Before we get started, thank you for spending your afternoon with us. My name is John D. Kelly, and I'm humbled to be here because the people I work with have taught me a great deal, and I'm looking at my, I call my thrower mentor, Ben Kibler, who has been ahead of the curve for decades now, and I'm humbled to see. John Conway knows more about the scapula and the teres major than I know about whiskey, so I'm humbled. But the throwing shoulder has always been a challenge for me, and I'm here to share with our distinguished panel the things that have worked for me in my 34 years of practice. So this is our lineup. This is the dream team. You know, Mike Frijo, if you don't know, played professional baseball. Mike, I was a lowly All-Star, so don't forget that. Brian Wooderman, tenomous, I love him, patriot, absolute genius, and he's going to talk about Latt and Terry's major teres, mutissimus teres. Ben's going to give us some revolutionary and I think some groundbreaking research news about the path of mechanics. I'll leave him, and Irish Mike's going to talk about super scapular nerve injuries in the throwing athlete. So we're going to start things off with W. Ben Kibler, Dave, so we can all have Dr. Kibler's talk. And then we have ample time for cases, and since the end of the day, have Ben and others hang around for questions. So Ben is going to talk about the path of mechanics. Thank you, John. Well, thank you all very much for coming. Thank you, John, for inviting us here to do this. I hope this is going to be very worthwhile. We're going to introduce some concepts and hopefully generate a whole lot of discussion on this topic. So we're going to talk a little bit about the path of mechanics and a little bit about my favorite bone in the body, talk about this term called Sisley, see what you all think about that. So I'm going to try to make four points. So the first point is internal impingement. This is a mechanical situation where we probably feel this is one of the main pathomechanical bases for the creation of a labral injury. It's been written up several times in the literature. It's combined scapular protraction and humeral head posterior translation. As the scapula and glenoid go this way, the humerus goes this way, and you get internal impingement on the posterior labrum. It's a compression and shear mechanism. So this is kind of diagrammatic here. So you've got your scapula with internal rotation and protraction. You've got posterior humeral head translation, either due to increased horizontal AB duction, decreased external rotation, biceps tightness, and that puts all the forces right on that posterior superior labrum. I'm indebted to my friend, Dr. Giovanni Di Giacomo, who did this beautiful animation here showing. So in normal scapular motion and rhythm, as the humerus abducts and externally rotates, as the scapula moves, that gets clearance on the backside, so the glenoid opens up, humeral head goes back, and there's enough room there to avoid any increased compression or tension shear on the labrum. However, if you have a protracted scapula tilting forward and anteriorly, now you've got your glenoid right in the way. Now if you do the same thing with your humeral head, as you come back, you get impingement, especially about 60 all the way up to 90 and above, 100 degrees, all the load goes on that posterior aspect. So the idea here is that this exists. You can address each of these issues. You can address scapular protraction. You can address humeral abduction and external rotation. Second is, once again, my favorite bone in the body, scapular dyskinesis. By the way, I put in a plug, dyskinesis rather than dyskinesia. Dyskinesia is a motor control problem. Dyskinesis is a mechanical problem. And so why is this important? What's going on here? And basically it impairs the scapula in its two roles of guiding and directing the arm. So you see on one side you've got kinesis, normal motion. You've got dyskinesis, or abnormal motion. And you can see obviously, as you can see right there, you can see the obvious dyskinesis with that anterior tilt. Now you imagine that guy. The reason he's in my office is because he has impingement. The reason he has impingement is because his scapula is sitting on edge. So there are two mechanisms of the scapula to do its job. The first is what I call the shoulder girdle mechanism. That's where the scapula moves the glenoid, and therefore the arm that's attached to it, into the position in space to let the hand do what it's supposed to do. Perfect example of the worst-case scenario, long-thoracic nerve palsy. Every other muscle, every other joint in the body is normal. You cannot raise your arm to do things because you cannot get the scapula into that abducted, externally rotated position. The second is called the scapulohumorism. Once you're there, now it's got to follow the arm, and the arm is doing what it's supposed to do. So getting it there and then maintaining the stability as it moves through space. Those are the two things the scapula does. Alteration of either one of those is called scapular dyskinesis. So it's found very commonly. Once again, it creates this component of internal impingement. Now, if you do have this antenna, there's a lot of mechanics showing that alterations of scapular position puts strain on the labrum. If you tilt the scapula anteriorly just five degrees, you increase the pressure at the labrum and on the undersurface of the rotator cuff by a factor of three to five times. So a lot of extra pressure just from that anterior tilt. Internal impingement, once again, decreased upward rotation, increases the area of impingement, and increased internal rotation. Those two factors that cause the scapula to go into protraction increase the area and pressure of impingement. So once again, and you can correct it. You can see it, and you can correct it. There's some stuff called show motion. It's a nice little motion monitor system that we're playing with right now. And you can see that in this picture with decreased velocity, shoulder pain, you can see that with anterior tilt, it goes into anterior tilt with the arm up through here, and it goes into internal rotation toward the, once again, up through there. So this actually is a mechanical fact. It's an anatomical fact that the scapula goes into that position in patients who have clinical symptoms. Therefore, evaluate scapular protraction. You watch the position and motion with the arm the way that I was doing with that one guy, and watch internal rotation because the internal rotation will tighten it up and pull it forward as well. So these are points that you can see on the exam and treat in a patient either with symptoms or in a patient who's just having bad performance. He's not into symptoms yet. Third is what's the spectrum of labral anatomy and pathoanatomy. You've got to understand what the labral anatomy is. There's two parts to the labrum. The superior part from about 10 o'clock around to about 1 o'clock is what's called a mobile organ of tension. It allows a little bit of play in the system. The fixed organ of compression, which is from 1030 all the way around under to about 230, is a fixed organ of compression. It's a bumper. It creates edge stability so the ball stays in the socket. So those two have to work together, and this has implications for treatment. This is a model to show here the basic anatomy there. You've got the superior mobile part, inferior immobile part. The area of transition is what I call a ripstop. This is where the mobile part meets the immobile part, and that's a key point to have. You see the upper part, the mobile part, is not attached to the glenoid. The inferior part is attached to the glenoid. So this ripstop is this transition point between tension band and the fixed bumper. It's an anchor point for the biceps labral complex. If it's working well, the biceps works well, and the labrum works well, superior labrum. If it's not working well, it doesn't. If it's not working well, the inferior labrum becomes mobile, and you get the labral tears. So we did a study. We looked at the location of the pathoanatomy on patients that were undergoing arthroscopic treatment, and we found this distribution of labral injuries. So that's a whole bunch of different places, but basically you can see that the superior posterior was 24.6, and the anterior posterior, the instability of 22, but 26.3 were all posterior. If you look at everything together, some type of posterior involvement was 86%. You notice the isolated superiors, the slaps, 7%. So if you're only treating the slaps, then you're not treating the right pathoanatomy. It turns out that we did this study, and also combined across anterior and posterior, anterior and superior are more common. We did this study, and another group in Atlanta doing almost exactly the same study. We didn't know they were doing it. Came up with exactly the same numbers, or pretty close. Posterior involvement, 74%, and isolated, 8% or 7%. This has also been shown by Bradley and then Kim in this journal, Shoulder and Elbow, last year. So the issue is posterior. The fourth point is because slap is not a very good term to use