here, this is number 10, he raises his arm, and what you notice is, if you watch carefully, he's out right there, and when he comes down, you'll see he's subluxed, posterior inferior, now he reduces, that group may be amenable to motor studies if you're showing the pacemaker, this is external rotators, posterior deltoid, he's shown some success with tough cases, but remember, this is posterior inferior positional, it's not for the standard MDI. Hey Rick, quick, just because we don't have too much time, from a technical standpoint, the need for anchors versus? So I'm gonna get that real quickly here, and so natural history, we had a big discussion, how long, this is probably still the best paper, Gary Mismore's paper, basically three months of really good rehab, if it's not gonna do it, it's probably not gonna do it, so I think minimum of three, is surgery effective? Well, Ponce's show with plication for every centimeter, you get a 10% volume reduction, so you can pretty much match an open procedure, labrum versus anchor, Preventure's intact labrum is probably as good as an anchor, but if the labrum looks suspect, then you wanna use anchors, what is a literature review? I just like you to know, if you have a serious, 75% of them have a Bankart lesion, that's not an MDI population, so read that carefully, because I think that might be either very late in the process, or trauma superimposed on someone who happens to be ligamentatively lax, and that's not MDI. Open versus arthroscopic, again, very comparable in these studies, this is a Baker study, 2009, and 86% back to sports, this is Jones' study, and he had basically 85% back, and these are numbers, I don't get that number, I don't get 85, I don't get 90%, I get more like this, about 77%, and this was a better group, 22 were atraumatic, and this was the most recent, this is 50 consecutive, not athletes, basically 90% return to sports, but these are casual sports, so I think I tell my patients 70, 75% best in terms of return to the same level of competition, and in post-op rehab, we've sort of gone through this in the pre-discussion, but essentially you have to individualize it to your particular patient, and I was telling my table, if you have a great working relationship with a therapist, I know Ben does, I know Buddy does, they know exactly what you want, they will save your bacon, if you overshoot the mark here, they're gonna save your bacon, if you undershoot, they may not, but if you get a little too tight, they'll save your bacon, and remember, volleyball, tennis, are very different than baseball, and you can't lump them in the same groups because they respond differently, you can take a chance on volleyball, you may not take a chance on baseball. Yes? Sorry, how long do you need to be in the hospital? So it depends on, you know, if I'm doing like an MDI true EDS patient, eight weeks. These typically, again, depending on, like this guy wants to go back to volleyball, she's probably four weeks, and what I do is I have them come back usually at every 10 to two weeks, and I have them lean forward and lower their arm like they're doing a dangling exercise, and if they really struggle, they start sooner, and if they lean forward, and they act like, you know, it's just easy, I say, put it back on, you know, come back in three weeks. So I try to titrate it because everyone's a little bit different. Yes? Doing a sling? No, no, no, so they're doing scap setting, things like that, you know, but they are not, scap, yes, but as far as actually moving their arm in an EDS patient, I'll hold them for eight weeks, I mean, I'll hold them longer if I need to, but if they're true collagenopaths, I hold them for a long time. And then, again, treating for capital first, I use nonabsorbable sutures, don't slide knots, a decrease in drive-through by 50 to 75%, we can talk about interval closure, it's again a big discussion, but again, plication for these problems that are sort of recalcitrant, I think you can get a good result in about 70, 75%, and it's as good as the open. Just restore enough stability so the compensatory mechanisms can once again be effective. Surgical stabilization, I can't tell you that it's a sure thing for elite-level sports, but I think it's a reasonable alternative for those who have failed, and the literature is just terrible. So you gotta be very careful when you read it. Thank you, thank you, Mike. Thanks, great job. So we'll move on now to Nick Verma, and then if the faculty can rotate tables just to switch things up a bit. All right, good morning. So we're gonna keep moving along to keep things on time. I think we're running appropriately now. We're gonna cover a shoulder case and an overhead throwing athlete. My name is Nick Verma, I'm from Chicago, Illinois. Disclosures are available through the Academy's online disclosure program. So this is an 18-year-old right-hand dominant male. He's a pitcher and an outfielder, though his goal is to pitch at the college level. He's got a combination of anterior and posterior shoulder pain with throwing, and as all these athletes come in, his main complaint is he can't throw. He has fatigue and pain that prevents him from returning to sport. He's undergone physical therapy, subsequently a throwing program. He made it about six weeks out of the eight-week program, and then starting having pain again. He's been treated with NSAIDs and a