On behalf of AOSSM and PBATS, welcome to Baseball and Beyond Night One. Thank you for joining us. I am Alexandra Campbell, AOSSM Manager, eLearning and Educational Products, and I will be the host for the webinar today. Before we get started, let's go over a few things so that you know what to expect tonight. First, there are a few options for how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the caret near the audio button to switch the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, click Q&A at the bottom of your screen, and then type your question. When finished, click the Send button. Questions you submit are seen by the presenters and will be addressed throughout the webinar, so please send those questions as you watch rather than at the end. Here are the disclosures for this evening's presenters and panelists. And finally, here is our agenda. Each topic will include a brief presentation followed by a panel discussion, so again, please send in questions throughout the webinar rather than saving them for the end. One quick note, next week's Baseball and Beyond webinar requires a separate registration, so if you haven't done so already, please go to sportsmed.org and register for next week's Baseball and Beyond night two. Now let's get started. We'll begin with Dr. Meister's presentation and then hear from our panel. I'd first like to thank Dr. Schickendance for the invitation to speak at this meeting as well as applaud him on very quickly changing gears, having to move this to an online event. I thought I'd present this case to everybody today, which I thought would be extremely apropos in paralleling the title of the conference, Youth to the Big Leagues, Managing the Developing Player. I have nothing to disclose. This is a 14-year-old right-hand dominated pitcher outfielder who presented with acute onset of right medial elbow discomfort after throwing a curveball in a game. He had initial acute onset of pain following a pop. He was seen by myself one day after injury for evaluation. He had some mild soft tissue swelling. It was tender over his medial epicondyle. He had a pain limited range of motion of 24 to 125 degrees. The remainder of his exam was unremarkable. The initial x-rays as presented, there was clearly some separation at the medial epicondylar fascial line. It was felt this could be treated conservatively. He was placed into a sling for comfort and treated with early physical therapy. He was then followed up accordingly. At his six-week follow-up appointment, he was asymptomatic. He was non-tender. His range of motion had significantly improved. He was instructed to begin a progressive throwing program and then two weeks following that, a hitting progression. It was recommended that he DH only for the fall season and ultimately had an uneventful recovery. This was his six-week follow-up x-ray. Just about one year later, he was seen in follow-up with a completely new complaint. At this point, he was a high school sophomore. He had some posterior medial elbow discomfort after a 77-pitch outing six days prior. He ultimately improved on over-the-counter anti-inflammatories and some rest, but at the time had some minimal tenderness about his flexopronator mass, some minimal tenderness about the olecranon fossa, with a range of motion of 3 to 140 degrees. All other testing was negative. He rested for 7 to 10 days and then had an uneventful return to throwing. Two years later, on June 1, 2017, he had graduated from high school. He had committed to an elite-level junior college. He then again had onset of right elbow discomfort, primarily initially posteriorly, with some ultimately medial discomfort that began in January of 2017. So six months prior, there was no acute injury noted. He threw throughout his senior year in high school, but had a steady loss of his fastball velocity from the upper 80s down to the low 80s. On exam, at this point, he was tender over his medial UCL, but rather diffusely. He had some tenderness about the posterior aspect of the joint. He had a positive odriscal maneuver, he had a positive posterior impingement sign, and he had a significant loss of range of motion. At this point, he had a nearly 20 degree flexion deformity in the elbow. These were his initial presenting radiographs, and you can see a very distinct posterior medial separating spur. This was the initial MRI scan. I presented to you the coronal stir images in three separate sections, as well as a sagittal PD-FAT suppressed image, and you can see there's a very high-grade partial tear to the proximal fibers of the medial UCL. The remainder of the fibers also looked rather degenerative and worn. So the initial diagnosis was an acute on chronic grade 2 proximal UCL sprain. The options at this point were rest and rehabilitation, and potentially adding some biologics to this versus some type of surgical management. The posterior spur was symptomatic, so part one would be arthroscopy with posterior elbow debridement. The real question was whether or not this could be treated with an internal brace or needed some type of standard tendon graft UCL reconstruction. In all truthfulness, this was typically a ligament that we would go ahead with a reconstruction and graft, but the patient was fairly adamant that he wanted to return to playing center field in a six-month time frame. That being said, our best option therefore became an internal brace, although this was certainly an extreme case with respect to indicating such. He was taken to the operating room, whereupon the right elbow was arthroscoped and that spur well visualized on both the x-ray and MRI scan was debrided and excised. This was the intraoperative appearance of the UCL following a muscle split. The ligament itself was thickened, it was scarred, it was delaminating in that central portion. There was significant opening of the medial joint space. My standard internal brace repair technique is a little bit different than that initially described. I use a standard muscle split with about a two-inch incision. Once we expose the ligament, we put our implant digitally at the sublime tubercle. We may or may not add a suture to that. Once we close the ligament tissue up with a primary repair, we put a through-and-through drill hole approximately, and we actually dock this and tie it down. We tie it down very firmly at 60 degrees elbow flexion, full supination, and then sew the ligament graft, or I should say the ligament tissue, into the underlying internal brace. He was placed into a standard brace post-operatively. He was in that brace for about four weeks. He progressed his strengthening. He was normal weight room activity by 10 weeks. He was in an interval throwing program at 14 weeks and a mound progression at six months. He started hitting progression at 16 weeks and was back in games DH-ing at five months. He actually began pitching again mid-spring season for his college team. Here was the interesting follow-up. We lost track of the patient for a couple of years. He ended up transferring to a major Division I athletic program as a pitcher. He played two seasons, was actually a Friday night starter with a fastball in the 95-98 mile an hour range. He ultimately was selected this past season in the top 15 rounds of the 2021 Major League Baseball Amateur Draft. I had the ability to examine him now following his drafting as a player. He was completely asymptomatic. Interestingly, he had a range of motion from 18 to 125 degrees. That was completely stable from the last time that I examined him several years earlier. Most interestingly, this is his MRI scan now four years post-UCL repair of that very degenerative ligament and high-grade injury to the proximal fibers. The image on the left, you can see that there's complete continuity and congruity to this ligament. The tissue looks improved. There's no further tearing and the overall appearance of the tissue looks qualitatively much improved. To be perfectly frank, this is not at all what I expected as an outcome for this young man, but obviously very happy for him. Obviously a