to define this spectrum of injuries and is not precise, doesn't help us think any further about that. Several of us came up with the idea. It's called SISLI. Slap is inadequate to really describe the actual relevant injury. It tends to make you look superior and anterior when the problem is more posterior. And so we call this a clinically significant labral injury. You can call it what you want to, but if you call it slap, then you've got to realize you're not really dealing with the right pathoanatomy or the pathomechanics. And so this is an anatomic labral injury that's somewhere on the glenoid that has either isolated or combined, and you can prove it. It's got clinical symptoms, and you can demonstrate it by a good clinical exam. You may try to do it imaging, but you're not going to necessarily get it with that. You've got to do it by the clinical exam. So what is labral-based dysfunction? It's when the inferior labrum becomes mobile. It's supposed to be fixed when it becomes mobile. It's an extension of tear from the superior labrum through the rib stop, or it can be an isolated posterior labral tear. And this injury can be of various types. It can be a tear away from the bone, flattening. It can be in substance, stretching, delamination. There's a whole bunch of causations, internal impingement, biceps tension, altered rotation, decreased rotator cuff compression, a whole lot of things going on. But the point is that all of them affect the ability of the inferior labrum to be a bumper, to be an edge stability. Or when the superior labrum becomes too mobile, you lose a tension band. So now you've got this arm going every which way and the biceps going every which way because you don't have that point around which the tension band can develop tension. And it's a posterior labral injury, and the rib stop is torn. When the rib stop is damaged, then you don't have any anchor for the biceps to develop tension. So right now we're talking about three different types. One is this, you can call it slap aid if you want to. I call it a posterior-posterior superior PPS injury. And you can see it has characteristics of tearing all the way around from the 12 o'clock all the way down to about the 8 o'clock position. And then if you keep on going, it will actually go down into the substance of the labrum and down into the PIGHL. Jim Bradley calls that the lambda lesion. You can also have this isolated posterior where the rib stop is intact, but all the injuries below there, and this is all just tension. I mean, this is all compression and shear in the lower right. That's flattening. That whole thing has just been flattened off. You see that yellow scar in there where the tear is. There's a third type that we're doing some studies on now. I call it the apple injury. It's anterior shoulder pain, posterior labral injury, and it's characterized by anterior shoulder pain, biceps. You can't get it better. Let's do a biceps tenodesis. No, you don't. The problem is the biceps is not anchored well. And you try all these things, it doesn't work. So you look at it, that looks pretty good. There's your injury right there. Rib stop is damaged, posterior labrum is injured. And so that biceps doesn't have any anchor points, so the whole thing moves. And so this does not need a tenodesis. It needs a repair to stabilize rib stop, stabilize the biceps anchor. So you evaluate for posterior injury. If you're still thinking slap, you're missing the boat. This is all posterior to a large extent. Look at the history of posterior location symptoms or anterior symptoms with a posterior component. And you treat for posterior combined injuries. Look at the labrum. Restore the anatomy. You don't, John Kelly, see it. What are we not supposed to do? Hog tie the biceps. You don't put that 11 o'clock anchor up there, which hog ties the biceps. What you do is that you fix the posterior labrum, fix the bumper, restore that 630 anchor is so very important because that's where the posterior band attaches. You've got to restore the posterior band. And then you go up and restore the rib stop, but you stop below so that you can make sure that you still have the mobility of the superior labrum like it's supposed to be. So understand this. It's pretty important. Understand what's going on here. Remember scapula. Understand that this is a posterior-based problem for most of the cases, and cystly is a better descriptive term than slap. Thank you very much. So we have two Irish Mikes. Next is Irish Mike Freehill, who's going to talk about refining the role of the biceps and when to do a tinnitus is when to save it. Thanks, Mike. All right. Thanks so much for the opportunity. So, yeah, the dreaded slap. I'm going to still call it slap because everyone knows C-prevent, P-prevent, or C-acnes, P-acnes. Everyone gets confused. All right. So my disclosure is none are relevant here. So you have a slap tear. All right. Who doesn't, right? If you're throwing overhead, who doesn't? What do we have to do first? We have to address the other stuff. This was touched on by Ben. GERD, you know, you move that humeral head up into the posterior-superior direction, so that's going to cause an exacerbation of slap symptoms, but probably total arc of motion is what we want to do. We know scapular dyskinesia, which was outlined excellent, and a lot of details in there that were great. And we forget about core strength. If you have a thrower in the office, you've got to check their core strength here with their abs, their hip external rotators, their VMO. That's all got to get straightened out. Numerous ways to address this that we've all seen. Stretching the pec minor is critical, as well as capsular stretching. Nonoperative management, you know, definitely shut them down for a while. Biologics and steroids we don't really know about, but you then get into the plyo and the proprioception. Sorry, these videos are running funny. All right. Imaging. Again, they all come into your office, they all have imaging from an outside facility, and they all were told they have a slap tear that probably needs something done for it. But what is really a slap tear? We know from our MSK colleagues that you can have these clefts. So the picture on the left there is that cleft that can be normal, but when you start to get the signal out into the body of the labrum is what's probably more pathologic type of tearing. We know from a study that's, you know, 15 years old now from J.P. Warner and, you know, a lot of the surgeons in this room probably looked at some of these vignettes and answered them. But even in the experts' eyes, the hardest thing to distinguish was type 2 slap tears versus normal slap. You know, is this a slap, maybe a type 1? You don't know. It's hard to tell. So it's not so easy. I think that there are some, if you find yourself in this situation, there are some hints of what's truly a type 2 type of slap pathology versus not, just looking for hemorrhagic or granulation tissue, seeing if you can see past that cartilage on the rim and just the way that the traction will pull it straight up into like an upside-down V versus more of an arch. You know, it started out as 4 types of slap, but now we're at 10, and I think it's critical why Dr. Kibler talked about this. Type 8 slap is really probably what we're seeing with the throwers and that maybe when we get into some results of why the slap repairs haven't done as well as we would like is because we were missing where we maybe should be addressing. When we do talk about the type 2 slap tears, which was historically the one that was really associated with baseball, I think that if you're addressing these, that you need to get a bit more granular. Type A, 2A, 2B, 2C, you know, because there's more than just a type II, depending on the position of that tear. It's important to note that this type of pathology, it's different with a throwing athlete, that being a baseball player or a water polo thrower, something that's truly throwing a ball versus other types of athletes, such as gymnasts, who tend to do, at least in my hands, relatively well. But you look at the position of where that slap tear is. The gymnast is truly more posterior superior, as Dr. Kibler said, more 11 o'clock, where in the baseball players, again, it's down farther. Steve Peterson was one of our shoulder mentors at Enduring Residency. And I thought this was a really cool study he did. It just shows you that a lot of the superior labrum has that meniscal type of property. It's not, as Dr. Kibler said, very adherent to the glenoid. So when we talk about addressing this surgically, you don't want to forget that fact. Because if you turn it into what you have on the inferior equator, they're probably not going to do well. The Rush Group put this out, looking at return to play in previous performance. And the bottom line here is you had all kinds of sports in here. But the point with the overhead athletes is that's where you're going to have the lowest return to play and the lowest return to previous performance. And with pitchers, it's the lowest of all. So be wary. So should we be fixing these? And if we do, or we have to, how do we do that? And again, I