I'd like to bring up Dharmesh, who's going to moderate this first session for us. Good morning, everyone. Thank you, Brad. So, we've got a great session this morning that is kind of active above your upper-body orthopedics. And we have three talks here and then a discussion and question and answer session. So, the first talk is going to be on clavicle and AC joint injuries. It's by Dr. Bill Robertson. Dr. Robertson is going to be doing it virtual, not in person. And he is the head team physician and orthopedic surgeon for the Dallas Stars. He's been in Dallas for several years now. So, Bill, are you online? Yeah, I'm here. Thanks. You got me? We can hear you. Perfect. Okay, great. I think we can get started early, no? Yeah, let me share my screen and see if I do this appropriately here. Does that work for you guys? Really good. Go ahead. Okay, great. Well, thanks for having me. This will be my 13th season with the Dallas Stars. And, you know, the first thing I did before I even started was attending this meeting in Toronto 13 years ago. And I gained a lot of great insight from it. So, I appreciate, you know, you guys inviting me and happy to participate. So, I'll be talking about AC joint and clavicle injuries and hockey players. And I'm going to set my watch so I stay on time for you guys. I know that's not important enough to you. Okay, great. So, here we go. So, I have no disclosures here. So, we'll talk about some of the incidents of these injuries, anatomic considerations and mechanisms of injury, classifications when they come into play and importance, and then kind of get to the treatment and return to play considerations. I think that's probably the most important. So, as we'll see in this morning's session, upper extremity and shoulder injuries in hockey players are fairly common. AC joint injuries typically occur by a direct contact with a player or the boards, ice, et cetera, and injury to the ligamentous complex. Clavicle fractures, similarly, player contact, but you can also have a direct impact to the clavicle causing a fracture. Interestingly, studies showed that if you make some adjustments to the boards, the flexible boards, glass, rounding the corners near the benches, we can have a 29% reduction in these injuries, and those have been made. So, hockey is a high-speed sport, very physical, and, you know, very similar to this Edmonton Oil player who tried to block a side shot with his cup. AC joint and clavicle injuries can result in pain, deformity, disability, some skin tempting, and loss of time from sport. Well, clavicle injuries are typically most commonly seen in the 15- to 19-year age group. AC joint injuries are a little bit older, and that's with the high-speed nature of the sport. In the men's U18 tournament, AC joint injuries were the most common injury. Similarly, in the Olympics and the World Championship data, AC joint injuries were the most common. In general, shoulder injuries constitute 12% of all NHL injuries, second only to head injuries. So, how does gender impact this? Well, boys have more common, or the most common injury in boys or men is upper extremity injuries, while in females it's lower extremity injuries, and that's related to the differences in the rules as well as non-checking in the female game. But interestingly, at the international level, AC joint injuries accounted for 50% of all shoulder injuries in both men and women. And in this 10-year study at the collegiate level, the most common upper extremity injury was AC joint sprains, 29% in men, 13.8% in women. And as far as the mechanism of injury, the most common mechanism was contact with the boards, followed by contact with another player, and then followed by contact with the ice. So, in general, AC joint injuries are very common. They account for 59% of shoulder injuries in hockey players. So, looking through some anatomy here, so we'll break this down into static and dynamic stabilizers of the AC joint. And so basically what we're going to have is the AC joint capsule spanning from the clavicle to the acromion, and that aids in reducing translation from an anterior to posterior direction. And then the CC joint complex, the conoid seen here medially on the left shoulder image, and then the trapezoid ligament seen more laterally. These attach to the undersurface of the clavicle at a fairly routine distance from the lateral edge, and they are critical in providing superior-inferior stability of the shoulder. It's important to note, too, that the clavicle itself does provide some axial compression and also aids in some of that migration, and that will come into the potential for whether somebody performs just a clavicle excision or does not during the time of surgery. The dynamic stabilizer is not to be forgotten. The trapezius muscle and the deltoid muscles help dynamically stabilize this joint. Okay, so looking at the classification system, the Rockford classification system is the one we most typically use, right? So it's a progression. So grade one injury, there's going to be some sprain of the AC joint, and that patient will typically present maybe with a little swelling, some pain with O'Brien's, pain, you know, with range of motion, but not significant deformity per se. X-rays might show a little widening at the AC joint, but no obvious, you know, significant changes. Grade two sprain is going to have a tear through that AC joint and maybe a sprain of those CC ligaments. What you might see on your X-ray now is a slight elevation or increase in the CC interval up to 25 percent, but you shouldn't expect more than that. The player on exam is going to have a little more pain, a little more swelling, potentially more deformity. And then a grade three sprain, again, the progression through. So now they've torn the capsule, they've torn the CC ligaments, and now there's an increased distance between the coracoid and the clavicle of 25 to 100 percent, and these are going to be a little bit more significant. There's an error on this diagram here. Grade five is this separation where you have a little bit more disruption of the musculature. I like the diagram, so I used it anyway. If we look at this study based on this was the Maple Leafs guys looked at a retrospective review of 24 hockey players that had MRIs after AC joint injuries, and they found that 46 percent of the most common type of injury was a grade two injury at 46 percent. They had one type five injury. The mechanism injury, direct impact to the boards was 54 percent. Roughly a third of these injuries were the result of receiving a body check, and only 8 percent were from players delivering a body check. What's also interesting to some degree in this study is they found that 75 percent of these injuries to the AC joint occurred on the shooting side, and what they postulated here was that when a player is up along the boards, perhaps their shooting hand, their bottom hand is lower, and maybe that predisposes them to going into the boards and with a little more risk sustaining an injury. Mixed factors here. If your center man sustains an injury to that shooting hand, it's going to also be their bottom hand, and if they're facing off, that could perhaps delay their return. As far as concomitant injuries, also important to note on this MRI study that 79 percent and 51 percent respectively had trapezius and muscle strain injuries, and that only 3 out of 24 of these athletes had no significant muscle tear. So I'd say whether you're getting an MRI on these injuries or not, just expect that there's going to be some muscular component, which can play into the pain and disability as well. Okay, as far as treatment, it's fairly agreed upon that types 1 and 2s are going to be treated nonoperatively. Type 3 injuries is a little bit controversy where some surgeons prefer operative intervention, but I think that's going to depend on the sport, the position, the reducibility joint, and I would say by and large in hockey, if guys even show to raise their hands, most people in hockey, we're treating these conservatively, these grade 3 injuries. If you look through the literature, mostly type 5 evidence that grade 4s, 5s, and 6s usually require surgical intervention, I would agree with that on the 4s and 6s. However, most of us have seen type 5 injuries. Guys that come in for pre-participation physicals have had a type 5, or vets that have had a type 5, and they'll have significant deformity, but they're doing just fine. So even in hockey players, you see guys with type 5 injuries that can cope. So nonoperative treatment, so typically ice, rest, immobilization for a period, and specific guided rehabilitation, certain things that guys can tolerate, isometrics, et cetera, and kind of get them moving from there. Particularly in your pro athletes, cortisone injections come into play. The one thing I would say is keep in mind in type 2s and 3s and beyond, right, you've ripped the capsule of the AC joint. So anecdotally, I just tend to wait maybe a couple days, just let that capsule maybe scar down a little bit, because I think otherwise the injection might just go everywhere. We'll use some anesthetic injections, and particularly depending on the time of season, playoffs, et cetera, when a player initially comes back, if necessary, to help them play. So as far as return to play, you want to make sure that they have good baseline strength. You're going to send them out and practice with another player, do some stick battling, some battling in the corner. Make sure they feel confident, that they have great strength, that they can protect themselves. And then our trainers do a great job with different tape jobs, padding, getting a little donut here to give the player a little more comfort, a little more support, and protect them a little bit better. So back to the study as far as the results of what they found in this MRI study of the NHL players, 24 NHL players. And there was no significant difference in return to play time between types 1s and 2s. So you had 20 days return to play in types 1s and 2s, sorry, and no difference between 1s, 2s, and 3s. And even in type 3s, 28 days return to play. What they did find was that there was more games missed with type 3s, 12.7 to 6.1. I'm still trying to figure out the math there on how you get six more games in eight days. But whatever. It might be that type 1s were a little less painful. The player wanted to do an injection perhaps. I'm just postulating here. But basically what I would say is tell your GM that if you have a type 1 to 2 injury, figure, hey, it's going to be three weeks, maybe a little less, if the player can tolerate an injection. And then the grade 3 injury, anticipate a month or four weeks out with 12 games missed. The scope of this talk is a little bit too much to talk about surgical intervention. But basically what I would say is shared decision-making with the player and then first doing no harm. So we looked in 2013. We looked at what would happen, what's the risk if you drill a tunnel through the clavicle. We found a significant fracture risk, even if you just did one tunnel through the clavicle. It didn't matter if you did one, two. One was enough. And if you filled it with interference screws by mechanical study, that didn't aid in that. And then right around the same time, Pete Millett, who a lot of people know, a very well-respected surgeon, Steven Hawkins, presented his data, 27% complication rate following anatomic reconstruction of the CC ligaments. And he had a couple of fractures in that series and found that good to excellent outcomes only came without a complication. Gus Mazak has done a lot of research on the anatomy and then the surgical techniques of this. And I thought that his opinion was, you know, kind of wraps this up nicely. Posterior displacement and irreducibility of the clavicle seems to correlate with worse results with conservative treatment. Posterior rotation of the clavicle is key in his opinion, and thus he feels that wrapping the graft around the clavicle to reconstruct the ligament may not be enough. And so he recommends the concomitant repair or reconstruction of the posterior AC joint capsule, repair the trapezius and deltoid musculature with bony anchors, and then avoiding distal clavicle excision if possible, again, aiding in that compression load and superior displacement if you can leave the clavicle in place. Moving on to clavicle fractures here, mid-shaft clavicle is most common. I'll try to speed it up. Eighty percent of clavicle fractures, distal clavicle fractures, have their own kind of issues because of the location of the CC ligaments. And we wrote a Yellow Journal article years ago. I'll direct you to that for further review if you're interested. So 30 to 50 percent of all clavicle fractures are attributed to sport. High school and collegiate ice hockey have the highest rates of any sport, so clavicle fracture is very common. When we break down clavicle fractures, let's just break them down into nondisplaced and displaced. So nondisplaced clavicle fractures have typically the mainstay of treatment is conservative treatment. We're going to immobilize those, and we get really good results, particularly in young kids that have periosteum. Again, this incidence is 15 to 19 years of age, typically the highest rate. Sling immobilization, usually around three or four weeks is when this fracture gets sticky. They start feeling better for ADLs, don't feel like they need a sling. Return to play, signs of radiographic healing, minimal tenderness, complete range of motion, excellent strength. And then you're going to weigh in the factors. What sports do they play? What's their contact level? I would say that my average return to sport is probably 10 weeks. I have a hard time returning a player before then. I might return them back to non-contact, but just for the increased fracture risk, I worry a little about that. So displaced fractures, so now we're talking about displaced fractures, typically those with significant displacement. Interrelated fragments are shortening, are favored towards surgery now. The impetus of that was this Canadian study in 2007 that looked at a randomized trial of displaced clavicle fractures, and they found that a lower nonunion rate, better functional outcomes, improved cosmesis, greater patient satisfaction. Here's some new clavicle plates that we use that provide great support and locking plates for us in different configurations. Other benefits I find is that a lot of times these kids are back to school in two days. They feel a lot better after it's stabilized, less narcotics, which is great in our environment today, and a quick return to sport. Here's a study of NHL players, 15 clavicle fractures. We can do a better job in the NHL of tracking our data. It's unclear whether these are displaced or non-displaced fractures, but the sense of common sense, I'm going to basically say that 10 of these that were treated surgically were probably displaced fractures. The 10 that were treated non-operatively were probably non-displaced fractures. And they found in the fixated fractures, 9.3% returned to sport with no—sorry, 9.3 weeks. So basically 9 weeks returned to sport with fixation. And the ones that went under non-operative treatment, 14 weeks of treatment non-operatively, but they had one refracture afterwards. Looking at this data here, this is some further studies of contact or collision athletes. If you look at Rana Letta's study here, he had 56 athletes. About 26 of them were high-impact athletes, and they found, similarly, a 10-week return to play. This Maesterling study was NFL football players. They expected a 14-week return to play, but actually found that 23% returned less than 6 weeks, 67% returned less than 12 weeks. And these are adolescent athletes in this Lindemann study, and they basically found 100% could return to sport participation in which to less than 2 months. To wrap this all up, systematic review. Basically this nice graph here, conservative treatment. If you look at basically if you have a non-displaced fracture and you treat it conservatively, expect 10 weeks. If you have a displaced fracture and you treat it operatively, expect 10 weeks. If you have a displaced fracture and you choose to go conservatively, expect a five-and-a-quarter-month return to play, very significant difference. And what I've learned over time here is as bad as things are, things can always be worse. It's been 10 years since Rich Peverley had his cardiac event. It's taken me probably, I probably dealt with this candidly without, never told anybody this, but probably dealt with this, you know, for seven or eight years. After that, you know, you don't expect your player to try to die on you. But if you surround yourself with great people, good things can happen, particularly a couple of banquet beers. Thank you very much for your time. References are here, and I've shared the talk. Thanks. Thank you, Tim. I'd like to welcome you back to the panel. Thank you, Bill. That was great. A really good synthesis of a large topic. Please stay online for the discussion and questions section. Next up, a close friend of mine, Eric McCarty, talking about shoulder instability, just like Bill, elite surgeon, and he's at the Colorado Athletic. Welcome. Thank you. Yeah, it's one of our favorites, isn't it? We love shoulder instability, don't we? But anyway, thanks for having me. I'm sorry I missed yesterday. I was down in Vanderbilt speaking to the residents about shoulder instability. So here we go. Some disclosures don't really have much impact on this. So much of this is data, but much of this is observations based on 24 years as a college football team doctor at University of Colorado in Vanderbilt for four years and 20 years at Colorado, 17 years taking care of University of Denver, and then in the past seven, as an NHL team physician for the Avalanche. And there's a lot of observations that are going on, but what I've found is that hockey players are different than any of the other athletes. And I've taken care of lacrosse, I've taken care of mountain bikers, climbers, but the hockey players are different. And if we all have taken care of hockey, we know what I'm talking about. So I see that more dislocations occur in games than any of the other sports. Dislocations are often after seemingly mild hits, which is very interesting. And the tolerance that these athletes have for shoulder instability is in a different category than any of these other athletes. So the approach to management of the shoulder instability is similar in many ways to other Christian athletes, but also can be completely different. And why is this? Why is there a difference in the management? Well, I think one is the toughness level. They have very high tolerance for pain. There's also an NHL level, there's contracts, there's agents, and not anything I had to deal with at the college level, although that's changing with NIL and those type of things. And there's a very short off-season. So all these factors go into the management of these. A couple studies, not great studies out there on hockey. We need to do better. I know gymnastics is working on some things that we can really do better with our NHL database. But this is one that's from the Toronto Group, 24 professional hockey players, shoulder dislocation. Average number of dislocations was 1.6. And there's an eighth here, Labrum, Ter, Bankart, and 75% of players. And of those, 75%, 14 had an associated heel-stack lesion, and the high rate of heel-stack lesions may contribute to a failure of shoulder stabilization procedures, may need additional procedures to address bone loss, such as large day or rough foot size. This one came out of the Columbia Group. They looked at the NHL players from internet public media, public data. So not great, but they found that NHL players instability upscaled from 2003 to 2018. 