glenohumeral injection with temporary relief. He's been able to hit, but his main issue is throwing pain. He does have a history of about 18 months ago being treated conservatively for an elbow olecranon stress fracture. His exam, he's got no asymmetry or atrophy, but he does have mild dyskinesia, particularly when viewing him from behind. His range of motion is overall fairly well-maintained when measuring in abduction. He's got external rotation at 110, internal rotation at 50, and full strength. As I think Rick already pointed out, it's very important to look at these athletes from behind, looking for core strength and shoulder stability. This is just a representative patient for examination purposes. I always check forward elevation, external rotation, internal rotation. And in fact, I think the easiest way to measure rotation truly, if you wanna get glenohumeral motion, is to actually, in a supine position, stabilizing the scapula, looking at a combination of internal and external rotation in comparison to the opposite side to evaluate the total arc of motion. He has anterior pain with an O'Brien's maneuver, as well as posterior superior pain, particularly with a crank-type maneuver. So I like to simulate the abduction external rotation position that these athletes get into via throwing to see if that reproduces their symptoms. And I think the location of pain, anterior versus posterior, is important. And his was anterior pain over the biceps, as well as posterior pain over the posterior superior joint line, particularly in an abduction external rotation maneuver, as well as a positive O'Brien sign. So these are his radiographs. You can see he's just about done growing. Really nothing of value here, in my opinion. And then finally, I'll let you see his MRI scans. So this is an MR arthrogram, just so you know. And we'll let these play for just a minute so you can take a look at these. And then here's an ABER view, which is basically just an abduction external rotation view. Let's see if that'll play. Which can be helpful, particularly in these throwing athletes, if you want to better evaluate the posterior superior rotator cuff and that posterior superior labrum. So we'll let that just play for a minute. In this case, based on his anterior pain, Albert mentioned this earlier, we did do a biceps injection selectively just to determine if the biceps was a component of symptoms. I think it's important to do this under ultrasound guidance, particularly if you're going to use this for treatment decisions. It's a fairly easy injection to do, so if you don't have a lot of experience with the ultrasound, this is one of the easy places to start. And if you're at a cadaver course, just put an ultrasound on the shoulder and you'll see how easy it is to see the biceps, and you can direct your needle directly into the spot. And he did have some temporary relief of the anterior pain, but not the posterior pain following the injection. So our treatment options, we can ask him to continue additional physical therapy. We can do a repeat cortisone injection. We can discuss locations, biomechanical analysis to see if there's some fundamental problem with his throwing position, and then finally, it's a time for surgical arthroscopy. So we'll stop there and let you guys discuss next steps. So comparative arcs were normal, just a shift towards external rotation. Total arc was symmetric within 10 degrees or so. Slap tear. Posterior superior slap tear. The cuff, I don't remember what the official read is. I think you can see that there's some undersurface scuffing, no significant cuff tear per se, but certainly some cuff abnormality, and then they did read the posterior superior cystic changes in the humeral head. All right, so why don't we discuss amongst the tables for five minutes or so, and then we'll come back and open it up. Yeah, I think that's a great point about the shutdown issue as well, and we had a discussion at our table regarding, you know, everybody comes in and said, I did PT, it didn't work. But really, what did they do? How long did they do it for? What was the period of time where they rested? This kid came to me in the spring. He had shut down for eight weeks, during which he had therapy to work on motion and strengthening, and then another six weeks of a throwing program. He got about two-thirds of the way through, and then started having pain again in the same spot as he got to higher velocities. JT, we've started using this biomechanical analysis. I don't know where everybody moved. There he is. You know, and I think it's really been helpful for me, because a lot of these kids, to Ashish's point, I mean, we see this all the time on MRIs, screening MRIs, when we sign players, and they're doing fine. So something has kicked them from a symptomatic to an asymptomatic world. Is that something that we should use routinely in evaluating these patients? Yeah, I think so. I think we asked you a question about arcs, right? And so we have the other piece on this is an evaluation of his retroversion, because we don't know whether this arc is bony-induced or soft tissue-induced. And so we know what his retroversion relative should be, and sort of in that place. And so we want to know exactly how much that is, and that can help us with how much posterior strep caps or stretching there may be left to do. And maybe he's got a deficit. That's sort of one of