Great, thank you very much. Well, I'd like to invite the panel up. So if Deepak, John, Josh, and Margaret can make their way up. And if we could pull up the first, can we do the other case, please, first? It should be the shoulder case. If you don't have it, then we can go with the elbow one. Just go ahead and put the elbow one up and we can check on it. We're currently in presenter mode, so therefore you can see the two slides instead of one while you're sorting that out. The case I'm going to present is a 55-year-old male who's a master rower, so I'm sorry it's not a thrower for those throwing enthusiasts. He's been lifting a boat. So I'm just going to present a shoulder case since this is the overhead thrower session. So this is a 31-year-old major league pitcher. Throws one pitch. He kind of looks funny as he steps off the mound, motions to the training staff, and he's done for the day. So again, 31, describes posterior shoulder pain. This is this past August. He had really no antecedent event. He was removed from the game. During the 2022 season, he had pitched effectively and had over 20 saves. He does have a past history of having a right lutecimate strain a year previously, history of UCL reconstruction three years previously, and has had an oblique strain in the past. We do have a baseline MRI, and his clinical exam, he's 6'3", 224 pounds. He describes kind of an achiness in the posterior aspect of the shoulder and some sharp pain, particularly when he goes into abduction and external rotation. And really his clinical exam overall is fairly benign with the exception of that he has pain with resisted external rotation in abduction. And really his stability testing overall looks pretty normal, but again, you know, he just came off the field or he's a day or two out from injury and really has no significant labral signs. So based on your initial diagnosis, and we'll kind of cut to the chase, he's got some posterior pain. Josh, you know, the guy comes out, you know, and you have this exam, what are you thinking originally? Well, I think just watching it, I mean, you kind of hit a lot of the things, but he's had a previous history of, you know, lat strain that's on there, that's clearly in the differential, but obviously just any baseball pitcher with the history of surgeries and injuries that he's had, just watching the way that was on the mound, you worry about, you know, it's maybe an exacerbation of some preexisting labral stuff, cuff pathology, especially with that weakness or pain with resisted abduction, external rotation. For me, to your point, you know, examining when they just got off the mound is sometimes a little difficult, not that it's difficult, but it's not necessarily the most elucidating time to do it. And obviously we're going to want to get, you know, advanced imaging and MRI. Sure. So, you know, just based on his clinical exam, you know, it's kind of the working diagnosis is maybe he's got a lat or a terrestrial strain just based on his description of things. So for the sake of time, we do have baseline imaging, but I'm going to skip those and just get to, this is a non-arthrogram post-injury study. Hopefully you guys are capturing that. We'll play it maybe one more time. So we'll go to our sagittal, our axial, oh, we skipped, there was actually a, I'm going to go back. So Jeff, based on what you see on the scan initially, what are your thoughts? Yeah, he definitely has some signal in the posterior cuff muscles, but it looks like he's got a capsule or either a high-grade strain or tear of the capsule. It looks like there's fluid extravitating out and I would expect he has a longitudinal split in the capsule. John? So I was just going to comment, the lower third of the subscap has got a bunch of fluid in it. And so that's a sign that you probably have an anterior capsule tear. So if you see fluid in the lower third of the subscap, first thought should be anterior inferior capsule tear. And so Margaret, any role for adding, so this was a non-arthrogram study because originally the clinical working diagnosis was kind of an extra-articular injury. Is this something you would go to an MRI arthrogram at this point or? Well, actually I do show that. Okay. So Josh, any role to go to an arthrogram at this point? I mean, no. No? No. John? No? Jeff? Yeah, I think I probably would. Might tell you a little bit more characterizing the tear and yeah, I probably would think about it. So acute injury for me, no contrast, 100% of the time, if it's a 3T magnet with thin slices and the tech actually lines them up right, a good MSK radiologist can give you a lot of information. But if you fill this thing up with contrast, it's going to go all over the place and I don't know that it's really going to define the pathology. You already have pre-existing MRIs that may or may not have been contrasted, but you have some understanding of what his prior pathology is already. Yeah. Well, it's not my money, so we did go ahead and go on to an MRI arthrogram the following day and it pretty much did confirm exactly what everybody has said, is that he's got an anterior inferior capsular tear. He does have edema in his subscap, he also has a little bit of edema in his teres major as well. So he's kind of done the gamut and he has his baseline labral pathology as well. So for the sake of time, so we have acute high grade anterior inferior capsular tear, he's got mild subscapularis and teres and lat strains, and he's got chronic basically round the clock labral pathology. From a treatment standpoint, Jeff, we'll start with you. Is there any role for non-surgical treatment in this setting? I would say not at a person at that level. I don't think that that's likely to go his way. I think that giving it a few weeks to settle down and maybe the tissue becomes a little bit easier to repair is okay, but I would think that I'd be telling this guy he's likely, if he wants to be a pitcher, he's probably going to end up having this fixed. And I think in terms of surgical repair, I don't think I would repair his labrum. I think you're going to probably put a lot of stress on the capsule by repairing