57 players with 67 instability episodes, a 98.5% return to play. Surgery was done in 48% of these. And recurrence rate in those that had surgery was 0%. And those that did not have surgery was 14%. The non-operative group experienced a decrease in points per game versus the surgical group. So very interesting. And then this is one that was in collegiate sports. And they found that the female athletes playing non-collision ice hockey experienced a significantly decreased shoulder instability rates compared to their male counterparts. Now, is it truly non-collision? I mean, it's still some, but was it really truly due to the non-contact? Other states have shown injuries up to 25% more likely in games in male hockey players than practice. So very interesting. So there's more of this, and there's more instability. So a shoulder dislocation can happen any time during a game. He just dislocated his shoulder, very seemingly not much, but there he goes, he's going to get off the bench, and he's not feeling too good. And again, you're watching the game. I mean, okay, I would have not thought that his shoulder came out, but it did. So what do we do with this athlete that has a shoulder instability episode? Well, the high energy nature of the dislocation is often more significant bone or soft tissue damage around the shoulder. The injuries and risks that come with a high velocity of collision injury result in a higher recurrence rate in the athletes, both treated non-operatively and operatively. And in non-operative treatment, the systematic reviews have shown non-operative treatments to result in high failure rate in this male contact collision athlete. So what would you do if this is your athlete with a shoulder dislocation, and you have this MRI that shows this Bankart lesion, if you look at this on the anterior to your left, posterior to your right, but you see this really very minimally displaced Bankart lesion, what would you do? What if it's your athlete? How are you going to treat it, and should it be fixed? So these are all questions that you need to look at, and then you need to look at studies that have been done. We did a systematic review of all the level one randomized controlled trials looking at arthroscopic stabilization of a Bankart lesion versus spleen. So you're either going to put in a spleen, or you're going to fix it. And so these were all studies that compared those two treatments, average age was 23 years. And if you look at these five studies, very well done studies through the years, that the operative group had a 6.3% recurrence rate, but the non-surgical group had a 46.6% recurrence rate. So a seven times higher chance of experience in other dislocations with non-surgical management. So what does the list say about this type of issue? Fix it. So the list says fix it, can we wait? That's a good question. So in this athlete during the in-season, and as we look at it, we need a thorough assessment clinically and with imaging, and we need to have discussion with the athlete, the parents, coaches, and then typically the agents in the NHL, and then we need to discuss the options and considerations of surgery and return to play. So what are those considerations? Well, we have to make sure that they can have a safe return. We need to have a safe return. And then is there any risk of further injury? Well, there's always risk, but how much risk is there? And then can the athlete protect themselves? And then we need to make sure they have ideal criteria of good motion, of good strength, of really minimal apprehension if they return. So Dan Buss in Minnesota looked at a group of 30 athletes in-season, and they let them go back to play, and they found that no further injuries were attributed to shoulder instability after these patients, athletes, had an in-season shoulder instability episode. Some of them were dislocations, and some of them were episodes of the shoulder instability. So that study was John Dickens' study that you see up here, looking at a group of West Point athletes, looking at all these, that these studies have found that in-season athletes can return most of the time, and two-thirds of these are able to finish the season, 40 to 65% will have a recurrent episode. So yes, they can. They seem maybe not to have any further injuries, but they certainly, most of them are gonna have a recurrent episode of instability. So can the athlete finish the season or return to play? Well, it looks like the answer is yes. However, the athlete does need counseling. They need to continue the rehab. They need to continue to strengthen their upper body musculature, and consider a harness. And so a lot of different harnesses that are out there, some underneath the pads, some attached to pads, and then it's a matter of tolerance from the athlete and if they can do it. And this will certainly help with anterior shoulder instability, maybe help with posterior shoulder instability. So will I let them play? That athlete that has that dislocation, and has this type of vanguard lesion, yeah, typically is yes. We're gonna let them play during the season if they can tolerate, if they're doing well. So what if that player, at the end of the season, didn't have any further energy, or any, I'm sorry, any further instability episodes, and then he says, doc, I feel fine, which so many of them do. So how do we approach that? What do we need to do? Well, if you look at the natural history of this with Hubelius, and looking at a 25-year follow-up, a non-objective treatment, those that were in contact in recreational sports, there was a 70% recurrent instability or need for surgery. So the odds are that these athletes are gonna have another episode. And is it better to fix it at the end of the season, even though you might have a short-off season, and miss into the next season? Or do you wait, and put it out down the road, and potentially miss more time the next season? Doc, I feel fine. Should I fix it at the end of the season? Well, the natural history for a contact athlete is to just say that yes, fix it. So if you are gonna fix it, what do we do? So in this case, with a shoulder that has a Bankart, and no bone loss, what would you do? So we have an arthroscopic Bankart as one option, an arthroscopic Bankart remplissage, open Bankart, open latter-day, open bone block, or an arthroscopic latter-day bone block. We keep getting more and more options as we go through this thing. And so it's a very interesting question, and I know we're looking at that, and there's a lot of different opinions for different people. We asked the same question of the NFL head orthopedic team, Doc, back in 2008, and again, 2016. And what would you do in your NFL player? Back in 2008, 79% said an arthroscopic Bankart. In 2016, 90% said an arthroscopic Bankart. Probably a little bit of a change now. A lot of people would add a remplissage. It changes with time as we learn a little bit more how to treat these athletes. So what to do? You can do an arthroscopic stabilization, an open stabilization, or some bone block procedure. My preference, in the majority of the cases, an arthroscopic stabilization based on a lot of experience, but also there's studies that are like this that came from the Rush Group that looked at, then analyzed all the studies of arthroscopic stabilization in the contact with an athlete. 26 studies, 779 cases. Advocates were young. So this was 19.9 years. This is the group that's gonna have recurrent instability. Rugby was the most common sport. The pool failure rate was 17.8%. However, the failure rate was only 7.9% in studies that used modern techniques and had bone loss less than 20 to 25%. So really honing it down, a lot less failure rate, although still, 7.9% is still, could be considered high. So arthroscopic bank card surgery works in the contact with an athlete. You need the right patients. Few episodes of instability, you need good tissue, and you need to avoid bone loss, and then you need to have the right technique. Now, this study, other studies are showing that laryngitis has less recurrence than doing a B-scare. Probably doesn't matter as long as you do a really good surgery. All path anatomy needs to be treated, and minimum of three to four anchors, as Pascal Boulod has shown us. And the recurrence rate in those collision athletes is 7.9%, so this is typically how I do it in the lateral cubitus, and this is what it might look like. Now, what about the bone block, or lateral J? So I use it for glenoid bone loss greater than 15 to 20%. We gotta remember that glenoid bone loss is a primary reason for failure after arthroscopic stabilization. So we need to recognize it, and we need to treat it appropriately. And why lateral J? Well, it addresses the bone defect, has a spling effect, it has a good fixation, it restores architecture arc, and a glenoid tract. So this is the spling effect, the bone goes in between the subcapillaries, and as the arm is abducted, it helps tether part of the subcapillaries, providing an additional support. And it extends the arc across the shoulder, so that it's less easy for that shoulder to slip out. And this is an example of it. So, onto your left is this shoulder with a glenoid defect, easy for that heel sac to engage and slip out. But when you have that lateral J, or bone block, less chance of it slipping out, so the tract has been extended. But we've got to remember, lateral J has a lot of complications. And most of it's really a nerve injury, but there are a lot that can happen, so we have to be very careful with that. And then, let's not forget the rempossage. Rempossage is basically filling in that heel sac, and putting in the infraspinatus into that area, and providing some tethering to that area, and providing additional stability. So we're gonna use it in revision, and combine defects of glenoid and humeral head, and certainly in contact athletes with moderate to large heel sacs. I'm even doing it in most of my athletes in hockey or football, even if they have really minimal heel sac lesions. So, advantages are, you can address the humeral head bone loss entirely orthoscopically, perform concomitant procedures, there's less risk of morbidity than with open bone graft, and it provides that nice kind of check frame. And so, there's a lot of nice studies. Bill Levine and the group of this systematic review in 2014, looking at studies, found good, excellent outcomes, and no significant loss of shoulder motion, which is some concerns. And there is this very nice study from Pete McDonald, our colleague up in Winnipeg, that takes care of the Jets. Level one, randomized controlled trial, this is across double sites in Canada. Orthoscopic Bankart versus Orthoscopic Bankart plus rempossage. Two year follow up. No difference in patient report outcomes, but there was a significant difference in recurrent instability. The Bankart alone had 18% recurrence. The Bankart plus rempossage only 4%. So, certainly a lot can be said for that. And then what about posterior instability? Common theme, the hockey athlete. Using on dislocation, the posterior labral tear associated with pain is slightly laxative. So, I got two cases, and then we'll be done. I got time, right? Okay. So, athlete presented with pain after the game. History of intermittent shoulder pain over a couple of years. So, he's been dealing, and he said, I had this MRI in Europe that showed a small labral tear. Okay, you know, typically we don't know what they had in Russia. We don't have it in Czech or whatever it was, right? And so, when he came in after the game, he had full range of motion, pain that's forward flexed and posteriorly and with adduction, normal strength, but significant pain with a posterior load shift. So, mild laxity. So, of course, we're gonna get an MRI. Anterior is up to the top, posterior. And then posteriorly, in the back, you can see that there's a large labral tear, and it looks like even a reverse haggle. So, it looked like a pretty significant injury. And so, we have this posterior labral tear, fairly distant in this reverse haggle. And so, you know, what to do? Do we do surgery? Do we rehab it, and we play? How many in here are gonna do surgery and talk to him about that? And how about rehab and return to play? So, majority rehab and return to play. And we talked to him about that. We rehabbed it. He returned in two weeks. Made it through the end of the season. Some pain initially, but able to play. He's got this lesion. I'm sure he'll find out. All right, we have that same discussion, right? Is this the same as anterior? Is this the same as posterior? Maybe not. But he said he's doing fine. His exam, he had really minimal pain on load shift. He opted for no surgery and was able to go back. And he had no issues. He didn't have surgery. So, here's another instability episode. Watch this limp shoulder. And you know, gosh, just puts his arm out. Our defenseman, and look what happened. I mean, it doesn't look like much, right? We see this all the time. So, he comes off the ice. Comes into the trainer. You know, he's kinda holding it. All right, something happened. We don't know what. You know how it is. You get in there. And I said, this isn't moving so well. It feels like a posterior shoulder dislocation. So, I'm trying to maneuver a little bit. I said, we better get x-rays. So, fortunately, NHL, I'll have x-rays at the rink. So, here's what we got. How many of you have seen a locked posterior shoulder dislocation at any event? There's a few. There's not many. This is the first time I've seen one. The first time I've seen it at an event. You know, all the years of taking care of college, being lacrosse, being high. First time I had to even try to reduce one of these. So, we tried to reduce it there. And the trainer couldn't do it. We had the EMS doing some things, even doing the intra-articular injection. Couldn't do it. So, we had to take him to the hospital. And fortunately, when he got enough medication in the emergency room, we were able to reduce it. But that was not easy. First time I'd seen that. Very rare. We did this at AOSSM. And, you know, nobody in that audience had raised their hand that they'd seen this, so it's very rare. It's going to be a rare thing. So then, as we looked at it, here's this MRI. So, this MRI actually looks a little bit better than that last guy, right? I mean, you can see a little bit of tearing, a lot of effusion. And in this MRI, again, bigger effusion. You'll see this reversal sac, but not a huge label tear. Obviously, some capsular injury. So, here's what we got on him. Looks a little bit different than that last guy. Obviously, it required a lot more manipulation than the other guy. So, what's next, right? Is it rehab? Is it surgery? What do we do? Show of hands again. How many wanted rehab on this one? How many want to do surgery? So, a mixed bag. A lot of people don't know. They don't want to raise their hands, so that's okay. You don't have to come in. What about return to play with either one? So, it's a good question. Well, here he is two weeks later. Okay. Remember, it's his left side. I'm trying to block his face. And, oh, his motion looks pretty good. He's moving really well. He's got a terrific range of motion. He looks good. We do some strength tests. And he said, yeah, I hurt a little bit in the front part of the shoulder. And, you know, a little tender there. But that's about it. His strength was really quite good. So, what's next? Well, he went back and got back out there and played that season. All right. End of season. Surgery. What do we think? Hey, I feel a fill. I'm fine, Doc. I'm good. So, good motion. No pain on the posterior stretch of the shoulder. No gross laxity. Okay. Opted for no surgery. Played subsequent seasons. Again, from about the mid-season until the end of the season, he was having pain. No instability episodes, but pain. So, he opted for surgery at the end of the season. Not a huge reverse or, quickly, a labeled tear. Fixed this. The castor flication did nothing to that reversal sex. So, you know, this just gives an example of, you know, the recurrent instability, recurrent dislocations, sublocations, what to do in these cases. You know, the patient with the recurrence or the hockey player with the recurrent shoulder instability. Hockey players tolerate more issues with their shoulder instability than most any other athlete. They don't always need to get fixed. Their tolerance for symptoms are quite high, but it's fixed it if it's affecting the player's ability. So, in summary, remember that hockey players are different in how they tolerate instability. Surgery at the end of the season, recommend it even if you're doing well, particularly for anterior shoulder instability because you hate them getting affected for the next season. Arthrostatization works well in a majority of the cases. Mutilation or some type of bone lock if you have greater than 15% to 20% bone loss. And so, I appreciate it. Thank you. Fantastic, Todd. We have so many more questions for you when you come up here after that. Next up, talking about the upper extremity, wrist, we're going to have Dr. Martin Boyer come up. Dr. Boyer is from Wash U, takes care of the St. Louis team. What about you, Todd? You have to have a token Canadian for your ad. So, wrist injuries in NHL players, exceedingly uncommon. 