So, I have a question. Sure. Because, you know, the external rotation, and you talked about it, Ben, a problem with, you know, you see it a lot. You know, you expect them to have hyper-external rotation, and every now and again, you'll get somebody who can throw. And they're a high-level thrower. And I wonder, those are the ones that scare me about the last time. Because they're an elite thrower, and they have to find a way. Their arc is decreased, so I think that they're pulling super hard. Is that a view? Yeah. What's the purpose of the lab? The lab is to do this. And they can't do that. Oh, okay. Thank you. I'm going to guess. It doesn't count. It doesn't count. It's wrong. It's wrong. Yeah. Relatively few ones that I've seen, and consulted on, they've got trouble down here. They, what's it called? They had two of them, actually, that had some hit display. So, they couldn't rotate. So, they couldn't rotate. Therefore, they couldn't get back. They don't get where they need to be. And they either compensate, or they throw from here and do too much right here. And so, every one that I've seen, and they're my first one I ever saw, usually a guy called me and said, what's going on with this guy's got a lap? He said, what's going on with his hip? I thought it was crazy. Because that was one of the ones that had a hit display. So, you've got to look down here. If you're going to get better, that's one thing to look for as well. But if you're right, it's that they're not allowing that lap to do what it's supposed to do, or making it work too hard. Yeah. The other quick one. Ben has taught me so much about that. One of the pearls, I'm blessed to work with a PhD named Steve Thomas, and he taught me a diagnosis, clinically, to diagnose a tight lat. If they lose foreflexion, then have them inch and rotate, they'll gain some foreflexion. For the teres major, he says, if you have GERD, and then you have them do a sleeper position, if their inch rotation increases, then he thinks that's due to teres major. So, two little clinical things to look for. As Ben has taught me, I think lat tightness can be an issue in arthritis. So, all about prevention. So, these are my disclosures. I'm going to say some things to tie things up, go right to the cases, and then have some, hopefully, time for some questions. So, as Mike illustrated, prevention is the word of the day. And we're going to talk briefly about the surgical pearls I've learned through the School of Hard Knocks. As Mike said, be kind to tissue and operate sparingly. I'm going to talk about hog tying the biceps that Ben and I talk about a lot, how you can dress the capsule. And as Mike indicated very, very elegantly, don't be a slapaholic. Most of these patients, this is Tony Romeo's term, most of these patients do not need surgery, and I think you can be doing a lot of harm if you operate indiscriminately. The MRI will get you into trouble. How many times have people in the room had a radiologist report, the patient comes in, I have a slap tear, and I'm like, yeah, I've got two bulging discs, okay? I mean, so, the radiologists hurt us all the time. You have to trust your exam. And as Ben taught me, unless it's clinically significant, then it doesn't need surgery. Slap tears occur with aging, and anatomic variants do exist. So, again, two bulging discs. There was a fellow named Fahler in 2003, looked at cadavers. As we get older, we actually develop separation of our labeled tissue. And that's the reason why people over at, you know, Matt Prevention did a great paper, over 35 failure rates, so I guess what? In my humble opinion, most of those patients didn't need the surgery. It was part of the aging process. It's like fixing an adrenal meniscus, in my humble opinion. So, remember, this happens with aging, and this is a Buford complex. Donny Buford's here today, or somewhere in these whereabouts. So, don't fix this. This is normal God-given anatomy, cord-like MGHL. This is what Mike showed, I think, an illusion of sub-labral foramen. Don't fix that. And as he also showed the meniscioid labrum, the meniscus, as Greg Bain says, is a mobile unit of tension, and there is mobility. You can disrupt native anatomy by making them too tight. And, again, as Mike said, a stretched labrum is not a torn labrum. Sometimes those athletes will need that stretched labrum to get the slot, and you will kill their career by making them too tight. Been there, done that. So, John Conway had this term, good slap, bad slap. Well, I'm going to take it a step further and talk about Ben Sisley. What's a consequential? What is a clinically significant labral injury when it extends inferiorly? When I see this, I'm like, Houston, we have a problem. This is a good slap. This person has little stretched tissue. Don't fix that. But here's what I get really granular. The old guy talking here, listen to the patient. Sit down. Listen to them. If they've had a precipitous loss of velocity, what we call a slap event, and then they notice that sometimes once in a while you have mechanical symptoms, but usually it's like, I lost my zip. So the exam has to fit. We call this the man scan, woman scan. And of all the tests that I use, the Mayo Shear test has served me the best. Ben taught me how to do this. You've got to really shear down that labrum master. If they don't have a Mayo Shear test, I'm very loathe to operate, and I am blessed with two wonderfully gifted shoulder therapists. If they fail my rehab or their rehab program, then I know we've got a problem. And don't forget, Sarah Edwards showed this years ago. She's a wonderful young surgeon from Mayo Clinic, trained 50% of nonoperatively treated patients, avoided surgery, but simply posterior capsular stretching, scapular strengthening. So rehab does work. But, again, that 63% number that Mike alluded to I think is from poorly done surgery, not indicated surgery, and failure to address the pathomechanics. As Mike's son did, this is a temple catcher I operate on and fix his slap. Look at his core. Look at that twisting. These are things that Ben and Craig Morgan taught me. Look for the interrotation deficit of the lead hip, tight quads on the lead leg, and also the spine mobility. Craig and Ben showed us that if you – this is the Royals data – that look at these kinetic chain abnormalities that were very prevalent when they did the physicals. And it was just almost pandemic when you look at the amount of people who had dyskinesis, stride length, core weakness. And their intervention program had a huge reduction in injury, 86% less injury. I don't know why more people don't do these things. It saves money. So choose wisely. A bad slap is real separation, not just the stretch Mike said. If I see