always show this figure, because you're the one holding the smoking gun if this goes south. And there's a high likelihood that it will. I use this. A lot of the studies since are about the same number. But this was kind of the first systematic review that came out from Mike Ciccotti and Dodson from the Jefferson Group. And that's the number that I quote, 63%. I think your numbers might be higher. But it's nice for a historic reference that that's what you can expect. Lou Yochum, he was my shoulder surgeon and one of my great mentors and very close to Dr. Conway and just did a lot for the baseball community, a great guy. And this raised a lot of eyes with the return to same level of 57%. But then when you got more granular, if they just repaired the slap and didn't touch the undersurface of the cuff, and we know that there's a lot of undersurface tearing or partial tearing, they did very well. But if he just debrided at all, 12.5%. Now, it's interesting because John Conway, who's here, and we'll probably talk about this later, with this study, they didn't routinely go into the subacromial space. And we can touch base about that later. If you're going to potentially do a slap repair, should you at least inject a general anesthetic at minimum just to see what kind of response you're getting? Do you need to go into the subacromial space or do you every time? So Jimmy Andrews, this was a study that I've added since the last time. Because again, a big baseball volume of patients, and they did the same type of breakdown, slap repair versus slap with debridement. They didn't have a difference. Now, maybe that's why the subacromial space, but the return to play was very similar to what we see in the literature, 59% for the pitchers. We performed this study a couple of years ago when I was at Michigan. And we had Hiro Sagai involved. And we went through all the literature, anything that did slap repairs, because we wanted to see, why is the result so poor? And guess what? You don't learn anything because half the studies don't talk about the techniques. Some do, some don't. The details, the number of anchors, where the anchors went, it's very all over the place. So again, potentially, maybe a reason they don't do so well is we haven't found the best way to do this. So in my opinion, some options, and Ben touched on this, of how to repair this, you want to avoid knots. So I think knotless is better when you're on the top of the equator. And I know this was used before, and then it kind of went out of favor, it seemed. But I think the PDS, something that's going to resorb, especially on the superior labrum, is probably beneficial. Here we go with our type 8, and I'll get into why I show that. But Ben going down, and even Hiro Sagaia's diagrams or figures showing us that it's anterior as well, and then going back. And why this is important is interesting, because we know that anterior laxity exists, which is why if you were just in that shoulder session where Paul Sethi was showing complications, the thermal capsuloraphy was a big deal in the mid-late 90s. I had that. And that was because these anterior capsules started to stretch out. And we know that happens in throwers. And they were trying to find a way, how do you tighten that up? That's where Hiro Sagaia, and again, this is controversial, because we don't do this in America. We're taught, stay behind the biceps. His thought is different than what we think and say, hey, if I just need to get that down just a little, just so when they lay back, they're not like a snowball going backwards. I don't know if this is the answer, but I do think it's interesting to think about. And we can discuss it. So that's food for thought. So this was a slap repair. This was a person, a player that didn't do well. And I felt we were at the end of the road, didn't have much option. Now, I'm going to ask Dr. Kelly to say what occurred here. I think they probably did OK. But this was the old method, right? Trans cuff, going through the musculotendonus junction, putting a heavy number two nonabsorbable suture going around. And what's that look like? Definitely a hogtide. Hogtide, right? This poor pitcher probably turned into a first baseman. Look what they missed. I know. I missed that. I know. I was trying to skip past that. OK. So then you learn from a lot of individuals as you go along. And these were two that I talked to a lot just because I was in some baseball meetings with them. And Javier Duralde took care of the Braves for a long time where she can dance with the Cleveland team. And they were getting back to the PDS and into the luggage tag. And I thought it was kind of interesting, some of the techniques. And I took a hybrid of that. And they thought, why are we going all the way around? If the labrum is really beat up, you can't do this. But if the labrum's OK, it's just detached going through the labrum itself and doing a luggage tag and putting it down in a knotless fashion. That's going to resorb with time. But the PDS, it's strong enough to hold. But it's got enough elasticity, if you will, that you probably are not over-constraining. It's probably not making it non-anatomic. And again, I don't know if this is the right answer or not. It's just what I've migrated to at this point in time. I think it's trying to reproduce the anatomy if you're getting to this point. So one thing that you can take from this or a very, very big point is all of you are taking care of athletes. You see what I'm doing down there with a collision athlete? We're all going to do that, right? And that's lower. But if this was a type VIII slap, the way I'm repairing that is how I would do a hockey player, a football player, a collision athlete, biting capsule, then re-dipping to get the capsulorophy with the labrum. If you do that with a thrower, you're going to be in trouble, right? And Jim Bradley's talked a lot about that, right? So in this particular case, when you flip, I've learned my lesson here, Ben. When you flip and look at the, sorry, I don't know. I'm just going to get under the labrum, just under the labrum, and put that down with a PDS. Again, not over-constraining it, but bringing it back, OK? Very different. You want to take that into account when you're fixing an overhead athlete. Post-op PT, another, you know, is a reason, historically, that these didn't do well. Because the surgery, maybe it was great, but you're putting them in this, and now they come out, and they've healed, and you're trying to get them back to here. Why is that? They should be immobilized here, don't you think? Doesn't that make it easier? It's just something to think about. Biceps tenodesis, really quick to bring this home. I think that it's great for revision if you failed the slap. The study that Matt Provencher out of the military academy said 36 years, that's kind of the cutoff of where tenodesis really outperforms a slap. We did a study when I was in my shoulder fellowship with JP at the same time, and it's very interesting. The cutoff was 35. It's interesting that they are so close. I, now, when you bring up, are you sure? Why can't we do this for an index procedure? You wouldn't have to worry about the rigidity of that repair. You wouldn't have to worry about getting back. We know that highly innervated portion of the long head that attaches to the superior labrum, we're getting that out of the mix. And historically, slaps have done poorly. So why not? Well, I throw this in there. If you do do it, I think you want to use a small caliber hole. You know, we don't want to be putting big holes in the humerus if you're going to do your tenodesis. But how do these do? So this was a study out of Rochester. And, you know, it's pretty interesting where they, if you do do it and you take the long head off, do not get into that superior labrum. You want to make sure that is there. Because if you start taking too much of that down, you're going to lose that superior translation resistance. If you need to fix it, you know, however you want to do that, do that. But don't just take it. So I thought that this was potentially a way to go six or seven years ago. Hey, do the tenodesis. And then if it's sloppy up on top, go ahead and fix. It didn't do as well as I thought. But Tony Romeo has probably published the most on this. And Dr. Waterman can enlighten us a little bit just because he was around with a lot of these as well. Early on, the 2018 paper, the return to play at least 20 games wasn't very good. And you can see it in the pictures. Now, they updated this in 2022. And they bolstered the N a bit. And the return to sport was 86%, but only 50% to the same level. And, you know, much like the Yoakum and Nary paper, you know, the biceps alone or the biceps or the, excuse me, like the other paper that I was talking about that I had done or that technique I had done with the biceps tenodesis and the labral repair, that didn't do very well either. Dr. Waterman's on this paper. This is a recent one at arthroscopy. Pretty interesting. It's not really high. And it's kind of a potpourri of athletes. But, you know, I think if you do this, you can, you know, get pretty good results. But there's some limitations if