Well, thank you guys so much for being here. I know it's a busy couple of days. We're obviously at the end of the long second day, and we have the president's party slash reception after this, so thank you guys. We appreciate you being here. So, I'm just gonna do a brief introduction of all the faculty, but, oh, you know what? Sorry, can you go back? So, this is my actual talk. Can you go just to the intro slides? I mean, it's slide one, I'm sorry. That's okay. Okay, perfect, here we go. So, we're gonna talk about current controversies in the management of the throwing athlete. To introduce our faculty, we have Dr. Brian Waterman, who is professor in the Department of Orthopedic Surgery at Wake Forest. He's also chief and fellowship director of the sports fellowship there. He's gonna be speaking about management of slap tears in baseball players, slap repair versus biceps tenodesis. And also, I just wanna give Brian another shout out and congratulations for being selected as secretary of ANA today. Next up, we have Dr. Mike Freehill, who is associate professor in the Department of Orthopedic Surgery at Stanford. He is chief of the shoulder and elbow service, head team physician for the A's Major Baseball Organization, head team physician also for Stanford Baseball, and he's a team physician for Stanford Athletics. He's gonna focus on UCL injuries, talking about repair versus reconstruction. Myself, I'm at Loyola in Chicago. I'm the director of our women's sports program, team physician for Loyola University Chicago, and I will be focusing on the risk of shoulder injuries in softball. And then Dr. Liz Matzkin from Brigham and Women's. She's associate professor in the Department of Orthopedic Surgery. She's chief of the women's sports medicine program and fellowship director of the sports fellowship there. She will be focusing on anterior and posterior labral tears in throwers. So first up, I'd like to have Dr. Brian Waterman. All right, so a key qualifier, surgical management of slap injuries because in general, as Dr. Freehill will say, you try to ignore these as long as you can, as long as is humanly possible and delay the inevitable. But there are times where you need to bite the bullet and consider operative management. I pluralized it just to be the overhead athlete just so we can incorporate a variety of different sporting subsets. I will acknowledge that in general, I have traditionally been a biceps killer. I'm a recovering biceps killer. I think we're trying to find ways that we can preserve the biceps, whether it's cuff disease or biceps labral pathology. All right. So we all know the lineage of the slap tear. It gets its origins by Jimmy Andrews, 1985. There's this classification that's been listed, and then it's been expanded through several subsets. I'm sure Mike can recount type 1 through 9 and several iterations thereafter. Most of us have to just go back to the key periodically. But 1 through 4 are the ones that we most commonly reference, and those will be my area of focus today. This has commonly been termed as an American disease, just because we're overexposed to throwing athletics. It's probably unique to us in parts of Asia and Latin America. Definitely over-diagnosed. Not a day goes by that I don't see a MRI read that indicates a type 2 slap tear. And then historically, when I was coming through residency in early practice, it was definitely over-treated, and we learned some hard lessons that way. But we also know the spectrum of anterior shoulder pain can come from a lot of different disease entities. And it can include the biceps labral complex, but the AC joint, scapular dyskinesis, obviously different capsular problems, early arthritis, and such. Full disclosure as well, this was my historical overhead athlete. This is who I predominantly treated in the military. And coming out, looking at how to take care of a baseball athlete, speak their language, was a little bit of a black box. But what we know is that these slap lesions are often acquired. This pathoanatomy certainly formats on top of developmental changes. But there's this posterior superior shift to the glenohumeral contact. There's this pathologic peelback that can envelop over time. And then what we see commonly is this lack of glenohumeral internal rotation, this posterior inferior contracture, hyperexternal rotation. And you see a very predictable course of weak posterior cuff and scapular stabilizers. I think the other thing that I commonly focus on this is what's normal. Normal is all over the place for the throwing athlete. And if you really scrutinize these MRIs, get comfortable, what you'll see is there's a high rate, upwards of 25% to 30% of individuals that have anterior superior labral variance. Labral foramen is common, or labral hole, the Buford complex. You have your sublabral recess, and then this meniscoid variant of the labrum. I think what's key to point in there is you see this underwriting of some of that fluid within the joint, but it doesn't propagate laterally. And that's one of the ways that you tease out diseased labral tissue. But there's also an age-related phenomenon, where you start to see circumferential detachment. You see hypermobility. That cracking starts at top and wraps its way around as you get towards your 50s. And so that's another important qualifier as you think about what truly is normal versus adaptive changes. Additionally, when you look at the long head of the biceps, it's a pain generator. And sometimes it's structural. Sometimes it's just this deep synovitic tissue that's around it. But additionally, it's also the way it interacts with the surrounding soft tissues. There can be a spectrum of subscapularis pathology, sidewall injuries, subluxation. And you can really see this activation of the pain fibers within the sheath. And that's something that's probably best rooted out on a physical exam. The physical exam and the overhead athlete is really the dark arts. This is trying to help to tease out what the diagnosis is. And then it's incumbent upon us to really delineate what the effective treatment is based on the best odds of success. We know that advanced imaging is helpful. In fact, it's become almost a little too routine. Careful what you're looking for. You might just find it. And when you find the disease, long head of the biceps, I think that's a good day because that guides your hand. But oftentimes, you're just going to see some of these anatomic variants. In terms of the gold standard for assessment of the long head of the biceps, definitely arthroscopic evaluation is key. You want to look at the labrum, but you want to look at these three zones. And oftentimes, you can't do this without unroofing the transverse humeral ligament. Well, how good are we, even arthroscopically, at assessing whether this is a true diagnosis and really what the next level of management? I'll give you the long and the short of it. We're terrible at it. In fact, 2 thirds of people have a hard time identifying what's normal. Type 2 slap is a coin flip. And when you look at this, we even have a hard time delineating between type 3s and 4s and ultimately diagnosing between normal and abnormal tissue. So what about treatment options, which is the charge of what Mary's laid out for us today? Certainly, we're going to keep therapeutic biologics by the wayside and really just dive in on slap, debridement, and or repair, and biceps tenodesis. This has generally been the guideline for treatment. Type 1 and 3 is a debridement, removing some of that bucketed tissue if it's a type 3. Type 2 has been repair. Type 4 has been sort of a source of confusion for a number of years. And then the other iterations, usually you're treating that pathology in a unique and specific way. Certainly, the concern has been that non-operative treatment is also equally mired in poor rates of success. You can see these rates of 22% to 66% success. Even when you do a slap repair, you can see the rates are all over the map. 7% success rate. That's a sad day for a slap repair and high rates of revision that has been shown throughout the course of history. Well, when you look at trying to look at consensus, what are the best practices of treatment, they're all over the map. There really is no consensus when you look at Ben Kibler's study and what we've laid out in the literature. The traditional slap repair looks like this. In fact, this is