very interesting case with a tremendous amount of follow-up and an outcome that, to some extent by myself, was somewhat unexpected. I'd be very interested to hear the thoughts of the panel. Thanks very much, Dr. Meister. We now welcome our panel to discuss Elbow UCL Reconstruction or Repair and Rehabilitation. Thank you all for joining us. Dr. Meister, take it away. Thank you for allowing me to be here. Any specific questions? I thought, again, this case was extremely apropos considering the title of the conference. I think I covered all bases in this particular case presentation. Specifically what it has taught me is that I think we're still finding out what the true indications are or absolute indications are for these brace repairs. I think that there are a couple of questions that come to mind specifically for me. Number one, what is the limit? I haven't reached that limit yet and personally have over 200 UCL repairs with internal braces alone and then another 60 or so hybrids, meaning brace plus tendon grafts. The second thing is, at what point do we consider a result a good result? Does every ligament outcome have to be 8, 10, 12 years down the line before we say that it's been a successful procedure? I think that there are areas of gray that we need to work in that may or may not be appropriate for, given the circumstance, I should say that three years of good outcome may be more than enough for that particular person or that particular athlete under that circumstance. Keith, that's a very interesting case. I'm curious as to what are your thoughts, what are your indications to do your hybrid repair versus throwing a tendon in here and trying to give him a new ligament? What is the difference in the rehab for you? How would it have changed this kid's trajectory? If you had thrown a graft in there, would you have rehabbed him the same or would you slow it down and if so, why? Yes, I think we all tend to be much more conservative with our standard straightforward tendon graft UCL reconstruction repairs. For me, that's a 6, 9, 12 timeline, meaning a standard UCL, meaning six months we start throwing, nine months for a pitcher off the mound, position player begin to transition back into his position. With the hybrids I've been doing, my first hurdle was to make sure that I wasn't doing any harm. I've got almost four years of follow-up on the hybrids now. As I said, I've got 56 or 57, 51 or 52 are actually all pros, so they're high-level guys. We haven't had any complications and to this day, again, I don't want to promote them yet because I don't feel like I have enough follow-up for the larger portion of the group, but I haven't had to redo any and actually I have almost 20 of those are revisions and we all know how difficult revisions are to get back. I think there are a lot of good signs here. I'm not ready to stand up and say that this is the greatest thing since sliced bread. I think we're all still feeling our way with indications and with respect to ultimate outcomes. But the hybrids, I have not sped up their rehab yet. That's the next step, but I want to make sure the outcomes were good first. Then with an internal brace, for me, it's 14 weeks start throwing, usually plows at 12, 14 weeks start throwing and for pitchers, six months off the mound for position players back in the game at that point. Usually I stagger their hitting progression a couple of weeks after I start their throwing progression to try and get them back to hitting in a game potentially in around five months or so for the position players, DH that is usually. Very good. Thanks. What do you think about the development of a spur like that in that young kid? That's pretty impressive for a young guy. It was obviously an abused elbow and that was part of my point showing all that stuff initially, that this was a high volume, highly abused young man, obviously talented that had a lot of secondary changes and yet still did well with a brace. That was the intriguing thing for me. I think that we are over-operating on a lot of these ligaments, not necessarily that they don't need a surgical approach on many occasion, but perhaps we're dropping a nuke on an anthill, so to speak, when we could be doing something much simpler with a quicker timeline to recovery and less morbidity ultimately for these, especially these younger throwers. We've got now over 20 pro elbows that we've done just internal braces on. Very good. Ronnie Porterfield, chime in here a little bit. Are these guys rehabbing different, these internal braces versus the recons? What's your feel on that? You've seen a handful of them. Yes. I've seen that. We've had two in the last year and we've been a little conservative on their approach. Of course, we basically really listen to the physician and treat each one in a case-by-case. I think what comes on with the internal brace, what comes up on us really quick is the return to throw much quicker than we're accustomed to with the normal Tommy John. With the normal Tommy John surgery, we're usually thinking about three and a half months of range of motion, strengthening, and proprioception. Then from about three and a half to four and a half, we put them into a pretty progressive and aggressive two-hand plyometric program, making sure they can tolerate that. Then we like about a month of a one-handed plyometric program pretty aggressively. With the internal brace, we're having to speed that up, so when we're getting to probably about that two and a half month to three month, we're already getting into the two-hand plyos and we're probably having to speed that up and cut it in half maybe to about two weeks versus four weeks, and the same with the one-hand plyo before we start on throwing. That's the tricky part. We've had two. They both have done pretty well. We had a little setback with one of them, but again, we just listen to each of those athletes, and of course, with the physician, he's the one that went in there, did what they did in either the repair or in the revision or in the internal brace, so we take each one on a case-by-case, but I think that the two internal bracing that we did this last week, they were both back pitching at about the eight to eight and a half month mark versus a little bit earlier than that, and again, we were probably a little conservative with them both. They both finished the season doing well. Very good. Listen, I want to respect the time that we have allotted for this panel. Sal, any thoughts about is there a difference how we approach a proximal versus a distal when it comes to making a decision to do a repair versus a recon? Was that question for me, Mark? I'm sorry. Yeah. Do we think differently about proximal versus distal when we're thinking about repair versus recon? Yeah. I think that as we're meddling through these waters of like Dr. Meister was talking about, I think it is important to take that into account from the studies that you've initiated. We've seen that proximal tears are different than distal tears, especially partial tears, and I think that the blood supply and different biomechanical factors are important for that, and I think that I would be more likely with a proximal tear to consider, especially in a partial proximal tear if we weren't able to get it better with nonoperative management, maybe even before trying that, depending on timing in the season, maybe considering doing an internal brace as a repair mechanism because we do have that blood supply and things like that that we know might make that more apt to healing. But again, I think that Dr. Meister's showing and I think that Dr. Cain has shown that, especially with internal bracing, they haven't really seen any difference with partial proximals or distals, so that might be more of a nonoperative versus operative-type thing, but I think for me personally, that would play a factor into my decision-making just from the healing potential and things like that. Great. Keith, have you seen any difference in proximal versus distal? I haven't. I've changed my technique. I say now I've got probably