you want to apply it to certain overhead sports like baseball. Just because, and Brian can probably tell us, we just don't know how many baseball versus softball. Probably there was eight. It wasn't defined. And we just don't know those levels. So you want to, in my opinion, continued caution for the tenodesis as an index procedure. So in conclusion, exhaust conservative management. Slap repair is still the gold standard if you have to do it. And it's your last choice. But be critical of the techniques that you want to use. Where are you going to put the anchors? What type of anchors are you going to use? How are you going to do it? I think it's all very important. Tenodesis and throwers is certainly an option. But in my opinion, you still have to remain cautious. But it's acceptable in the revision setting. Thank you. Suprascapular nerve issues and throwers. Thanks, Mike. Thank you, J.K. Thanks for the invitation. We're going to talk about just isolated suprascapular neuropathy. Here's my disclosures. So, the suprascapular nerve arises from C5-C6, and the two areas of compression that it can occur are the transverse ligament at the suprascapular notch or at the spinal glenoid notch. And that's distinguishable, because if it's compressed at the suprascapular notch, you're going to see weakness of supraspinatus and infraspinatus. But if it's just at the spinal glenoid notch, then it should be infraspinatus weakness only. This is a cadaveric dissection that we did. And the image on the left, we're viewing from superior. Lateral, or the acromion, is going to be at the top of your screen, and then medial is at the bottom. So, you can see the base of the conoid ligament, the CC ligaments. That's the suprascapular transverse ligament across the suprascapular notch. The white arrows are showing the nerve going under the ligament, and then the white arrowhead is showing the artery going over top of the ligament. And there's variability, but that is the most common variation. The image on the right, which is kind of hard to see, is as that nerve comes out under the transverse scapular ligament. It then sends branches to the supraspinatus before it dives around the scapular spine to innervate the infraspinatus. So, here we're viewing from posterior now. So, that switching stick is pulling down on the infraspinatus. So, that's the nerve now coursing around the spinal glenoid notch, and then it fans out on top. So, it's kind of doing that, as you can see in that illustration there. Isolated neuropathy symptoms are going to mimic rotator cuff tears. And so, usually, when this happens, and this can happen in isolation in baseball, softball players, overhead athletes, the pain will be acute and severe, but then they'll be left with this residual weakness. And so, most often, it's going to be weakness in external rotation. So, they can be weak in supraspinatus and infraspinatus if it's at the suprascapular notch. The other time you might see it is with a partial rotator cuff tear, where the weakness is way greater than you would expect with a partial rotator cuff tear. So, when the weakness is way out of proportion, then you want to think about suprascapular neuropathy. If you get an MRI and the cuff is intact, but they're still weak, you want to think about suprascapular neuropathy. There's not much on physical exam, because this is severe, and usually in your young overhead athlete, you're not going to see this amount of muscle wasting. But you want to look at them from the back when you're examining their scapula and see if there's any slight atrophy. If you have them bring their arms forward and kind of protract the scapula, you can see the infraspinatus fossa a little bit better. On imaging, you might see edema in the muscle belly. So, this is neurogenic edema, where the whole muscle belly lights up on the supraspinatus and infraspinatus there. So, when you see that, you want to be thinking suprascapular neuropathy. You might see increased signal of the nerve, where it's coming down on the coronal views there. That can be hard to pick up, but if you're suspecting suprascapular nerve, if you look at that coronal image, you might see some inflammation around the nerve. Where you'll really see it in throwers is posterior slap tears, sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis- sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis-sis- So it's worth a try, especially if you're facile with ultrasound. Surgical indications are when non-operative treatment has failed. And so, compression at the suprascapular notch, you're going to get weakness of supra and infra, hopefully confirmed by EMG. Spinal glenoid notch, really weakness of infraspinatus only, and that's what you'll see more often with the paralabral cysts. So, in this video I'm about to show you, we're in the beach chair position, the scope is coming in through the lateral portal, and then we're going to start to work our way down anterior. We're going to follow the CA ligament to the coracoid, and then you keep going medial. And it's more medial than you expect. You keep going medial. As you fall off the medial side of the coracoid, you'll see the suprascapular notch. We're going to look for a room with four walls. So the floor is going to be the base of the coracoid, the ceiling is the clavicle, the wall on the right is the CC ligament, the wall on the left is supraspinatus muscle, and we're going to keep going medial until we find it. So this is a right shoulder, viewing from lateral. There's the rotator cuff. As we work our way up anterior, there's the undersurface of the acromion. There's our CA ligament. So we're going to follow the coracoacromial ligament there, all the way down to the coracoid. And I've already kind of cleaned off the top of the coracoid. So there's our coracoid. As we keep working more medial, here's a switching stick, and this can come in through the visor's portal, and then we're going to make a more medial in the visor's portal to cut the ligament. So there's our room. So we've got the CC ligaments on the right, supraspinatus muscle belly on the left, coracoid at the bottom, clavicle at the top. And now we're going to drive the scope medial to those CC ligaments and keep moving over. The switching stick can then be used as a retractor to pull the supraspinatus out of the way. And as you drive medial, you fall off the medial side, and there's our suprascapular notch. So now the switching stick is on the nerve going below, the arteries going above. So that's the suprascapular nerve. And on the left-hand side here in a sec, we'll see the ligament. So now there's the nerve running under the transverse scapular ligament there on the left. The artery is in the background going over the top. So now the switching stick is going to hold the nerve down out of the way, and I use an arthroscopic scissors. We're coming in through just a more medial in the visor's portal. So when you drape these out, you want to keep your drapes really medial so you can make two in the visor's portal. You can cut the ligament, and then the nerve can safely float up. Sometimes you'll see a calcified ligament, so you have to be prepared if there's bone in there to use a small straight osteotome to take it out. But usually with protecting the nerve, there's plenty of room, and then the nerve can glide freely. Releasing at the suprascapular notch, this one is in a lateral position here. And so this is a labral repair with a paralabral cyst. So there's our posterior superior labral tear, and there's the cyst contents coming out. So if it's a small cyst, you can just debride the cyst through the tear, and then repair the labrum so you're closing the door so it doesn't reform. So you can get your shaver in there, and you can suck out the cyst contents, and then repair the labrum back. And in this case, this was a big cyst, so we're also going to decompress it from the subacromial space. So now we're up in the subacromial space, viewing from lateral. There's scapular spine, and this switching stick is coming in from a far posterior medial portal. So you have your standard posterior portal, and then you make a second one more medial, and there's the nerve. So as I push this fat out of the way, the nerve is right at the...that's the nerve at the tip of the switching stick. So I'm pushing the fat out of the way, the nerve is coursing around the scapular spine, and this was a big cyst, and we can just decompress it really with the switching stick. So the nerve is draped over that cyst, which you can start to see now. There's the cyst, and I'm just going to pop it with the switching stick. And so you can quickly decompress this from the back. And so if the cyst is really big and they have profound weakness, you might decide to decompress it in both places to try and get their strength back. This is the shaver. I just have the suction on. I'm not running the shaver just to suck the cyst fluid out. There's multiple case reports about suprascapular nerve decompression. There's not a lot of series in the literature. This one looked at nine patients, studied prospectively. They all had EMG evidence of suprascapular neuropathy. Eight underwent an arthroscopic