1.3% of all NHL upper extremity injuries are of the wrist. So, really, fundamentally, what I'm going to be talking about is something that you'll see maybe once, maybe twice a season. I am Canadian, so you may not understand what I say from time to time. So, just ask. Disclosure, I'm an MBOS director, consulting hand surgeon for the St. Louis Blues Hockey Club. Go Blues. What I'm going to say, what I'm going to give you really is a laundry list of things that cause upper extremity pain, both on an acute and a non-acute basis. Okay? So, I'm going to divide it into non-traumatic injuries, traumatic injuries, and the non-traumatic injuries, ones you can inject, ones you probably could inject, and ones you shouldn't inject. The injection I like to use, if you want to get a recipe, is 0.5 cc to 0.5% morphine without epi, 0.5 cc to 2% lidocaine without epi, and 1 cc of deco. The first thing that you'll all see, the thing that's most common, at least in my view of NHL players, is tendinitis or subluxation. They're treated by or they're investigated by MRI in the supinated and pronated position. What you'll see is you'll see the tendon, as you see in the upper right, subluxed out of the ECU groove. A lot of these players have shallow grooves, and the treatment for this is immobilization, and if it happens a second time, the treatment is operative. I like transplosing the tendon. Others like deepening the groove or repairing the subsheath. TSEC, atraumatic, is more common in baseball players. You can see here the central tears. It's the avascular zone. Those are treated generally by corticosteroid injection and by immobilization and then return to play. Ulnar carpal impaction is just another version of central TSEC tears. You see here the proximal ulnar aspect of the lunate. There's a, blessed be the big hole there, and you can see on the plain film, there's a hole. It could be a ganglion cyst, but basically what this indicates is that there's impaction between the distal radial end of the ulna, the so-called ulnar cheek, and the proximal aspect of the lunate, proximal aspect of the triquetrum. Again, these are bones you could probably swallow if you had to, so it doesn't really matter in terms of operative treatment during the season. Popular's wrist is something that I learned about when preparing for this. The upper wrist is the wrist that's affected. Basically, it is a dorsal ulnar triquetral ligament, so it's right in the back. If you feel the ulnar side in your wrist, you can feel the ulnar styloid, and then what you'll feel is you'll feel a gully. Then that's the triquetrum. It's the next mountain you'll feel. Then there's another gully. That's the mid-carpal joint, and then there's the base of the fifth metacarpal. So on the radial wrist, there's one gully, which is the snuff box. On the ulnar wrist, there's two gullies, just distal to the styloid and just distal to the triquetrum. What you'll have when you see here is Phil Kessler and Patrick Linais. They're both right shots. It's the left wrist that is supporting the stick, and you can see the flex in the stick. It requires a tremendous amount of support, and you can get impingement of the triquetrum on the ulnar dorsal. Again, those are treated by injections. We're not talking about the box. We're talking about the metacarpal box, oscyloidium. It's a paper out of the Hospital for Special Surgeons that showed that NHL players that have oscyloidium, which you can see there with the arrow, have a greater frequency of metacarpal boxing. Decorvains and intersection syndrome. The Canadians and Minnesotans here know about footprints on freshly packed snow. It's sort of crunchy feeling, about 5 centimeters or 2 inches proximal to the radial styloid. Again, more common in baseball players, but can happen in hockey players, treated by corticosteroid injection and immobilization. In terms of things that you could inject but may or may not, depending on the player, are all non-hockey-related conditions. Just remember, all hockey players, at least as related to their hand and wrist, are fundamentally humans, and they have the exact same thing as non-hockey player humans. That is scapulae, ligaments, wrist, osteoarthritis, scapulae, yarn unions, etc. Things that you can't treat with injection, the injuries, one is a hook of the hamate fracture, and that's a patient that will complain of pain about 1 inch, 45 degrees from the tibia form. If you take your hand and you just extend it, and you bend your hand on the desk, that's your tibia form that you're bending. About 1 inch oblique, about 45 degrees from the tibia form, right there is where the hook of the hamate is. Very common in golfers, but also in hockey players. Here we see a patient that was read by our radiologist, sadly, as a normal carpal tunnel view. We see here, that's the tibia form, and that's the fractured hook of the hamate, which is there. The MRI, those are best treated by excision. If you don't excise them, you can have flexor tendon ruptures, specifically the profundus of the small finger, and also ulnar nerve compression right at that area, the motor branch specifically, and that can lead to weakness of grip. This is Doug Wickenheiser, HAB's number one drastic. He was a blues player when he was diagnosed with a, quote, ganglion of his forearm, when we weren't taking care of the team. This is not his forearm, but you can see cancer is best treated by people who do it frequently. So moving on to traumatic injuries. It wasn't us, I'm telling you. Viparated fracture, common when players go into the boards with the wrist extended, the Coley-type fracture, apex volar, tendons go dorkily, begins with a closed reduction and appropriate three-point immobilization. This is the patient with a so-called dinner fork deformity. As you can see, I inject 10 cc's of lidocaine and 0.5% marcane during my residency in Toronto. We had a lot of these in the snow and ice, right into the fracture site, and then two people, one applying counter-traction, one applying traction. Following that, flexion, ulnar deviation, and pronation, and then feeling the ulnar and the radial side to make sure that you have achieved the reduction. Interestingly, if you get to these acutely, there's not a lot of swelling, except for the anesthetic that you put in, and you can feel before you get the x-ray that you've reduced dorsally and you've reduced radially. And then you mobilize in the cotton loader position. No, I'm just kidding. You hold it in that position, and then you mobilize it with a dorsal and a radial slab, non-circumferentially. Ulnar styloid fractures are only treated if there's an associated DREUJ dislocation. You can see that on the CT scan here. I like treating them with Kirschner wires. One of my partners likes using screws. But the bottom line is this is the time where you do treat ulnar styloid fractures. Most of the ulnar styloid fractures, as you can see here, are treated non-operatively because they don't contribute to DREUJ instability. PSCC tears, they're a way for me to show the... Oh, there we go. So here's a patient that an attempt was made to repair by someone else, but fundamentally the patient presented with a clunking rib. There's only four things that it can be in a clunking wrist. First is an unstable SL. Two is mid-carpal instability. Three is a dislocating DREUJ, which is what you see here. And four is ECU subluxation. So if the patient comes in and says, my wrist is clunking, and they do this clunking maneuver and they make it clunk, it's one of these four things, and it's up to you to decide which one it is. Scaphoid fractures in hockey players are the same as scaphoid fractures in non-hockey players. They're either treated non-operatively at the end of the season, if they happen when they're fishing up in northern Canada, or treated operatively during the season to get them back a little quicker. Perilunate dislocations are when players go onto the boards and they don't break their wrists. You can see here the capitate is behind the lunate, and you can see the scaphoid on the right in purple and the lunate in green have widening in that area. You don't necessarily have to have an x-ray that shows scapholunate widening in a perilunate dislocation. Some of you may remember Joel Murphy, he was the number one draft pick in 98, I think, of the Red Wings. When he was with the Blues, he had an injury, went into the boards, the x-ray was looked at, it was normal, but when you examine him, the fee was swelling, and it was spectacular, and he actually needed to be fixed, and we fixed him at that time. Take a look at Kirby Dock, left, or, yeah, there it is, his right wrist, excuse me, there. Okay, a minimal injury, okay, when he went in during the World Juniors, and he actually ended up with a radiocarpal dislocation. And if you notice, can we just play that video one more time? I don't know that I can do that here. Thank you. So minimal, not really even a cross-check, just holding the stick up, and you saw the way the hand kind of fell off the radial side. That was a complete radiocarpal dislocation. The key there, again, is swelling. The key to any wrist dislocation, if you see profound swelling within the first 10, 15 minutes, something happened, even though the x-ray may not look that impressive as on the right here. So here we see all their shaft fracture. This is one of the cardinals, but the same thing happens when hockey players get flat. Take a look at his left arm. Boom. So that was miserable. I don't think that a hockey stick is necessarily as traumatic to the forearm as a baseball bat being swung at about 90 miles an hour, but still this is something that requires operative treatment. Again, DRUJ dislocation. If you can't supinate, then the illness is at the back. If you can't pronate, then the illness is at the front, and this is something that, again, is treated operatively. We're getting towards the end. This is Evander Kane coming into contact with Pat Maroon's, I think, left skate. Take a look at what happens here. Look at his left hand. There it's in slow-mo, but the hand goes out, and there's that tiny little area in between the glove and the forearm. Look at the amount of bleeding that comes out. It's spectacular. So, again, direct pressure when you have arterial injury is the way to go, and all bleeding stops eventually, so you put pressure on it and then take the patient to the ER. You don't necessarily need to repair it that night. You don't need to find a hand surgeon, but you do need to get one eventually. You can do an Allen's test if you so choose, compress the radial artery and doppler the small finger, and compress the ulnar artery and doppler the thumb, and that'll tell you if the arch is intact. Very rarely do these end up as vascular or dysvascular limbs because of a stage laceration. So, in summary, what we've talked about is non-traumatic injuries that can be injected, non-traumatic injuries that probably shouldn't be injected, some that might be injected, and traumatic injuries that need acute intervention. And with that, I thank my teammates on the blue, and that's it. Sorry, guys. Number one, what success level do you see in these harnesses for hockey players for shoulder instability? And then two, what do you tell, what's the timeline you tell for return to play after a surgical stabilization? So, for those who didn't hear, the two questions were, what's the success with the harness in the hockey players and return to play after surgery? So, the harness, you know, we like to put it in, some guys will use it and they feel like it helps, other guys feel like it's a hindrance. So, I would say it's, I couldn't put in any percentage, but I would say a little over half, probably, put it on already, it feels like it helps. Does it really help? I don't know. And then in terms of return to play, you know, I tell these guys that it's a five to six month recovery that you go out there, not to skate. Well, they'll be doing skating much sooner, but the play and the season. Now, have we pushed that? Yeah. You know, we've pushed it certainly to, you know, four to five months. I think five to six months is generally considered an appropriate timeframe to get all their, you know, they're going to be healed by that time for sure, but it's really getting all of their endurance and their neuromuscular function and their ability to do so much on the ice. So, basically, it's an impingement syndrome in the back of the wrist, in that kind of between the first and second gullies that I was talking about on the back of the traqueatrum. I probably would immobilize, treat with anti-inflammatories, heat before, ice after a game, obviously warm it up and then ice it down, standard stuff. But fundamentally, the injection should take care of things. The injection should be, depending on the player, not the first thing to do, necessarily. It's always the upper hand, the upper hand, and the right hand shots the left hand, left hand shots the right hand. I have a question for Donna. I'm so excited. I just covered baseball, and I love the size, and the existing operation in a hockey player. How often now, in 2024, would you not add a rempel size in a hockey player? So that's a great question. We'll get, and we got some guys, obviously a lot of people are doing that in here, but my feeling now, in 2024, especially with Pete McDonald's study, and looking at what the data is with the rempel size, that I'm adding that almost to every hockey player, even with a minimal pill sacks, maybe even, I have to roughen up a little bit on the back part, it's rare that they don't have some kind of pill sacks, but I'm adding it pretty much to all of these guys that are doing contact, including sports, football, hockey, lacrosse. I'm doing the same. I'm adding it to all these players we publish on, and it's showing that it has far less risk of returns. We don't know what rempel size really does. We talk about an internal brace, we're not really sure, but if you look at Tony Romero's, and even before him, people talking about a bankrupt being a 180 degree lesion, I think you can go without a rempel size. If you repair the labrum and plant pills that close to your capsule, at a 180 degree lesion, then you can avoid the rempel size, that would be a one indication, but if you don't, don't have the rempel size. I would agree with what's been said. I think that for Pete's study, it's a great study, and his data, they found that regardless of the size of the pill sacks lesion, there was a difference. I have a question. If you do get forced to operate on an AC joint, I don't either, but let's say you get forced to do something, what are you doing now? Are you putting holes in, wrapping a draft? What do you do, Bill? Yeah, so, and I think that you're exactly right, forced, and I've gone away from trying to treat these acutely, because you really want the athlete to decide. They hurt a lot, and then by the time you get to the guy to the OR, he's starting to feel better already, and so what I, you know, when I first came out of HSS, it was really cool to do these arthroscopic assisted, clear up the, you know, all that stuff, wrapping the proline sutures around, but then I found at the end of the day, another centimeter and a half of incision, and you just do this thing open, pass it underneath the coracoid, and so, I'm wrapping a graft anyway, so I would wrap a graft around the clavicle, and then based on what, I think what Gus is saying makes sense, you know, take care to, you know, maybe bring that graft across and reconstruct or repair the posterior AC joint, and then repair your dynamic stabilizers of the deltoid and the trapezius, which even goes more towards the open, because if you don't, if you do it arthroscopically, you're not repairing those muscular structures. I've never had to do one on a hockey player, but if I did, I mean, I think that, you know, my regular patients, like, every day, guys, I do their AC joint, I drill, I drill, drill holes and put a graft across and use interference to, in the clavicle. In a hockey player, I probably wouldn't do that. I literally would crank that thing down, tie that graft all in a day. So, it's changed over time for me, you know, seeing some of the failures with the arthroscopic, like Bill's talking about, and I love doing that, and there were some nice techniques with dog bones, with little buttons and things like that, but what I found to be the most reliable, consistent, and is using this lockdown that came out of Great Britain, that basically is a high-tensile tape that goes around the coracoid and then comes around the top of the clavicle and is held in by a screw and then adding in ligaments, and I've really been happy with that. I had several, you know, the players still did well, and this is coming off contact, not necessarily hockey, but the players did well, but all those arthroscopic, or many of them, tend to just migrate a little bit, and they always are asking, hey, doc, this doesn't look the same. You're playing, and they're fine, but they're saying, doc, it doesn't look the same. They get worried about it. I've gotten to using that lockdown with the graft, too, and, you know, I've got talked into doing it in a hockey player with kind of a chronic grade 5, and two years later, he was playing in the East Coast League, and the doc sent me a picture of his broken clavicle. On the topic of clavicle fractures, especially in NHL players, if they are going to be fixed, the rate of re-operation, irritation from the plate hardware being in the shoulder, is there been any push that you've seen towards the more dual plating with the mini crag plates to avoid that risk of plate removal and re-operation? Yeah, so the data says about 15% incidence of plate removal. You know, I don't do the dual plating. You know, I'm pretty happy with the locking plate, but also, if I can use an anterior plate, but that's all going to be based on the configuration of the fracture. If I can use an anterior plate, then you're going to have more muscle covering that plate, and less chance that, you know, it's going to be prominent the doctor of it. Dr. Boyer, so, I mean, we don't take care of hockey players all the time. I'm Canadian as well. You know, these faithful roommates are... So we can speak in our native language. Yeah, yeah. And so, these partial faithful roommates, where it's a source of pain, you know, it takes the pain off, it bothers them, can you just kind of go through your thought process? Just different treatment options that you suggest? So, basically, what those... Can you hear me? Yeah. What patients like that present with is dorsal pain, about a centimeter distal to the lister's tubercle on the back of the wrist, sometimes with swelling. I think what you have to come to first is a diagnosis of a partial scapulonate tear, and they're usually distal in the scapulonate. They don't leave the scapulonate instability, but they are symptomatic. In those particular patients, I think, just like you treat anything else in the hand and wrist, immobilization, anti-inflammatories, corticosteroid injection, they don't require surgical treatment because there's really nothing that you're going to do surgically that's going to make them better. What I would do in those particular patients that are recalcitrant is ultrasound them, make sure there's not a ganglion. If there is a ganglion, get an ultrasound directed injection into the ganglion or just inject it. And that should take care of things. At the end of the season, you can always take ganglions out, and that shouldn't be an issue. But partial SL tears, I don't know. I don't see them in regular humans, and I certainly don't see them in superhumans. So, we're Canadian. Any other questions for Elliot? Yeah, well, it's anonymous. I'll ask Dr. Boyer a question, if you don't mind. Please. Dr. Boyer, so we've had a couple of these ECU dislocations over the years, and I was unaware, actually, of during an MRI getting a supination pronation view. Is that kind of