five different elbow ligament operations that I do now, so what I will do on the proximal tears is I take a 1.3-millimeter or 0.9-millimeter suture tape and I reinforce the internal brace with that. I go three locking stitches down either side of the split ligament, and then I pull those up and dock those, and that's the advantage of docking. I pull those up and dock those and tie those over the bone, or I'll put a banal-type stitch, one of the two, and it reinforces that proximal tissue. And whether it's necessary or not, maybe that's overkill. I don't know, but it makes me sleep better at night. I feel like the repair is better reinforced, and the results really have been incredibly consistently good, so. Good. Thank you very much. That's very interesting. Alexander, how are we doing on time? We've got about two minutes. Great. I got a question for you, Mark or Keith. Have you guys seen any differences in these with being from a different nationality or being from Central America or being from North America? Any difference in the bone structure or how they accept the internal bracing? It's a fascinating question. I've not even thought about that. I'll have to look into that. That's a great question. Jeff, I have not. I have not seen a difference. I mean, the numbers are pretty big now that I have. I mean, I feel comfortable saying certain things with some certainty. I still think ultimately, obviously, the follow-up, we still continue to need more follow-up, and I think we can get a couple more years out of what we currently have in the database than I think we're going to be able to speak much more smartly and comfortably about, but I haven't seen a difference. Now, we all see different tissues and different types of individuals, but from a nationality standpoint, no. That's great. Great discussion. We've got one question from the audience if we'd like to. Yeah, Dr. Robert Dugas asking how the ulnar nerve is typically handled with brace and the hybrid procedures. I actually, I elevate the ulnar nerve off the proximal aspect of the medial epicondyle and release the medial intermuscular septum, and so it allows for untethering of the nerve. So I haven't had any problems with the nerve. I haven't had it slip. I've had to go back and redo an ulnar nerve, or I shouldn't say redo, but I've had to go back and secondarily do an ulnar nerve transposition on just one patient out of that first group of internal braces that I've done like that, and that was somebody that started having symptoms several months down the line after they began to initiate a throwing program. So. Hey, Docs, one question. Do you see anything, or what's just your idea on the life expectancy of just your regular Tommy John graft versus internal brace, or is there anything? I know it's early. Is there anything you can suggest on that? Yeah, I mean, Ron, we've had these discussions and side conversations, and I think that what scares me and part of my impetus for starting to do these hybrid reconstructions was A, the internal brace repairs had done phenomenally well, and B, we have a whole new generation of pitchers over the last five years or so. The average fastball velocity has jumped a couple of miles an hour in just a five-year period of time. I think that we've seen, number one, the incidence of ligament injuries go up precipitously. There were, I think, 68 total in 2012, there were 168 in 2019, and I don't have the numbers yet for this year, but I suspect they're 200 or above. And so I think that I felt like the engine had gotten too big for the chassis, and we had to improve our chassis. So adding the internal brace was the impetus for that. And then the other side part of that was that these guys were breaking their ligament reconstructions down a lot faster, and so now we're faced with a higher incidence of revision, which, again, the newest numbers we don't have yet, but I'm gonna guess that these ligaments are not lasting as long that we reconstruct, so I think we need to be a little bit more creative and perhaps figure out a better way to do this operation to keep these guys at the highest level healthier longer. I mean, they're starting to break down at four years and five years now, where we used to think, well, we'll get eight to 10 out of this. I don't know, man, I have to be honest with you, I haven't figured out how to quite get those kinds of results anymore from what we were doing as a standard. Now, there are exceptions to every rule, but I think as a whole, I think we're all being more and more challenged. I think, you know, Mark or any other panelists, I'm sure can weigh in and seen a lot of the same things. Yeah, absolutely, Keith. Absolutely, that's great. That's great insight, great experience. All right, everybody, thank you all. We're gonna turn now to Dr. Coleman's presentation and then move on to our next panel. Thank you so much for inviting me to speak on the painful hip in baseball and beyond. Here are my disclosures. Today, I'll be presenting a case presentation of combined FAI and poor muscle injury. This occurred in a 24-year-old major league baseball catcher with a two-year history of FAI of his left hip. He was treated with intraarticular injections twice and was able to return to play. He then developed an acute core muscle injury. And what we know is that FAI with loss of hip internal rotation can result in secondary injuries, including a core muscle injury. His complaints were a loss of explosiveness with batting and throwing to second base, increased hip soreness with play and now with ADLs. On exam, he had adductor tenderness, pubic tubercle tenderness, pain with resisted ADduction, zero degrees of internal rotation of the left hip at 90 degrees of flexion, and pain of the left hip with flexion, internal rotation, and ADduction. His coronal pelvis MRI shows a combined injury of an adductor longus tear combined with a rectus abdominis injury. The sagittal MRI shows the rectus abdominis muscle tearing off the cartilaginous plate that coats the front of the pubis. This is pathognomonic for adductor and rectus abdominis injuries. The x-rays of the hip show good preservation of joint space and an elevated alpha angle of 73 degrees. The MRI shows good preservation of cartilage with labral tearing. The CT scan shows a 3D reconstruction with an alpha angle of 78, a femoral version of 10 and averted, and an acetabular versions of four, eight, and 15. We often use a hip map to confirm our 3D CT findings. The diagnostic workup includes selective injections of the hip, the pubic bone, and the adductors. In this patient, we found with the hip injection, 60% relief. The pubic bone injection resulted in 30% relief, and the adductor injection was equivalent. Treatment options then include conservative treatment with return to play, core muscle surgery alone, or a combined hip arthroscopy and core muscle surgery. I do all of my combined surgeries with Dr. William Myers at the Vincero Surgery Center in Philadelphia. The decision initially was non-operative treatment with cortisone injections, rest, and return to play, if possible, at three to four weeks. However, the patient was unable to return to play, and so the decision was made to perform a combined surgery, beginning with the core surgery, and then the symptomatic FAI surgery of the left hip. The adductor was initially then repaired back to the pubic tubercle in the core muscle surgery. Here you can see it repaired back to the tubercle. The cervomatic cord is then identified and protected, and the rectus abdominis injury is identified, and stitched back to the cartilaginous plate on the pubis. We use a postless traction table with 10 degrees of Trendelenburg. The leg is internally rotated and adducted, and traction is set to up to 150 pounds. Here you can see successful traction with an air fluid level. In the supine position, we use standard arthroscopy portals, anterolateral, initially for the cannula, and then the camera. Here you can see showing the torn labrum. We then use the mid-anterior portal, with the cannula, looking back down on