decompression. One underwent an aspiration. All showed complete resolution of their symptoms. Laurent Lafosse published this one in 2007. Ten patients, older patient group, age 50, 90% excellent results, one satisfactory results. So in summary, you want to suspect suprascapular neuropathy when the weakness is out of proportion. So if they have posterior pain, but especially weakness with a normal MRI, start thinking about the nerve. Look for muscle edema on those sagittal cuts, which is neurogenic edema. And then you also want to look for any slap tears with a big posterior paralabral cyst that might be decompressing at the spinal glenoid notch. And if you diagnose that and treat it surgically, most will recover very quickly. And this can be back to play in four weeks. That's it. Thank you so much. Next, Brian Wooderman is going to talk about some of the less common occurrences in throwing athlete, including latissimus dorsi tears. Thanks, Brian. Just by show of hands, how many of you take care of throwing athletes currently? That's great. That's great. My disclosures can be found online, none of which are relevant to the content of this talk. I will say that a lot of my, as Mike alluded to, a lot of my thought process on this are attributable to Tony Romeo, who's a good friend and mentor. And this was how I was initially introduced to this was the referral base that he established in his throwing related practice. And you can see it's a very uncommon source of injury that can occur at the elite level, and it usually comes with a sudden onset and pain pronounced posteriorly. This is a patient of mine that I saw several months after the fact, so 29-year-old former professional pitcher, and you can see the notable contour difference. And so what you're trying to avoid is getting to these individuals fairly late in the game where the solutions are much more complex. Oftentimes, this is what you can see in the chronic setting. There's nothing that really jumps out, and unless you're really getting those nice axial images and the cuts go down low enough, sometimes you definitely can miss this. So look at those axials as well as the parasagittals. Those can be very helpful for following that contour of the tendon. So what do you do in that type of scenario? Well, I think it requires us to really relook at the anatomy. This is a three-dimensional application I have on my phone, and it's just a really good way to kind of re-review the anatomy, particularly neurovascular structures at risk, as you're looking at the trajectory of both the latissimus dorsi and teres because, you know, the path is fairly serpentine. It kind of escorts right through the armpit, and there's some important functions there. It acts in internal rotation with extension and adduction, and it undergoes that 90-degree twist in order to get there. It has a really important role in controlling the arm as it goes into layback, and so there's kind of two different modes of injury. One is that layback and transition to early, I'm sorry, from late cocking into early acceleration, and then it's kind of the final terminal delivery where it's limiting internal rotation and cross-body movement, and so that's where you can see it. You know, the presentation, if you're lucky enough, you can get it with an acute onset, and it's just, like many things, a loss in velocity and accuracy, pain in that late cocking motion. You can see disruptions in that normal contour, echemosis posteriorly, and then weakness that can be precipitated with adduction and extension. I like, like was shown in the video, putting on the hands on the hips and pressing down, same type of mechanism I use to try to engage the pec when I'm trying to identify that, particularly partials. Many of these grading systems are not always that helpful, but what they do assist in is allowing us to more effectively communicating with each other to make sure we're comparing apples to apples, and that's what you'll see come out in the literature. You can see they go from grade one through grade four, and grades threes and fours are the ones that you more commonly enter into a broader discussion about repair and or reconstruction, and again, these MRI tiles just show the extent of the injury as it extends over, and you can see that's two centimeters of retraction, full thickness tear. Sorry that got cut off a little bit at the bottom, but you know, non-operative management has definitely been one of the mainstays. Mark Chickendance is the one that really probably most commonly spoke about this early on, and this was his series of 10 MLB athletes. You can see 90% of them were able to return to sport at three months, and that's really quite good. You can see one sustained a re-injury at six months, one retired, so obviously returned to a prior level play. Why would you want to do anything different? Well, the caveats are there were no performance metrics, and really they didn't really look at maybe more discerning outcome measures in that study. Similar study looking at 16 athletes, again relatively small, but again a lot of heterogeneity. You look at the types of injuries. There were both full thickness avulsions as well as strains, and you can see most of these they were able to return 94% at in and around about a month to throwing. Avulsions, maybe a little bit longer, but again the emphasis has been on non-operative management with low rates of recurrence. You can see 12.5% there. So from that data, the question is, is there a role for any surgical treatment? And I think there's definitely a weighing of the pros and cons, especially in a more delayed onsets type of scenario, and so we'll go through those individually. The footprint is something that is both a difficult to access and fraught with, you know, surgical misadventurism. There's been a lot of different ways that you can access there, and we'll go through a little bit of this, but it's important to realize where the axillary and radial nerve are, and then the mechanism by which you get there is something that I'll review. So the primary open repair, you know, classically this is the way it looks in the textbooks, right? You deliver this beautiful thin tendon. It's prepared in a whip stitch fashion. You can use suture anchors or buttons, but the reality of that is it doesn't look like this in real life, I will tell you. This is one of the first ones that I did. Mike and I were in residency in El Paso, and we never saw a thrower to save our lives, and I saw this first Special Forces operator who came in, and he had a chronic nine-month out tear, and so I approached this through a two-incision approach, and it was very, very difficult. Now I use a much more utilitarian approach, which is using an axillary based incision, and are able to expose and address that through one incision. Also made the move towards pec buttons because that's allowing you to get a slightly angle, a better angle of trajectory with intracortical placement. This is what that looks like. A couple caveats on how you present. I always use an arm positioner because what you're trying to do is invert the hand on your standard positioner and go into max internal rotation, and that's allowing you to deliver down to that inner tubercular groove and restore anatomy. Again, that utilitarian incision through the back, getting down to the epimysium, identifying the stump, very often much like a pec or any other large tendon rupture. There'll be this seroma there, and then you just trail that down. The scary part is when there's scar and continuity, and that often happens in very rapid fashion. Then you have to take a couple leaps of faith, and that's where it's really important to have a change of underwear as well as to make sure you know your neurovascular anatomy. That's what we've just underscored here. Again, you use retractors to box yourself out. You tunnel down to bone, find bone, stay on bone, scratch that to a nice healing bed, and then get your buttons for fixation. This is what that looks like. Certainly I probably should have typed and crossed the patient. You can see it's not an elegant procedure, but you want to make sure that that's fully mobilized so you can decrease tension. Just as much on the front on the front end is the back end, making sure you're doing a really meticulous closure because it's not very great skin back there. This is what that looks like. Remember from our anatomy textbooks, it's the lieutenant between two majors. You just go to the base of the intertubercular groove, and you're restoring it. That's what your post-operative images look like as well. Thankfully, I'm this professional thrower. I had the opportunity. He was a PT as well by trade, and so we were able to kind of dig in on that and look at ways that we could maybe shorten up the rehab, and at the same point in time, giving special considerations to those that are trying to resume at the highest level because there's not a lot of good data in here. Thanks to Rob Blanc for being able to modify some of Dr. Romeo's existing protocol. For any of those that are interested, I have this throwing progression. How do they do? Ultimately, you have these great anecdotal experiences, but when I was in fellowship, they were just kind of finishing up the remainder of this case series. You can see 11 patients, so again, quite small. You see an average age, fairly young. Injury to repair, that's a pretty interesting timeline, right? 