the newest sort of theories. Maybe he has a deficit of external radiation, which we never would have thought of before, sort of coming into its own in that regard. So I do think a very detailed bony and soft tissue analysis will get you a good idea about where to start with the pathology is and what the conservative options that you might have to make. Right. Right. I think, you know, where there's an asymmetry in the arc of motion, most of the time we assume this loss of inter-rotation to, at this point, it may be external rotation. It may be more problematic when you have this loss of inter-rotation. I have a hard time differentiating. One of the things that I've noted is that if I measure their external rotation in a 90-90 position in the scapular plane and then put it in the coronal plane and there's a difference, I think that indicates the anterior structure is more tight than the posterior structure. Just measuring their arc in the coronal plane, the anterior structure is likely to be a little bit more relaxed when you get it out truly to the full coronal plane. So that's one way I've been able to sort of get a sense of maybe this is more loss of external rotation than it is loss of inter-rotation if there's an overall asymmetry in the arc of motion. Yeah, and I think you're right, George. The external rotation loss is the kiss of death in these players because then they have to compensate to get their arm into the position to generate velocity. And the other group that I think is hard to manage is when they have hyper-external rotation. That's another group that gets themselves into trouble when they have 120 plus. Ben. And so, we find that B, you can't get back to your... So, yeah, I... So, two things. Number one is, I think when you're taking care of throwing athletes, it's really important to have kind of a core group of therapists that you use that have some familiarity with some of the concepts that were already discussed regarding, you know, what's normal motion for you and I is abnormal motion for a throwing athlete. So, I think you do want to establish a core group in your local area, people that you trust, that understand the throwing athlete and how they have to rehab them differently to a normal athlete. But, you know, we're fortunate in that we have a throwing lab that we use, which is basically a motion sensor lab that can look at throwing mechanics. I think that these are coming in many of the major metropolitan areas. I think you should look for one and figure out what they use and how they create normative data to analyze with. But you're right, it's not applicable widely, depending on where you are in the country. But that's what we use as a lab that we've developed. And I think many of the guys in these tables have those available to them. But I think it's something you should look for in your area as they're becoming more and more popular. So, you know, if we just look at pitching mechanics, it's one of the most complicated human motions. And really in the shoulder where we get into trouble is this cocking phase, where they have a combination of hyper-rotation, abduction, and extension that causes abnormal contact between the posterior superior rotator cuff labrum, articular cartilage, as well as irritation or tightness in the biceps and the front of the shoulder. And if you have subtle changes either in glenohumeral position or range of motion deficits, now you start taking what's normal contact and create pathologic contact that results in a variety of different problems, such as rotator cuff undersurface tearing, labral problems, articular cartilage, and biceps. And here's just an example of how some of these hyper-rotational events can become really severe. This looks like a Hillsex lesion, but this is really just a bony lesion that's evolved from this abnormal contact between the glenoid and the humeral head at the terminal position of throwing. We know that this can occur from a variety of different mechanisms, and this is part of the difficulty that we have in evaluating these patients is that they can have many different problems that all lead to a common endpoint. And this can include capsular tightness, laxity, most commonly in the front of the shoulder, slap pathology, biceps pathology, scapular pathology, and they all present very similar. And in many cases, the same athlete can have more than one pathologic conditions going on, and your job is to try to figure out what's really giving them the problem in order to come up with a treatment. As a result, we see slap tears, we see biceps pathology, we see capsular contracture or laxity, we can see undersurface rotator cuff pathology, and often in many patients, we see more than one pathologic conditions, and we try to treat as little as possible to return them to their baseline status. We know that the physical exam can be extremely difficult. When you take the exam outside of the person that designed the test, most of these tests are really a 50% specificity and sensitivity. And the same thing is true with MRI scans. We know the MRIs are very nonspecific for evaluating this pathology, and much of these changes that we see can be common even in the asymptomatic throwing athlete. So really, when we're talking about slap pathology, I think it's a diagnosis of exclusion. It's the appropriate history, the physical exam findings, as we've talked briefly about, the