ourselves, and performing an interportal cut using a beaver plate. Here you can see the delamination of the labrum and cartilage junction, which is pathognomonic for FAI. We then use traction sutures of the capsule, which we snap directly to the skin, to expose the subspine region and the pincer region. We then shave this region down to create space above the labrum, and then perform a labrum repair using interrupted simple stitches with suture anchors. The hip is flexed, the cam is exposed, and we use traction stitches on the hip joint. And we use traction stitches on the capsule to then expose the cam. The cam is then removed. Here you can see the lateral, before we burr the cam. Here you can see after burring, the capsule is open, and then we close the capsule. Here you can see the preoperative and postoperative x-rays, showing the normalization of the alpha angle in the lateral position. Postoperatively, we use a brace and partial weight bearing for three weeks. A combined physical therapy program focused on both the core and the hip. Generally, the patient returns to running at three months and return to play in 89% of our patients at six months. So there exists a subset of patients with combined FAI and CMI pathologies. A comprehensive multidisciplinary approach is critical to identifying these concomitant pathologies and deciding on the best treatment options. When indicated, combined FAI and CMI surgery is safe and results in a high rate of return to play for the athlete by six months. In the words of Frank Jobe, the core and especially the hip is the key to the kinetic chain. A weak core equals poor pitching mechanics. Thank you very much. Thank you so much, Dr. Coleman. We now welcome our panel to discuss the painful hip. Thank you all for joining us. Dr. Coleman, over to you. Great, well, I thought that would be interesting to present this case because, you know, I think that everyone has pretty much got a handle on sort of standard FAI, and FAI is incredibly common in every sport and particularly baseball. What we know from FAI, and FAI can often be treated without surgery for a number of seasons, getting the patient through the season with rehab, core strengthening, glute strengthening, and the occasional injection into the hip to avoid FAI surgery. What changes things often, and I think everybody on the call probably knows that, trainers and other doctors, is often when they get a secondary injury related to their FAI, and there are a number of those. And what I mean by that is if somebody has no internal rotation of the hip at 90 degrees of flexion, they're more prone, and we've shown this in a couple of studies, to getting core injuries, including core muscle injuries, oblique injuries with batting, you know, and proximal hamstring and adductor isolated. So, you know, it becomes a management issue for these patients. And what's really frustrating, I think, for everybody is when somebody has an asymptomatic FAI. So when you flex their hip up, they have no internal rotation, but they have no pain. So you can't justify going in and doing a hip arthroscopy. But at the same time, you know that that loss of internal rotation is resulting in a lot of these other injuries. And so the question is, when you fix the core, if the patient has a big FAI, big cam, although they're not particularly symptomatic, should you remove the cam at the time of the core muscle surgery? And so this is something I think everybody struggles with. Dr. Myers and I have spent years looking at our research and our data, and we're still sort of figuring this out. Yeah, Dr. Coleman. So I think it's interesting as a non-operative physician, the true value to this case is, how do you intervene before he gets to that season ending injury? How do we find those guys who are asymptomatic and try to stop them from having that injury before they can't finish the season? So all of the non-operative things before it gets to the point where he just couldn't finish. So that's the value I think in this case. Yeah, and that's the million dollar question because the player wants to keep playing. And so if you set it up that they're doing a great core strengthening program, glutes are really strong, they're working on their external rotation, avoiding too much internal rotation, and they get one or two cortisone shots, that's probably controversial, and they can get through their season and play their best, then it's really hard to justify saying to them, and their cartilage is also, let's say normal on the MRI or relatively normal, it's hard to justify convincing them, and I would never do that, convince them, but to have a hip arthroscopy before something else happens or before they start to break down their cartilage. So I think the bottom line is you have to be very vigilant, particularly with the cartilage where serial MRIs, maybe one a year, and then if you see something else start to develop like a core muscle injury, then you have to really think about should you manage this hip, especially if it's symptomatic obviously. Right, I watch those hips as closely as the range of motion, I watch that as closely as I watch the shoulder range of motion. As soon as they start to lose a few degrees, you really have to get every person on the team on them. Yeah, I think that's a really important point too, because on the most elite level, a lot of these guys, and certainly some of your dancers, Melody, they don't necessarily always realize how limited or changed their anatomy and their function starts to become because they're able to perform, and they just figure that they can keep going. Meanwhile, this pathophysiology is evolving over time, and we all look at it and say like, man, this is just a ticking time bomb, but to them, it's just what they're used to, and they can play through and keep hitting until they can't, and then we're all left to say, okay, well, what do we do? And so I think counseling them on the ramifications over time on what can happen versus what could happen, where's their contract, and all the things that come along with that has to be part of the discussion, certainly during the preseason, but any opportunity that you have when you know that there's pathology has to be part of the discussion. Yeah, that's a great point. Yeah, Melody, you brought up a great point there, which is we've done a couple of papers now looking at sort of hip internal rotation, but maybe more importantly, total arc of motion as a predictor of core muscle or core injuries. And what we found was exactly what you said, as players started to lose the arc of motion, so internal plus external at 90 degrees of flexion, they were more prone to getting proximal hamstrings, oblique injuries, all those things. So you're absolutely right, it's just like the shoulder. I think one of the things is, obviously you keep the core strong, the glutes strong, but at the same time, you have to really work on that external rotation of the hip. Internal rotation is bad, that's gonna cause impingement symptoms, that's gonna flare the hip up. But if you stretch that hip out externally, the players will do a lot better. Well, and also learning how they respond to mobilize that. So a lot of these players, they learned how to stretch themselves. And when you have a hip with that kind of bony abnormality, passive stretching isn't the most effective way. So figuring out how they respond is, I find super interesting, because you go down the row and each guy responds differently how you're going to get them to mobilize and teaching them how to do it themselves and listening to their body, I think is also a great way to give them some empowerment and also give them some responsibility over their body. And when you look at how they start to respond to some of these things, it becomes that positive predictor of how you can control it. Because when you look at a lot of other injuries, like quadricep injuries and hamstring injuries, pain is always one of the biggest indicators for concern or certainly re-injury. And when you have a player that has very little