389 days, but with surgical repair, they were able to reduce pain quite significantly to less than one. ASES, which we know is not a very discerning score, 100%, and KJOC, quite good. I don't know what you would think, Dr. Kibler, but I'd say that's pretty good for an operative upper extremity patient, and all were able to return to their prior level of play. Again, another study to look at a comparison from a larger aggregated data series, non-op and op. You can see 75% were able to return, irrespective of treatment, but again, I'd probably point to some of the sport-specific metrics which may favor operative treatment. What about those chronic tear patterns? If you can't deliver that tendon back to bone, again, we've learned a lot from our experience in using some of these dermal grafts or other interpositional grafts like an Achilles allograft, swaddling it into there for better substance and restoring it to bone. We wrote up our series in this VGSM article. This is what it looks like with this individual and returning to throw, and my proposed algorithm, which is certainly by no means the Bible, but I think that's been a good frame of reference for guiding my treatment. JK, I do have one case that maybe we can tack in on the tail end or somewhere in between yours. You want to do it now? Okay. Some of our conclusions in terms of acute and partial thickness tears, you can have an average return to play of in and around 90 to 94% in an average of three months with non-operative care. For those full thickness or retracted tears, again, you can anticipate 75 to 100% return to prior level play. Selective reconstruction can be utilized. We were talking about some of these atypical sources of shoulder pain, and this is one that I think maybe has seen us, but we haven't always seen it. This is an 18-year-old male who presents with two to three-year history of indolent onset of pain exacerbated with throwing activity. Much of his physical exam maneuvers were normal. I mean, much like every thrower, it hurt in some of these episodic positions. His imaging suggested here, anything you see, JK, in your brief view, if I can put you on the spot? I didn't see a lot either here, but you know what the MRI imaging subsequently suggests is you can see some of these cystic changes within the glenoid. This is a really interesting pathology. This is 0.6% of all OCD lesions, and it's probably some element of osteochondritis desiccans with that aberrant posterior shear and repetitive stress and microtrauma leading to these types of injuries. And so you can see the imaging as you go from top to bottom. Hypertrophic posterior labrum, as many of them have, right, Dr. Kibler? And then you can see this potentially unshouldered lesion, and you can see on the sagittal images quite a big lesion. And so we had a discussion. He had failed conservative treatment at that point in time and ultimately ended up undertaking a surgical evaluation with arthroscopy and then doing a curettage and cryopreserved cartilage transplantation with bone marrow aspirate. I did this after much discussion with many of the thought leaders, including John Conway and Jeff Dugas, and thankfully I was able to absorb a lot of their feedback and success. So this is some of what we encountered. So you can see, frankly, irreparable lesion, right, delaminated, poor tissue quality. Many of our non-throwers, you would just probably perform a curettage of this and try to advance the labrum over top. The labrum was otherwise uninvolved, and we know that wouldn't be good for a high-end thrower. Sorry, it's a little bit jumpy here. So we get that to healing margins. In some cases, I have done marrow stimulation. Mike, have you encountered... yeah my most recent one was a tennis athlete but then I've also had a gymnast dr. Kibler you've seen a number of these I'm sure Do you mind, are you able to speed that video up towards the end, and then I'll just turn it over to J.K. We'll pull up his imaging, but again, a novel application for something that I don't think we have a great solution for, but definitely I've been seeing more of these mostly in skeletally mature individuals. I've had the shoulders and non-weight-bearing extremities So... The bio-cartilage also for OCD, the capitellum, I think has some measurable success, but Brian, that was awesome, as expected. I'm going to try to tie things together, a little bit of redundancy, just reinforce certain principles that I've worked in my 34 years of this wonderful vocation. So in summary, trust your exam. Ben told me I'd do a wonderful dynamic labral shear test. If the throat doesn't have a DLS, I'm very wary to operate. And sometimes, as Irish Mike Freehold indicated, the MRI can be very, very nebulous. Sometimes the MRI is questionable, but the exam's positive. So I tend more to trust my exam as I get older. We're talking about restoring the bumper. Mike talked about the prominent knots, hog tie on the biceps, and we're going to talk about, just real quickly, the capsule and the cuff. And don't be a slapaholic. Don't need to coin this term. We can argue everybody has a slap tear, everybody has a bulging disc, right? And don't forget the study by Failure, which showed that in cadavers, this is why I'm a big fan against fixing labral tears in people over 35, because it's part of the aging process. As we get older, we develop, it's almost like a degenerative meniscus, we don't fix degenerative menisci in 55-year-old men or women. And John Conway taught me this, a stretched labrum is not a torn labrum. That thrower may need this laxity to find the slot, right? So I love John's idea of a good slap, bad slap. And I see a lot of good slaps that I leave them alone, that enables that thrower to get the slot. You over-constrain that, you're going to kill their career. You'll hog tie the biceps, you're definitely going to kill their career. This is a good slap. Don't fix that. It may be a little stretched, so leave that alone. This is a bad slap. This has mechanical consequences, as Ben, this probably goes towards ripstop, as Ben indicated. As you go, especially inferiorly, as Mike and Ben have illustrated, this is a worrisome, this has to be stabilized. You've lost all semblance of posterior stability and also the bicep anchorage. So remember, the Mayo-Shear test is the test that has served me well, the DLS. And don't forget the horizontal adduction that Ben taught me. If that lights them up in the back, then Houston, we have a problem, right? And you know, the old paradigm is anterior pain precedes posterior pain. Now, Ben has a new paradigm, but usually when I see the people in the clinic, anterior pain usually some biceps issues and pain, anterior cuff. When they get the pain, get posterior, then I get a little more nervous. And I've been blessed with very, very good therapists, and I failed therapy in my Marty Kelly, Brian Leggin. These are nationally known therapists that I know I need to help. So as Mike talked about, these are some things that Craig Morgan and Ben have taught me. Don't forget the internal rotation deficit of the lead hip. We don't think about that often. Tight quads of the lead leg, spine mobility, the hip abductor weakness, have them do their single leg squat. Those are things in the core exam that we often forget. But don't forget hip internal rotation deficit. These are all manifestations of pathologic entities and throwers. We get the systole. We can also see sometimes Bankart and sliders. But don't forget anterior laxity still exists in this subset. We've kind of gotten over GERD because we treat GERD. Now Ben can talk, and John can talk about in a half an hour about tight lats, tight triceps, tight biceps, tight teres major. We've kind of gotten GERD fixed, but we have to look at these other things because they're there. So I'm a big LouderCube guy. I think it gives you more capacious. But this is what Ben, this is a take-home slide. This is Greg Bain's work, and the superior labrum is mobile. It is a mobile organ of tension. When that biceps contracts, it dynamizes the labrum to the glenoid. There's a normal cleft, and when the biceps contracts, that's why I'm not a biceps killer and a thrower. Right there. And this is another Greg Bain slide showing that as the biceps contracts, not only is it stabilized and dynamized, the superior labrum, but also gives you some tensioning of the intercapsule, the SJL and the MTHL. So that's why Greg Bain, I love that term, a mobile organ of tension. This is why I'm not a biceps killer and a thrower. Despite what all these well-known experts say, I think that, and I have some data from Ty Lee that I can share with you after the talk about the adverse mechanical consequences of cutting the biceps. So our goal is restore anatomy. And as Mike talked about, just the bumper only. Don't go crazy with the capsule. You'll kill the career. I'm a knotted fan because I don't like any suture whatsoever. Craig