Next, we're gonna have Mike Freehill is gonna talk to us about a deeper dive on who really needs a labor repair and when is a bicep stenodesis indicated. And don't forget, Mike played pro baseball. Mike, I want you to know, for disclosure, I was a Little League All-Star, so. All right, thanks for having me. It's a great honor, great faculty, and thanks for all of you who are attending this morning. So, some of this we talked about yesterday. I tried to, some things I needed to leave in and then wanted to dive deeper with some other items. Some of the disclosures, you know, so this was touched on, but the bottom line is, first step, I mean, we all know going into it, we don't really want it, we want to do everything we can to avoid operating on a thrower shoulder, end of story. That's the bottom line. And not to say that sometimes we can't avoid it, but that's the bottom line here. And regardless of the arguments of osseous change with humeral retroversion, soft tissue with GERD, GERD does exist, you do need to measure it. Yes, you need to get total arc of motion, but you want to have a reproducible way, and Dr. Kibler showed this, but the bottom line is, this was a great paper, Grossman, JBJS, back in 2005, the normal biomechanics in throwing, you're going to go posterior superior. If you have internal rotation deficit, you can see the other picture, how it exaggerates where that humeral head is going, and that's what's mashing up against that posterior superior posterior labrum and the undersurface of the cuff. So that's why we need to have the GERD stretched out. Scapular dyskinesia, again, Dr. Kibler did a great job, but you have to look at their back every time, make them do repeated forward flexion. How much are they getting tired with the repeated forward flexion? When you put your hand on the scapula and assist them, does that help them? Always touch the medial side of the coracoid, because the pec minor gets very tight, and this is all just running off what Dr. Kibler said. You can fix all this, and this is what, in my opinion, what 90% of people that come in, players of any age, that have elbow pain or shoulder pain, these things are in play. Oh God, it's unbelievable. Core strength, I'm embarrassed to say this was my own son a couple years ago. I needed a video, and he started doing this. I was like, oh my God, I'm like the worst. He's not like that anymore, thank you. He straightened that out, but in all honesty, again, every time you get them to do the step down, and these are guys that are just ripped, and they're in great shape, and they can barely keep their balance, and if they don't have that, everything downstream is gonna take a hit, so we can manage these things. We can stretch out the pec minor, do the posterior capsular stretching, build the core back up. I like this video from Javier Duralde a couple years ago. I just think it's nice just to see, look, hey, diagnosis lap, find some deficits, shut them down, plus or minus on biologics and steroids, et cetera, but you can get them going with the rehab, and then get them back on a throwing program. All right, so let's go a little deeper with regards to, we've straightened them out. They're doing better, but they're still having trouble. We know that imaging is a problem. It's hard, even with arthrograms and everything else to determine. I talked about this yesterday, and Jeff Dugas mentioned it. This is a normal anatomic cleft. Generally speaking, when you look at these MRs, regardless of what the radiologist, not all of us have the dedicated person that understands throwers, and a lot of slaps will get called slaps, but you want to look for the extension out into the substance of the superior labrum, not in that position of the cleft. This was a great study because these were experts that were looking at intraoperative video that J.P. Warner sent around, and guess what the hardest thing to do was? Even in experienced hands, distinguish whether it was truly a type two tear or not, and those were the experts in the field. I showed this video yesterday. That tissue's ratty. You could call that a type one. It's presenting like a type two, but there's cartilage on the top of the glenoid rim. There's not a full thickness tear. You can see, so is that real or not? And I think that you do need to have some intraoperative tricks of what's real. If you get that really sharp kind of top of a tent with granulation tissue, some hemorrhagic tissue, you don't see cartilage, I think that's probably more down the road of a slap versus the one below, which is more of that cleft. We know all these slap types, but which ones do we need to worry about in the throwers, generally speaking? Remember, Craig Morgan published on this that there's three types of slap, type two slap tears, and that's important because you can see it's about a third in each one, and I think different sports and different positions within sports, you see these different subtypes. In the baseball players, usually you're gonna see more of the type two Bs or the type two Cs. There's more experienced people than me in the room, but that's what I think. I came across this study, and I put it in yesterday as well, but I think this is really fascinating because in my experience, the gymnasts, and maybe it's just because they're freakish athletes who overcome all kinds of things, but they do really, really well when you have to do a slap repair versus the baseball players. I'm not so sure. I'd love to hear what Dr. Kibler thinks why the baseball players are more this type eight versus the gymnasts, and is that changing our repairs? Are we missing them? Is this a reason why we're not doing as well? This never got as much traction, Steve Peterson, who did this great study, but the reason I put this in here was to remember, again, I think the repairs went south a little bit because we were driven to do it in a way that's not anatomic. The superior labrum is much different than the inferior equator that we need to really get tight. It's more meniscus-like up top, and if you're a thrower, as was mentioned with the external rotation, you have to be able to get back there, and if you mash that down and they can't get back their external rotation, you know, that's a big problem. Look at, you know, this was at a rush just this year in arthroscopy, and as expected, the biggest part of this cohort was baseball players and softball players, but what we really wanna look at is return to play and return to previous performance just so we know, look, if a position player needs it and you've exhausted conservative management, you can probably have a good shot at getting them back, but if you're gonna do it on a pitcher, you better lay some crepe. So should we be fixing them, and if we do, how do we do this? Because, as we know, the outcomes have not been so hot. You don't wanna be the one holding the smoking gun, so to speak. This was the original kind of systematic review from Jefferson or Rothman, and this was the bottom line, 63% return. How many of us are telling our throwing athletes that? Lou Yochum did my shoulder back in the day, but I thought that this was really relevant because of that