standard? Obviously, it's something that I would think I have to order as a non-hand surgeon. And then secondly, when you immobilize these guys, how long are you mobilizing them? I would imagine long-arm cast is a pronation supination. Correct. I would immobilize them in neutral, not long-arm, but Munster-type to prevent pronation and supination. I like meeting people with elbow motion, and they appreciate it as well. I think the MRI should be done in pronation supination if, when the player feels their ECU is out, the MRI shows that it's in. And then I would basically turn them over and do the MRI the other way. So, fundamentally, it's a game-time decision, as it were, to pronate or to supinate the patient. Usually, it's when the patient is supinated that it's out. And an MRI done in supination without contract is going to be your diagnostic testing. Perfect. That was a great session. Thank you guys very much. Thank you. So, our next session is, thanks very much, by the way, for moderating. Our next session is the lower body. We're basically starting a core and going visceral, and Joel Boyd will moderate the lower body session. Good morning. So, we'll start our next session with core muscle. I'm facing Dr. Michael Brunch of Washington University School of Medicine, a professor in St. Louis Blues. I've known Mike for a while now, and he's awesome and excellent at these types of injuries. So, he will offer up some pearls. Good morning, Mike. I don't think we can hear you. You may be on mute there. Sorry about that. Good morning, everyone. Can you hear me now? Yep. Perfect. Okay, great. Can you also see my screen? Yes. Great. Sorry. Sorry that I'm not able to be with you in person, but we met up in another meeting, and I appreciate the opportunity to speak to you today. This is the overview of what I'm going to talk about, the anatomy, diagnosis, clinical presentation, and then we'll talk about imaging and treatment options. So, first of all, you all know that groin injuries in athletes are common. Most of these are soft tissue injuries, and the groin is the adductor that's the most common muscle group injured. They don't typically result from direct physical contact, although they can. And they can be a little bit of a pain. They don't typically result from direct physical contact, although they can. And the good news is, it's most resolved with conservative treatment. The differential diagnosis is pretty broad. It includes issues around the bony pelvis, muscular strains, of course, hip injuries, the sports hernia, athletic, and valvular core muscle. That's what I'm going to focus on, even anal hernia occasionally. And you always have to keep in mind, especially in female athletes, non-athletic causes. The anatomy around the pelvic core is some of the most common. The anatomy around the pelvic core is some of the most complex in the entire muscular skeletal system. You've got your rectus abdominis that comes in and attaches to the pubis. The adductor muscle groups that come up from below and attach there. The inguinal canal. Your obliques. There's a lot going on. If you look at the side view, and this will become relevant as we talk about this problem, the ponderosis of the rectus abdominis and the adductor longus in particular attaches and wraps around the pubis here. This is just a cadaveric dissection that we did at one point and just to illustrate the attachments of the adductor muscle group. If you take these off the pubis, the R is the rectus, the A is the adductor, there's this fibrocartilage plate that attaches across that pubic insertion. And that's oftentimes where these injuries occur. It's important to understand risk factors because the best strategy is to minimize the risk of these injuries occurring in the first place. This is a very excellent study that was done by Winnip Melissa's group. Prospective study in HL. And they found that fewer sports specific training sessions of prior history of broader abdominal sprain or better in player status were associated with increased injury rate. And in this study from Tim Tyler's group, which is a prospective study of hip strength and flexibility in one HL team. And they found that the adductor-to-adductor strength ratio was greatly diminished on the side of injury and that players that had less than 80% of adductor strength were much more likely to sustain an adductor strain. And the good news was that an adductor strengthening program reduced the incidence from 3.2 to .71 in player game exposures. And I would say it's strength but also flexibility and not being tight. In terms of the history, you'll want to know about the onset. Was this acute or chronic? Occasionally, I'll see somebody that has had an acute injury, but more often these are chronic and have been going on for a period of weeks to months. Where is the pain localized? Does it radiate? What makes it better? What makes it worse? Any predisposing factors? Any change in their training regimen? I think there's been some confusion just because of the terminology. And so I just listed here all of the different terms that have been used for this condition. Of course, sports hernia is pretty firmly ingrained in the lexicon but has fallen out of somewhat this favor even though that is the ICD code you have to use for this diagnosis because it's not really a true herniation. It's more complicated than that. Athletic tubality is a very good descriptive term but it's hard for non-physicians to understand and use. Annual of disruption, and then more recently, abdominal core muscle injury. And so that's really where the focus is. If you consider the core though, it's really from that lower mid-abdomen all the way down to the mid-thigh. So it's a pretty broad area that we're talking about. And so I really want to focus on the core muscle athletic tubality that is symptoms and findings that occur for the most part around the pelvis and pubis where the trunk and the lower abdominal musculature occurs. These athletes typically have chronic abdominal or abdominal exertional pain. The exam findings are somewhat subtle oftentimes. The pain tends to occur during the extremes of exertion like sudden starts, turns, cutting movements, those first two or three steps an athlete takes, kicking motions. And the challenge is that it often limits that sudden accelerated movement which is oftentimes the difference between success and failure in an elite athlete. They can also have pain with coughing, sneezing, getting in and out of a car. It's very common to have associated advector symptoms. And in my experience, the onset is often usually insidious. Maybe noticed a little something during a game and just soar the next day and then this progressed until it didn't resolve. About a third of the time, there was a specific exhibitating event. They got their state cut. Extreme exertion model is eccentric contraction of the muscle. The exam findings are classically, they're tender on this medial anal canal, lower rectus insertion right off the side of the pubis. As someone who does a lot of hernia surgery, I think I can appreciate this bit of a palpable gap over the anal floor. They often have pain with a resistant sit up or trunk rotation. And this is usually not a true anal hernia bulge. So this is one of the maneuvers that I put the athletes through after I've done a standard hernia check. Palpate across the pubis. Palpate that medial anal floor distal rectus area of insertion. And have them do a sit up and trunk rotation. And do those movements without palpation and with resistance. And often times, they'll have discomfort on the side or the sides of their injury. Planting rates usually are not important. There's some groups that have gotten expert at doing dynamic ultrasound. I think that can be useful in appropriate hands. Part of the challenge with it is that you often can't interpret the images unless you're the one doing it. And then finally, pelvic MRI. Which gives the most information and also can rule out a lot of really different pathologies. This is the preferred imaging modality in our center. You can see I've circled a couple of vines. There's the pubic edema here. And there's this cleft right off the central pubis. And then angling over toward the left vine. Which you can see on the coronal MRI. There are a number of pathophysiologic mechanisms. And most commonly, this involves a rectus insertion injury. A rectal adductor complex. But the other thing that I see really consistently in combination is that they're deficient in their posterior abdominal wall anal floor. And it's more or less, rather than acutely torn, it's like it's frayed. And just sort of worn out. And the problem with that is they lose that stability and support across the pubis. And if they're tied on the adductor side, then it gets very difficult to overcome that. And that creates stress and tension across the pubis that is a part of the pain pathway. In selected cases, there can be a component of anal or genital neuropathy. But I think that's oftentimes an incidental finding. It's not the primary source in pathology. There have been a lot of different variants that have been described. Bill Myers has published more on these than anyone else. And there's the three most common variants. So pure rectus, rectus adductor, or pure adductor. And that's over 90% of these. And there's always going to be different potential components. But if you just consider that's the vast majority, I think you'll understand this a lot better. Oftentimes we see on MRIs, or sagittal MRI sequences, here on the left is the anatomy where the rectus adductor tendon come across the fibrocartilage plate at the pubis. And here you can see the normal scenario on the right. Here's the pubis adductor. And then here's an athlete who has a tear here. And this aponeurosis is somewhat more prominent on the adductor side than the pubis. And the normal side is seen here on the right. The other finding that I see on the exam is this really deficiency or weakness in the posterior anal floor. So this is a video from a case with the anal floor exposed. The spermatic floor is over here. And you can just see there's just a very thin, weak layer that's overlying the pre-peritoneal sac that's sort of sitting there. So surgical indications are symptoms, of course, that limit athletic performance. In general, athletes will rehab for a period of time first. It's eight weeks of conservative therapy. But there are exceptions in which we'll operate on an individual acutely if they've had acute care and a major disruption. And, to some extent, you're excluding other pathologies, such as hip pathology. There have been a couple of small, post-traumatic randomized studies. This one was from Scandinavia. This was patients with chronic groin pain and suspected sports hernia. They had three to six months of symptoms, and they were randomized either to laparoscopic repair or conservative therapy, and they did very careful pain scores out to 12 months and returned to sport. And what they found was that the patients in the operative group, by three months, had a very high percentage, were back to sport, compared to only 27% in the conservative group. And after six months, seven of the 30 athletes in the conservative group underwent surgery. So even this is a small study, I think the data from it are pretty compelling. Now, there are a lot of different surgical approaches, and I know this is mostly an orthopedic and athletic trainer group, but I think it's helpful, perhaps, for you to just understand the different approaches that surgeons use. The primary pelvic floor repair, most popularized by Bill Myers. There's the minimal repair technique, which is the primary feature of repair, but analogous to the still-life hernia repair. This is primarily used by Olivia Mijuic from Munich. Open anterior mesh repair is what I preferentially use. There's laparoscopic posterior mesh repairs that are done in a lot of European countries as well. And what's the overall outcome? This is a study that was done of NHL players over an eight-year span, and they looked at the number of games played and their productivity in terms of points as well as ice time over the course of their post-surgical repair. And there was a little bit of decrease in the number of games played and their goals in the fifth, but there are also veteran players that mainly had some decrement in performance. My experience has been, for the most part, the players do just as well, if not even better, after they've been repaired because you've restored them back to that more normal format and physiology. This is the primary floor repair. It's the primary sutured repair. It kind of realigns the lateral rectus and transcendentalis floor over to the anal ligament. There can be a tension associated with this, so often a relaxing incision is done. This is the minimal repair technique in which just a little bit of the floor is open and the overlapping sutures are used to repair it, and oftentimes with an associated neurectomin. And then the laparoscopic repair, which is used somewhat selectively in my practice. I do it for athletes with chronic or I have car-open anal surgery to avoid that gar and that evidence of a demonstrable rectus injury on MRI. And here you can just kind of see the posterior, the weakness in the posterior floor here along the pubis. Preferentially, I do an anal floor repair using the tension-free mesh approach. It's a lightweight, macroporous, polypropylene mesh. We switched to doing tension-free mesh training repairs over 20 years ago, actually closer to 30 years ago. I do almost all these under local anesthesia with sedation and I'm very selective about doing anything on the rectum. There's also surgical treatment, again, in the 90-plus percent range. The follow-up intervals reported are a little variable. Sometimes it's hard to get follow-up in athletes who come from all over the place. And there's only one direct comparative study of the different techniques. And this was a randomized prospective trial from the U.K. and Europe, 55 athletes. They compared the open, minimal repair technique, which would be the nucleic technique and laparoscopic repair. They had less pain at one month, and at three months the return to sport was a little bit lower in the open group. But this is a primal repair group. This is not the tension-free mesh group. So this is the approach that I use. I just want to show you some of the pathologies. So this is looking down at the floor. This is your rectal speed transfer, speed transfer, say, osteoporosis. The angle of ligament is over to the right. And what you can see, this is good, healthy tissue. There's not much healthy in between. And there's a pretty big gap there, so it makes it hard to get that over in a tension-free manner. So these are the anchoring sutures that I use in that healthy tissue. This is internal oblique, which is more superficial here. And I usually, after I do the mesh repair, I bring internal oblique over it, the suture to the angle of ligament, so that there's really minimal mesh in contact with the cord. And now just a little bit about abductor strain injuries. So these are very common in sport. There's often a history of a sudden injury. Most of these can be managed conservatively. Abductor release is done in some athletes. I try to be very conservative about doing any surgical procedure on the abductor. This is a serious number of studies that have been reported out here with the overall variable we're trying to support. If you do an abductor release, it's a division of some of the anterior epiglottial fibers, and just to decompress the compartment and take some of the tension off of it. Now a little bit about abductor repairs. I've talked to lots of different sports orthopedists around the country. There's a very limited number of individuals who actually do abductor reattachments. There was one study from the NHL, conservative management versus surgical repair. Very small number of players, and the ones in the conservatively treated group generally got back quicker than the ones who were treated surgically. And then more recently, there's been a small study of six abductor ablution repairs. They were repaired on average about 2.7 weeks after surgery, used over three bone anchors, returned to normal about five months. So those are usually very selective athletes with a significant disruption in care, and oftentimes have failed other measures. Just a little bit of my own experience. This is through 2020, probably. This is well over 500 athletes now, mean age, 28 years. The vast majority are male. Duration of symptoms, 11 months, and most of these were repaired in the off-season of some sort. They're pretty balanced between right and left sides, and about 20% bilateral. A lot of them had abductor symptoms. A number have had previous pediatric surgery elsewhere, and there have been a small percentage that would present with the opposite side involved and emerge in two to 34 minutes after the initial repair. Almost 90% open-tension free mass repairs. A few limited primary repairs. Usually young athletes who are still in their growth phase and then some laparoscopic for the reasons mentioned earlier. Most have had only a floor repair. I'm much less liberal about doing abductor releases now, and probably only do it in about 10% to 15% of the athletes, and a few had abductor release only. And this picture on the right just shows an entrapment of the nerve. We'll usually release it, but sometimes we end up accepting the nerve. Mean follow-up, 13 months. 