what I was trained on. Over-constraining the biceps, you see these knot stacks that have a high tendency towards migration. And I think you probably over-constrained that throwing shoulder. As you evolve, you see sometimes this has progressed towards mattress. Again, same issue with these knotted constructs. And we know that these will continue to roll on the articular surface. They'll lead to crepitation, squeaking. It has humeral head contact, and ultimately, iatrogenicity. So, this etiology of the failed SLAP syndrome is certainly, much of which is implant related. It can also be to overtightening, and so your charge here is not to take capsule, but just labral alone. How do I approach it? I prefer many of these in the lateral decubitus position. That just allows me access for treatment of any combination as it extends around the back. You can obviously look down the rim if there's any bony hyperostosis, and it allows me to circumferential access, and this is what the new SLAP repair looks like for me. Very often, it's a knotless construct. I do try to do more mattress-based sutures just so I limit humeral head contact completely. Again, the push has been towards knotless fixation, and that's traditionally what I'm doing above the equator for sure, but below as well for most of my instability procedures, and I'm sure Dr. Matzkin will delineate that as well. So, this is the benefits. You can see it's almost like we were never there. You can see that as you extend around the rim, and I'd submit to you that that's an effective SLAP repair. This is one of my own recently. What about negative prognostic factors? Well, you can see these are kind of the no-brainer ones, the folks that have tenderness in their biceps groove, those that have some history of substance abuse, those that have heavy laboring positions, those that have had prior surgery, and so forth. Don't be afraid to learn from the missteps of others, and certainly, Dr. Preventer has led the charge in teasing out how these SLAP tears do. You can see 37% failure, and with an age greater than 36, even an odds ratio of 3.45. So, I accept that wink, and I will not try to reproduce his results. In terms of other things that we've learned from our patient population, placing that anchor anteriorly to the biceps, you have to have a really good reason for that. That has a tendency towards over-constraint. I'm really going to focus on 12 o'clock and behind it, because I think that that has important repercussions on motion. So, this is a great slide to just take a photo of. We won't unpack this all, but this binary concept of good SLAP, bad SLAP, I think is very helpful as you guide through the process. So, is there an alternative to repair? So, the big question is, should you do the last operation first? There's been discussion that the biceps is a humeral head depressor that may have some association with humeral head deceleration, but the effect of a biceps tendinitis in my hands and in the biplanar fluoroscopy images that are shown here suggest that it's a fairly nominal effect. You can see throughout the pitching motion, there's very limited changes, although they are different from the native state. What about biceps tenotomy? Certainly the patients that I've experienced have been 100% dissatisfied with this, so I don't do it, but I do in a throw or do a subpectral approach, and this is a traditional interference screw fixation. I think we're all relatively familiar with this. You go and dissect down to the groove. You try to restore that normal length tension relationship, however, there may be some issues related to the size of the aperture and the increased torsional stresses. What we know is if you get that right and there's no associated fracture issue, they probably all do the same, but we're really focusing on smaller implants and probably less morbidity with the dissection. So we've looked at all suture implants, again, a size 1.3 millimeter hole and an omlet type of fixation, which has comparable biomechanical properties. So how do these patients do? We had our series that we published and looking at range of motion, was there any adverse events postoperatively, and what you can see in a throwing motion, there was no compromise in abduction or external rotation. And then in terms of patient-reported outcome measures, could you backtrack that slide one? Yeah, no worries. So we did show that VAS and SANE score did improve, and you can see in terms of our rate of return to prior level of competition, 81% in a predominant baseball patient population at 4.1 months. The others that have returned to a lower level of competition was for other reasons, and then there was one that didn't return because of fear of re-injury. Are we alone? There's other authors, includes those from NYU, that have suggested that a septopectoral approach can be beneficial for treatment of symptomatic SLAPP pathology in active overhead patients. But do all our patients do great? No, certainly Pete Chalmers has shown that in this mixed group with primary and revision procedures, only six returned to their previous level throwing activity. So I would submit to you that the jury is still out on who should be more adequately treated with a biceps tenodesis. So here are my guidelines for treatment. Type 1 is benign neglect. Type 2 really is going to be relative to where it is on the biceps anchor. Type 3 is generally debridement versus repair. I'm really worried about loss of that tissue substance. So if it is a substantial amount, I'll try to capture all that and get it with a knotless construct. And those type 4s where they extend into the biceps anchor is a tenodesis for most individuals. In conclusion, SLAPP repair can be effective in carefully selected patients. You should consider a knotless construct. Be careful about these risk factors. Physical exam and advanced imaging should be combined and help to elucidate bicipital pathology. But there's no consensus on surgical technique and a primary biceps tenodesis can be very effective with reproducible clinical outcomes, low complication rates. In our series, 81% at 4.1 months and there was no evidence of over-constraint in a throwing motion. But it is important to counsel your patients that pain may persist in that biceps groove. Thank you. Next up, we have Dr. Freehill speaking about UCL repair versus reconstruction. All right, so repair versus reconstruction, I think that this is a really good topic in this day and age. So, the bottom line... Are the ones whose numbers are really going through the roof and they're the most concerning and hopefully a lot of this talk can Answer some of those questions for them. So, you know previously I thought of UCL tears and proximal mid-substance distal and tried to really make this, you know, like Neapolitan ice cream it's going to be chocolate vanilla or strawberry But as you start to see more and more of these players We start to realize that just trying to put them in one of those baskets is was was more of a three stooges by me because it's it's a it's a lot more delicate and There's just more detail there. I do a lot of work with this cutter group from various institutions around the u.s and the very first manuscript that we published agreement was, was the proximal tears, even amongst the experts. It's very hard to tell the way it ribbons up there versus at the sublime tubercle versus mid substance. So the point of this is when you guys are looking at MRIs in these throwers and it comes in and it's been done outside and they say there's a proximal tear, don't always just bite on that. I go to this every time now, this is the game changer for me. So any athlete that I see they're getting the fever view and Pam London Phoenix was the one that talked about this. But the reason that this is so important, you can see here, this is one of our Stanford pitchers just recently. You know, that looks a little questionable up there on the proximal side, but you want to make sure how is that ligament completely incompetent or not, especially with the proximal tears. And you can see when with a fever view, it opened up to 3.6. By definition, if they start gapping past three, you should start thinking. Now you can have some, some asymmetry and that can be someone's baseline, but if they're having problems and there's a reason they're in the tube. Now it's a lot different, right? Because I, same, same, this is