last part. If you did a slap repair and just debrided the partial, the pasta, the return to the same level was 12 and a half percent? I mean, this was a high volume guy for baseball athletes. That's astonishing, because every time you do a slap, you dust a little bit of that under surface of the cuff. Will Workman, who's here, been the head doctor for the Oakland A's for over a decade and played pro baseball as well. We had this idea of looking into the literature and how often the surgical technique was discussed, and guess what? A lot of times it wasn't, and then when it was, we noticed how much variability. So I think when we say slap repairs don't work, that's probably an unfair generalization because I'm not so sure that there's technical ways that we might be able to do it better and make sure that we report that moving forward. In my opinion, if I'm superior to the equator, I go knotless and I do a luggage tag type of technique that Javier Duraldo talked to me a lot about, and then I use the PDS. Why? Because I don't want the suture in there. I want it sturdy enough that it's gonna allow it to heal, and then it's gonna go away. Maybe it's right, maybe it's wrong. My mind opened up a little spending some time with Hiro Sagaia in Japan, and as we heard from Dr. Kibler, the type eight, you gotta look for it. Hiro Sagaia's point is, and I'm not saying this is right, but I'm saying I think about it. Why do we have this dogma in the United States not to go anterior? Because they're gonna tighten down too much. That's why we do it, and that's why I was doing it, but when you get into these biomechanics of the throwing shoulder, we know that the anterior capsule stretches out, which is why they were doing the anterior capsulography, why the whole Curlin-Jobe was more on that anterior side. Are we not doing enough to just leave it alone? I don't know. There's so much more to learn, but Hiro's thought is, hey, I'm not gonna over-tighten it, and you don't wanna get into those anatomic variants, but just right up by the anchor, do you just put it down enough that you get that superior glenohumeral ligament just to allow a more normal translation to occur? Maybe, I don't know, food for thought. All right, I made this point yesterday. Again, the type eights, be aware. I showed Jim Bradley, because he's got the biggest cohort of posterior labral repairs, but remember, the thrower, whatever sport it might be, water polo, whatever, different beast than the collision, hockey player, football player, you have to do the capsulography with them. You don't wanna do that with the thrower, whatever sport it might be. Here's what I used to do, and I'll show you a little example of that, going all the way around and smashing it into a knotless. Then I got into more biologic, if you will, with the PDS and the luggage tags, and still doing knotless. So here's an old technique, or how I used to do it, and we don't have to go through this whole video. It's just a minute or so long, but rotator interval base, that's probably, is that a type two? Probably a type one. I don't know. The person failed non-op, roughing up the superior glenoid tubercle, different than what Tony Romeo showed with bank cards. You don't have to see the subscap, much like the posterior labrum. You don't wanna disrupt everything. There's some full thickness. You don't have to make a big full thickness all along. You wanna kind of keep what you have, because it's hard to put that down. But here's the way I used to pass this. You know, I'd shuttle this in, use a little tape or a heavy number two, and then retrieve from a port of Wilmington. Now, this has been published by the HSS group. Back in the day, you can go transtendent. You wanna be medial to the cable through the musculotendinous junction, and they all come back. There's not rotator cuff problems, at least that we know of. So we'll just show this one part, and I just wanna show you what this looks like once it's a good repair, but is it a good repair in a thrower is the question. I like to use peak versus biocomposite. Everybody has their opinions, and that's okay. I just think that it's nice and space-occupying, and if something goes awry, you can go right back down on top of it, and your angles are better. It's not quite as brittle as the biocomposite. So that's pretty tight. It's a pretty good repair. Here's how I do it now. I change this after talking to Mark Shickendance. Instead of going all the way around, I'm gonna go mid-substance. Why? Because the PDS is gonna dissolve, and I don't wanna over-tighten it. I just wanna re-approximate it to the point where this is gonna heal down a little bit better. I don't know if it's right. This is my thought, and I can say since I started doing this type of technique, I don't do a ton of slaps, but when I do do them, especially in the non-baseball athletes, they do pretty good, knock on wood, but anyway. Baseball players are very superstitious. That brace, I think it's another reason why we struggle to get them back. If you put them here, they're gonna be closer to getting to where they need to be as overhead athletes. Bicep tenodesis, we have to talk about it. Look, this is gonna open up all kinds of discussion because I can understand the allure to want to do it for those reasons below. Slaps don't do well. How do you repair it? How do we? But for me, I only do the bicep tenodesis in a failed slap at this point. If I do do it, I use small caliber. Regardless of what those studies say about the interference screw, I don't like that big screw. Smaller caliber, Scott Rodio's published on the mineralization on the groove. That's where the healing is. It's not in the tendon in the intramedullary canal. I thought that this was gonna be the next great solution. Do a tenodesis and then do a slap above it. Maybe the slap's still gonna give you normal stability and translation, but you're not gonna get the long head tugging on the superior labrum. I think it works great in crossfitters and those types of athletes. I don't think it works well in throwers. We're gonna hear more about this later. Wait, you were on one of these, weren't you, Brian? No. So, Tony Romeo published on this and he just published again. And the bottom line here, and he mentioned it yesterday, even in this year, 50% can return to play, but they're not returning to the same level. And I wanna see his high school and college data, but in the more elite throwers, I don't know if that's the best thing, the biceps and the slap. So, in conclusion, we all say it, but really do the whole exam of the whole entire body and have a good physical therapist that understands the overhead thrower. Don't write evaluate and treat. Write out what you need them to do and they'll appreciate that. Slap repair is still the gold standard. I think that knowing these technical pearls and working with them and seeing what works for you can be very, very beneficial and they can do pretty well. And then tenodesis, I do a lot of tenodesis, I love it, but I'm just saying in the thrower, I'm still a little bit cautious. Thank you.

bicep stenodesis

scapular dyskinesia

rehabilitating the shoulder

slap tears

athletes