internal rotation, you can work on stretching the external rotation, but they still don't have any pain. Again, they're thinking like, okay, well, as long as I stretch this out, I can keep playing. And so when you don't have that really positive, strong sign of pain, you lose that power with the patient. And then when you layer in, okay, we can do injections and diagnostic lidocaine to help, it still muddies the waters, but it all comes back to, if we could figure out a way to really drive it into them, that this is something that cannot just be ignored. It's something that we're going to need to pay attention to over time. It becomes a very important thing. Yeah. I mean, one of the things that I've done probably in the last eight years is I do many more bilateral hips. So if I have a player who is at the point now they need a hip arthroscopy, you know, they're ready to have it. You know, we've tried everything, it's conservatively. If that other hip has impingement, even if they're not as symptomatic, I really convince them to do both hips. And I've really had, I think, positive outcomes doing that because what I was finding was you finally get to the point that you do the hip arthroscopy, patient, you get rid of their FAI, they feel great in that hip, they restore internal rotation. And then suddenly the other hip starts to hurt. And they're like, wait a minute, why didn't you take care of that? And so I think with new advances, you know, no post in the table and other things like that, we've really been able to kind of, you know, push forward this idea of bilateral hip arthroscopy. And frankly, at three months, whether you do a single hip or both, they're pretty much exactly the same place. I think Steve's idea of this, you know, making sure that they know when they have pain is pretty interesting. And that's why, I don't know, James, if you have any comments on this, but I find that having a low threshold for them to ask the athletic trainer or the physical therapist, you know, is this okay? I think, you know, if they feel like they come in with pain and it's going to be a big deal, then they don't want to come in and see you. So having somebody that's just super easy for them to see is really valuable in the team treatment. Yeah, we, it's a great point. I would like to comment on the, you know, tracking and monitoring their range of motion throughout the season. We do try to create that environment where they are coming in and they have a routine with us almost every single day, especially off starting pitchers. We definitely see fluctuations in range of motion. I think one of the interesting things we're seeing is not just passively, but actively. Like one of the things we constantly check is not only their passive motion, but how are they using those end ranges? And over time with fatigue and use, we're seeing not only external internal, but they're not really owning those end ranges that well. So not only where are we incorporating our massage therapists and doing a lot of joint mobility work, but our Pilates specialists, strength coaches, and really like learning how to feel those end ranges and use them, because they start to avoid those end ranges over time, as we all know. So it's there's definitely several factors involved with with that. And so I just want to add that in. James, there's a question for you. Um, are you testing strength, testing the hip sort of before pre preseason and then mid season and postseason? Are you looking at the and what are you testing exactly? So we we rely heavily. Um, we do some strength testing. Yes, but we rely a lot on function. First of all, I kind of like to see how they're going through some of those those top tier movements a lot. And what might be limited? Is there something you know, tying in the hips, certainly paying a lot of attention to the core and the thoracic spine and then the lower half too. But we're relying on I like, I like to rely a lot on active versus passive, like okay, they can't do a motion, but okay, can they do it actively or not? Can they can they can they do it passively or not? So kind of rely more on the functional and the motion more than strength because that tells you a lot to obviously they can own that in range. And Steven, are you if you have a player who let's say he just can't activate his blue is does that push you a little bit more towards suggest, you know, suggesting to him that he has a hip arthroscopy? Is that something you use at all? Yeah, I mean, if you can't activate your lateral hip stabilizers like that's a huge red flag for me. Sometimes it's like, you know, if I'm seeing a patient in the clinic versus in the training room, like you have to get really creative in ways to kind of demonstrate to them like this is clearly abnormal. And if you can't do this, ramifications are so well beyond what's actually happening into your joint. And if it's if it's not an important priority to you, everything else is going to be difficult. So you know, when you have all the access to the training room, it's fairly easy. But when you're in the clinic, like you got to get really creative. But if you can't activate those glutes, like it's a really bad sign. Yeah. No, it is interesting how, you know, everyone's so focused on those joints between the hand and the collarbone. But, you know, the fact is that you really have to keep track of the hip because especially someone with impingement, you can't just let it go because everything else starts to go. If their core strength starts to diminish, and as you say, they can't stabilize their pelvis, their arm angle drops just as much as if their rotator cuffs weak. Yeah, there's all the evidence and the data that's out there for, you know, internal rotation deficit, and you spend so much time in baseball on the shoulder, but, you know, the hip is no different. If you have an internal rotation deficit in like zero degrees of internal rotation for flexion, like there are significant ramifications, musculoskeletal over time for that. All right, I think we're out of time. That was great. Thank you to all the panelists. And I think we're now going to move on to the next session. Thanks, everybody. Yes, thank you all for that discussion. Next up, we'll be looking toward Dr. Stasch's presentation and then moving on to that panel. Hello, and good evening. My name is Steven Stasch. I'm the Chief of the Division of Non-Operative Sports Medicine at Rothman Orthopedics in Philadelphia. And I'm here tonight to talk to you about core muscle injury. I've no financial disclosures. And I've highlighted some pictures here from various sports with mechanisms of injury that are not uncommon and can lead to a core muscle injury. So I'd like to start by presenting a case. We have a 25 year old professional baseball player, right handed first baseball player, right handed first baseman performing well throughout the season. He starts to develop left sided groin pain. Pain is initially responding to modalities and treatment through his athletic training staff. But on one particular evening, he reaches for a ball and feels a pop in his left proximal groin with sudden onset of severe pain. He is subsequently unable to continue to play and has difficulty ambulating. The player walks with a limp, antalgic to the left, and pain in his gait cycle with left toe push off. He has tenderness to palpation directly over the pubic symphysis more on the left side than the right. Reproducible pain with posterior hip extension, fader, favor, and over. To highlight the physical exam techniques that I just mentioned here, we have images that show appropriate technique for palpating the proximal area of the adductor muscle group, posterior hip extension, fader, which is forward flexion, adduction, and internal rotation, hip rotation, favor, which is forward flexion, abduction, and external rotation, as well as the over test, which is posterior hip extension, as well as a knee internal rotation. Differential diagnosis for this type of injury includes an acute core muscle injury, FAI or labral tear related pain, pubic