92% playing sport at one year, about 96% are pre-injury level. There have been a handful of required re-operations. It's very uncommon in my experience. You have to undergo a re-operation on the abdominal side, and the primary reasons for failure generally have been abductor-related pain or hip problems or hip surgery. Now, I think it's really important to have a structured rehab program. Ray Borrelli, head of Opioid Fair, with the St. Louis Blues for the last 30 years put this rehab protocol together, and it's a series of phases that one should go through. Just some of the details are outlined here. Gradually progressing over 3 or 4 weeks. By 4 or 6 weeks, they should be doing some advanced work and usually returning to the 7- to 8-week range. But really, progression is determined based on symptoms and findings. And if it's off-season, a lot of times they'll drag this out and just have a more gradual recovery in process. I do think that this is important for a multidisciplinary practice for a sort of physical therapy. It's good to have a really soft-tissue expert, because a lot of these things respond to soft-tissue therapy. I rely heavily on musculoskeletal radiology. It's important to have a very defined MRI tubology protocol that's used. Of course, that's where I train her. And a surgeon is not just a hernia surgeon that really understands some of these other problems in the structured rehab program. So thank you very much. I appreciate the opportunity to be here, albeit virtually, and I'm happy to take any questions. Thank you. Thanks, Mike. And I really appreciate you dragging all of us orthopedists along, because when we first started, it was very, very confusing. So thanks for putting up with us being orthopedic surgeons. Our next speaker has already been introduced several times, so Dr. Ranawat, and he will talk to us about fit. Yeah, exactly. Thank you, Joel. Again, I just want to thank OSSM and all of our supporters and sponsors. I love how everyone shows, especially all the St. Louis guys and the Colorado guys at Stanley Cup, and I'm still sitting here. And I remember Steve Zoboda gets on the mic at one point, you know, does all this stuff with the military. He's first here covering the cast, wins the Cup, and he shows me a picture of the Cup, and I'm like, well, we're Marines and doctors, and it's 1940 for us. So we're still waiting. We always get close, but still waiting. So here are my disclosures, nothing relevant. I'm going to pass them to my colleagues. So the way I think of hip is my evolution from becoming a baseball doctor, where if you're a baseball doctor, you're a shoulder-elbow doctor. A hockey doctor has to understand the hitting court. And if you look at the history of how, you know, hip preservation really grew in the United States, right, you have the West Coast guys, Mark Sullivan, Canadian, right, love hockey. East Coast guys, Brian Kelly, you know, got into hockey. And if you take those two teachers, both of them taught me a lot. It's really how we really exploded that field, as Joel said. And then we brought in Dr. Brunk, Bill Myers, and a lot of other people to really understand this complex understanding. And now I would say the third frontier is understanding the lumbar spot and how the spot, just if you're a throwing shoulder doctor, like you can't have a throwing shoulder lecture, but understand the scapula. You can't understand the hip and the core unless you understand the lumbar spot. And our A-teams and our T-teams really understand that. Sometimes better than us dumb surgeons. Arthroplasty surgeons are finally getting us to understand how the lumbar spine, if you ever went to any joint conference, saw how the lumbar spine affects the hip and the mobility of the lumbar spine is what protects the hip. And I'm going to actually challenge you guys that SAI, which we're all talking about, SAI actually had more hip motion, people with bad inclination, than people without SAI. Because people without SAI have a very functional lumbar spine. Their spine protects the hip. When an FBI patient who goes down, the spine gets locked. It loses its ability to roll back with sitting and standing. And then so to sit or to play sports, you've got to recruit more motion. For the FBI, it actually flexes more. And then you create a wear spin around your hip. And you go back to kindergarten, you've got a square head, a circular socket, my kid fails kindergarten. Sorry. You know, musical analogy. And you create a wear spin around your hip. And that's what SAI and all of our players, you know, will eventually come to meet. And all of our players will eventually come to meet 20 years later, right? The patient with the hip OA in this disease, and our patient population, right, all of our ex-players, all their hips fell off. You know, I mean, not all, but a very high percentage. So it's just a fascinating thing to be a happy doctor, and you have to understand the hip and the core. So, you know, what do we know is that, you know, we're just seeing this more and more. You know, there's some data that shows, you know, obviously goalies have bad hips. It's also it's really changing how, you know, how the goalie positions change. There's some data that shows that centermen have the worst hips. And then there's also it's the workload. It depends on your own life all the time, you know, it's the workload issue. I mean, and realize where we got here is understanding engagement. And we talked about this before. If you talk about why is it hard to prevent? It's a flexion support. So these kids from 7 to 16 are in a flexed position. They're putting stress on their places. And that stress on their places, what it can is actually is an adaptive response to that constant repetitive stress from the flexed position, and it makes a bump. That bump, you know, pays for, you know, my kid's project, you know, where his goalie goes. So, you know, I like that bump. But that's really what it is. And what they did, in terms of Scott's credit, they looked at two groups. They looked at kids who played at spots all day and kids who played soccer, and they had a scoring case, so they had X's on both these kids. Guess what? The kids who got a flexion support had spherical heads. And the kids who didn't play flexion sports had spherical heads. So this is just an adaptive response in the LS player. And we talked about workload and all that stuff. So I think you've got to think of a hockey player as a baseball thrower, and especially a goalie who's going drop down. I gave my son a pitch count or a drop down count. That's how we're going to get with hockey metrics. Maybe we get, as a baseball, there's wearable technologies on your shoulder and your elbow to look at force velocities. We're looking at developing wearable technologies on your hip to see where the motion is coming from and the spine. So there's a lot of stuff that's really interesting here. But let's get back to the basics. You've got an eight-spherical head. You've got a cam. You've got a taster. You've got both. My biggest thing with understanding a fit diagnosis is understanding any diagnosis. The history, the physical, and the energy have to correlate. Impingement has to have reduced motion. I love people to see physicals because I can just, I love it when I see a goalie with internal rotation and how you assess internal rotation is really critical. You have to keep the guy lying down. You immobilize their insides. You immobilize their pelvis. You get them 90 degrees, and you feel any degree of bone block. And you'll be shocked how common impingement is in our players. It's symptomatic of injury. And the reason why is they've got great lumbar spines. And once that spine goes, then the hip goes. Image analogy is really important. There's so much symptomatic impingement. Don't chase after x-rays. Don't let your doctor chase after x-rays or MRIs and test scans, because those guys have functional spines. But it's a really interesting concept. So why does physical therapy work? Well, there's a really good paper out of England where they basically show that, you know, the difference between surgery and therapy wasn't that much. But surgery did show security, and it was a high crossover. But the reason why physical therapy works for the hip is you're not doing anything. You know, obviously, abductor strengthening is important, but these guys are all pretty strong. Their glutes are strong. They have to have tailored glutes, because their glutes are so big. How do you help them build it? So it's not about a weakness in this population. It's about recontrolling the lumbar spine and recontrolling that core and having that balance attack. Think of it as a scapula. Whatever you can do that way, you're going to reengage the lumbar spine. And we do a lot of theos, which is functional x-rays, shooting and standing, and I can show you when the spine is functional again and when it's not. And that's a really interesting thing. So, as we've done before, ART is really good, but it's really hard. The art of unlocking your lumbar spine is really a critical thing for all of our PTs and ATs. Now, in terms of arthroscopic development, this procedure went from being a very rudimentary procedure to now a very advanced procedure. And, you know, when we started this, this was an open operation. We were in Switzerland, and, you know, I was a fellow with Professor Gans. And now, you know, this is now improvement surgery is pretty much 95% to 100% arthroscopic, certainly 100% in the hockey players, where we first get into the joint, you get into the joint, you fix the labrum, you get exposure, you're going to do a scan, and then now, catheter management is critical. Understand that catheter is really critical. Return to play is really high. I would say this is one of the best operations in professional sports, doing a hip scope on a hockey player. It's really one of the best operations. You compare a hip scope to a hockey player to operating a shoulder on a surrogate, I think it's at 90 degrees. It's close. At instability, Eric gave a great lecture. He said it's 7% to 25% failure rate with an arthroscopic procedure. And that's it. So that's not what it is. So I would say the hockey players make every hip scrotch over play. What's the biggest failing point? It's the level of arthritis. And that's really how you really inspect the failing joint that's really critical and when to kind of go into it. So that's something that you really want to think about on these athletes. We heard a great lecture by Dr. Vaughn. I just want everyone to understand that you have to, you know, sports training is hip. It's an E.O. Halstein-Bend diagram. There are people who are pure hip, people who are pure sports training, and there's a big overlap. When you have a tight hip, then it's kind of like a lumbar spine model. The next thing that fails, you've got to get motion somewhere else. So if your hip doesn't work, you're going to recruit motion like tearing through your adductor, tearing through your rectus, tearing your oblique, tearing your hamstring. It's a fusion model. So you have to understand that. So the best thing about sports training exams, it's a pretty, I would say now, because it's what I've always learned, easy to get a palpation exam. Palpate the rectus, palpate the adductor, do a crunch, learn to rotate, and then learn how to do range of motion and length. If you can't diagnose this particular problem, I call it the spring pack of an egg. Straight flexion, flexional adduction and extralocation, and I say this, flexional adduction and extralocation causes any fear of pain. So all three of those are positive. I am very confident in saying this. I also don't really believe in a hip flexor strain. Hip flexor strain, to me, is what we would say whiplash for compression. It's what you want to say when you don't really want to say what's going on. I think it's almost inevitably in the joint. Now, it could be mild in the joint, but whenever you say, it's all hip flexor, hip flexor, hip flexor, the hip flexor goes right over the anterior capsule. The iliopsoas has been blamed for years, and we've been cutting it and abusing it. It's like, I have an adductor. What did the iliopsoas ever do to me? Why do we always abuse it? So, I don't want to get into this, but one thing I want to talk about, so, sports hernia conservative management, to me, it's a little bit harder. Hip conservative management really works, And if you unlock the hip, you will then protect your sports hernia disease, you'll protect your abrupt disease, your hamster disease, all that kind of, I call it a fusion model. And we learn about this. My main thing about understanding operative care of the sports hernia, sometimes you have both athletes. The sports hernia is an easier operation to recover, it's done very well by Dr. Braun and things like that. It's an easier operation. And even if you have a hip problem, it's an infection that happens there, sports hernia is even faster. And understand that. Whether you do it first, whether you do the hip first, or now we do a lot of these sometimes together at the same time. And there's pros and cons for all those classes you can talk about later. I think an adductor is different from sports hernia, it's also different from the hip joint. An adductor is very common in hockey players, the muscle tendons chunk from injury, this is treated non-optimally, and you know, you take care of enough hockey players, I mean a goalie has an adductor every other week, and it's just something that you have to understand how patient exam is critical, and strength exam is critical. So here's what I think is the more interesting thing now we're seeing in hockey, and also in professional sports, right? There's been two professional type players who's had a hip resurfacing, there's been now maybe six to seven professional hockey players. It's not the holy grail, but you have to understand that understanding the failing hip and the non-describable procedures sometimes is the wrong procedure, if I want to ruin a guy's career, I will operate on it, we'll need to monitor our fitted hip, and do an FAI surgery, and then I will guarantee that's the only way you can take that spot out and do plastic. So you wait. But really, you know, realize the natural history of the hockey hip is OA, especially if they have a defective plastic socket. So what's the perfect storm? This head, this plastic socket, it's a wear simulator, that hip's going to fail. So obviously, you know, we're talking this with injections, and that would be crazy, understanding the core, we have a whole section on this I don't want to belabor it, we'll talk about, you know, with Dr. Leary during the HCA course on therapy, they all have a role depending on where you are in the season and other things. So here's this understanding of a hip resurfacing. First of all, so you know, when an athlete asks you, oh I want to get my hip resurfaced, right here, it's great. You know, we can say some names out there, we are an athlete that had a gun. It's a maximally invasive arthroplasty. It's the most maximally invasive arthroplasty. Like what? Again, you preserve capsule femoral bone, but you have to take off the glute, you have to split the glute, it's a very, very, it's the biggest incision arthroplasty you can do. And I don't make an argument that a huge, little standard non-semitical hip on these guys who are so strong and great, they'd be able to play hockey too. So there's a lot of debate whether a resurfacing is really that much better than a total hip. But clearly, there are some advantages. And here are the disadvantages. It's a metal-on-metal bearing, which means it's in ions, and you have to monitor, the athlete has to be monitored six months yearly and all that stuff. And there's a chance that they can feel great and their ion levels go up, and then you want to talk about a revision or an exploit. Because if you don't, you can get a disease called mellosis, which is a massive failure and a massive problem called asthma. In the U.S., about 15 years ago, the incidence of metal-on-metal bearings was 15 to 30% of all total hips, and resurfacing was flying high. Now it's .0001%, because of all the lawsuits. So when you're counseling your young hockey players who have a lot of runway to life left, I'm not saying you can't do it, but it's not the holy grail. It has a lot of drawbacks, but you look at Andy Murray, it's like his name, because he's not a hockey player. He got five years out of it, and a lot of other tennis players did. So there's a couple elite cyclists that have done it too. But it's not an average man's arthroplasty, and there's only a few arthroplasty surgeons I really trust to do it. It's a critically hard operation. So let's go through a case. 20-year-old hockey player, working the left corner playing, mechanical symptoms, obviously what do you want to hear? He says, I can't play hockey. Right? But if you talk to these guys, what you really also want to hear is, he needs pain. Fuck, my hip hurts, it's not comfortable on the airplane. Once you get that, you know that eventually at the end of the season, something's going to happen. So here's what I really want to focus on is that physical exam. He has reduced flexion. He has reduced internal rotation. Flexion's a low arched hip. There's two types of hips. There's a low arched hip, the total range of motion is low arched, and then there's high arched hips. Now, there are people who can cure their labrum with a normal arch range of motion of the hip. Those are the ones, actually, I don't like operating on. Those are the ones, historically, if you look back, when you think of caring, look back at Dale, that's actually some of the hardest results, because you're like, I'm not sure why they're hitting standards. It's hard to understand. The low arched hips are better because you know you can give them more motion. And once you take more motion in that hip, all the secondary issues will get better. And if you really want to see that ACMC, the anterior lateral aspect of the proximal femur, an MRI. I don't get an MRI to diagnose an intraocular phenomenon, right? A label carrier is all diagnosed. There's a label carrier imaging by me. I get an MRI to just look at the cartilage house, right? A label carrier is a bad word. It's chronical label injury, and you diagnose chronical label injury by physical exam, right? Not maybe with an injection, if you're really working feet. But you have to learn how to aggregate a hip, and that's how you diagnose it, not by an MRI. So, this is something that we do a lot on our athlete. This is a set. You can see the ancient history of that femoral head. This is a pistol grip, tan lesions and quadrilaterals. You mentioned the alpha anal. This is now what we do at HSS, is that we get a lot of cat scans, because this is predicting their combined anterversions, femoral anterversions, not tabular anterversions, of how well they do post-operative. So, this to me is the perfect hip. This is how we do the operation. Femoral head's to the left. Labrum beat up to the right. You're cutting the capsule. These low arch hips, just doing the capsule release, to a certain extent, helps them, gives them more motion. Before toe hip was invented, actually, patellaectomy was a treatment of choice, and it's still a treatment of choice in the arthritic shoulder. So, you're closing the capsule, and you're connecting your torsos. You're burning on the rim. So, joints go left. You're decompressing both sides, inside both the acetabulum and the proximal femur. Right, this is above you. That's the sub-spine area, the A-I-I-S area. And then we place our anchors, and you, you know, it kind of looks like a shoulder. Just a much tauter scale, so it's a little bit harder than a shoulder, it's right here, close to that. And then we put the hip back in the socket. It's amazing how much surgery you do on these guys, and they come back, and they're ready, they want to skip a few months, and in four months, they should be playing hockey. So, it's a profound, it boggles my mind how quickly this happens. So, that's when you, you know, catheter management is the key to this, and you want to really do a good job of closing a capsule. It's the new frontier of hip surgery. And this is what you want to do, you want to restore offset, and then you want to make sure you increase range of motion. And on average, a good cam, you'll increase between 15, 5, and 10 degrees. Here's the other spectrum, right? Low-arch hip, here's high-arch hip, right? You know, goalies need their motion, right? And when you, if