that real separation that extends – that's a marginal, Mike, honestly. But if I see a real sisley one that extends inferiorly, and you can't see Bankart lesions, you can't see Kim lesions, you see anterior laxity, posterior tightness. I'm a lateral-to-cue fan. I love percutaneous portals. They get me wherever I want, the Port of Wilmington. I fix the sisley tears. I dress the caps as needed. And we'll talk briefly about the cuff. I like knotted anchors, knotless are fine. But as Mike said, please avoid suture exposure. I've seen some of my own patients significantly injure a young shoulder. These Kevlar-based products are not to be taken lightly. There was a fellow named Hagstrom from Buffalo who did show that the best bumper was horizontal mattress. But I think if you do a good one like Mike with knotless, that also works. But don't forget, this is Ben Dom's technique of data, that one mattress suture worked as good as two simple sutures in terms of pull-out strength. So if you do it right, you don't need a lot of anchors. And that's what Buddy taught me. You don't have to go crazy with anchors. So labor height, I think, is key in the recurrence literature for bank cards. Labor height correlates with diminished recurrence. So I'm going to get that high bumper. Just a word from Craig Morgan's work about the capsule and the CHL. It's an important player. Once in a blue moon, as Mike alluded to, you'll see players with anterior laxity and sometimes corporeal ligament laxity. And if you see that little sort of chandelier sign Craig calls, the biceps is flopping down, then their CHL is probably a little loose. Don't forget, Jed Kuhn showed us that the CHL is a significant restraint to extramotation. So if someone has hyperextramotation, they've probably got a little bit of extramotation laxity. And I'm not quite sure what to do with that yet. But if they have a sulcus sign, it's symptomatic. What we did show you, one of our wonderful residents showed where the corporeal ligament lives. And we put some spinal needles through it and mapped it out. And it runs east to west. So interval closures have a bad name because for years we did north to south. But it does nothing to the CHL. If you're doing east to west judiciously, especially when some of you are instability patients, I think you can help some throwers. And I still haven't figured out, Mike, who needs this yet, honestly. I toy with the idea. Let's talk about the surgery for the anterior capsule. You know, Mike said, I don't know this, but sometimes you'll see some throwers with some anterior laxity. And I will do, and again, this is the Curlin-Jobe, Frank-Jobe, open, we call it capsule label reconstruction. And this worked. I'm an old guy in the 80s and 90s. He did this, and he got throwers back. So there may be something on the intercapsule. We kind of went full pendulum back towards the poster side. I don't know the answer, but I do know this. GERD still exists. It's still an issue. And when this came out, I got to tell you guys on the panel, my friends, I was doing some poster capsule releases. Nah, not anymore. Most of the people I see do respond to stretching. But then once in a blue moon, I will do a poster capsule release in a stretch non-responder, usually an older thrower. So I work as, I think Mike showed, anterolateral portal. And I work from the portal Wilmington, posteriorly, and I use an advisor, pass sutures. Steve Burkhart showed me this trick. Needle never lies. Make your portals decisively. Bang. Don't be pushing around, fussing around with blunt optorators. Less tissue trauma. I use percutaneous portals, the portal Wilmington. I keep the knots away. Craig did use PDS for years, Mike. I've gone to horizontal mattress. This is something Ben and I feel strongly about. And we don't know this for sure, but I think if you put the anchor too close to the biceps, they will lose external rotation. We call that hogtie on the biceps. So we like to keep it at least a centimeter away because if you look at Jen's Chapman here, in that thrower, in external rotation, the biceps is 90 degrees posteriorly. If you hogtie on the biceps, as Ben would say, I love his southern accent, makes it sound more authoritative, I think they'll never find the slot. That's my humble opinion. So one time I mentioned this at a conference. Jimmy Andrews got up and said, you're nitpicking, son. You're just nitpicking. Well, I don't think so. We know that those throwers need to find the slot. And if you hogtie the biceps, they ain't going to find it. So prominent knots, prediction, pain. I love showing this. Mr. T, I love that. And if you see an MRI with a DEMA like this, you have a prominent knot in tuber and otherwise. This is a young, I think, lacrosse player. It was like a bomb went off. This is another guy inherited. You know, just one prominent knot will literally, and I so appreciate Mike's talk about the reverence for knots. So like Mike, horizontal mattress works. What I like is a bumper with knots. And I want to show you Ben's, this illustrates Ben's paradigm. Look at that band IGHL. That's the Sisley lesion. Look at the IGHL tension now. That is why, my friends, the inferior lesion is biomechanically acidic because you lose that tension of the poster band, the IGHL, and now it's restored. So again, no tape, percutaneous portals. There's a portal for every storm. I even shuttle percutaneously. I keep the tissue kind as I can. One of the pearls I learned from the Koreans is prepare from a contralateral portal. If you think it's a Sisley, put your elevator in. Bang. There it is. I prepare from the other side a portal for every storm. And the other pearl I want to share with you is I use the divisor portal to shuttle sutures. And again, I use percutaneous portals. I don't care where I am. I use these sharp obturators, and I will use the divisor portal to shuttle. So internal impingement, as Ben mentioned, pinching of the glenoid and posterior labrum, painful cocking. Look at these findings in MRI. You'll see edema of the posterior more head. This is what it looks like grossly, and this is what it looks like when you put the arthroscope in. You'll see that internal impingement as that person comes into extra rotation. Ben Kibler, who's a genius, taught me about the scapular retraction test. If their internal impingement sign goes away when you retract their scapula, then they need to work more on their scapula. They don't need surgery. So my take-home points are don't be a slappaholic. Please remember the kinetic chain. Be kind to tissue, percutaneous portals. Don't hog-tie the biceps, and address the capsule as needed.

shoulder injuries

shoulder surgeries

external rotation

labral tears

scapular retraction