diagnostic imaging, selective injections, and then I would say the appropriate nonoperative course. And we can be successful in a vast majority of these patients when treating them nonoperatively, so that's generally our go-to as an initial course before we think about a surgical situation. If we do think about surgery, the options are starting with a diagnostic arthroscopy, the evaluation of the rotator cuff, a debridement or repair of the slap, and then we can talk about what's somewhat controversial as to how we manage the biceps in these situations. If you've got a tear like this, it extends into the biceps, it becomes easy. But if we simply have biceps-related pain, such as in this case, the question is, as Ashish pointed out, is it a primary or secondary phenomenon, and how aggressive do we need to be with the biceps itself? So here's what we did in this case. We'll start with the diagnostic arthroscopy. So I like to do a dynamic shoulder examination, basically with the patient out of traction, bringing them into the provocative position of abduction external rotation. So you can see we've got the scope in the back of the shoulder, and we're actually trying to simulate that cocking maneuver. And this is where I finally understood what internal impingement was, is when you can actually see it in the operating room. And you can see the undersurface fraying of the posterior superior rotator cuff. You can see the peelback of the superior labrum. And as you bring them into that hyperabduction external rotation position, you can actually see how that posterior superior rotator cuff comes into direct contact with the posterior superior labrum and the edge of the glenoid itself. So then we've got them up into traction, and this is what it looks like. So we'll just go through the diagnostic scope. When I make this portal in the front of the shoulder, I always try to do it so that I'm parallel to the biceps itself. It's slightly different than the position I'll use for true inferior instability, because I need to get more to the top of the shoulder. Here's what his biceps looks like. You can see that he's got a little bit of tenosynovitis extending down into the groove portion. And we can see just a hint of that posterior superior fraying of the undersurface of the rotator cuff. Here's what the labrum looks like. So he's got some detachment of the posterior superior labrum. We're going to put a portal in the anterior superior aspect of the shoulder, so we can look down the shoulder itself. And I'll show you what the posterior aspect of the labrum looks like. A little bit of extension of the tear into the 11 o'clock position. Here's the undersurface rotator cuff showing some fraying. And then here's what the posterior labrum looks like. So Rick, what do you think in here? Yeah. Yeah, even lower, probably 10. Yeah. Buddy, any technical pearls that you would talk about? Are we at the stage now where we can definitively say we should avoid knots in these regions, that the knotless anchors are the way to go? What are your thoughts on that? They're back up on the surface. And you do that from the subacomeal space? How do you do it just from the inside to the inside? The airspot comes up, the same area you watch where your cuspid is, and then look at it, but just a huge amount of intrusion to expose the latitude velocity, right here at the subacomeal space? Do you want to answer or ignore the question? it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think it's a really good question, and I think the jury is a little bit out in terms of what is the implications of biceps, but I understand the concerns and why there can be a potential problem with removing the biceps, and I think we just don't have that answer yet. So this is what we did. We repaired it. We did put one anchor in the front. George, to your point, we tried to do a really good job of removing the biceps. We tried to do a really good job of removing the biceps. I think the jury is a little bit out in terms of what is the implications of biceps, but I understand the concerns and why there can be a potential problem with removing the biceps, but I think we just don't have that answer yet. So this is what we did. We tried to avoid the ligament complex. I won't have any concerns about releasing the capsule if I think I've captured it to try to maintain their motion. Do we have a slide on rehab here? Correct. Yep, we check it. So what about this concept of we've gone to just taking the biceps as a primary treatment for slap? Is that applicable in throwers, buddy? Or is that that 35-year-old that I was talking about who gets So, you know, the other area where I've seen a lot of biceps problems is the windmill pitcher. Have you guys seen that? Anybody in the audience? Is that a different animal than this? I can't give him back his tissue anymore. So, I think that this is a MLB data that would support what Buddy's saying, which is, I think for the vast majority of us to take care of high-level athletes, we still, in the right situations, would rather fix a slap than actually doing a biceps tenodesis as a primary treatment option. So, we won't go through this just in the interest of time. We're gonna stick with this topic, just because I think it's enough of a discussion point instead of rushing. A quick question on the technique. Where does everyone stand with using PDS versus the