Morgan used PDS for years, God bless him. But Hagstrom showed that the best bumper, and I'm a big bumper fan, is with a horizontal mattress suture. I know we can argue about this. This is level 27 data. But JCU taught us that in instability, the whole universe, higher labral height correlates with left recurrence. So I'm a big fan of getting at labrum as high as possible. In my hands, I do it with a horizontal mattress. And Ben Dohm showed that, in strain and failure, one simple horizontal mattress was as good as simple sutures in terms of pull-out strength. So you can see coraculum or ligament laxity. Craig Morgan taught me about the interval when looking at the pulley. That roof, if it's really capacious, you may need to tweak that. But very, very rare do you see this happen. You'll see a sulcus sign. And we actually, in one study, mapped out the course of the CHL. And it kind of runs concordant with the biceps. So if you need to do any CHL tightening, remember, east to west, not north to south. But this is extremely rare. I just wanted to mention it. Buddy taught me years ago, Buddy Savile, the scope will tell you what's going on, boy. If I see some antrafissuring, antratranslation, they may have a little bit tiny antralaxia. Now, some of my Korean colleagues and Japanese are actually tightening the antracaps with hamstring allograft, autograft. I don't know if I'm just missing this, but I think that, in my experience, the antralaxia is usually with scapular work, posterior capsule tightness. I take a tuck in the capsule. I have not gone to open arthrotomies and putting. But there's many Japanese authors now in throwers that are reinforcing the antracapsule. So it tells us we don't have it all figured out yet. So the posterior capsule is kind of reconciled because of our sleeper stretches. But don't forget, lat tightness. Steve Thomas taught me this. Terry's major, biceps, triceps, subscap. And you can tell by very sophisticated exams, which I can share with you after the program. I like to look anteriorly and work anteriorly because I can repair that labrum from a contralateral portal much better than I can. Steve Burkhart 101, sharp, decisive portal creation. I don't want to be stuffing things through my cuff or large cannulas. Be kind to tissue. I percutaneously shuttle. I use these. I have no royalties, whatever, but I guess spectrum set, just percutaneous. I don't need a big 8.25 millimeter cannula in the shoulder. I prepare from a contralateral. I can see that Sisley lesion, which is inferior, as Ben talked about, much better from a contralateral portal than I can ipsilateral. And I use a portal for every storm. You get around the shoulder, percutaneous. I use the Port of Wilmington, which by the way is my hometown, Delaware, thank you. And I like to shuttle in the visor. Why? Because when I come above and shuttle, I can compress the labrum down versus either a suture hook or whatever. I feel like I'm pulling the labrum up. I like the visor because I get a port of entry that is proximal, so that makes me compress the superior labrum. This is just what I've learned the hard way. And again, this is a classic hogtie right here. That career's over, okay? Right there. I'd like to show that again. I just love that. I'm not from the South, but I wish I was. Chapman, 105 miles an hour, hogtie the biceps. Again, please, please, please be mindful. All these implants, these Kevlar-based suture materials are significantly appreciably stiff and rigid. And these are patients I've seen in my, I say, extended career, I've inherited because of knot trauma. And you can injure and trash a young shoulder with just one prominent knot. Be mindful what you're doing. So the bumper is very important in my experience. I like horizontal mattress even superiorly. And it's just one tape aberrant. As Ben taught me, if you think it's a Sicily lesion, it probably is, especially if a thrower with symptoms and their dynamic labial shear test is grossly positive, definitely probe that and you'll find that you'll have a Sicily lesion. This is what it looks like. You see the IGHL is restored when you fix them, the ones that need to be fixed, horizontal mattress. Buddy taught me, don't go crazy, I used two or three anchors, that's it. Whenever I hear a patient say, I saw Dr. X and I have eight anchors, I get a little nervous. I get nervous. This is going to be some suture morbidity in my experience almost. Quick word about the cuff. Less is more. You can kill a career by doing an anatomic cuff repair because you're advancing the supracapsule. So less is more. This is a career killer. You do a posture repair on a thrower, they're done. Guaranteed. Take it to the bank. You're sure as I'm Irish, they're done. College pitcher, I'll shave. And most John Conway taught me about maybe side to side, a paint tear. Do not over-constrain. Do not advance the anterior capsule. So stretch labor may be adaptive. Cis lesion look for. Be kind to tissue. Don't hog tie the biceps. Address the capsule if necessary. And once in a blue moon, I will imbricate the intercapsule once in a blue moon. Those of us that are over 60 know that Job did a capsule labor reconstruction. What did he do? He did an anchor shift anteriorly. There is an element of anterior laxity in some throwers. For the cuff, less is more. And please look at the kinetic chain. And I want to bring up my friend Ben Kibler just in time. He has one stellar case. I have two. So Ben, can you load that Grantham case there, Dave? I want to thank this guy, Dave, who's crushed the IV. I took one last Xanax when I saw you, Dave. Thank you. Yeah. Well, Ben and I are lucky. He's a mentor. We just came back from Ty Lee's lab. Do you want to introduce some of the data you took? We just did. Well, very, very quickly. We're writing this up now. We looked at posterior labor. All this data you've been seeing. It's a lot. is slap, which usually means, you know, the superior part, so we figured let's look at the posterior. It's never been looked at that much, the mechanics. We see that posterior labral injuries, when you scope them, they're there. Now, are they what, is they the reason why you're scoping it? We didn't know for sure. So we looked at posterior labral injuries in follow-through. We did mechanical testing with Ty Lee's lab. We found that, indeed, the posterior injury from 6 o'clock, I mean, 6.30 on up to about 12 o'clock produced posterior and inferior humeral head translation, and we know that the only translation that's supposed to happen is anterior and superior, so it does create the kinematics. It also creates more tension and more compression on the posterior labrum. So then we say, okay, how are we going to fix it? So we use that ripstop concept. We're going to fix it up from 6.30 up to the ripstop, and you can see this. Next time you all scope, put your probe in there, go on the superior labrum, take it down, and all of a sudden it'll reach a point where it won't go anymore. That's the ripstop. Between the superior labrum that's mobile and the inferior labrum that's not. And so we fixed it to that point, did the kinematics. It turns out that restored the kinematics back to the intact state. Then we did the posterior repair, did the slap repair by putting an 11 o'clock anchor in there, and we shifted the kinematics so now the humeral head is going anteriorly, inferiorly out of the joint in the follow-through. So very definitely that stitch up there, the slap stitch, created all kinds of bad stuff. So fix it the way it's supposed to be. Fix the bottom part to make it work right, and let the top part do its thing, just like you were talking about. Remember, all this stuff is on slaps, and the slap itself is a very small percentage of the total problems of the labrum in the shoulder. So I'll show you this case. This is a college baseball player. He bats left, throws right. I'll show you why that's important in a minute. He got all this chronic pain with acute exacerbation through one throw, and he felt it make it worse. Now he has trouble both in cocking the follow-through. He has difficulty throwing for accuracy and for distance, but this thing, he can't bat. He can't swing. He's got pain clicking on batting. The exam shows he had a pretty good range of motion because we've been working on this stuff. He had tightness of the biceps, so he had some biceps tightness. He had this positive DLS. He had a lot of biceps tests that were positive, speeds, O'Brien's, uppercut, and he had DLS. So now you've got a guy that's got anterior pain and findings, but he also has posterior findings with DLS. And he'd had therapy, and so his range of motion was pretty good. We'd worked on that. So like we mentioned before, imaging, get the imaging. And so now, how many of you all would consider that MRI a positive MRI? I'll put the arrow right there, but that is a tear of the posterior. That bumper is not good because it has this extra motion right there. And there's a very good study from Kim that said if you look on patients who you're doing, if you start probing a posterior labrum, there's always this injury. This is always present. So this is what we found. So once again, biceps entirely intact. Superior