one of our high school pitchers in the area. That looks like a pretty high grade partial on the medial epicondyle, I was very worried, but you get the fever view and he didn't open. So these are two different treatments and that's really important. I give a lot of credit to Keith Meister because I think these five Ps are really what also allow us to make decisions for the younger players, especially, you know, what level are they at? What position do they play? Where is the terror? And does it gap with the fever view? Where are you in the season? And what's their potential? If realistically, they just want to finish their high school career and move on, that's a much different, you know, treatment options that you can give them. So three main choices, really, we know the classic reconstruction and there's different aspects or techniques within that, the repair, which is now with the internal brace. I don't think most of us probably repair just without an internal brace and then a hybrid reconstruction. You have the internal brace and the UCL reconstruction. So what do we do with this player? This is a 19 year old, another Stanford pitcher. It looks like a full thickness sublime tubercle or distal tear. And we know that that could be trouble. So one thing to think about is where is that tear and what are the likelihoods for healing? So we know from Hackett's work, and this is great work, proximal medial epicondyle, the vascularity is excellent. So you can treat a lot of those non-operatively and they'll heal, especially in the younger population. But when you start looking at those full thickness distal tears, very hypovascular. And the likelihood of that healing without doing something is very low. This was my mentor and gentleman who did my shoulder surgery a long time ago, but just a great guy, Lou Yoko. And this was the Sentinel paper looking at PRP. But when you dive into this a bit more, you realize that 32 of the 34 were off the medial epicondyle. So not to say the PRP didn't help or maybe it was the reason, but the bottom line here, it was going into an area that already had good vascularity. So maybe it gave it some synergy, but it didn't tell us much about that sublime tubercle. Not a lot there. So I would be careful and generally speaking, I'd love at the end to see if any of you have had any luck with the sublime tubercle and distal tears with PRP or biologics. With the proximal tears, here's an example. This was an elite level pitcher kind of sputtered down the home stretch here. I don't have fever views. This was before I started doing that routinely. But at the end of the year, we did some PRP. You know, he seemed to do very well, went on and was a high round draft pick. Now, we're not talking about the proximal tears. Here's our case, the sublime tubercle, full thickness. We all know Dr. Dugas, he talked about this today. Enter the internal brace. And why was this so important? I think the best part about this was because the reconstruction has such long timelines to return. So if you could do something that could allow somebody a quick return, and in this case, the original literature that they put out throwing it 10 weeks back against competition in four months, that's a pretty nice alternative. We also know that, at least in his work, that it doesn't over constrain the joint. Now, I show this picture of one of my cases, and I have a mosquito underneath the tape because I do think you can over constrain. You have to have some control. That brace can really tighten down. But this gets back to the regular biomechanics or the intact UCL better than a reconstruction. So it is a good option in that particular way. We published on this last year, and it was in arthroscopy. And just so this isn't misinterpreted, when you look at this data, this is saying repair with an internal brace versus repair alone. It's not saying repair with an internal brace and you shouldn't do reconstruction. So if you're going to do a repair, you should probably add the internal brace. That's what this says. How about other outcomes with internal brace? Well, if you look at the not much literature out there, most of these are in amateur athletes, Buddy Savoie and the early Dugas papers. Getting back to the five Ps, I know that Meister and George Palletta have a lot of players in their database. It's not yet published, but they do relatively well. But again, you have to pick appropriately. You know, in preparation for this talk, what's out there, you know, if you try to get a systematic review of this, it doesn't really exist yet. So this, you know, in a lesser probably journal, I'd say, you don't have much. This is what we have, seven position players and 11 pitchers. So not a lot. I would caution time to return. In my particular hands, I think that we're probably rushing them a bit. You can go again, player by player, depending on where they're at. But I think that that's a little bit aggressive. This is one of our Stanford players. And the one that I showed you, I did an internal brace. We got him back fast, played the next season, did great, and then started having trouble. And he blew out proximally. And because of that, I've changed my technique. And again, this is based off conversations with Keith Meister. If you're doing a sublime tubercle repair, and then we're going up and putting a screw in the medial epicondyle. And we know that that ligament has a broader, rounder insertion. And now we're reaming that. And now putting a screw up there. So it makes sense that the proximal ligament is at risk. And I think there's more of these out there than we think. So now with this technique, you can take a little three millimeter drill bit, go up, and then two millimeter drill bit, just like you're doing a docking type of technique. Because all you're running up there is the suture tape, and you're doing a lot less disruption to the footprint, in my opinion. And again, I follow Meister's lead on that, and he does more than anybody. So I think the internal brace is great work, great advancement. I show this picture of an AC reconstruction, because I think that's what tape does sometimes, especially in a joint like the AC joint, you see all that lysis, right? And I don't know if that's gonna happen when we get longer term follow-ups with the internal brace, because I think that the isometry is different at the elbow than it is at the AC joint. But I thought, is there something that could be more biologic? So we did some work with a biologic scaffold that's out there, and you can see these results are pretty good. It's not as good as the intact ligament, but it's better than repair alone, and it's better than staying torn. I do think that if you were to do this, or this catches on, that you need to caution that this, it's not gonna be the same quick return. You need this to go in there. It's not a internal brace that's holding everything stable at time zero. So bottom line, I think that the UCL repairs is a great instrument and great technique, especially if you're trying to get someone at the end of their career back, a high school kid just to get through his career, certain types of tear patterns. But I think that it's probably longer with regards to the return to play. So with UCL reconstruction, to bring this home really quick, these do very well, should we just be doing this on everybody? It gets back to the timelines, right? We know, Jobe described this, the original classic eight figure eight, and we know all about that, and then we know that the modified Jobe split in the FCU, but still doing the classic figure eight tunnels. Then we got into docking, David Olchek, just instead of making these tunnels up on the epicondyle, just make one tunnel and tie over the medial epicondyle. The number of strands going across, trying to do single tunnels on both sides, looking at the hybrids, Meister's pictures are so good, it's hard not to use his. But there's pros and cons to all of these. How many tunnels you're using, the muscle splitting. I think that generally speaking now, most people have gone to the docking and gone to the muscle splitting or the modified Jobe, if you will. And that's what was first described here by David Olchek with good results. Now, getting back to why that is, why would the docking be better than the classic tunnels? I think Chris Camp's work is really excellent here, just looking at that perfusion of the medial