heavy, non-absorbable suture, especially with the slap and the labral pathology with throwers and trying to get back that more kind of meniscal properties of the way the head's gonna roll on the labrum versus potentially over-tightening them more like you would a collision athlete? Do you find anything? I think, as maybe it was Buddy who pointed out, I do think the knots can be a problem, particularly in that posterior-superior space. You can see how close the contact is in that abduction external rotation position. But I think now that we have these low-profile knotless constructs, I don't have any experience with PDS, and I just use knotless implants. I don't know if anybody has any experience using PDS as their primary suture method. I use PDS and knotless, and since I made that change in knock on wood, they've done okay. Yeah, it's an interesting concept. In this population, just because I worry. And the other thing I'll throw out there, and again, this is controversial in the United States, but spending time in Japan with Hiro Sugaya, I'm not so sure with the anterior laxity that we see with throwers that that's potentially not as much of a problem, and that we've really gone into stabilizing below and posterior to the anchor, and that maybe putting one spot of stabilization anterior just to kind of rebalance a bit. I'm interested in that, and kind of trying to investigate that a little, because it makes some sense. I think it does, and to your point about PDS, we definitely know that hardware complications are real in this segment of the population, so I think it's not a bad idea, particularly with newer knotless implants where you can do that. So. I don't know if that was successful. What we're going after is kind of goes on the subtext of anterior capillary reproach. We wrote, unless you think it's out of our state, we all think that would be preeminent right now. We got out there and said, I'm gonna do this operation, but y'all say that's terrible, and I would submit for the first time. But she said it would be great if the secretary disclosed to me after Dr. Dove operated on the antipyretic capillary reproach. What do you think of the antipyretic reproach? Do you think that that antipyretic is the start? And then, as we know, that's the secondary capillary that started there, but not long. It's just that we didn't have to do all of it at the time. Yeah, it's a great discussion, buddy, because you're right. I mean, and even Jimmy had the early series looking at the thermal device and slab repair with or without. The problem that I've always had is how do you titrate that capsular closure? And if you lose external rotation, you're gonna kill them. So I just don't know how to make that decision intraoperatively. front Bob did you have a comment And is it PDS in a similar way to kind of hedge your bets? PDS in a similar way to what Buddy described? Yeah. So I think that's a little bit controversial, right? So, I mean, this is the big argument between Joe Theory and the Walsh Theory about whether destability even exists in these players. Internal infringement, as you guys well know, is demonstrated in 100% of cases without accident. So that's one question, right? Secondly, I remember Jimmy Andrews, when we would push him on this in ICL, we'd say, hey, well, he said, I always keep one of those old thermal devices. I'm telling you, Buddy. But then you take a look at the basic science of thermal, isn't it? That's not only stretched out, it's stretched out further than the treatment. So it's not working. So this concept of us, you know, treating it, and then, you know, with Joe's original procedure, while Oro was successful, you might argue that Oro was going to be successful no matter what you did to that cat. And there's a story about Nolan Ryan walking in with full thickness rotator cuff hair, and he'd say, you've got to have it prepared. And he goes, I think I'll be all right. He threw two more no-hitters. So I'm not going to, in that particular paper that he's quoting, the return to throw in pitchers was only 60%. So sometimes successful, but not always successful. You look at the best results in the literature on the throwing shoulder remains Jimmy Andrews, right? 85%, 89% of Connelly if you've had a pain lesion. But throw that one out for a second, and you go with 85% of his, and what did he do? So little. Debridement of the cuff. A little bit of the rest of it. So less is more in those patients, and I think that's the, we should be the clipboard quarterback here. Send the therapist a little bit out. Well, and I think that's a great point, because the problem is when you get into these shoulders, you're going to see eight different things that are wrong. And I think the temptation is to try to fix everything, and that's the kiss of death. So I think that's where the exam findings, JT, are very important, because you've got to decide what you think is relevant and fix that and leave everything else alone. One other thing, you know, you bring up about less is more. When you're an advanced-age therapist, you're trying to get the wheels back on the bus, and you're trying to go fast. When you're younger, you're going to have to address it. So the 18-year-old kid you're talking about, you have to address it. And then you have to go from there, and you're going to have to come up with something else. You have older people getting the wheels back on