labrum is mobile, but the rib stop is okay. And as soon as you see, you're probing there, and that whole backside, see that yellow kind of junk? That whole thing is off. And you see that kind of a valley you have there. And Craig Morgan's red brick road sign, all that posterior labral inflammation points us to that area. That plus the exam, which showed a DLS, suggested that he needed to be fixed posterior. Is anybody going to do a biceps tenodesis? Is that not recommended for anterior pain? It is. But this guy doesn't, and his bicep's entirely normal. It's just long for the ride because of the backside, the anchor point's not good. So you fix him up to the rib stop, and you put the bumper on there. You like the bumper there, JK? So this is why the right hand, he's left-handed better. What happens to a posterior labral injury? And remember, the golfers are the, when you get out here, that posterior labrum's going to get in your way back there. So we helped his batting as well as his throwing, got back to throwing, playing without any trouble. And he had no biceps tenodesis. Once again, this idea that you got to fix the labrum anchor, I mean, the biceps anchor there at the rib stop. And so either you got some external rotation or internal rotation, tightness on the biceps, is going to create, if you don't have that rib stop, it's going to affect all the way down posteriorly as well. So just put this into your data bank and think about it. Thank you. I'd like to have our panel real quickly. I have two cases, if you guys can indulge us. And have a seat there, brother. It's funny, I've been doing this 34 years, and, yeah, Mike, or Bill, sorry. You know, Dr. Andrews' idea of the weed pulling, I think, is very definitely true. There's no doubt that that's probably the case, too. Exactly. And I guess my Irish episode, I hear people say, I saw a lipstick sign, so I tenodized the biceps in a 14-year-old. No. The lipstick sign is a measure of dysfunction somewhere else. So just real quickly, this is a 20-year-old prospect. He had pain after sliding. And you can see there, what Mike Friel talked about, some of that labral injury extending into the substance of the labrum. A positive jerk test, positive relocation, positive DLS. But that was a positive jerk test. So Mike, what are you thinking right now? That's not the patient. That's another one, but just to show you the jerk test. Post-year labral tear. So the point is, this is a CICLI, which in the true sense of the word, will introduce some post-jerk laxity, as we see right there. So it extends superiorly. And Ben, please comment on this, though. So that goes all the way down to close to 7 o'clock there, which is at the top of the screen. So that whole thing's off. And you might have, you say, well, you created that. No, you didn't create that. You just brought it out, and you made sure that you get that completely debrided and ready to repair. You didn't make that lesion. No, sir. No, and one other thing, we talk about the Kim lesion. When your liberator falls into it, you've got a problem. So there's our bumper restoration. You can see the IGHL to the lower left. That's a very important point. You see, you can't get out of the shoulder if your PIGHL is not under tension, because that's really part of that whole thing. So real quickly, this is illustrating what Ben said, that sort of abortive healing. This is a 90-year-old 6'4 prospect. Ben, what do you see here, buddy, on the post-year labrum there? Well, it's off. It's in substance injury. But it's retroverted. Mike Friho and Brian, would you agree? You see that there's there's two points that one is that that that's an in substance injury It's a linear in substance injury plus then the part that is attached to the to the bone itself So you got two parts and you got mobilize that piece you got put that whole piece back up on top to make that bumper Right. Yeah, it's that right there. You got to go under that bring it all the way back up there on top as well It's amazing audience what I've seen that some of these Kim Lee's with just a little bit of Condor label retroversion And the young high-performance something can be to say disabling because it it does interfere with the origin or the insertion of the IGHL so Then and look at that there's no IGHL and I can make it appear see that so we've lost that whole structural, you know integrity there. So this is a Young man, I think did quite well with just you know, just a couple anchors and there's to the Right in front of my probe there there's IGHL stand out there there's some capsule plate and I probably made a mistake of too much capsule be careful that but I think this was a Sort of an allegory of look at the bumper of the restoration. We Restored the anter version of the labrum or the retroversion You got to be careful when you're preparing those two because that poster labrum gets pretty wispy And if you stick your shaver in there and turn on the suction you can suck it up in and then it's gone So you want absolutely great reported with an elevator and be really gentle if you get the shaver in between the labrum and the bone Again, I prepare from the contralateral port. It was like an axis instead of coming down the back Like I'd like to know all the experts in here to take care of throwers for a while the recalcitrant GERD, which does occur every now and then if it's not a Bennett's and There were some reports of people releasing and if you're releasing you're releasing The posterior IGHL, so did anyone have experience with that? Did you ever do that John? And that was a made Craig Morgan famous because he released Curt Schilling's booster capsule Hypothetically standing I did bless me for our five cent. I did it years ago. Not anymore Mike There's several points to be made here. First of all, no capsular plication ever lasts in an instability patient. It doesn't. It's always gonna revert, so don't worry about it. What you gotta do is fix the anatomy. So that stair step means that you gotta put that whole bumper back up there. You don't take a little swipe at it. You really mobilize it well and you put that anchor and you pull that back up there and get it back up there where it's supposed to be. But you know where you're missing the problem? Is that you're stopping there and you're not worrying about the scapular control and internal rotation and external rotation post-op, because all you're doing with these patients is giving them a chance for their muscles to work. And if you don't take advantage of that, where they're now, they're for a while, they got this glenohumeral stability, now work on your muscles. The muscles are the key. Remember, that's the only thing that's gonna make this. And so if you take your instability, your laxity patients like that, MDIs, and you give them that benefit and really make that bumper and then do your muscles, then you're gonna have a much better result than any amount of capillary application around the clock that you'll ever wanna do, because it won't last. My quick answer is you should always examine the other shoulder and restorative anatomy. And John Conway taught me, just the scope will tell you. You'll see fissuring, you'll see elements of increased translation. But using the other shoulder as your baseline, you try to restore normatomy. Yeah, because both of them are bad, but the only one symptomatic, and those are the ones that have those splits and tears. Oh, that's not labral injury. That's the labral injury. Yeah, it's after fives. Those who wanna leave now, I just wanna show you a case that is allegorical of the old days. And this is the Pathomechanics 101. This is a 19-year-old freshman, college baseball player, I lost my zip. And I'll have Ben tell you what's going on here. 30 degrees of the GERD, he had a type two dyskinesis. So this is what happens when we don't rehab. He's got internal impingement. He's got what we call the old peelback, which extended to the ripstop. Ben, what would you say about this? This is a rehab nightmare. Yeah, but first of all, you have not told me what's wrong with that patient with your scope. Because why? Because you've been concentrating on the superior. We can finish this outside after the show, okay? I thought you were my friend. This is a long time ago. I just wanted to show this illustrative case because it shows what happens with the pathomechanics. There's the internal impingement. So you gotta work on both things of internal impingement, which is scapular protraction and humeral translation. Now, I don't know if you're gonna get that one back, because that's a pretty bad pathoanatomy, but that's where you're gonna start. Yeah, you can see it. You can see it right there. Well, I wanna thank our distinguished panel. It's a little after five. So I'm sure I'm speaking for the guys, and you'll be hanging out for a little bit, right, for some questions. So thank you for your coming in this afternoon. So it's happy hour time. So thank you. Thank you.

shoulder injuries

throwing athletes

internal impingement

labral anatomy

scapular dyskinesis

pathomechanics

suprascapular nerve injuries

surgical treatments

slap tears

labral tears

rehabilitation