epicondyle and how much you're disrupting that with the more bigger tunnels that you're putting in there. And if you don't need to do that, you probably shouldn't. Graft options, there's a lot of them. Most will use the palmaris first. The gracilis has been studied, but there are other options. As we know, be careful. I know that all of us know that this can happen. Make sure of the Schaefer test and make sure that that's a palmaris. I personally harvest the other side. People say, how can you do that? The IV's going in there. It's like, I don't put the IV in the foot. I mean, we get that. What is pitching? Pitching is all here. It's all grips. Why would I do anything that could possibly disrupt that? Anyway, looking at biomechanical analysis, there's no biomechanical advantage to using a bigger graft. And I think that's why people continue to go to the palmaris, and you don't have to make quite as big a tunnels if they have it. And then you look at other work by Chris Camp, docking and palmaris. That seems to be the trend of popularity. So that's what most people are using now, if you can. I always quote this. I go back to Jimmy Andrews' original paper. He had the biggest cohort and in high volume expert hands, 83%. And you guys see this, the kids come in and the parents come in. The parents want you to do the surgery because he's gonna throw even harder and he's gonna pitch in college and pitch in the big leagues. But that's not the case, 83%. So just say that number and make sure they know. Just having a Tommy John surgery doesn't mean that you're gonna be successful and be any better. And then lastly, we'll bring it home with this dock or a hybrid. I think if you're gonna do the Tommy John, especially in a high level thrower, like an elite high school kid that's gonna pitch in college, a college kid or a pro, they should get the hybrid. And this was interesting, Akizuki's description. I do it different. I think that making the tunnels distal on the sublime tubercle is better in putting the internal brace closer because that's how we do an internal brace anyway. And if you remember, the sublime tubercle is longer. That insertion of the UCL is not one point. It's long along the sublime tubercle. So I think with this technique, you get more collagen along it for healing. So just remember, it's a different game today. Again, these are the highest levels with these. They throw so hard and there's so much forces going across the elbow that I think that the hybrid just gives you a little bit more. Advantage is that docking, it's the same technique, better time strength zero. So that fights some of the creep during rehab and it's just gonna be the more robust construct. So in conclusion, here's kind of the way that I lay this out there. But generally speaking, I think that again, taking the five Ps into account, but sublime tubercle, good looking ligament, full of volition, that's the one you wanna repair. That's the internal brace. I think be careful with how you're going into the medial epicondyle. And if you're gonna do a reconstruction, do a hybrid. Thank you. That's great. Thank you guys for your excellent talks. Can pull up my slides. This one start from slide. How many in the room do UCL reconstructions as a part of your practice? Okay, good. Yeah. Looking forward to... I had a lot of questions. I don't do UCL reconstruction, but I have a lot of questions for you guys later. I'm curious. Okay, perfect. So, I'm going to focus on risk of shoulder injuries in softball, and I just really purposely included this as part of this session because as throwing athletes, we talk so much about baseball, but I just really wanted to try to raise some awareness about the risk of shoulder injuries in softball players because the force across the shoulder is pretty tremendous. These are my disclosures, none of which are directly relevant. As an overview, I'm going to touch a little bit on the epidemiology of shoulder injuries in softball players, some of the biomechanics of the windmill pitch, and then shoulder injuries in pitchers versus position players, and a little bit about injury prevention. So, softball is an incredibly popular sport. It's the third most popular women's sport in the NCAA. There are over three million players registered with the American Softball Association as of 2024. There are a million adolescent females playing softball. And despite all of this, there's very limited research on the windmill pitch. Softball injuries have been found to be more common at the collegiate level. I did include this picture, too, just to show you that in 1996, softball was actually added as a sport in the Olympics, so very popular worldwide. The conventional belief with regards to pitching in softball is that the underhand throwing mechanism places very little stress on the arm, and that in turn, pitching-related injuries in windmill throwers are quite rare. Unfortunately, though, there are no rules limiting the number of innings pitched or the total number of pitches thrown in a game, and that is in stark contrast to baseball, where there are very strict guidelines, even starting at the youth level. Also, there's no regulation on the amount of time in between games pitched for softball players. So, competitive female pitchers can actually pitch six, seven-inning games during a weekend tournament. The windmill pitch, there are many, many studies that show that the windmill pitch places similar biomechanical stresses on the shoulder, as does the overhand pitch, and there are also studies that support that the overall injury rate in softball players is comparable or actually can exceed that of what we see in baseball. So, when looking at softball and baseball head-to-head, softball relies on one or two ace pitchers, right? That pitcher may pitch consecutive games, an entire weekend tournament, or, in fact, the entire season. Sometimes, they're the only pitcher. They can throw 1,200 to 1,500 pitchers in as few as three days with a big tournament. Compare that to baseball, where pitchers are in a four- or five-man rotation. They'll pitch a maximum of 100 to 120 pitches per game, so huge differences in the regulation of pitchers. This 2022 study showed that weekly and yearly pitch counts were higher in softball players reporting pain or injury. When pitching more than 85 pitches per week, they were more than twice as likely to see a physician for pain, and they reported often playing through the pain a higher percentage of the year, again, oftentimes because they may be the only pitcher or one of two pitchers available to play on the team. So, high pitching volumes definitely are commonly associated with injuries in high school and collegiate pitchers, definitely associated with pain and injury, and this is related to the cumulative volume of pitches. We looked at the medical advisability of softball youth pitching, recommendations that are available on the internet, and this was published just last year. So, we looked at websites on Google, used the search term softball youth pitching recommendations, and we actually compared what we found to recommendations that are put out by AOSSM, the AOSSM Stop Sports Injuries Softball Injury Prevention Guidelines, because we wanted to just see, is information out there actually adhering at all to something that we respect in the field of sports medicine? Fifty-one percent of the websites had no mention of any recommendation from AOSSM. And the most common discordant guideline was differing opinions in terms of pitch count. So, we concluded from this that educational websites, websites discussing only softball, and the first 50 websites had the highest scores, and hence were most likely to have medically advisable information. We clearly need a lot more research to determine optimal pitch counts for softball, and we can all work together between ANA and AOSSM and our sports medicine organizations to disseminate softball pitching recommendations and try to prevent some of these injuries. The windmill pitch, I include, let's see this video here, just so you can all see what does this look like in a little bit of slow motion, but the arm is in the plane of the body. There's a lot of centrifugal force placed on the shoulder, so forces across the shoulder and the elbow. As the hand, as the ball is released, the hand actually hits the thigh to slow down the arm. And the windmill pitch is broken into four