Thank you very much. The importance of this talk is not so much the technique of how to do this, but after 33 years or so, how can I get these little boxes off here? I think that I understand a little bit better this continuum of problems in the thrower's shoulder that begins actually in childhood, and I'm more and more convinced of that for some of the following things you're going to see. Capsular procedures account for nearly 10 percent of surgical treatment in professional baseball players, and that was reported in 2019. In my practice, I don't know if it's a bias because more and more are coming my way with this problem or not, but I know that that's increasing, and it's probably about 20 percent of the surgical things that I do in baseball players have something to do with the capsule. Dr. Jobe originally thought that the anterior capsule was undergoing nutritional damage over time, causing micro-instability anteriorly, and then that was leading then to problems with the rotator cuff, and what we have come to know as internal impingement. The pathology that we're seeing now is different. The capsule is not atretic. It's actually thickened in some spots, and the kinds of pathology we're seeing to the poster labrum and to the poster glenoid is significantly different. The repairs of the anterior inferior capsule tissue and its mid-substance or from the humeral attachment are a rare but increasingly reported source of pain and dysfunction in overhead athletes. So this is where it occurs. It actually occurs parallel to the thick anterior band of the infragleno-humeral ligament, and it occurs on the pouch side. It doesn't occur superior to it, and the anterior band, as you'll see in the surgical demonstration, is very thick. It's thicker than normal. For those of you that look at a lot of shoulders when you're scoping them, this capsule is very thick, and it fails in parallel from the humeral head down to the glenoid. Here's a picture of that. I'm looking at this through the high anterior rotator cuff interval portal with my scope adjacent to the bicep, looking down along the anterior rim of the glenoid, which is on the right-hand side of this picture, and that's the rip. The muscle tissue you see in there is the muscular tongue of tissue on the inferior part of the subscap. So I want you to focus on the left side of this slide. Internal impingement is a continuum, and it happens over time, and it most likely begins in childhood because of what happens to the glenoid. The reason we're seeing more of it now is because now the kids that were then involved with high-velocity throwing programs and year-round baseball, now they're coming of age, and we're seeing them at college age in pros now. That whole trend, year-round baseball started about 20 years ago. High-velocity programs started about 10 years ago. When you have looked at the difference in kinematics and throwing mechanics in the immature athlete compared to the mature athlete, you see what's happening. You get significant hyperangulation. You have an immature athlete on the right, and you have a potential Hall of Famer on the left, and what you see there at foot strike is the marked difference in angulation of the shoulder. You get a horizontal abduction that takes the humerus behind the plane of the shoulders, so the humeral head and the undersurface of the rotator cuff near the attachment to the greater tuberosity is compressing the posterior portion of the glenoid. Now the glenoid has its fices wide open at this age. In fact, the glenoid doesn't completely ossify through its secondary ossification centers until the late teens, and so you get a good indication of that. If you look at the ossification and the fices in the coracoid, you can still see that well into the mid to late teens, and the secondary ossification center of the posterior glenoid ossifies at about that same time. So the mechanics of the immature athlete set them up for problems then with hyperangulation, which compresses the posterior glenoid. You get glenoid dysplasia, and this is not a version problem that you've seen earlier today in some of the talks where they're talking about posterior slope and version of the glenoid. This is a thrower's dysplasia that is markedly different, and then that leads then to motion loss because you get a thick wedge of fibrous tissue that forms in the posterior capsule and labrum. Sometimes that ossifies and you get a bony Bennett's lesion, but oftentimes it stays as a big thick fibrous wedge that impinges on the undersurface of the rotator cuff in external rotation, and it also is a very firm, hard, almost like a diving board of tissue that can crack and gives you what John Conway and Bradley and I call a type eight slap lesion where it goes all around the top and then extends down to the bottom, cracks through the labrum and then out into the capsule. So what we're seeing then, sorry, the actual capsule tear and the rotator cuff failure are the end catastrophic events of this whole continuum. These patients present typically with pain and late cocking, early acceleration phase, and the pain's in a weird area. It's in the axilla. Sometimes the anterior axilla, sometimes the posterior axilla, but it's down a lot lower than what we would normally be seeing with some of our slap type symptoms. These can be confused with lat tears. Peck tears don't happen in throwers. Subscap primary tears happen exceedingly rare in throwers. If you see injury to the subscap, better be thinking there's a problem with the capsule. It's like periligamous edema that you see in the elbow, and edema in the subscap is not a primary problem until proven otherwise. It's a problem with the capsule. Often it's insidious because patients are going through treatment for this. They're going on and off throwing programs, and then they can come back then with a catastrophic failure and actually buttonhole through the capsule. On exam, it's hard to reproduce the kind of position and force necessary when these guys have this weird axillary pain, but if they have an instability episode associated with it, it's really easy to reproduce the symptoms. It's important whenever you're going over the physical, rule out things. Rule out things like the lat problems, biceps problems, superior labral problems, and what you'll be left with is the problems that are related to the capsule. X-rays are typically normal with the exception, if you take a good look at the posterior glenoid, you may see a Bennett's