So, with that, I'd like to ask my distinguished guests to come up forward, and we'll go over some cases. And Lord willing, we'll have some time for some questions, and I can't thank you guys for what a wonderful job you've done so far. You know you're getting old when you get cold, so I'd ask you, when I give this audience their money's worth, I would like the panel to give short and sweet, concise answers, so we can get their money's worth. So, this is a case I just showed Ben, this is a 19-year-old freshman baseball player, I lost my zip. He has 30 degrees of GERD, he has type 2 scapula stenosis, what do you see in there, buddy? He's got the anatomic, patho-anatomic findings of internal impingement, but look where the injury starts, starts at about 1030, and you don't show me posteriorly, inferiorly, but he's got obviously a peel back, and look at the in-substance injury, not only is it away from the bone, but it's in the substance of the labrum itself, and then of course he's got that internal impingement of the undersurface of the rotator cuff right there. So what are you going to do next, Irish Mike, are you going to send him to the pen-throwing lab, are you going to de-breathe it, are you going to fix the labrum with knots, or knotless, or are you just going to have Ben tell him to retire, what are you going to do, Mike? Yeah, send him to Kibler. I think, well I assume at this point, he's in the operating room, so he's failed everything in the operative. Good answer. I was a little behind on my car payment, so. Yeah, so I would not pull out the scope and send him to more rehab, I'm assuming we've addressed everything that we've talked about, checked his hips, checked his core strength, made sure that his shoulder rotation is symmetric, so I would fix his posterior labrum, I would not hog-tie the biceps, and I like to keep my anchors, hope for this, kind of like Freehill mentioned, posterior to 12 o'clock, and fix it down the back, and I'm like, Freehill, I like knotless anchors above the equator, just because of the pictures that you showed where some knots can get some abrasion of the cartilage and cause some damage to the undersurface of the infraspinatus, so I've gone to knotless anchors above the equator, and I do mattress sutures below the equator. And I would de-breathe that infraspinatus tear, you know, and kind of like Mike said, I'm not sure the right answer there, but I would clean up the infraspinatus and fix the posterior labrum. John, can I ask a question of the panel? Where would you, you talk about fixing that posteriorly, where would be the most superior of your posterior anchors, in that situation right there? Would you show the video again? Mine would be at 11.30, and then working down the back from there. If you look at that, if you look at that, I think you're right. You said it starts at 10.30, I would say 11.00, so I would start at 11.00. Yeah, see right there, see right there, 11.00 is about where you'd go with that. Yeah, I'd start at 11.00 and go down from there. And Greg Bain's work, if you haven't read it, it's really good, he talked about the two different types, like was mentioned, this meniscoid, and the posterior end of that meniscoid tissue is about 10.30 or 11.00, and so you want to fix that. Anything above that, I think you're going to hog tie it, or you're going to restrict this motion, so if you start there, and what I do is I fix it from there, down around the back, and you've got to see that posterior band become tense, then do the peel back again, and you will find that it won't peel back. If it does, then that's when I fix heroes, anteriorly, but only if, once I fix the posterior, he doesn't really lift off or peel back. Because the whole problem is that the labrum, the biceps labrum goes around there, and when you lose that, then the whole thing just lifts off, everything lifts off, and you've got this disaster of no stability. So if you put that 10.30 or 11.00, then things don't lift off, the biceps doesn't lift off anymore. Buddy Savoie taught me a good trick, so if you have an avulsion of the superior glenohumeral ligament from the one o'clock position anterior, if you push your cannula in and push that down, and then you externally rotate them, if the cannula pulls off, then don't fix it. If you externally rotate them, and the cannula stays down, then that may be a pathologic tear of the estrogens. Wow. Hey, you're good. You've got to get it. Oh, that's Savoie. That's not me. Irish Mike has a comment. I was going to say, so 30 degrees of GER, and they're in the operating room. One thing I would caution, or to look for, is those Bennett's lesions. George Palletta and the Wash U group, 15 to 20% of throwers have it, and they present in a couple different ways. People that are recalcitrant, and they can't get the GERD back, start thinking that they have a Bennett's. We published on this, because those Bennett's can be anywhere from where Bennett described it down by the triceps insertion, it can be posterior, which is most of the Japanese literature, and