the bus, younger people are going to fix it. Did you take that bicep? No. Pathology. I can't see the slide. George. JT, that wasn't pathology. The bicep was... Yeah. That little stuff on there was supposed to be the bicep. It was tight because he'd been doing this, and the muscle gets adaptively tight. Because he's got bad wheels, he can't generate, so he's got everything up here. He's got an arm. So that bicep and that patient right there is not pathology. George. George. So Nick, I don't know if the trends are true, but two comments. If you look at what is happening in the world of major league baseball, the number of shoulder surgeries and slot repairs is plummeting compared to 10 years ago. So clearly our experience, collective experience, hasn't been very successful, and we've moved more towards non-operative treatment. But I think one of the keys of this is when you do operate on these kids, I think they need more frequent follow-up than perhaps your 45-year-old. Because in our series, we had eight players out of 67 who lost 10 degrees or more of external rotation here. Not one of them ever came back from pitching in. So you want to keep a careful eye on how they're progressing with their rehab. If they're getting tight in external rotation, you need to modify their rehab protocol. Because that's not something you're going to be able to correct later on down the road. So I don't disagree with what's being said here, but I'm very cautious about that anterior superior quadrant and messing with the anterior calf. I don't know how to do it. I really don't. George, your elbow patients get tight external rotation too. What's in it? Well, this is where I think one of the problems that we have when taking care of this younger group is getting them the appropriate rehab. Because you can't just send them to the rehab place down the street and say, slap repair overhead throwing athlete rehab. And because of the issues that you just pointed out, which is the goals of achieving a successful outcome in that patient, even early on are markedly different than the goals in just your regular patient who may come in off the street. I think you should... Say that again? Your therapist better have a meeting in the office before we get these things out. We can watch them. Yeah, or at least a place to transition them to as they get to that point. Yeah. Yeah. Right. You've got no back muscles. I mean, how do you address that? I mean, he just had to go straight home. All we do is give him one leg squat and all this. Okay. And he's struggling with that. And you follow him. Right? He can slide down and you follow him. You follow him. So, you tell the parents, you look at that, and you do a... I mean, what would you tell the kids? You know, you've got your assistant. What would you tell the kids? You know, you've got your assistant. What would you tell the kids? Mom, you didn't last. You were all baseball moms. Right? This is mom for bad. This is mom for bad. You say, look, that's horrible. Yeah, you have to fix this before you can do any surgery. So, we need to go to therapy. And if he doesn't walk out of therapy sweating, and tired, and doesn't like it, and you sit down in the car, they're not doing their job right. She'll go to therapy, and there's nothing worse for a therapist than sticking a baseball mom on and saying, I'm going to do this for her. And then you win. I wouldn't even say that. That is a $10 biomechanic side of what you just gave me. Right? If you don't have a big biomechanic side, you just gave me $10 in five minutes, and you did everything. Alright. One other point, when you talk about low flexibility, it has to do with flexibility. The other is do a stride. You've got to stride. So, get in that position, and watch your stride. It'll be short. It'll be loose. So, you can do that in the office. Just kind of do that right there, and see where they actually come, where they're supposed to go. So, low flexibility, stride, step control, brain motion. And you can get most of the mechanics that you need. I mean, that's fantastic. I mean, I really like all this stuff. And that's expansion, but it's all based on that right there. So, you can get that in the office. We have a guy that, twice a week, we get all of our hospital players. They come together, and they work. There's a 45-minute station drill, game station drill, where they do all that stuff. We get to the hospital. Every single one of them. Yeah. The problem is, though, that's 70% of the kids that walk into your office, right? Because all they do is throw. They don't do any conditioning work whatsoever. And that's the hard part, is to do what Buddy and JT were talking about, which is to convince them that that's a problem that they need to fix, prior to fixing their arm. Ben, the question that I always struggle with, and you and I go back and forth on this, is the scapula, right? Because many of these inter-articular problems have secondary scapular dyskinesia, but the scapula can also drive the pain that they're having in their shoulder. So, how do we make that differentiation between the chicken and the egg? How do we determine that we've done everything we can for the scapula, and now it's got to be an internal problem? Do you think the joint injections help you in that diagnosis at all, or is it just you can correct the scapula by shutting off the pain response? Right. Bob? Yes. What do