symphysis injury, hip flexor injury, hip stress fracture, hip osteoarthritis related pain, osteitis pubis, all of the above, or some combination of the above. To discuss the core is to discuss the complicated area of the body that includes significant amount of musculature. It's loosely defined as all muscles below the chest, on the anterior aspect of the body down to the knees, and the muscles of the posterior gluteal region, lateral hip and lumbar region. Obviously, these muscles are highly involved across all sports, which is why injuries to this area can be so difficult to diagnose and treat, and one must pay very close attention to the types of physical exam findings and imaging, which we'll discuss in a moment. Another important concept when discussing this injury is the term aponeurotic plate. The anterior pubic region is a confluence of different forces from different muscle groups that work in opposition. In the image with the blue arrows, you see that the force in the vertical orientation from the rectus abdominis is in direct opposition of the forces from the adductor muscle group, and thus this area is under constant strain. In the abdominal region, there is an aponeurosis between the rectus abdominis within the sheath as well as the oblique muscle groups. There's a secondary aponeurosis directly over the pubic symphysis between the rectus abdominis and the adductor muscle groups. The complicated nature of this injury lies in the fact that there could be technically a four dimensional injury where you could have a tear or damage in the X, Y, or Z axis, as well as a detachment of the pubic aponeurosis from the pubic symphysis or anterior pubic wall. Core muscle injury is a term that has evolved over time through different nomenclature. Other terms that you may have heard of include sports hernia or athletic pubalgia. The traditional teaching was that athletic pubalgia is a descriptor for pain in the general region without injury, and sports hernia implies more of a traumatic injury. There's some fluidity between these two terms, and thus far there's still a lack of consensus. At Jefferson in the Philadelphia area, we have adopted the term of core muscle injury to imply all of the above. Core groin injuries are common, particularly in soccer players. A recent survey showed that groin problems are reported weekly at a rate of about 29%. Previous adductor groin injury is the most common consistently identified risk factor for subsequent injury. Concomitant pathology is also common, and FAI and other interarticular pathology have been shown in the literature to have a rate between 16 and 33% in professional and collegiate athletes. The workup should include a thorough physical exam. Plain films can be helpful to evaluate for concomitant interarticular pathology, and an MRI with athletic pubalgia is essential for accurate diagnosis, and my esteemed colleague, Dr. Adam Zogel, discuss images during the question and answer panel portion of this presentation. Non-operative treatment often includes rest. However, this can be very difficult as pain can resume upon returning to activities. A number of studies demonstrates return to play after a dedicated exercise and program to improve core muscle strength and proprioception. A tool that we've adopted here in the Philadelphia area is a combination of ultrasound guided percutaneous needle tonotomy and a corticosteroid injection as a means of allowing an athlete to return back to play and attempt to complete the season. PRP, standing for platelet-rich plasma, has become a popular treatment for various sports-related injuries. However, there's risk of heterotopic ossification, so this is something that, in my opinion, should be used with caution. Surgical repair is often the final stop in the pathway if an athlete cannot be successfully returned back to season. There's variations in surgical technique, and here in the Philadelphia area, we have Phil Myers at the Vincere Institute, whose numbers are very promising. Physical therapy in the post-operative period is absolutely essential and helps establish a progression to return to play. Overall, the treatment should include a collaborative approach and certainly multiple disciplines, including athletic trainers, physical therapists, sports medicine physicians, radiologists, and orthopedic surgeons. Here are my references for the images, and here are a few important citations for literature highlighting the data regarding this injury. Thank you very much for your time, and I hope that you appreciated the details in this presentation, and I look forward to the discussion in the ensuing panel. Thank you. Thank you to Dr. Stasch for that presentation. We now will move to some MRI images from Dr. Zoga. Thank you. Hi, I'm Adam Zoga. I'm a radiologist, and I've been dealing with core muscle injuries with Dr. Myers as a partner for about 15, maybe 16 years. Thanks to Dr. Stasch for inviting me to support his case presentation. Thanks to Dr. Harwood for inviting me to the session, and Dr. Schickendance for tolerating a radiologist. As we've heard from the last two speakers, the core really is everything from the nipples to the knees, and that includes the low back musculature next, the hip, but we're talking today next about a particular kind of more core muscle injury, and this is a book that's really sort of directed more at ATCs. So Dr. Myers wrote the book. I provided a few story embellishments and photos. Next. So to understand the pathophysiology, we've got to understand the anatomy, and I just want to reinforce what we've already heard, but this fibropneurotic attachment, as my colleague Phil Robinson published way back in 2007, is a broad attachment on the anterior-inferior aspect of the pubic bone at the pubic tubercle, and when you get in there in a cadaver, it's actually a really gnarly attachment. It's sort of analogous to the rotator cuff attachment on the humerus, but it's thicker and bigger, and when this thing starts to destabilize, the whole pubic symphysis joint destabilizes, and I think that's what happened in the case that was presented. Next slide, please. So the first MRI, when he first felt the pain and heard it pop, we really didn't see a heck of a lot. I could see where this would be read as normal, but if you look, there is some asymmetry to the left side, the front side, and in my experience in baseball sluggers, it's always the front side, and you can see there's some degeneration in that pubic plate, asymmetric to the left, and the left adductor longus is larger than the right. Next slide. If you look closely, the sagittal or the lateral images really give you the key to the early injuries, and we're starting to be able to treat these early injuries. We've shown a lot of success treating these early injuries percutaneously. I'm not sure we've had great success treating baseball sluggers' early injuries percutaneously, but other athletes we have, so we need to get better. Next slide, please. So that little detachment on the lateral image is really the key to diagnosing early, and this is a higher resolution image. Next slide. And not surprisingly, Dr. Coleman, this patient also had a left-sided anterior acetabular labrum tear. Next slide, please. So a month later, he's playing. About every other game, he gets a little worse, but now look at the next, look at the edema at the lower left rectus abdominis muscle. So now we know that the core is destabilized because there's edema in the left rectus abdominis muscle. Next slide, please. And now we see that actually the adductors are sort of, it's almost like the plate is broken. They're revulsed just a little bit, and he was still able to play with this. Next. High resolution imaging shows a clear gap, sometimes called the secondary cleft, where the plate is fractured and the adductors are being pulled away from the rectus abdominis. One more next, please. So at that time, we used our ultrasound and we tried a therapeutic injection, and he actually was able to continue playing. Next slide. But then three weeks after that