lesion, which is a spike of bone that is not confluent with the posterior glenoid rim. It's a little bit medial to the rim, but more often you'll see what you see here on the slide on the right. You'll see a downward sloping when you get to the very posterior portion of the glenoid. I didn't know when this would occur, but I got these slides from John Conway. I was talking to John about the problem, I was seeing more and more of it, and I told him what I thought was happening, and he said, that's interesting, I'm going to send you some X-rays of somebody I just saw. It's a 13 year, 4 month old kid, and the people that are coming in to me, when I asked them, were they in high velocity programs when they were kids, they universally had been. On the left, you see the posterior thrower's dysplasia. It's a lack of ossification, the secondary ossification center of the posterior glenoid. His normal shoulders, the non-throwing shoulders on the right. Here you see another view of it, sort of a striker notch view. Again, you see the loss of the posterior glenoid rim, and then the normal findings on the right. MRI scans, the easiest way to diagnose a capsule tear is with a contrast injection, however, I tend not to like to go right to contrast injections, and so you can really see this injury if you suspect it, or at least are looking for it, you can see it without contrast. These are contrast studies, and it shows the clear evidence of the tear in the capsule. It's important to look at it, line up your views. You've got your coronal view, axillary view, and also the sagittal view. Line those up because you want to see if the anterior banded inferior glenohumeral ligament is a valse off the neck, or if the tear is in the capsule, because that's going to change your surgical approach to this. This is another picture of this, and so you'll see on the lower slide on the right, there's no contrast in that. You see a Bennis lesion in the back, and you see the edema in the subscap in the front. So the salient points of this is that you had a posterior chondrocapsular hypertrophy with posterior glenoid dysplasia. That then causes that big wedge of tissue to start to violate the undersurface of the posterior rotator cuff, and in the late cocking or early acceleration phase, decenter the center of rotation anteriorly. That begins then the whole problem with bursitis in the front, sometimes confused with biceps tendonitis, and then causes a gradual thickening of the anterior banded inferior glenohumeral ligament, and then you can have a catastrophic event at the end stage of it whenever you're starting to lose more and more of your dynamic stability, and then you can actually rupture through that. If you're looking here, that's another axillary view of a shoulder with no contrast, but you see that edema and the disorganization of the muscular portion of the subscap. Think capsule when you see that. So the treatment for this, pretty straightforward, and as I said, this isn't the most important part of this, but if it truly is a capsule tear as I'm describing, this can be achieved, the repair can be achieved arthroscopically. There's the hole. There's the subscap looking right through the capsule. The anterior band of the inferior glenohumeral ligament is going to be at the top side of this view, and we're going to make two portals through the rotator cuff interval, high rotator cuff interval portal adjacent to the bicep. Here's your anterior band of the inferior glenohumeral ligament on the left. You've got the tear, and then the hammock, the bottom part of the capsule on the right. Look how thick that is, though. This is not the normal capsule that we used to see whenever we do these with Dr. Jobe. So I'm using the poster viewing portal for access for my suture lasso, and also using the accessory anterior portal, starting up near the humeral neck and then proceeding then down towards the glenoid. I'm crisscrossing these sutures, and the reason I'm not tying them as we go is because every time I would tie the sutures the first couple times I did this, I would be closing myself off. I would be getting tighter with my very first stitch, and this is not an easy place to reach to begin with. So I saw that if I did it like shoelaces and just left the shoelaces loose as I was coming down, then at the end I could go back and tighten them all up, and I would not have lost my view. Recently I've been playing with the nanoscope and being able to put a tiny little needle scope through the subscap, and now I have access through my two interval portals for suture management. I can put a grasper in, so my learning curve is pretty vertical with regard to this at this point. So this then, you approach it. If it comes all the way to the labrum, then you can use an anchor to go ahead and fix that, and you don't have to tie a knot adjacent to the glenoid. You can just go ahead. I'm just going to speed this up a second. Fix that, and that's the repair. This is what happens whenever you have a lack of diagnosis of this. This is a kid that throws it 103 miles an hour. He's a Dominican kid, and he was picked up by a professional team, dislocates his shoulder right there, and he had been having all the same symptoms that were going on. The problem with this was, though, instead of just the capsule tear, when he buttonholed through this, he tore his rotator cuff off, and he tore the humeral attachment of the anterior inferior glenohumeral ligament. So I couldn't fix this arthroscopically because the ligament was actually torn off of the neck. So I fixed everything else arthroscopically, the cuff. That's the posterior cuff and capsule there, looking at it from anterior, fixing that, and then pulling up this big thick wedge of tissue on the posterior rotator cuff cable, then going up in the subacromial space, and then repairing the hole on top. Then I had to open it and fix it open because that humeral attachment was gone. So the post-op protocol, this takes a long time to recover, and I think we presented the results of this, there was, we have now 12 people, 12 professional throwers, and they've all made it back, but it takes about 16 to 18 months to come back. So I'll leave it there. The most important points is the continuum and understanding what's happening to the tissues because at each stage, you're going to have a chance to intervene, hopefully not surgically. Thank you.

thrower's shoulder

continuum of problems

capsular procedures

glenoid dysplasia

capsule tears