Burkhart called it a pitcher's mound up on the posterior superior. When that cracks, and it becomes fragmented, it can be painful. Keep that in your back of your mind, because that could be in play. I think what Jen Bradley taught me is, I think those KIM lesions are from the avulsion, because of the GERD. They just shear it off, because they can't get here, and all of a sudden, so I want to continue. Brian Witterman, this is a Whipple test, which Buddy taught me, a leading edge of the supraspinatus. What are you going to do with that cuff, Brian? Are you going to leave it alone, or dial 6734 Betty? You're going to debris with a shaver, do a partial repair, anatomic repair, or are you going to do one of these patches that we see prevalent? Brian, how are you going to treat that cuff? Yeah. I mean, I tend to like my patients. I don't think I'll do anything other than debridement. That's really up to 60% to 70%. I think you've got to address the underlying issue, treat the underlying cuff, shaver, a little bit of RF if you need, just to get nice annealed borders, and then try to fenestrate that marrow to try to- I like the way you think. The reason for that is because the rotator cuff is the victim, it's not the culprit of this pathomechanics, and you will make it the culprit if you tighten it, for sure. That is, it's like you want to trash a knee, take it out of a meniscus, you want to trash a thrower's career, fix the cuff anatomically, because also you advance the superior capsule. So what I would do, I'd call Father Murphy, that's what I did in this case, and I just debride it like Brian said. But Mike Frio, what's the problem of a posture repair? Have you ever, ever fixed a cuff anatomically in a thrower? I haven't. Good answer. Because what we learned from the work of Sagaia and others, superior capsule reconstruction, that when you advance the cuff, you're also advancing the superior capsule. And one of the things we learned from our posture repairs, those that do it, they all get stiff. My posture repairs get stiff. I'm probably advancing too much capsule. So fix the cuff camp. You can't handle the truth. Nope. So Mike, you told us about the suture configuration. You would go knotless in this young thrower? Yeah, I would. Any other technical pearls? Do you like that shuttle through the front or do you ever use an advisor? I use the Port of Wilmington. Okay. I think you can get a better angle. The visor is good, but even if you're doing SCR, sometimes it can be a little steep and you're fighting. You can almost come out too lateral through the glenoid phase. I liked the technique that Mike showed too, of with your passer, you're just going kind of through the mid substance of the labrum to repair the labrum back and not going all the way around it. Because I used to do that as well. And I think you grab too much capsule and you overtighten them. That's another reason I think the failure is too, because especially, yeah, and I think I do beach chair and lateral, but for instability and labrum work, do lateral. I think in the beach chair, even if you think you're going to torture that, grab that little biter, you can get a nip of capsule. If you do, that's fine. Trash the career. So just to give you a reverence for the suture, this is a player that I inherited, and this is just like one or two prominent anchors. So please, take Mike Freehill's words with great reverence. Just one prominent anchor can really trash a shoulder. The other problem with that is that you have taken that mobile organ of tension, which means it has some mobility, and you've converted it into the equivalent of the inferior part, which is the fixed organ of compression. And now you're just compressing the heck. I don't care what's, because I've seen that right there in a knotless stitch. If it's put up there, they're wrong. But if you put there at the 12 o'clock, the knotless stitch will, because now everything's compressed right there rather than mobile. So I've seen it with a knotless, that kind of damage right there, because you've fixed the superior labrum into this compression situation. You've tightened it down too much. So be careful about whatever suture you use that you don't put it up there and convert it to, and the point I always look at, you know, when you're 9 o'clock, right shoulder, the biceps always has a little bit of a kind of an angle, you know, going out. So it's about like that. And if you put your stitch in there and all of a sudden your biceps is sitting this way, you've hog tied it. Now it cannot come forward and come back. You ought to put your first stitch here so that it can still do this. But if you tie that down and it does one of these, wow, I really fixed that good. Yeah, you did. You really did. Now that's okay at 6 o'clock. That's not okay at 12 o'clock. So this is a picture of a thickened capsule, one of the few ones I released. And also Brian Wooderman, you, you got a gift, Brian. You're good. You're good. I want to go real quickly in the last minute here. I'll skip that last case. And