one, the big injury. And now with a gap like this, a player is no longer going to be functional. You can see how the adductor, you can go next, I think I have some arrows and annotations, and one more next. And you can see how the adductors are now revulsed away from the pubic plate. There's edema all throughout the adductor compartment, the pectineus, the adductor longus, the adductor brevis, and even the obturator externus. So now it's a big injury, and the player is probably not going to be able to play. Next slide. So this is just a cadaveric dissection that I did some years ago and have published. And it just gives you an idea. Look on the lateral view, how thick that epineurotic plate is, the rectus abdominis. Next slide, please. The rectus abdominis, next slide, is a huge thick structure, and the attachment to the pubic tubercle is broad and strong. And any injury, one more next slide, any injury to that location is going to destabilize the central core and probably lead to an unstable pubic symphysis and the osteitis pubis that we all see and treat, and ultimately a bigger core muscle injury. So I think that we've shown we've made progress in treating these things early on and identifying them early on, but in some scenarios, and they're scenarios that I see repeat themselves, like a baseball slugger or a tennis server with a frontside injury, we haven't really had much success in preventing the big injury. That's where I'm at. Thank you for that, Dr. Zoga. And we now welcome our panel to discuss core muscle injury. Thank you all for joining us. And Dr. Stasch, take it away. Thanks, Adam. It's always incredible to have you walk through the images in I really appreciate that. I think it's really helpful. As you said, you have to understand the anatomy. I think if you could take any one thing away from this type of injury, if it's a truly isolated core muscle injury, I'm just trying to start to make a count on my head on how many times you said destabilizing, right? Because that's really what happens. And if we go back to the talk before, and it is within that 30%, and I'm sure Dr. Coleman, you could probably quote higher numbers with the patients that you see, with the impingement setup, that's already destabilizing things in another manner. So you have just another layer of forces. And so I think we have Scott Sheridan on here. I'd really like to hear what your opinion is on trying to monitor these athletes over time, with the focus on today's talk being baseball. Once this is identified, knowing that there's obviously the risk for progression and the fact that as it destabilizes, can we needle, can we inject cortisone? And when is enough enough to say that this isn't going to work and we have to really take a step back? Yeah, I'm going to answer with a thought, and then I'm going to ask a question to the group. Because I think as I've gone through this, I think first, James Quinton was right on. I think monitoring hip rotation throughout the season for our athletes is probably a primary need that we need to pay a little more attention to and talk about. I know that'll make Dr. Coleman pretty happy. For me and my past experiences with these, if after about three or four weeks, you're not really making good progress with them, and they're not becoming less asymptomatic, I think you have to kind of re-evaluate exactly what's going on with them. And sometimes you can get their core a little bit stronger, but if the symptoms remain, then I think you're kind of going down a bad path that's going to lead you to a longer extended return to play. But I think the other questions I have as we go through both of these past presentations are like, is there one predictor for just a core muscle injury? If you see this core muscle injury, what are the best predictors that this is not going to be successful from a conservative approach? And then I think the other thing is we end up doing surgery, Dr. Coleman, where are we at on return to play timeframes? I know there are some protocols out there that look at six weeks for return, but I think all of us would kind of agree that that's a pretty aggressive approach, and I'd be curious what you're seeing on just isolated core. I know if we had the FAI component, it's going to be a little bit different, obviously, but just what your thoughts are on that. So I think that's a great question, obviously. So there's a lot of controversy, I would say, among the different leagues, the NFL, NHL, what core muscle injuries can the athlete play through, and what injuries really are predictive of needing surgery? And I think that there is a consensus, which is beginning to develop when I check with my colleagues in different leagues, and the idea, I think, is that an isolated adductor, probably you can get through it, except the ones like Adam showed, which are, you know, significant, retracted, multiple tendons, you know, that kind of thing, but appealing off of the adductor longus that's sort of stable, and you inject it, and they get through it. As soon as the rectus abdominis starts to go, I think that most people will agree that any sport that requires explosiveness of the core, whether it's a running back in football, or baseball player running for the ball, running to first base, hockey player, as soon as you tear that rectus abdominis aponeurosis, I think that's when patients will need surgery. And then in terms of return to play, you know, everybody out here can probably comment on that. I mean, that's, you know, very player dependent. And Bill Meyers will say six to eight weeks, and maybe that's right for some people, and maybe not. But I don't think the point is, once you fix the core muscles, you can try to get back to play in six to eight weeks, and you're probably not going to do any damage by doing that. That's sort of the amazing thing, but not everybody gets back at that time. I'd agree. I mean, I think, from my perspective, most of our athletes were somewhere in the three to four month time frame, where they felt like they could go back to being explosive and comfortable. But I've also had those extend to six months, eight months. You know, I've even had a player that said he really felt like it was almost a year before he felt like he was back as powerful as he was before as a hitter. Yeah, I think one of the things that is really important to pay attention to, in the opposite sense of the asymptomatic FAI, is really just the pain. When you look at the correlates with proximal hamstring injuries, pain with daily activity. So it's not just the ability to perform on the field, but when you're just standing up from a chair, it's really hard. Marcus, I wanted to ask you a particular question. When it comes to the rehabilitation for these types of injuries, do you have any major red flags that you would think like, okay, this athlete's not going to follow that projected six to eight weeks time frame, and we really need to make sure that they understand we have to move a little bit slower? Yeah, I think we really hammer on more like motor control type of exercises early on, and if a player is able to kind of get a handle on those, it sets them up for a lot of success. So we really hammer transversus abdominis, even some low-level pelvic floor and multifidus contractions, just to see if they can really isometrically stabilize their core. And once they start to get that from the table, then we start to get them more upright and start to move. I think that's where we see a lot of good prognosis in guys early on coming off of surgery is they're able to kind of master that technique, and then we can really start to progress. But I would echo what Scott said. We've generally seen that three to four month return to play, and kind of give them, take it easy the first six weeks, really let that repair take hold, and then just start to progress functionally baseball activity after that. Awesome. Thank you so much. I wanted to make one last comment. I know we're kind of focusing on the professional level since this is a Major League Baseball sponsored event, but I