phases. I'm not going to go into this in great detail for the sake of time, but windup, stride, delivery, and push-up. But windup, stride, delivery, and follow-through are kind of the four main components of the pitch. We looked here, too, at softball pitching mechanics and the association with shoulder injuries. This was just a review article, but in terms of softball pitching mechanics, the forces resisting the distraction at the shoulder and elbow were greatest during the delivery phase, and that maximum shoulder compression and distraction forces were about 98% of body weight, so tremendous force. These values are actually comparable to what you see associated with shoulder injuries in baseball pitchers, so a lot of forces going across that shoulder. So, just a picture showing what are the differences between these two pitches. We all know this, but breaking it down a little bit, some of the similarities. The pec major is the power generator in both pitches, and the stabilization against anterior forces is provided by the anterior wall muscles. The serratus anterior, on the other hand, is a scapulohumeral stabilizer. So, when looking at these, you can see the pec major, big muscle, obviously, on the front of the chest, and then the serratus anterior, which works as its antagonist. And then some differences. So, with softball, the humerus is actually in the plane of the body. There's less contribution to the pitch in softball players from the posterior aspect of the cuff, and adduction contributes to the power of the pitch. The greatest resistance to distraction across the shoulder is during the delivery and acceleration phase. Now, compared to baseball, where the humerus is abducted, the posterior cuff actually assists in acceleration and deceleration. Internal rotation of the humerus contributes to the power of the pitch, and the greatest resistance to distraction occurs during the deceleration phase. With shoulder injuries in particular, so pitchers are the most likely players to sustain shoulder injuries. There's about 1.14 shoulder injuries per 10,000 athlete exposures. 50% of these injuries are overuse or chronic, because they're pitching all the time. And the most common diagnoses are tendonitis and muscle strain. And then looking at pitchers and position players, so practice injuries overall are more likely associated with non-pitching throwing, because every player out there is throwing, but obviously not everyone is pitching. The incidence overall of shoulder injuries is about 17% in pitchers, compared to about 6% in position players. And pitching is the most common mechanism of shoulder-related injuries in softball players that can lead to more than nine days of missed time. About 50% of pitching injuries lead to at least two weeks of lost time, so pretty significant implications. The stress on the shoulder that pitchers feel is actually amplified by the increased weight of the softball, so the softball is definitely heavier than the baseball. And then you have a more extended elbow, which leads to increased centrifugal force across the arm. The biceps also actually works to resist glenohumeral joint distraction, and it produces elbow flexion, so it's working across both joints. The posterior shoulder muscles actually tend to be injured while they're contracting to actually work to decelerate the arm, and that dysfunction can in turn lead to instability anteriorly, and joint laxity can lead to further injury of the shoulder. For our position players, the lower body creates the majority of the energy in the overhand throw. We all know about the kinetic chain. So the gluteus maximus stabilizes the pelvis during throwing. The pelvis and trunk then influence shoulder movements, and we know the pelvis has to support the scapula, and the scapula supports the shoulder. So they're all working together. A little bit about injury prevention. So training and conditioning programs definitely decrease fatigue. We should have position-specific interval throwing programs. That's really important, and also incorporate some flexibility training. We looked at this a little bit and found that in terms of upper extremity injuries, novice pitchers relied more on the upper arm segment, whereas intermediate and elite pitchers tend to rely more on the distal arm segment. Also, the biceps and cuff fatigue and weakness and shoulder range of motion deficits were all risk factors for throwing-related injuries. So the more fatigue, the higher the risk of injury. We also noted that only one article actually specifically described an injury prevention program for pitchers. It focused on dynamic stretches for flexibility and exercises to strengthen the gluteal muscles and the lumbopelvic complex. We concluded overall that the lack of regulations regarding pitch count, season duration, and athletes transitioning to year-round sports, we all see that all over the country, definitely contributes to injuries, and that having a balance between increasing strength and retaining range of motion is important. That can limit cuff tears, slap tears, and hip complex strains. And there's a higher injury incidence actually at the beginning of the season which can indicate that maybe we need to change what we're doing in the off-season in terms of training too. But important to remember, overuse injuries are difficult to avoid even when we have these targeted prevention programs due to lack of pitching regulations. So that is really something very important that we can work on. We need to just keep doing research and working together to try to get more information about this. For pitchers, for injury prevention, incorporating shoulder proprioception training is important. Having exercises for the cuff, the back, the abs, hip, and groin, all of this is really important to try to decrease their risk of injury. And then in terms of regulating pitches, quality overall is much more important than quantity. So they can do fewer pitches but just do it better, and they're still going to get a lot of benefit from that. We want to try to limit using anti-inflammatory medications just to mask the discomfort. Of course, try to limit the number of pitches. That would be very beneficial to these players. And try to limit the time between games. But again, one of the major factors is that there's often not enough pitchers to be able to do that. With cross-training, very, very important. It can help reduce the stress of the throwing motion, including things like pool workouts, aerobic conditioning, cycling. All these cardiovascular exercises can be hugely helpful and have light days where they're focusing on leg work instead of doing stuff with the arms. For the position players, working on gluteal activation, stabilizing the scapula, and just facilitating fluid transfer of energy, that can decrease stress across the shoulder. There's also this concept of periodization, which is during the off-season focusing on aerobic-type exercise, and then in the pre-season doing some strength training. And that can also help decrease the risk of injury. In summary, the windmill pitch can predispose our softball pitchers to injuries of the biceps, the labrum, and the cuff. Shoulder pain then leads to further breakdown of throwing mechanics, which can cause more injuries to the shoulder. We really should try to focus on and develop position-specific injury prevention programs, and again, work on trying to limit pitch counts and characterize the relationship between the pitch counts and overall injury. So thank you so much for your attention. I really appreciate it. Thanks for being here. And last up, we'll have Dr. Matzkin speaking about anterior and posterior labral tears and throwers. All right. It's like the seventh inning stretch. All right. So I'm going to wrap this up, and we're going to talk about anterior and posterior labral tears and throwers. So these are my disclosures. None are pertinent to this talk today. So I think we've kind of already heard this, that the throwing athlete is not our typical athlete, and that's what we're going to focus on. They are not the norm. So it's really important, and I think we've already heard this from our speakers, that when we're working with our – especially our throwing athletes, we need to get a good history. It can really help us provide a diagnosis. We want to know when their shoulder started bothering them, how, what sport they're