his labral tear, which may be adaptive. And if you fix both of them, you probably over-constrain him. So I would say probably just fixing the capsule, if you had documentation that he had a pre-existing labral tear, I wouldn't fix both. John and Josh, anything different? I think you have to ask yourself why now does his shoulder sublux anteriorly enough to split through the anterior capsule? And he does have a slap lesion. He does have some posterior labral pathology that does affect translational and rotational stability. I don't know how you evaluate these guys. You could have had some underlying posterior instability that because now he's a little bit loose at the back, he gets his arm in just the wrong spot and the ball comes out the front. You have to look at what's inside the shoulder in the context of our current understanding of what's pathologic and what's not. A lot of our superior labral pathology can be managed unoperatively, even if you're having to fix the anterior and posterior labrum. We want to try and leave a mobile superior labrum as much as we can and recreate the bumper. Dr. Bain has spoken to a lot of this stuff. The bumper effect that you get from the rigid posterior inferior labrum and the posterior inferior band, and of course, you've got to repair that split in the anterior capsule. Another thing I'd comment on is, and Jeff alluded to it, the results of capsule repair are not great. We had a series from HSS where the results are mixed at best. You take that on the back end of Verde, a UCL reconstruction a couple of years ago. I don't remember the guy's age, but I think it's a discussion that, is he willing to go through this another year-long rehab basically before getting back? He does not want surgery. He is vehemently against the idea of surgery. He gets a second opinion, which of course everybody does, and he goes elsewhere. He gets the opinion that he's going to get some sort of a biologic injection. He gets an amniotic-derived injection, and the idea is, okay, we'll evaluate him in a few months, get a new scan, and see where he is. To cut to the chase, this is two months after he gets a biologic injection. Now I would do contrast. So the second opinion did not order a contrast. So he does look like he's got some sort of scarring in there and some healing. Has the stability exam changed for you at all? He really doesn't examine like a true instability case, and that's what I think is really interesting about these scenarios. What tests are painful? Abduction, external rotation, resistive testing. Does he hurt lifting across his body in circumduction? Does he hurt for outlet impingement tests, or is it just ABAIR that he hurts? Just ABAIR, yeah. So he goes and he does two to three months of rehab, and then he initiates a throwing program, and what do you think happens? Well, he's got shoulder pain. Now what? Contrast MRI. Or Jeff? Tell him to call the guy that did the amnion shot. And go get surgery. And go get something fixed. Which is exactly what happens. So this is the surgical findings at the time of surgery. He did have a capsular split, and the concern that I have is two or three months after the injury is the capsular split is probably going to be fresher. It's going to be easier to repair. It's going to be easier to identify where you're not, you know, maybe taking additional tissue more acutely as opposed to chronically, and particularly after some biologic. He's undergoing this repair. So not only does he undergo a capsular repair, but he does undergo a labral repair at the same time. These are some pictures that were sent to me. So that's actually pretty common. The split almost always comes up to the labrum, and then usually involves some small segment of labral detachment with it. And so you can include that. Neil Eltrush has a really great single suture method that comes down and gets pushed in a push lock. You can also do that side to side, much like this is done, but that's a pretty common pattern. So just for the sake of, to be thorough, Josh mentioned the study that was out of Dave Olchek and published by Larry Gulotta out of HSS looking at five cases, and essentially four out of the five were able to get back to, you know, high-level throwing. So that's just a quick shoulder case. Greg's going to, can we load up that elbow case for Greg, please? So this case is an older gentleman. If, I would probably just keep it there. So it's a 55-year-old gentleman who's had a lifting injury. There are my conflicts of interest that are declared. These videos won't show, see how you've got, oh, you've got a different screen there. Okay. So you can see the biceps contour there on the, this is on the normal side on the patient's right. There's a normal contour. And if we go to the left elbow, which is the injured one, we can see the biceps muscle tends to be flatter, the tendons thicker. And as the patient goes into pronation, they have associated pain and restricted range of pronation. And the term I use is a yielding hook test. So as you push on the tendon, like Sean O'Driscoll taught us, but it actually yields away. So it's not strong and hard like a normal patient's. And at supination at 90 degrees, clinically, it's normal. If we put the arm into almost full flexion, we're able to then assess supination. In that position, because of the way the Blix curve works, they're run out of tendon and muscle coordination. The patient will then have weakness of supination against resistance. So this patient, what investigations would you do, gentlemen? Actually, we might start with you, Margaret, because you weren't lucky enough to be involved with the previous one. Yep. So it's likely that to be a dislocated bicep, some kind of dislocated bicep here. But as you say, you can still feel the hook. So probably it's not going to be a complete. But in any way, I'm going to do MRI to. In the interest of time, this is the imaging that was done. So the two images on the right are both MRI scans. You can see there's an obvious effusion around the distal biceps tendon on the middle image and also on the right. Interestingly, on the image on the left, which is