you ever see a goalie with bad, you know, my friends are goalies, and Brian Kelly always tells me, when am I going to scope this concept? When am I going to scope this concept? But I'm like, thanks, Brian, that was amazing. But, but when you have more in-cam laughing, you know, there is a, this is an example of, they have more of an instability pattern. They have more of an eber, and they, they walk with a little bit more of an internal location. So, looking at the foot progression angle is really critical. You see, internal location here is 35 degrees. That's location 7, a high-arch hip. Very good for, for motion. You can see here, a little bit of a dysplastic socket, right? So, you know, and you can see a big labrum, juicy labrum, very beat-up labrum. So, what you do, I'm, I'm this with a hockey player. So, I've seen this hockey player maybe six times. When they're very, very young, I talk about the scope of the P&O. That's analogous to saying, doing a lot of Zay. The P&O's a big operation each year. But I've had hockey players come back. An NHL player, there's no, there's been no NHL player coming back after a P&O. Just like when we talk about osteotomy, there's only one NHL player coming back from fetal osteotomy. But, you know, he was kind of a beast, and that was a GM. So, this is how you do it. Big labrum, repair it. It's just trying to, you know, how, how, how, how, how you, how, how you can do it instantly and stabilize. When you see that label, hematoma, that's called the vein cartilage of the hip, because the hip wants to go out forward. So, just to still be, still in time, and then capture a minute or two as we talk about really critical things. So, just quickly, return to play, you know, again, nothing is about time anymore. It's all about evidence-based in terms of criteria and things in some sport-specific movement assessment. You know, return to play is, you know, four months for a stroke. Booger operation or resurfacing is about nine months. You know, these guys can normalize their game in about, you know, 30, 40, 50 games to get back to normal levels, and that'll support that. So, I think you have to really do a diagnostician for the hip and understand it. You know, arthroscopy is, you know, really changed, and, you know, and until you can get an athlete through the season. I really can't remember, for the, for an NHL athlete, the last mid-season player we did, but at the end of the season, it was always about two guys, you know, in our whole organization, not just in the NHL, including the NHL and other guys. Hyposcrypsy is promising, but, you know, there definitely is some problems in El Nino Morgado, and as my father would always say, the odds always seem with the mighty wise. That's great, Anil. I'm sure we're going to have a lot of good conversation later. Our next talk, our next talk is about knee ligaments. Thank you very much. Really great. Anil's like a savant over here. Like, I learned stuff there. Anil was reading textbooks, and the rest of us were question-and-answer fraternity guys. Like, unbelievable. Great. Well, we'll do a quick summary of some knee ligament injuries. These are my disclosures. And then, so why are we looking at the knee? Ornell and his colleagues have published in 2020 that the lower extremity injuries were probably the most common orthopedic injury in hockey players. If you're looking at the knee, it's right up there with the shoulder in terms of the amount of injuries that these hockey players get. It's superseded only by concussion for the most part. I had to show this to paper. This is Dr. Mark Aubrey and his colleagues published this. And when they looked at the seven-year period in international hockey and Olympic winter games, the knee was the most common lower body injury of which half of those injuries were made up by the MCL and about 10% by the ACL. Just a quick summary here on MCL injuries. This is an important diagram. This is by LaPrague. We all know how to examine the MCL. There's a couple things you need to be aware of. If you open in full extension, then you have a really bad problem on these players, especially in a hockey player. You have to be starting to look at a cruciate ligament associated injury or a posterior medial capsular injury. So really pay attention to your hockey players. Most of the time, it's not just the MCL, but if the POL is involved, then you've got bigger problems. Very rarely you'll actually see an isolated POL. When you palpate back, they don't come along. And those will heal very quickly because of an isolated POL. I just wanted to show you this diagram to kind of keep things in order. We'll try to debunk some of the myths that we grew up with. Can you play that video? MCL injuries happen very commonly in hockey. There are very fellow guys come off the bench. They're like something with a break in my knee. And you'll see this at least three, four, five times in a season. So how do we treat these, and what are some of the myths that we learned? Switch over to the next slide, please. There you go. Can you play that video, please? So this is a case. I'll show you some cases. When I grew up, what did they tell us? Most MCL injuries are non-operative, and that's true. What I tell my players, though, is that 80% of an MCL injury is going to be non-surgical. 20% are going to need an operation. Those numbers usually have 95% and 5% of needing an operation, but you don't want to box yourself in that corner in case something goes up. This is a 25-year-old male. He's one of our players at the Stuntman. He sustained this left knee injury, and he complained of mediated side of pain. He opens at 30 degrees, then a slight opening at zero, but he had a good end point to it. And he was coming over with a distal MCL and a stable opening. Again, during my training, proximal MCLs all heal. Distal MCLs never heal. That's what they taught us. That's the myth. This is a distal, hybrid MCL in this player. He went on to be treated non-surgically with complete success upon this. Not an issue at all. How do we treat him? It's a Grade II-III distal MCL. We treated him in a permanent hinged knee brace. I did a PRT injection. That's plus minus. There's no value to do no PRT here. A lot of players want you to do it because they talk to their other athletes. They want something short of a surgery to fix this. So you inject PRT. Just do it one time, not multiple injections. You can create a chill in this area. Off-ice workouts should be higher and more intense than on-ice stuff. So until they are really doing off-ice stuff that's higher and more intense than on-ice, that's the time you're going to get back on the ice. And then return to play and spend a week with a brace or a high grade. My general guidelines for my players, Grade I, two weeks for the most part. No brace. Grade II, it's going to take them four to six weeks. That's no brace for me. And then for Grade III, that's going to be six to eight weeks for these guys because that usually involves a POL injury associated with it. And then we'll have brace for the first four weeks of game play, and then it's up to the player if he wants to keep it on for the rest of the season or take it off. Some guys it's plus minus for them. So this is the general guidelines for me for MCL injuries. All right, so when do things not go well? Can you go back one slide? I'm sorry. So this is a 31-year-old player, and he sustained a goggles injury to his left knee. Again, the same type thing. He opens up at 30. He opens up. He's got a proximal MCL. Again, in our training, these all heal, right? This is him at about one month after the injury. So in the meantime, Alba operated on his other knee. He had some chondral defect on his other side. He's like, Doc, I'm going to be out for this MCL. Let's just do the operation. So we operated on it. He's going fine from the opposite side. This MCL is healing appropriately. He gets back on the ice. And without a contact injury, it tells something. He's got a brace on. That's it at one month. Okay, so now we've got a bit of a problem. So a PRP injection here. Let's wait it out a little bit longer. Yeah, I want to wait it out. Two months after injury, this is where he's at. The edema's quieted down. The ligament is not healed. Again, the 5% of people, you will see this. So do not box yourself out. Just tell these guys, 80% is going to heal, 20% won't. And so if you're in that, why did this not heal? Well, I told you, you know, 2 out of 10 people don't heal. So him at the end of the season, he went on a MCL reconstruction with ALGRA because he's got an unstable knee. He just could not play with this at all. Okay, for treatment guidelines, I just showed you that. Grade 3 injuries, consider operative management. Grade 1 and 2 should go on to heal just fine. Biologics, plus or minus. If your players are the kind who like to have biologics put in there, by all means, inject it, but don't do repeat PRP injections. You can create some HO there. Switching gears a little bit, let's talk a little bit about ACL injuries. While less common than in other sports, ACL injuries are still present in hockey at about 10%. Surgical decision-making for hockey players, what's your draft choice for the year? If it's an offending guy, or if it's a quad defendant. I've had several players, junior players, come to us in training camp from Canada, having had hamstrings, and are doing absolutely fantastic. Whether you add a lateral arthrotic or tenodesis, or a meniscus injury, you have to be comfortable with this. That's up to you. What's the difference between ice hockey and other sports? Based on the college list of the studies, showing that in hockey players, there's less lateral bone bruise pattern in these players. No medial bone bruising. Less frequent lateral meniscus injuries, unlike football. And there's really no difference in ACL, MCL, and medial meniscus chondral injuries between them and other sports. ACL outcomes in the NHL. So, Bernie Botting's colleagues looked at 37 knees, 101 ACL reconstruction while in the NHL. 100% able to return to sport the season after ACL reconstruction. The length of the career in the NHL after ACL reconstruction was just over four years. After an ACL reconstruction, player performance was not different from pre-injury performance. Now, the data showed that that's not necessarily true. Revision rate was 2.5%. Brad Nelsons, the red-thumb major, did a great study in 2016 AGSM, looked at 47 players, meaning age was about mid-career for them. The average length of time they played was about 2.8 years after the injury. Decreased compared to a control group of four years. Presence of meniscus injury obviously has nothing to do with decreased length of career. That makes total sense. Scratch failure was just under 10%, with 20% re-operation rate. And about 10% of these players never returned to play whether that was because of the injury or at that time in their career. Hard to really say for sure. Where it becomes kind of tricky is when it comes to ACL combined to MCL age. So I'm going to go over this whole slide. But there's no clear agreement on how to treat these injuries, whether you fix the MCL or don't, or do not. So what's my treatment modality for this? Basically, I use this paper as a good guide for me if a patient has residual values for the time of the ACL surgery, then go ahead and fix the MCL. How does this play? Let's take a look at a couple of examples where we've dealt with. So this is a player of ours. He was 34th professional hockey player sustained an injury to his knee, contact injury. He always had an ACL tear. He had an MCL injury as well. You can see the MCL injury on the far right there. That's a grade 3 proximal MCL. Unfortunately, about a week after his injury, he got a DVT PE. So we had to treat him. Get rid of the DVT PE, do the low-venous ingestions, etc. And then six weeks after that, he had a clear exam on his ultrasound. So we moved forward. We got him to repeat MRIs six weeks just to see. And here's his MCL. That's gone on not to heal at all. It's become atrophic. So this is an example of an ACL MCL. So that's what we did. We talked to him about autografts, open MCL reconstruction autografts. He went on to play four or five more years before he retired because of a recurrent PE. So that's the treatment modality for him. Another player, and I'll just show you a different example. This is going to be kind of tricky. So this is a 34-year-old guy. He's a professional hockey player. Non-skeletal injury. He came in. He had had a previously drugged run between. He had an ACL reconstruction done with ultrasound and autograft. And it had done well for about 10 years. He sustains a repeat injury to this knee. He had opened up a valgus. He had a Lachman that was positive. But he had a good end point to his Lachman. He just told me, he said, knee doesn't feel right. I pulled him up from the game. I checked it. He was not feeling any kind of a pop. His Lachman had always been kind of asymmetric. So this is his exam. These are his pictures. And what it shows you is a high-grade, grade II ACL. It's like a grade II MCL. So we sat down with our general manager with him to discuss some of the ñ can you roll the middle one, please? He had a high-grade ACL, intermediate-grade MCL. So what do you do with one? You know, he was like, I'd like to give this a go and see how it kind of plays out without surgery because it's an operation. We'll put him up over here. So we said, okay, we can give it a try. Let's see what happens. Can you go back one slide? Oh, no, never mind. Leave it here. So, elected for non-offered management on his partial ACL MCL. We did a PRP injection just because, I mean, we did also, again, one of these players. Three weeks on a break. Three weeks allowed to return to the gym. That's six weeks. He returned to skating and progressed to full contact play. So things are going really good at this point. Ten weeks, he goes, like, he's doing great. He gets another injury in a game. Now we got real problems. Now he's starting to get some pivot. We get a repeat MRI on him, complete repair of that partial ACL. MCL is built for him. All right, so now what do we do on this guy, right? So at this point, I mean, he's just full of cholesterol. So we're like, all right, we got to revise this ACL. I mean, he's one of our better players here. You can play that middle slide just to kind of show them. MCL doesn't look hot. It doesn't look terrible. So we're like, okay, what are we going to do with this guy? ACL's got to, you know, be redone. The questions here were, what's the draft choice? So, you know, he had a couple of options in what to do. I suggested to him to use a fifth lateral quadriceps tendon. He had been given options of contralateral BCD. And a lot of athletes, I'll tell you, have made any choices. I'm not a professional athlete. If I do the contralateral, it means most of them are going to walk out of the office like a player. He's like, all right, let me see the quad tendon. Let's go ahead and, you know, use that. So we did that. By the time I had to make a decision on him, like, what am I going to do with this MCL? I tested it improperly. You always want to test your MCL before you do anything to the ACL and then make a decision and then reconstruct the ACL. So he felt strong enough to the point where I was like, all right, I think I'm going to leave this MCL alone. I can tell you I probably lost about two months of sleep over that just to make sure that things were going okay. But I reconstructed his ACL with a quadriceps tendon autograph, and then I added a lot of extracting opportunities just because of a rooting in case. And, you know, he came back. He did great. What did the literature show about LEPs? This is not in hockey players. This is in soccer players from Europe, and they show decreased graft failures. So there is some literature support adding an LEP to this. And our athlete then returned after revisioning the ACL. Six months on the ice. Six months on the ice. At seven months, he was like back to playing. And after revision cases in NFL players, we know the average can be up to a year. So I told him, I said, listen, I may not clear you early, but if you're doing great, we can. So that's the general consideration. Limited data on in-season management of partial ACL tears in the NHL or in any sport for that matter. Point of graft consideration is revision ACL cases, located to use at your lateral extensive donor site. Revision of the MCL in our athletes considered non-operative. It's stable on exam. And the return to play after ACL, you get better outcomes in elite athletes than we do in recreational athletes. Thank you. I'm going to move on to our last talk after Dr. Sparkas on foot and ankle. Hi, can you guys hear me? Yeah. Yeah. Great. And can you guys see my presentation? We see you. We see you. You're looking great. Let's see. There we go. We good? Yeah. I can see this. Okay, great. So thank you guys for the opportunity. Thank you to Neil and the AOSSM. I'm going to talk about foot and ankle injuries in the NHL. These are my disclosures. So I started helping out probably about seven or eight years ago, and I definitely had some misconceptions going in. One was that there weren't a lot of foot and ankle injuries in hockey because you had a skate to protect you. Two is that I don't need to get a lot of MRIs. As one of my chief residents taught me, pucks cause edema, so you already know what the MRI is going to show a lot of times. We often get CTs, or often preferred to, without fractures. And then the third thing is that a lower body injury on the injury report can be anything from an ingrown toenail to a tibial shaft fracture. So there's a lot of variability when you see that type of stuff. So the first thing I'm going to talk about is just some of the epidemiology. So this was a study in the NCAA looking at injuries in both men's and women's hockey. And the most common injury was a foot or toe contusion, usually from a puck, sometimes from a direct blow. Women actually commonly sustained a low ankle sprain, and foot or toe contusions accounted for the most non-time loss, so less than 24 hours. The biggest or most morbid injury was the high ankle sprain, the synesthematic injury, which accounted for the most severe time loss. When looking at the NHL, this was a systematic review of what type of injuries. Ankle injuries accounted for 10%. Foot injuries accounted for 7%. So about 17% of all the injuries were foot and ankle. And again, high ankle sprains cause for the most morbidity and the most time loss. So I'm going to go over a bunch of cases and kind of illustrate some of these things. This is a 29-year-old male professional hockey player presented with left ankle pain following a direct block from a hockey puck in the third period. He kept playing, and the game went into triple overtime. When we finally got to examine him and do take the skate off, he had focused pain over his medial malleolus, echemosis, tenderness of palpation. And this was his X-ray. So he had almost a vertical