playing, what's their level of competition, where in the throat does it hurt. And really asking all these questions will really help you figure out, are we – you know, before I even examine them, am I worried about a slap? Is it anterior? Is it posterior? What's going on here? So a careful physical exam history can provide really important information for us. And then imaging is used to really confirm the diagnosis. So physical exam, we've heard about it. We have to definitely examine both shoulders. You're going to look at range of motion, strength, and then these are the special tests. We heard about our slap. My talk is focusing on anterior and posterior labral tears. And you can't forget the whole kinetic chain. You've got to think about the core, the hip flexors, the abductors. So this is really important when you're working with throwing athletes to make sure you're examining the whole kind of thing. You never know what their throw may look like. These are just some of those typical exams we'll do, especially if we're looking for anterior-posterior instability. Posterior, we're going to do some more internal rotation adduction. Imaging, we're always going to get radiographs. Our typical views are going to be a grassy view, an axillary, a striker notch, and a west point view. An MRI is really what's going to help us confirm the diagnosis. In my practice, usually patients under the age of 30, I will get an arthrogram if I'm worried about labral pathology. There are several studies out there that shows that an arthrogram is more sensitive and specific for looking for labral pathology. CT scan, if you're worried about any glenoid bone loss, we've heard this throughout the meeting today. I put this slide in here. This is a real recent article that looks at risk factors and injury prevention in the throwing athlete. This is ideally what we want our athletes doing. We want to prevent these injuries to begin with. There are lots of programs out there that these athletes can use. Pretty much every throwing athlete, certainly in college and above, are going to be on these programs. We've got to talk to them about our high school athletes. When you're seeing them, make sure they're working with physical therapists who work with throwers because, again, it's going to be very different than our routine shoulder. Again, we're going to focus on anterior and posterior tears here. These can happen in a variety of ways. You can be sliding into the base. You can dislocate. You can subluxate. This can be overuse from this crazy external rotation. We just heard about the windmill pitch. You can subluxate by swinging a bat. Then we can't forget about our other throwers. We've got shot put. We've got javelin and all sorts of things. One of the most important things is throwers really require a balance of shoulder mobility and stability. We're going to keep that in mind throughout the rest of this talk. Traumatic shoulder instability, it's not super common in our baseball players, in our pitchers, but it can be in some of our other throwing athletes. We've got quarterbacks. We've got javelin shot put and other things. It can happen diving for a ball, sliding to a base. When your patients present with anterior labral pathology, they're usually complaining of instability. When they present with posterior labral pathology, they're often complaining of pain. Micro instability, this is from the repetitive motion of throwing, that extreme external rotation, abduction. It stretches the capsule. You can get some impingement posteriorly. The capsule can get a little attenuated. It puts more pressure on the labrum. Then you can get an acute atraumatic labral tear. They've had this micro instability, these micro tears, and then they throw really hard. Now they have an acute atraumatic labral tear. What's really important to remember, too, is that we can restore stability of the shoulder. We all know how to do a labral repair, capsular shift, remplissage, whatever we need to do. Throwers do not return to play at the same level as our other athletes. We're going to go through some of that data. First and foremost, non-operative management. Studies have shown that up to 50% of our overhead athletes can decrease their symptoms, improve their function, and avoid surgery. If you can get your athletes in to work with a very experienced physical therapist, and you can get them back to playing with non-operative management, that is a win for you and the athlete. Most of these programs are a phase-specific approach. Phase one, get pain-free range of motion, capsular flexibility, stretch it out. Phase two is going to be rotator cuff, scapular stabilizer, neuromuscular control. Then phase three, we advance our muscle endurance, strengthening pylometrics, and then a progressive throwing program. These programs can take time, and you need to let your patients know that. If you can get a throwing athlete back with non-operative management, it is a win. Operative management, if they fail non-operative management, and then you've got to figure out timing. Who is this athlete? Are they going to go on to play in college? Is their career ending at the end of the season as a senior in high school? What's their eligibility future plans? You have to have a lot of conversations with the athlete, the parents, maybe the athletic trainer, coach, agents, whoever's involved. But we're all very good at doing surgery, restoring our labral bumper, whatever we need to do. But it's very different for a thrower. You've got to think about the reason they're good at what they do is because they have adaptive capsular laxity to accommodate their mechanics. And we can't over-constrain them. We already heard from Dr. Freehill about using knotless anchors, knotless reconstruction, especially in a thrower. And then remember, you have to balance stabilizing them without over-constraining them, or they're not going to be a happy camper. Returning a throwing athlete back to their pre-injury level of performance remains challenging, even in the best of hands. And I'm going to go through some of this in the literature. This is just a table of six different studies looking at throwing athletes. And if we just look at their return to play, it's 85%, 84%, 70%, 92%, and 94%. So it's good in some of them and not so good in other studies. Return to sports after an arthroscopic bank cart in an overhead athlete, 62% returned to the same level or higher without any complaints in their shoulder. And it took them an average of 13 months to get there. 62% is not a great outcome in a throwing athlete. But you have to let them know these things. What about after a bank cart and a remplissage? This was a systematic review. Return to sport for a contact or collision athlete, 80% to 100%. Return to sport for an overhead or throwing athlete, 46% to 79%. So my football players love these surgeries. All right, different story in your throwers. What about another five-year follow-up looking at remplissage? Throwing sports, 51% versus 95% for non-throwing athletes. So you've got to keep these numbers in mind. This was a recent study. I thought it was interesting. This looked at actually a mid-substance capsular tear in high-level throwers and a repair. So it's a little bit different than a labor repair, but 90% of them got back to playing or returned to sport. But something that you probably need to be aware of and look out for. And then lastly, this was a very recent study for dynamic anteroglenohumeral capsular ligament tensioning, or called DOT. And I don't know if that's exactly how they pronounce it, but this was a group that decided to do their labral repair and capsulography in an abducted external rotation position, so mimicking late cocking phase during surgery. And they said they were able to avoid any over-constraint while positioning the arm in this, and they had better clinical outcomes, higher return to the same level of sport versus their conventional kind of positioning and tensioning. So there's not a lot out here on this, and I don't know if anyone's ever thought about doing this, but it's just another way to approach that throwing athlete. So this is just a video that I'm not going to talk through the whole thing, but a lot of times these are kind of acute on chronic tears in these throwers. They'll have like a chronic posterior labral tear and maybe a little chronic anterior labral tear, and then