a 3D CT scan, we can see that there's a, I suppose it's an enthus more so than an osteophyte because it's not actually a joint, over the posterior aspect of the radial tuberosity. Any comments, gentlemen? Older patient. Older patient. Well, I don't have all the views I would like, but it appears that it is either a partial tear or you're dealing mostly with a hypertrophic bursa surrounding a distal biceps with some enthesopathic exostoses. I can't really follow the tendon all the way down well, but it does have some high signal where it attaches. So the other view you might want is what's called the FABS view. You can see this is with the elbow inflection, the shoulders in abduction and supination. So you get this line beautifully down the biceps tendon and also the brachialis. Does that help you? So you like on this FABS view to be able to see the line of the tendon come all the way in. This would suggest that there's a significant injury. I don't know if we're looking more at the short or the long head, but there's clearly high signal in the biceps tendon or what's there. FABS tenosynovium, but it doesn't look like the biceps tendon makes it to the tuberosity on that view. Okay. What do you want to do? He's frustrated with it now. How old is he again? He's 55. I mean, just in my experience, you know, and John, I don't know if you're the one who wrote up just the decreased, you know, interval there that probably contributes to the underlying pathology with that kind of enthesiophyte off the radial tuberosity, but the high grade partial tears just don't play out well. I mean, I think it's reasonable to try conservative treatment and I almost always do. You can try biologics, but that's a group that I've definitely gotten more aggressive about fixing if it's affecting them because it just doesn't play out well conservatively. That's our experience as well. All right. So what are you going to do? You don't open approach endoscopic percutaneous. What do you like to do for these? I like just a simple transverse incision anteriorly and I do. I anchor these if there's the, if the most, you know, medial fibers are still attached, which is usually the part that's still down, you've basically got a elevation of the tendon almost like a undersurface rotator cuff tear is kind of peeled off the tuberosity. This is the same kind of thing. So generally that's the way they are. Freshen the bone, put an anchor or two in and tie it down. I have not taken down and completed these tears. I've done them all that way. Okay. In the interest of time, I might just show what we've done because otherwise we should be finished. We've been doing this as an endoscopic technique for some time. Isacost has a number of publications and this is one that I was involved with on disorders of the elbow and it goes into detail about how to do this as an endoscopic procedure. But basically what we can see, it is an endoscopic procedure. This is dry. We can see the granulation tissue. We can see the partial tear. We can see when we look at this in a bit more detail, no fluid's been added here. You can see the quality of the granulation tissue is really just not going to do the job. So we do a tenotomy. We do that as an endoscopic assisted procedure. We then debride the footprint and this can be done more as a tuberoplasty because in fact in this particular patient and particularly the older ones, the tuberosity is quite prominent. So if you just repair it, it's probably not going to do the job. So we release it and then we reattach it. So this can be done as an endoscopic assisted procedure. So we're basically using a technique and I acknowledge Dr. Tanner who was involved with some of the initial development of this. So we're basically passing searches through. So I was involved with the development of the endobutton and we put that through the front. This is really going to the back of it and so what we create, if you look at the image on the left, is the concept of the endobutton. The image on the right, which is what I call a footprint repair, we can see the moment arm is significantly greater. So we've done an isometric muscle testing study. We've demonstrated this superior supination strength and flexion strength when using this footprint technique. I might take any questions. So I kind of cheated and looked all this stuff up before I came up here, but you've published a lot of stuff on endoscopically approaching this. It's a really nice technique for the partial tears too when you think they're just low grade and you're dealing with hypertrophic synovium. I really have not ever done it. So my question to you is, what's your anxiety as you began to do that, working around in between the radial nerve and the median nerve? Can you always find that space? And there's many times that really huge vascular plexus for your anterior portal to have to work through. So, firstly, I do it as a mini-open, so it's a small open approach and I put a retractor in. Deepak Bhatia, who's actually written on the program here today, he's developed a lot of the true endoscopic techniques. He's also done the vascular studies and demonstrated, I think it's the vein that's associated with the ulnar artery is the one most at risk. But when you're doing it endoscopically, you saw the view I can see, you can basically see everything pretty clearly and it's one of those things you go slow. That's really the sort of thing that I think we should look in the models that we have with ISACOS and other sports groups where we're using a cadaveric dissecting labs. I think that's a good idea to do this, but I really think the endoscopy gives you a much greater understanding of the pathology and anatomy. And in this scenario, it's a little bit like in the rheumatoid hand, you get this attrition rupture. I think they often have an attrition style rupture of the tendon and that's actually why they can't create the strength and why they have the weakness. That's great, Greg. Excellent. Great. Thanks for everybody. First day into the end of the album. Thank you.

shoulder pain

diagnosis

surgical repair

elbow injury

partial tear

conservative treatment