shear-type fracture of the medial malleolus, which was intraarticular. It's minimally displaced. You know, even though, as a general rule, these vertical shear injuries tend to be unstable because it's a direct blow, I know it's not a syndesmotic injury or a rotationally unstable injury. That being said, it is intraarticular, and we had some decisions to make about whether and what to do and when he would potentially be able to play. We did get a MRI again just to confirm that the ligaments were intact and also to take a quick look at the cartilage. But ultimately the decision was made to fix him. So the way that we fixed it was we did an arthroscopic-assisted ORF. I removed any hematoma that could have been blocking the fracture. This is looking at the medial malleolus after we tried to compress it down. And we basically put two headless screws across his fracture site. Now, normally for this type of fracture, you'd use an anti-glide plate along the medial side. You know, particularly one of the issues in hockey players is they don't really tolerate a lot of metal, certainly in their foot or ankle. That area of the body just has a very thin, soft tissue envelope, and you can start to feel it, particularly on the medial side. The medial side is worse than the lateral side. So the thought process was, again, this was a direct blow injury and we're going to put in some percutaneous screws that he's not going to hopefully be able to feel, and that will afford some sort of stability to this fracture. And this was his pictures afterwards, where basically we just used poke holes to try to prick it. And then he was kind of chomping at the bit on the soil. We got him walking in about a week, about two and a half weeks post-op. He's wants to kind of get back into the swing of things, wants to show what he can do. Again, what's nice about this skate is that it's almost like a cast. It does kind of protect the feet to a certain degree. So he felt pretty good about it. And then he ended up returning to play 23 days or a little bit over three weeks post-op. He played the majority of the game. They won the game. The Rangers actually give out stars of the game, and he was one of the stars of the game. And everybody's feeling pretty good about themselves. Around this point, my son kind of asked me, like, Dad, what's the worst thing you think that could happen? Like, I don't know. I mean, I guess he could get hit in the same spot, but that would be pretty odd, pretty rare. So this is about a week and a half to later. He's going to be at the bottom right of the screen. And the guy who's taking the shot right there has, like, the second fastest slap shot in the league. That actually hits him in the exact same spot, and he kind of crumbles the ice, and then he kind of is trying to make his way off the ice, not in great shape. So I'm at home watching this with my son, and this is my reaction. I'm a little bit nauseous. I'm a little bit upset with myself, wondering what we're going to do. So he actually came back into that game and continued to play, and he did play throughout the rest of the playoffs. And this is what his X-ray looked like at six weeks. So the screws basically held to a certain degree, but, you know, just to be critical, there was a little bit of gapping in the front of the ankle. He was having some pain still, although he said it was getting better. We decided that we were going to watch it. Comes back at three months post-op. He's doing okay, but he's still having some pain. And now he's basically got a partial non-kneeling of that anterior part of the fracture, so kind of in this area right here. And one of the screws, particularly the front screw, it looks like it's having, like, a windshield wiper effect where it's probably loose. It's probably not doing a heck of a lot in terms of stabilizing the ankle. And this area in the front doesn't look like there's a heck of a lot of healing. So at this point, what we did is we brought him back to the OR. We did basically a screw exchange where I put in a bigger screw, a little bit longer, too. And then through a percol, we actually bone grafted the front of that non-kneeling where we took a little bit of iliac crest bone graft, threw a jammed sheeting needle, and also some bone marrow aspirate. This actually bone grafted that area, put in a new screw, allowed it to heal properly this time, and he went on to heal completely. And then, unfortunately, never had any further issues with that. He wasn't able to feel the screws. So we're looking at weight-bearing after these fractures. So historically, people would put people in casts and really shut them down. So this is a study looking at weight-bearing after ORF. Now, the downside about studies like this is it's kind of a mixed bag, and there's a difference between a fracture I just showed you and a trimal and a diabetic. So you don't want to lump all of these together. But as a general rule, you get weight-bearing ankle fractures pretty quickly. You get good fixation, there's the bone. In this review, there's no significant difference in the complication between protected weight-bearing and the early weight-bearing and the non-weight-bearing. In fact, better functional scores were in the early weight-bearing group. So I think it's safe to kind of move these along. But again, you don't want to lump them, because the ones that are more rotationally unstable, the ones that have more soft tissue injury, those are the ones that you risk having late phytostasis. So in terms of sports, this is a review of almost 500 patients, 400 stable ankle fractures. And most patients return to sport. On average, it was about four to six months. So we all say our bones take about six weeks to heal. So what takes that next few months? Well, there's a lot of atrophy that occurs. So getting that muscle mass back is usually like one of the biggest issues. And then again, what are the component injuries that are related to soft tissue injuries? But almost everybody, close to 90-plus percent, were able to get back to sport care. And predictors in terms of getting back to sport were younger age. So case presentation, this is a 37-year-old professional hockey player. His right skate got caught in a divot, and he suffered an impact from another player. And his chief complaint is a right lower leg and ankle pain. These are his x-rays. So he was complaining of pain in his proximal right lower leg. And you can see here, we have a long, oblique fracture of the fibula. It's this right ankle. We did get comparison x-rays. Here's his right ankle. Here's his left ankle. We can see some heel clear space widening. The other thing you can see is a little flex sign right by the deltoid. So this is an amazing youth injury. One of the things we're doing a lot now in the foot and ankle world is we are getting standing bilateral CTs to look for, essentially, asymmetry. So this is a standing CT of the ankle, bilateral. The affected side, this side on the left on the screen, it's his right ankle. And then, as you can see, there's some heel clear space widening. The other thing you can see, these are the axial cuts. So he has this fleck in the back of his ankle, significant for a PITFL injury, again, within the sinusculosis. The other thing is, again, you can look for the syndesmotic widening and see more widening on the affected side than on this side. So for subtle injuries, I think this is another good tool to have to evaluate the extent of these injuries. And we did get an MRI to show that he did have a complete deltoid tear as well. Big soft tissue, a lot of soft tissue swelling, in addition. So I scope all of these, and the reason I scope all these is there's a high incidence of concomitant cartilage injuries. So for Maison Newt's, it's upwards of 70%. He was actually pretty lucky. He did not have a full fitness cartilage injury. He had some stuffing here, as you can see in the picture on the right, where basically we just created that so that we didn't have to do anything for any full fitness lesions. But you can also see in the picture up there, there's a full fitness deltoid injury. A lot of times a deltoid will rip off medial malleolus approximately. Sometimes it'll flip inside between the medial malleolus and the medial gutter in the callus. And you'll try to take that tissue out to reduce it. You'll have basically this ball in the medial malleolus that you'll reduce. So for him, you know I had some more time, so we fixed the syndesmosis with the suture button technique. I like putting the suture buttons to a plate just because the plate acts like a big washer. So as opposed to a small finite point, it kind of brings the whole fibula over to reduce the ankle. And in addition to that, this guy was kind of a thicker guy, so we needed more time. So I wasn't as worried about the incisions. So we used a plate because the lateral side is a little bit more forgiving. And then on the medial side, all I did was we used a full suture suture anchor that was knot less to repair the deltoid. So we did the syndesmosis and the deltoid. Normally, you don't have to fix these proximal fibular fractures. And I didn't do anything in the back either. That would have been a much larger dissection. So I'm at six weeks, and then at three months, he's doing pretty good. He's back to skating. And again, with this guy, because it's a rotationally unstable injury, these obviously are gonna take a little bit longer. There's a lot more risk, too, if we were to bring him back earlier. So we gave him three months to come back to playing by three months. It felt pretty good about the fractures. This is the fracture at six weeks, but by three months, you can see more callus and more abridging bone. So he returned to the ice for the playoffs. The first game back, his skate was caught in a divot, and he suffered another impact, a direct blow from another player, and then complained of right lower leg pain. And so what's interesting about this one is he now had, this is a stibula, and you can see the callus from where he healed his fracture. He has a new fracture now. It's a transverse fracture through bone fracture. And again, in this case, and in the last case, these guys were padded and protected, and because it's the amount of forces that can generate from that sole cause, obviously, significant injuries. Nice thing about this injury is this is a stable injury, so this doesn't mean surgery. He was essentially weight-bearing. He's tolerating the boot. So he did essentially fracture through his left fracture. So mesonews are a different animal, and again, with hockey players, getting skates caught in either divots or close to the boards and having a rotational injury, usually an external rotational type injury, these things can be, as one of these injuries can occur. This was a study looking at mesonews where they did use a suture button technique. Again, kind of as I was saying before, they can have these prominent neonatal osteochondral lesions. Average full-weight bearing was nine weeks, and returned play was seven and a half months. So in our case, we did get him back earlier, but again, he did have a re-injury as well. And again, the hardest part with these is the soft tissue component is usually what takes longer to heal than the bone. So these fractures are variable injuries, and you get MRIs of these, and they come in lots of different flavors in terms of the amount of soft tissue damage that's occurred. We'll get CTs and MRIs of these. I think an ORF, the syndesmosis-indicative report, is unstable, as well as a deltoid repair. We'll do those pretty routinely. So in terms of syndesmotic injuries, the type threes are the ones that pretty much everybody agrees on should be fixed. The type twos are where there's a little bit more debate, but those are the ones that are stress-positive. Most people tend to fix those, and nothing else has the potential to get people back faster. Then the type ones are stable, and you definitely don't need anything. But what you find is that they come in lots of different flavors. We have neurosis membrane injuries, a lot of AITFL, PITFL injuries, stable. So it's hard, you don't want to lump these into one specific, like I said, they come in different flavors. I like as a rule, so the fracture in the proximal is sort of for the community, we do not offer. Here's another case, number three, this is a 26-year-old, he got hit in the foot by a puck during a playoff game, and he presented with pain in the mid-foot. So this was his fracture. So he suffered a mid-shaft burst and a tarsal fracture. It was kind of a stellate pattern, which in a weird way was actually good for him, because what happened was his fracture actually, you can see it almost anchored, he just hit it. And so, which actually kind of gave it some inherent stability, because with the first kind of tarsal, you don't have a lot of great fixation model options. You know, you could put a plate on the top of the foot, but you'll probably feel that with the skate. Obviously, trying to get someone back early, sweating in a skate with an incision, it's like it's just a recipe for disaster. The other thing you're doing, an intramedullary fixation, there's not a great spot to start for that, or you're potentially going to have to do some footage. So, in this case, because of the pattern, we were able to treat him non-op. He was able to play three more playoff games with the arch support and a protective shell over the skate. And fortunately, you know, it didn't really shorten that much. With these types of injuries, you worry kind of about two things. One is that the metatarsal shortens, and the other is a lot of these will actually dorsiflex. If they dorsiflex, it throws off the balance of the foot, you can get this transfer metatarsalgia in the lesser rays. So, in his case, we were pretty lucky in that he wasn't, it was actually pretty stable, and it ended up being a pain thing in terms of how to manage him. He was able to play, and it was him four months post his injury, and then we did get CT, which shows what we feel like. Unfortunately for this guy, he did not get hit again in the split rebreak, so he was the one that actually didn't get hit again. This is final, that's right. So, what have I learned in taking care of hockey players? So, I think hockey players are the toughest athletes I take care of. They're ranked right up there with the UFC fighters in terms of things that they can play with. I think that the NHL should consult the military and make the skates pull it through, figure out a way to make more on them or something. Because even though the skates are hard, and I understand there's a balance between performance and detection, I mean, you just see a ton of these. I think protecting all these guys afterwards were protected with either some sort of shell or plastic or fiberglass, but that doesn't necessarily prevent injury. And always ask what's the worst thing that can happen to someone who does injury. You hear from some of the other guys talking about recent injuries. Thanks again for the opportunity to talk with you. Thank you. Thank you. So, I think what we're gonna do is bring our panel up and our virtual speakers can stay online. We'll shorten our panel a little bit. I still want people to get a break at 11 because we've got some good stuff coming up right after the break. So, Anil, Eric. So, real quick, Anil, there's one question from the virtual world. They are wondering about ceramic hip resurfacing which apparently is available in Europe and Canada. Yeah. Do you think that's a potential solution to the metalosis problem? I mean, yes, but no. Ceramic, you know, on poly, it's the standard modern hip replacement, the young hip replacement resurfacing in the United States. But now ceramic resurfacing, remember, we know metal head, the new pin on the block. But, you know, ceramic on ceramic was also the trendy thing to do here 15 years ago. And then there was a thing called squeaking and all that stuff. So, I mean, it's not gonna be something you're gonna try in your first, you know, they've done metal resurfacing for 30 years and learned what's good and what's bad. So, I would never try that. You never wanna be the first. You never wanna be the last. So, these spaces are gonna be a little bit of repetition, but I just wanna try to draw out a couple of things that might be helpful. So, this is our typical hockey player. He lands awkwardly. He doesn't have a history of shoulder injuries. He's got an anterior fullness and a tenderness. This is not him, but this is another patient of mine because I thought this was a classic picture. So, this is our standard anterior shoulder dislocation. So, what I wanna know is do you reduce it in the training room? So, Dharmesh, Anil, Eric. Yes, I think all of us feel pretty comfortable doing that, right? The athletic trainers feel comfortable. But like, how do you do it? Is there a secret sauce here? I just put up an example of one technique. I mean, let's just start with inter-articular injection. Do you do that or not? Before we go there, for the hockey coverage of the non-NHL athlete, where you don't have an x-ray, there's always a debate about that too. You tug on somebody without an x-ray. We all get a quick x-ray to confirm what's seemingly obvious. I still think for the high school hockey player, I'm gonna give one small, get his pads off, one small tug, but if I can't get it easily, then I'm referring out versus somebody with an x-ray that's a different animal and how much harder I'm, as Eric was saying, closer, but how hard? He tried really hard before he referred that one out. Yeah, and I actually don't get an x-ray. We just reduce them. I mean, usually our athletic trainers reduce them before I can even get there with the, you know. I agree. I encourage our athletic trainers to go ahead and do it because that's gonna be the best time to do it. And that includes the high school. I'm okay. And I do, I think this is a nice way to do it. I actually, when I was at HSS and we went to Vermont and covered the ski place up there, they would always have these guys prone, wait for x-ray, just hang that weight from their wrist. And those guys always reduce. You know, I'll do the same thing. While they're supine, I'll just gently just give a little bit of traction and just let the muscles give out. And then typically that happens, but occasionally I'll do an intraocular injection. So you'll try it first before injection? Yeah, I should do that. Yeah, that's the best time to get her. It's just when you're locking the breast when they're on the field, these guys, you bring an injection out, they start panicking. So things get more hairy at that point. So just leave them there and pull on it and usually it goes back. So Eric covered, you know, operative versus non-operative treatment. I think it was a great summary. Bottom line is, if you look at the literature, it's better to fix the first time dislocated than treat them non-surgically. It's just in the world of athletics, time is, you know, an issue. And so I think, you