this is my divisor technique actually where I put the needle through it. I love that. But I want to show you guys just a thrower, a couple throwers. I want to have our panel of experts analyze. Irish, Mike, how about this guy's kinematics? Show us the good, the bad, and the ugly of this thrower's mechanics. Yeah, it looks like he's got tightness of his lead hip. So his left hip looks tight because he's having trouble stepping through, which is throwing off his trunk rotation. He's not tall. He's not tall on his back leg. He's collapsing down. And Mike, how about his throwing in this scapula plane? And how would you comment on the position of his elbow? I agree with what Ben just said. And I think this is the problem that a lot of the younger guys have. And even major league guys, when they start to go right, I think that they don't stay back long enough. They start to fall down the mound. Once they start falling, your arm is playing catch-up. That's a good point. He's not bad. He's pretty good actually. Yeah, watch his release point. His release point's down here too. His slot is low. Well, it's trying to catch up. Yeah, yeah. Get Rich Quick gimmicks online. Man, I don't know how many of you guys see these throwers come in and dad found something online. Throw like Verlander. They're throwing weighted balls and standing against a wall. And then they go forward. Because they think if you're standing against a wall and then throw, your arm has to speed up. So you do transiently maybe bump up, but it's a recipe for disaster. Finally, just bear with me, this is a slow-mo. I want our distinguished panel of experts to all weigh in, starting from left to right. We'll watch this young man throw with the markers. This might have been from our lab. Look at the elbow. Okay, Mike, what do you think? Not bad really, but be hypercritical here. We're here to learn. What do you think? You know, I think it's okay. I mean, he stays back pretty decent, but his arm collapses a little bit. He's stable. His platform is stable. Yeah. He's not falling down. I think there's a lot of work to be done still, in my opinion, on what knee extension versus flexion, what the back leg should be doing. There's a lot. I mean, we have now at Stanford the KineTrax and TrackMan on the field. Most of the data at this point in time has been in a lab, and you can see if you've ever had those markers attached to you, we've got to go to a markerless system and then really start to clue in on what's happening at game speed, and that's going to give us a lot of detail because it's so hard. I talk to people who know a lot more than me about the biomechanics of pitching, and it's very enlightening. What's good? What's bad? We don't know. We know some. Right there, right there. See his elbow? It does a weird thing. He kind of does one of these numbers right there. Inverted W. Yeah, it's inverted W, and he has to get out of that inverted W by doing one of these, which then makes him slow. And his push-off leg collapses, so his hips are probably a little weak. So his back leg, look at his knee right there, collapses in a little bit, so his hip abductors are probably a little weak. When Mark Safran introduced me to Dr. Kibler, you were doing a lot of the tennis work with him, and I think there's some critical stuff with the tennis players with the serve that you would call them nodes, because you don't want to make somebody's mechanics perfect. Hitters love that. They're like, oh, it's perfect. Your mechanics are perfect, and I can see everything perfect as well. So you want people to be who they are. It's like a golf swing, but balance, keeping your weight back, not opening too early. There's nodes within it that if you hit those, you're still safe, I think. Yeah, exactly right. So finally, Brian or Mike, any other comments? Elbow position a little low. And Brian, how about his throwing with respect to the scapula's plane? Yeah, I mean, I would just make a quick plug for bringing in a multidisciplinary team. I'm certainly not an expert on analyzing the throwing motion, and Mike's point about making it too formulaic I think is a concern. I usually will look at this with our biomechanist. I will loop in our strength and conditioning coach and then bring in our physical therapist. And I think together you can really assemble a plan to get this person back. It's a wonderful concluding comment that I learned through humility is don't be a hero. I work with a guy named Marty Kelly, and he challenges his whole scapula. He says it has to be symptomatic. It also has to be relieved with restoration maneuvers. So if someone's scapula's a little awkward to throw in 98, no symptoms, you don't necessarily want to be a hero necessarily and change them too much. Capisce? Thank you for your time. These guys are going to hang up here for some questions, and I thank you all for your attention and my wonderful friends who crushed it today. Thank you all. That was very good.

shoulder injuries

baseball players

panel discussion

treatment options

throwing mechanics