something happens and that becomes more traumatic. And most of the time when I have an athlete with a large or an anterior and posterior labral tear, I like to fix anteriorly or my bank cart, then I go posteriorly, and then if I need to, I'll go superiorly. That's just the order I like to do them, but in a throwing athlete, I will fix anterior, posterior, anterior, posterior, so I can continue to balance the shoulder and make sure I'm not over-constraining. I think it's also really important that, you know, posteriorly we're just repositioning that labrum back onto the glenoid. You should not be tensioning any capsule or tightening any capsule in the back. And in the front, you know, in my football players, you know, sometimes we'll, you know, nip and tuck and whatever we want to the capsule, but you cannot do that in your thrower. You have to restore their ligament, but you cannot over-tension that capsule. I mean, even, you know, swimmers, volleyball players, throwers, all these overhead athletes, you have to be very thoughtful. So I do think that we just have to keep in mind that throwers are a different breed, and you have to have honest conversations with them ahead of time. You know, a lot of laboral tears and athletes, they do great. I mean, a lot of these athletes came back out in a field in four-plus months, but a thrower, it's going to take them longer, and I tell them that. Even if you have a great outcome, you're not going to be throwing at a high level at four months like your friend who's, you know, playing soccer or football or doing something else. It's a different, even though it's a similar surgery, it's going to be a different rehab to get you back to that level. And I think that's all I got. Thank you. Thank you. Okay. Excellent talks. If anybody has questions, please come up to the microphone. There's plenty of time. I... Oh, yeah, please go for it. Great talks, everybody. Thank you. Sorry. It's Albert G. from University of Washington in Seattle. Mike, I had a question for you because I've been trying to figure out how to do the hybrid reconstruction as well. And I get the nice pictures from Dr. Meister as well for all the guys that choose to have their operation with him. And it's clear that he puts an anchor right kind of proximal in the sublime, and then his bone tunnels for the reconstruction are more distal. And I've been trying to kind of play with that as well. But obviously, you don't have a ton of space in the sublime tubercle. I've been putting my brace through my tunnels. So I just, in addition to passing my palmaris graft, I'll pass my, I don't use fiber tape because it's hard to get that to tie on the medial epicondyle, so I'll use suture tape and I'll pass that with my graft. And so it makes the same route as my reconstruction, as the graft itself, but I tie that as well. And then again, I use docking technique on the humerus, so I'll pass those grafts to those two independent tunnels and tie that over the bone bridge. Yeah, so a lot of the tricks I learned from him, so you do your tunnels. It's interesting because he'll make his distal tunnels, the sublime first, and then do his internal brace. I usually go the other way because I get scared if you get into that tunnel, then you got a problem. So I'll put the internal brace first, then do the tunnels distal, and then with regards to the docking, you know, you just bring out, there's a couple tricks with that. You can either bring out two separate, so you pass like two, say, zero-ethel bonds or something, have those passed, and then you pull your graft before your tape. You can pass it the other, if it works for you, you can do that, but I'll pull the posterior one first, and that will pull your tape, and that will pull your graft. And then you have to cut down your reconstruction, cut it down and whip it. But what he'll do on that, and what I think works well, is pass the graft first, and then you use a DeBakey, if you use a DeBakey and run that up the tunnel, it will flatten things out because I think when you pull everything in there at once, they can get on top of each other, and that's where you might get a little bit of trouble passing. So that's one trick that I do think is helpful, and then you can pass the tape second. And then another thing that I've kind of followed suit on that, is he'll actually use a suture passer to tie down tape first and then graft second, and I think that's a nice trick too, because a lot of times you're back there and you're kind of battling and you're pulling it down and you, I don't know, so I've gone to that. Do you think it's important that the graft comes from one single, or excuse me, that the brace comes from one single point on the subline instead of coming from your tunnels? Oh, I see what you're saying. Do you see what I mean? Oh, so you don't put... What I mean is, is there a need for that separate anchor when there's already limited real estate in the subline? It's a good question. I just, I worry about... Having that thing running through your bone tunnel. Yeah. Yeah. Is it going to cause osteolysis? That would be my only point on that. I just, I'm always amazed that there's that much space for that. what do you drill on the sublime for your on the sublime yeah that's a three five yeah it's like a big hole that's the same well so the drill hole is what three and a half for the well to go line to line yeah when you tap it and you can tap they have two taps yeah yeah so you got to go up with the tap but it's also you know peaked for what it's worth that won't be a void so it fills it but i agree you always have to think about who's going to come after you It's slightly different, a little different. Okay, thanks guys. So it's got a funnel of more proximity. No, the anchors will probably have a little bit of extra freedom. Did you have a question? Yeah. So my question to you, is there a cutoff age where you would say, okay, this guy is 25. He's not getting a slab repair. Yeah. So historically it was 40 and then Preventure issued his paper, which was really a watershed moment for a lot of us. And that was 35, 36. And then we've seen the age go down lower and lower. So it was 30. Now I would submit to you, it's probably 25 and if it's a non-thrower, I've got to find a reason not to do a primary biceps procedure. So to your point, if it's a collision athlete, if it's anybody other than handball or whatever the analogous European sport would be, I would generally probably lean more heavily towards the tinnitus on average. Yeah, what do you all think? I know you're a little bit more reticent to recommend it. Yeah, I'm probably more like age, I would probably say it's 35 for me. But I often think about physiologic age versus numeric age. And so if I have even like a triathlete that goes off their handlebars and has a slap, and I will sometimes just tack it back down versus do a full-on tinnitus. But I would say if I had to give you a numeric age cutoff, it'd probably be more like 35 in my practice. But it doesn't mean I don't do it in 25-year-olds, but. Yeah, it's interesting. The same year when I was at Harvard doing the Shoulder Fellowship, Albert Lin and Louis Shih and I looked at Warners, and we went back. And it was published like six months after Provencher's. And we published it in JSCS. And it was crazy. And guess where the breaking point was? 35, 36. It was wild. Same exact thing. But yeah, it's different, I think, with the general population versus the throwers. I think if you look at these throwers, you don't want to be doing surgery on the shoulder unless you absolutely have to, number one. I think number two, we also published on this and went back and published on arthroscopy techniques. You look back in the literature of all the SLAP papers and how often they were describing their surgical techniques. And you should have seen how all over the place that data was. Like, no numbers of anchors, where the anchors were placed, what they were using for anchors. So I think that the classic literature of how poorly the SLAP tears and SLAP repairs did, I think, was in part because there were so many variables and so much variance of what people were doing. I think the newer thought process is that Ben Kibler's talking a lot. I think that we were missing the real SLAP pathology. I think they're type 8s. And we're viewing from posterior and talking about not to put anchors, not to hogtie, and did