know, the hope is that you can fix them at the end of the season. And they've only had that one event. But you got to tell your GM or your coach something, right? First time dislocation, you pop it back in and you're going to tell your GM, who's probably already texting you, how long is he going to be out from us? I'll say two to four weeks. I like that. That's good. Be conservative. And if they're back in one week, everybody's happy. If you tell them it's one week and it takes four weeks, then everybody's mad. So do you, what return to play criteria do you use? Is it same strength motion? Do you know of any, like, better functional tests for the shoulder? Or are you just kind of doing our standard, you got to have normal strength, good motion, no pain. That's what you get in the office is, you know, the pain, the strength, the stability. But then our performance guys put them through a wide balance test, make sure they can balance with their shoulder. And then we do contact, simulated contact, and see if they can tolerate all that stuff. So together, all those decisions have to come together as a group, as a committee. I probably do more after surgery, looking at return to play than I do during the season. It's more, hey, how's their apprehension? How they feel? How is their strength? Can they protect themselves? And then letting them go back, and obviously in a simulated contact, you know, going back to practice. Can they skate? Can they functionally do well? And then letting them go back. Do you use a brace? We start with one. Yeah. I love how there are eight teams out there. Who, you know, Sully brace? Something more restrictive, Sully? So one final question, and we'll go on to the next case. So you've got a guy that's had, you know, three or four dislocations, right? And he's gonna make it through the season. It pops out, you reduce it. Do you let him go back in that game? Like, you know, you pop it back in. He's fed stock, good strength. Do you let him go back? What game is this, 10 or 15? Yeah, I think so. So it's another thing that depends. So what do you mean by that? Three or four dislocations, if he demonstrates decent strength to you right there and then you can let him go back in because he knows that shoulder better than you know he has a shoulder. The one thing I would add, Brad, is in the last 10 years, when I first started, first time dislocation, there was never even talking about operating on him. Now, you have a first time dislocation and a young athlete, meaning like, you know, he doesn't, he's not a vet yet. I've had now three guys on, not our athletes, but I put them back in and they were away and they all got fixed with their first dislocation. So that's one thing I'm seeing a lot on the early NHL guys because the GMs now are like, look, I got 10 years, I want to have this kid or eight years, whatever. And I definitely see a small change, or definitely a change in the culture where the GM is now much more accepting, the docs are a little more power. And you're pointed, right? First time, it's better, surgery's better, easier for all you guys. So that's definitely a change in the culture. I think agents also are also savvy and they're driving that a little bit too. Cool. Yeah, so I think it's on. So let's get to a question. So you have a player, he has a dislocation, looks reduced, feels pretty good. Maybe he does get his strength back. Of course, you got to make a decision when you're going to call his operant arm if he's the first time dislocated kind of deal. Makes it to the end of the season. Doc, I feel great. I don't think I need to do anything. I want to go home and enjoy my summer. Go, go, go. I mean, come on. Yeah. I mean, are you pushing this kid? I mean, and that could be anterior or posterior. I mean, like. I mean, you spell those cases. And they have MRIs that have a vocal tear. That's what we face every single time at the end of the season and I'm pushing for, hey, get it done. And then maybe you'll come back to October. That's fine. We got a long season, right? But they all want to go play golf. None of them want to have surgery. I mean, isn't that what we're having every single day? I think it's one of the hardest discussions to have because they feel great. They want to golf. They don't want to have surgery. And as such, you tend not to want to talk somebody into surgery, but man, do you look stupid if that thing comes out in September or November? Is that what I'm doing? I think you're right. Because one of the things that we're studying right now is to see which shoulder it is. So if it's your top hand, you have a high risk of re-dislocating that shoulder much more so than the bottom hand. It has nothing to do with how you shoot. Has everything to do with the fact that these guys lead contact with your top hand shoulder. So your risk of leading contact the next season with the top hand shoulder, that thing's going to come out. So I'm pushing really hard, especially for the top hand. And that's why I say it's so dependent on contract agent and where they are in their contract. And that's why younger athletes, it's a much easier sell. Meet with your guy, there's no chance. I mean, it's like Eric said, they'll find out by, I mean, sometimes it's not even a conversation. They walk out as a physical, and you're like, whoa. Oh, hey, come back. We'll go on to the next case real quick. So, again, that's one of our players. And, again, sometimes the hit doesn't look so bad. It's just shoulder-to-shoulder contact. This is his x-ray. I think we've all seen this and had to... So, Bill, you're up there. Let me ask you this question. We'll just limit the discussion right now for the elite-level player, right? So maybe it's Howard, your pro. Are you fixing all clavicle fractures in hockey pros? What? I think if it's a displaced clavicle fracture like that, yes. The non-displaced, I think that you're going to worry that it could refracture, but there's a little bit of data there that they can do okay. You might just wait a little bit more time. It might cost you another... You know, this depends, right? Could you take a non-displaced fracture and get the guy back sooner and not wait ten weeks yet? Probably could. I think it would be a hard discussion there. How about that one? That one's easy, right? That's like butterfly deployed. But the one that just does that, are you fixing it? I would say looking at the data, NFL data mostly, football data, some hockey data would be to fix it. They're going to get back to function sooner. There's more reliability. And you've got to have that honest conversation about what the pros and cons and infection and all those. But I'd say most of the time we're going to be fixing them. Yeah, to support what Eric's saying there, there's some NFL data that when guys rebroke, refractured through that area, they're missing a season and a half. I mean, it's a significant amount of time lost at that point. Bill, if it's playoffs, are you doing a CAT scan to clear them, or are you just putting them on an x-ray and physical exam? We'd probably get a CT scan to see what kind of healing there is. That's my next question. When would you let a guy play after open reduction and internal fixation? Depends, probably. Depends on the day. Going into the playoffs, the reason why you operated on them was to get them back. So this is probably a playoff discussion. Strength's good. Everything's good. Probably four to six weeks. The thing that skews a lot of the data in the literature are these cyclists, right? These cyclists are getting their clavicle fracture fixed, and they're out a week later back on their bike. And that skews the return to follow-up in some of these studies. I think, depending, you have to get back in several weeks. All right. You've got to give your GM something. Yeah, I'm going to tell him six to eight. That's what I'm saying. But if he's good at four to six. Yeah, four to six. If you tell him that, he'll know. No, but if he's good at four to six, then we're okay with that. Right. So let me ask you this question back then. Your question about his CT scan is, does it matter? I mean, does the imaging matter? Because there's no way that thing's consolidated on CT by six weeks. No, we don't actually get CT from those clinics. Because if you're going to go six to eight weeks, and he's doing great at five, and you want to clear the scan. You don't want to know. Well, they don't want to know. What's the CT going to do for you? It's just going to create more questions than it's going to answer. That's actually I have a question to Mark. Because, Mark, we always ask you with the first case, why don't we CAT scan him? Why don't we CAT scan him? And we never scanned him because he was skating at two weeks. Right? So, I mean, did that ever cross your brain, Mark, to want to scan that meal now earlier? Well, I told him six weeks. We were in the middle of the playoffs. And I figured the negotiation would start around two. If it was up to him, he would play at two. But, yeah, I think that, in my mind, the worst thing that could happen with the sprues in there was that, you know, he re-breaks, but it's probably not going to be displaced or ultimately lead to a worse prognosis. And worst-case scenario, you could always fall grafted and inflate it. So, I agree with Mark's concern. It wasn't going to help me decide whether or not to clear him early on. We're doing it. Go ahead. We had that same injury this year, and we treated it non-operatively. Not that Mark and, you know, the Rangers, you know, it's actually good to see a little bit of a different approach. But the player actually denied surgery. He was offered surgical fixation. But the concern was that because it was intra-articular, the fluid might extend into the joint, keeping and continuing to wash out, you know, the healing process with motion of the ankle. So, we, you know, I think we had him in a boot for six weeks, non-weight bearing for, I mean, it took him two to three months to get back. But that's where, for us, I think the CT scan helped because it allowed us to look at the joint line to see if the joint line had sealed up. And that was the area that took the longest to seal up. It sealed up more proximally, but even in Mark's pictures there where he showed the joint line, that's where the residual fracture was. One more. I have one more, and then maybe, I don't know if we'll have time for it. You know, we'll go on down. So, this one is, and maybe Mark can help us with this. This is kind of classic. Struck in the lateral aspect of the right ankle. He wasn't able to come back. He had some pain with ambulation. A little bit of swelling. Tender on the fibula. You can see that minimally displaced fibular fracture. So, Mark, are you going to operate on that? Probably not. You know, this is like the first one that, when you normally think of high fibulas, you think of rotational injuries. If this isn't a rotational injury and the deltoid's fine, that person's going to be weight-bearing as tolerated in the boot, and the healing rates are really high. Now, I don't know that you get an added benefit of a nail, and I certainly wouldn't plate it, just to be definite, but a much bigger incision. I would probably treat that one a non-op, weight-bearing as tolerated. Not someone that probably would get back into, like, two- to four-week fall apart. Yeah. Any other comments? Can I ask a question, Dr. Brunt? Dr. Brunt, if you have a hip and an FAI patient with a core, and you think they're both surgical, what's your gestalt of doing together, not doing together, doing one? How do you approach that, you know, that mixed bag athlete? Yeah, I mean, it's a good question that comes up occasionally, and I think the first aspect of it is sometimes it can be a little hard to know for sure to what extent each component is the verdana variable in the player's symptoms and in their limitations. All else being equal, my general approach is let's do the floor repair first, because the recovery time is very predictable, you know, and it's usually within that six- to eight-week frame. And sometimes, you know, they'll be largely back to normal and maybe don't have as much of the hip component that's actually bothering them, and because the time frame for recovery from the hip is, you know, usually a few months. So all else being equal, I'll typically say let's go ahead and get your floor repair done and let's see how you do, and then a decision can be made about the hip. It's challenging for us to try to schedule these at the same time, and so I'm not, you know, in my experience, we've not done that actually. I mean, I think that may be logistical possible in some circumstances, but that's generally the way that we approach this. I also sometimes see people with a core injury after they've had a hip surgery and been through it and, you know, still have some limb incentives. But typically, it's the other way around. Dinesh, is that your approach too? What have you been doing? In the vast majority of professional hockey players, we just do the core and not the hip. However, in collegiate and high-level youth hockey, we do both at the same time. So core muscle repair, hip arthroscopy, labor repair. And I've only had one patient who shares a collegiate-level hockey player. She had both cores and both was done at the same time. Came back to the office in a wheelchair. I told her she would. Yeah, so let me just go back to our, you know, Mark just said, what's the worst thing that can happen? This athlete, we decided to treat him non-surgically. We thought maybe we could get him back a little bit quicker. Playoffs were coming up. And so I think he went back at about three weeks, three to four weeks. The first time he put his skate down on the ice, he felt a big crack, displaced it, ended up needing surgery. So that was the worst thing that could happen. And it did. One maybe quick question I think would be helpful for this audience, Mike. A lot of us struggle trying to get core muscle injuries through the season. I mean, early on you might pull the trigger because you can get them back. But when we're in the latter half of the season and we're trying to keep guys on the ice, it's been a struggle. I mean, our athletic trainers are working hard. You know, I know you and I have talked about this a little bit. Is there any role for injection in core muscle? Yeah, I mean, I think the answer is yes, there can be. It really depends on the individual's circumstances. Where is it that they're hurting the most? And you can get someone through maybe two or three weeks, maybe more extended than that with a local steroid injection, provided that they have a relatively defined and specific area that's bothering them. If it's right at the pubis and that distal rectus insertion, sometimes I will inject them. And I use a pretty good volume because you usually have to hit three or four spots around that just to get everything. And it's a mixture of 0.5% epivacaine and 1 mL of Kenalog 40 in a 1 to 9 ratio. So I will do that occasionally. I think, you know, the timing on it depends. If there are a couple of months left in the season and you're looking at the playoffs and they're struggling, it may be better to go ahead and do it then. You know, get them back in six, seven weeks and they'll be ready to go for the playoffs. So it partly depends on the timing. It depends on the severity of their symptoms because the whole spectrum. And some of them, it's relatively low level. They do what they need to do, but yet it bothers them. And others just really can't go. And if that's the case, you're better off just doing the surgery and getting them back as soon as you can. Yeah. What do you do with the player that's pretty symptomatic on one side and minimally symptomatic on the other? Well, so if they have imaging findings, exam findings on the contralateral side and any symptoms, then I'll just do both sides. I don't do contralateral sides for typically I want to do them at the same time if a player has absolutely no symptoms and no agent findings on the other side. In other words, I don't do the contralateral side prophylactically. That's what I meant. Yeah. But if they're having any symptoms and imaging findings and it kind of fits, then I think you're better off just going and doing both. And, you know, they'll have a little bit more comfort early, maybe a little bit slower progression. But particularly if it's off-season, they've got plenty of time to rehab and recover. So we have a question from the link. We just talked about injections for core muscle. They also asked about PRP in those same areas. So we have a whole session on that. So I'm just going to use the moderate prerogative in saying we'll talk about it. Give us that hour. Keep watching. Stay on. My question was, anyone can speak on quad compartment syndrome or quad confusion? Yeah. You guys had one? I had one guy that was a bleeder. Yeah, I had one. Yeah, exactly. You know, we, this guy had to get taken off a plane because of almost upper extremity injury, no injury, compartment concern in Canada. But then he had a quad. He didn't develop into a compartment syndrome, but believe it or not, these guys are crazy, right? In office, took a jam-sheeting needle and stuck it into his quad down to the area of the bleeding and sucked out blood out of that thing, and he declined. But never had a true full quad compartment. You know, one of the things we published out of West Point a number of years ago was a pretty good trial looking at treating quad confusions with deep knee flexion. And, in fact, you know, we had the luxury of actually just admitting the cadets to the hospital so we could have the nursing staff just force their heel to their butt. It made a significant difference in recovery. I'm sure you guys are all doing something like that. It's like 18-dog model right now. If you try not, if you don't let them bend a knee, look at me really quickly. You have to do that. It works. Any other questions from the audience? I'll just make a comment because I'm not going to be on later. So to the point on the injections, I would implore all the hip guys for sure and hockey docs, if you do not do ultrasound-guided injections, I would highly recommend that you get yourself, get your hands on an ultrasound. I have no formal training for the last seven years. I've been doing injections. You can really help tease out things in the hip joint, your inter-articular shoulder, getting into the hip, getting into the shoulder, not very difficult. Even in the bubble, we had a guy with a non-displaced system, fracture that I was injecting twice a game and had no pain with that, believe it or not. Five grand is what you're going to pay for a handheld with an iPad. It can be very helpful for you.

musculoskeletal injuries

hockey players

shoulder injuries

hip injuries

ankle injuries

foot injuries

shoulder dislocations

clavicle injuries

hip preservation surgery

core muscle repair

ankle fractures

syndesmotic injuries

ultrasound-guided injections

PRP injections

sports injury management