you actually tell them if you come to surgery about their success rate of getting back to a pre-symptomatic, pre-annual functional life? 85% sounds like Moses to me. So, you're not saying to tell them that they don't get back to their skull? Cool. That's all right. It's a hard step. It is. So, this is data that is just being published in arthroscopy, trying to look at isolated slap repairs with and without rotator cuff, and you can see that it's not great. I mean, it's 60% in the high school group, about 50% in the professional group. The rotator cuff plays a big role in terms of whether they get back or not. Actually, this is the discussion that you have with them when you're trying to talk them out of surgery, because many people think, I'm going to just come in, you're going to fix my shoulder, and I'm going to be good, but the reality is, the goal is to avoid surgery, not to get them better by having surgery, and so I think this is the crepe that you lay at the initial discussion when you're trying to talk them out of why you have a surgical procedure, because the reality is that it's two-thirds. It's probably, if you take all comers, it's about two-thirds who are actually going to get back at some point. I don't know. George, any different thoughts? Yeah. I think they're trying not to have surgery. Yeah, I think in general that's true. At the professional level, it's probably a harder discussion at the younger age level, and the reality is, I think we're much better now in terms of rehabbing and treating these conservatively to be able to get them over the hump without having to get to a surgical approach, and I didn't show the graph, but we've had the exact same experience as you did, George, in terms of the number of slap repairs that are being done. We have four shoulder elbow surgeons at Rush. We do probably around 35 to 40 slap repairs a year, cumulatively, so just the numbers that are happening out there is markedly less than what it's been in the past. No, I think we're... George, before, I think we're better at finding who needs to have surgery rather than it used to be all purpose, and we need to have surgery. I think we're leaving it to a more active understanding of who should have surgery. Yeah, I think there was a key slide there, and I talked about this at our table. I think putting these post-slap in a regular abduction sling, or a regular sling such as that gunslinger, or external rotation, I think that's key. I put them in neutral. Yeah, the neutral, or a little bit of external rotation, I think that gets them back. Another thing about the therapist we talked about as well, I think you got to know who would... It's not just a place, it's a person who understands the overhead throwers, because you really got to make sure that they understand the core and the scapula, and then the last thing I'd say in this day and age of going down the biomechanical route, let's keep in mind that we do not know what are exactly the right biomechanics, so I think we still need to be careful of who's making that assessment, what pitching coach, what biomechanist. There's still a lot to learn, and I think it's coming fast, but looking for major issues, but not trying to make everybody a clone, because if you make everybody a clone, they will not pitch very effectively. So... Steve, last question. What do you think about the fact that he had the elbow injury 18 months earlier? We see this combination not uncommonly, right, where a shoulder becomes an elbow and vice versa. Anything we should be doing differently in that situation to try to stay out of that dogma? That's a great point. I do see it. I feel like most of the time I see it as the elbow piercing the shoulder. Sometimes they come together. For me, and you show the high school athletes, you look at the discrepancy between high school college versus pro, and they're different animals. Even Mike's comments about a clone. These are different people. Once you become a professional pro, there are a number of nuances. For the high school kids, for me it's just a red flag that there's a lot more going on here than just some sort of shoulder fatality. We talk a lot about how you evaluate them, look at their core, look at their strength. These guys are often undersized and they're just throwing the hell out of their arms. It is something that when you look at range of motion, shoulder range of motion, can dictate an elbow problem in the shoulder. I think they do piece together quite a bit. For me, it just makes it very clear that it's more of a global problem than an isolated problem. Volume of throwing mechanics, inability to stabilize the core, all those things we need to look at. I think the professional versus high school data is to JT's point. You can do a lot to a professional athlete who has a talent level and they can probably overcome more than the high school or the collegiate level. All right. Thanks guys. Those are two good cases. I hope everyone learned from something. Thanks for your participation. If they want to get a picture of anyone who was on the faculty before you guys leave, I'd appreciate it. Thank you so much for coming. Thank you.

chronic shoulder pain

multidirectional instability

capsular shift

arthroscopic limited thermal treatment

undersurface fraying

posterior superior labrum

rehabilitation

conservative treatment

scapular dyskinesia

surgical interventions