these SLAP repairs. And the real pathology was down the posterior aspect of the glenoid, where now we're getting into these high anterior portals and lateral decubitus and getting a better look and realizing that we can get up to that inflection point where it's more meniscal, if you will, and there is some play. So somebody's humeral head can roll back to effectively throw whatever it might be, and then repairing 11 o'clock and down. So I think it'll be really interesting to see how SLAP repairs in the last three years and moving forward do. is in the back and non-anchor in the front. So that might be also a process of changing how to repair the slab. Yeah, and I'd love to get your thoughts on this, Brian, but I went and spent time with Hiro Sagaia, who, you know, takes care of probably the highest volume of baseball players in Japan, which we know is their primary sport. His mindset is completely flipped. He says, yeah, the slabs don't do well, but where people are missing the boat is that the superior glenohumeral ligament, you don't have to go too high up by the biceps anchor, but just on the anterior, kind of more anterior aspect. And sometimes he'll just repair that back, not over-tightening it, but just simply to help control some of the translation. And he might be right. I don't know. I know I was the same as you. I'm like, I don't want to put anything anterior. So, you know, I just, I think the type eight stuff is real and that's probably what's going to help. For the general population or thrower? General population of 35. Tennis is probably the worst like Giovanni Giacomo says tennis is the worst with slap pathology. Everybody's worried about a pitcher. I'd be worried about a tennis athlete. That's a nightmare. Good luck. Liz, question for you. So when are you pulling the trigger on repairing anterior posterior labral pathology in your throwing athletes and what do you tell them in terms of post-op rehab like what to expect in their progression and estimating of time to return to play? Yeah I mean I I'm not taking them to the operating room basically until they come back to me and say I can't pitch I can't throw I can't do what I want to do with my shoulder and I think a lot of them will nurse them along through their season or whatever it is and as soon as season ends then they go to the operating room and and I tell them that you know in four months they're gonna feel really good but it's gonna probably take them another four plus months to get back to a high level of throwing like if they're a pitcher I mean especially just because you know I say like we've shut you down for months and now we've got to build you back up and and you know that includes your core your your you know hip flexors abductors quads the whole kinetic chain and you know it takes our non throwers four plus months who aren't even using their shoulders so I tell them you know and in some of the studies you saw it took them over a year to get back to the same level of throwing so it is it's just a different beast and you just have to lay that out for them and I say look I know your friends have the same surgery and they're back much quicker but it is very different for a thrower. That's a really important point Mike or Brian anything you do differently anything you do to educate the patients about what to expect? I would just say we talked about this a lot but just so we don't even start with the shoulder when they come in step down you know do they have positive step down first 90% of the high school kids are gonna have it they're gonna have weak VMOs their hip external rotators are all over the place their core is weak they're gonna have loss of internal rotation sometimes loss of external rotation they're all gonna have scapular dyskinesia with no ability to control they're gonna have tight pec minor I mean and that's what Liz is saying you got to have that therapist that's your go-to out throwing therapist because just the bands isn't going to do it they really have to emphasize the whole kinetic chain. I have some of these high school kids come in I just have them try and do a bridge on the on the exam table and it's astounding and you know even they're embarrassed. Did you have a question? I'm Dr. Funakoshi from Japan so I'm just a comment for the can I go back to the lab room? Sure. So the most important thing my concept is management the stability and laxity so the I think the problem is not just only lab room the problem is a capsule ligament so if the titer is getting worse but just not only we have to I think we have to consider not only lab room the Dr. Sugaiya just only the anterior this is maybe to make sense for their stabilization the anterior superior side the Dr. Mitsui D.A.G.H.D. I'm sorry I named this one so Dr. Mitsui claim to the dynamic dynamic is the most important factor for him so the it's the D.A.G.H.D. for the D.H.D. for method the focus on the appropriate tensioning especially the including MGHL not only lab room yeah so we avoided it how we concentrate not to the titer just the appropriate tensioning it maybe does work I think I believe it. How are you putting them in this position? Maximum, almost maximum. So Dr. Mitsui the on the B chair positions I love to the that are the incubators positions that I'd like to check every time the time and how to the bite yeah and much much different and here and here we found the MGHL behind there we usually view from the posturing but the deep line the back in the deep the granoid and the anterior superior side granoid but this position we found the MGHL almost guys but some some baseball players does not feel like that the I do the reconstruction but they're almost players we found the MGHL including not not only MGHL the whole the whole bunch of the anterior capsule the the part is the age is laxity the younger usually it depends a patient but laxity is much so you know the young young players yeah yeah yeah yeah that's the reason why there some the slap tears does work for younger guys but the oldest doesn't work because they are tighter thank you very much for that comment we appreciate that any other questions from the group please yeah super similar to hip yeah I'll tell you whenever I've gone and done a second look arthroscopy there because of persistent pain inevitably when I've done a simple suture it always loosens up and so everything looks ratty around it the concept of this is an inverted mattress so you're placing the anchor you're passing it through often you have to put a passing suture and then you deliver it underneath and then you're just passing or shuttling the suture and it creates coaptation with a mattress suture while maintaining that that sub labral sulcus so I think that's a different thing it's achieving a spot weld more medially while maintaining probably a little bit more mobility and I learned that from from Tony Romeo yeah so if you place the anchor and in the anchor position is also something you could draw from the hip analogy you want to make sure that that's not on the rim but really really Oh farther away as possible because you can really compromise onto the face quite readily place the anchor suture lasso coming in from either anterior superior posterior superiorly passing getting that repair stitch then another passage from the back passing it through and either inverting your suture passing device or getting a link suture and then passing that one back through so it's so it converts as just a mattress suture now where that can go wrong is if you make your holes too close to each other or there's not substantial enough tissue it could just lacerate through that so my thought process has always been and Mike's got me a little shook up here as I've always just tried to avoid the SGHL which is I think where we've over constrained things and just gone with a labrum alone that's why I like the benefits of the lateral position but sometimes the beach chair can be a little bit more friendly when you're working up top and going front to back but no very hip inspired approach that's that's way a lot of my partners do it that's great well thank you guys so much I think we're at time so enjoy enjoy the reception tonight thank you again for being here

throwing athletes

baseball injuries

softball injuries

SLAP tears

biceps tenodesis

UCL injuries

internal brace technique

shoulder biomechanics

overuse injuries

labral tears

sports medicine