do think that for all the clinicians out there, like unfortunately, I see a fair amount of core muscle injury in the general population and younger athletes. So it should always be kind of beyond your diagnosis. And again, really paying attention to that internal rotation with the concomitant FAI is important. So make sure you're evaluating for rectus abdominis and adductor strength and tenderness when you're hearing about the athlete with an anterior hip pain, injury or non-injury. So it's out there for sure. And that's a good point, Stephen, is, you know, you want to use your selective injections, especially in that situation, because even though both may not need to be treated, you want to make sure you make that diagnosis. If it's a core muscle injury with a hip, FAI, you know, you want to make sure you can tell the player, the parents, you know, what's going on. Yeah. And that's a particular shout out to the, the Adam Zogas of the world and our colleagues in radiology and other individuals who can do those ultrasound guided injections. It's a really important part of the process. Thanks. All right. Thank you so much to all of our panelists. We're going to go ahead and move on to Dr. Hardwood's presentation and then on to the next panel. Thank you again. Good evening. Thank you so much for joining me. This is going to be a case presentation on COVID-19, but instead of being a traditional case presentation, it's going to be more of a choose your own adventure, depending on what my esteemed panel has to say. So I'd like to introduce my, my panel. Dr. Jason Womack is the head team physician at Rutgers University, and Dr. Michael Duncan is the head team physician at Villanova University. Both of these individuals have been knee deep in COVID and COVID treatment and mitigation strategies for the past 20 months. And they have dealt with more COVID than you can possibly imagine. So let's move on to our symptomatic case. So you have a minor league catcher for a Florida based team. He was vaccinated five months ago with Johnson and Johnson. Background team vaccination rate is 65%. He calls with three days of cough, tactile temperatures, and chills and a runny nose. And he just tells you he feels like crap. No ill contacts. You diligently contact the athletic trainers and the team physicians from the most recent opponent. And they tell you that no one's sick over here. Not that we know of. So the catcher is currently at the hotel room in North Carolina, awaiting your input regarding whether or not he should report to the training room today. So for discussion to start with, number one, is the Johnson and Johnson vaccine versus an mRNA vaccination status relevant? Number two, how relevant is his position, a catcher versus an outfielder versus a pitcher? What does that mean in terms of contact tracing? Number three, what kind of testing would you recommend? Would you recommend point of care antigen testing, PCR testing, both, neither, something else? Let's open it up for the panel. Thanks for setting that up for us, Dr. Harwood. And we welcome our panel to now discuss COVID management and return to play. Thank you all for joining us. Dr. Harwood, over to you. Great. Thank you so much for joining us tonight. There are no experts with regard to COVID-19 and the management mitigation strategies. We know there are clearly wrong things to do, but we don't always know what the right thing to do is. And oftentimes when an athletic trainer calls me with a case like this, I think to myself, you know, you can do X, Y, and Z, but I'm only about 20% certain that that's the right thing to do. So I'm going to open things up to the panel. So Dr. Liu, what would you do in terms of testing for this individual? Um, thanks for having me, Dr. Harwood. Uh, we have come across this many times, uh, throughout the season. And, um, one of the first questions we do typically ask is, is the individual vaccinated and you know, J&J versus the mRNA, um, type does make a little bit of a difference, but you know, what's more important was where they actually are or not. Um, the biggest issue here is that he has symptoms. And so he's got symptoms. He was vaccinated. Um, the first thing that we usually do is we'll, we'll do some sort of testing. Um, typically we would have the individual do both a point of care antigen test, as well as submit for a saliva sample, as we all are familiar with both of those. Um, now I think we have come up in the horizon. We have point of care PCR testing as well, uh, which it would be interesting to see how that will change, uh, our management if, if, if at all, but, um, yeah, we would submit this individual for testing. Great. And, um, so, uh, from a collegiate level, I'm going to ask Michael Duncan, um, it sounds like, um, at Villanova, there isn't point of care testing available or you don't do it. So, um, let's get ready to rumble. Let's, uh, let's, uh, let's talk about that. Sure. Thanks, Mark. We, um, you know, we were actually fortunate enough to have, we have wrapped a PCR testing. So we did not utilize point of care antigen testing at all, uh, during the entire pandemic, except when we were playing teams that required it on the day of a contest. So if you remember some of the Philadelphia teams required that, uh, you know, ironically for us, um, we moved away from antigen testing around January, uh, of 2020, uh, with, in regard to flu, because we were not satisfied with the false negatives and false positive results. So we'd actually right before the pandemic and move to a point of care testing and, um, you know, combining that with our, uh, in-house saliva PCR lab, we were able to provide ample testing opportunities. We personally, um, you know, as far as the, the type of tests we just did not see, um, with 7,000, uh, students living on campus, we felt that, uh, a rapid point of care, um, PCR test was the way to go. So we, we exclusively utilize that during the pandemic. Um, so we, and we, we did see, you know, we did have to play, uh, against some teams in Philadelphia that required day of antigen testing, and we would get positive antigen tests and we'd have to back that up with a point of care PCR in order for them to play. So for us, um, we were able to utilize PCR for the majority of the pandemic. Great. And, uh, Dr. Womack, what, what, what's being done? What would you do with this person? If this was a Rutgers athlete? Yeah, I think that it's, it's interesting and how things have changed. The first thing is it's, it's an outdoor sport. And one of the things that we've seen is that if you're outdoors, the likelihood of transmission did seem to be a bit lower. Um, in our experiences, the problems we had were athletes were probably transmitting among each other and we can't prove it, but things like wrestling and basketball, where you're indoors in close proximity to each other, and maybe even a rowing event where people were training indoors, but we saw very little, if at all, I don't know if I could point to any, um, places where even someone who ended up being positive with very mild symptoms, uh, transmitted to somebody outdoors. So, but as you mentioned, the catcher, I'd be concerned if, uh, how many, how close are they going to be to people versus if outfielder, I wouldn't be worried so much. So, so, you know, I, because he's feeling so bad, uh, we, we would hold him and test him and, uh, do some of the things that, that were mentioned before. Uh, but if he had a little bit of stuff, he knows and probably would hold off to, you know, I mean, let them do some things and, and, uh, you know, again, as long as they're outdoors and staying away from folks in the locker room and everything else. Sounds great. Um, I'll, I'll, I'll pose the question to you, Mike. Um, do you get palpitations with, uh, the amount of contact tracing you're going to have to do based on the fact that he's a catcher? Like, uh, what, what, what would be your, um, uh, uh, concern level with this guy? Yeah, it would be the one position, uh, to Jason's point where we didn't see any outdoor, we didn't see any outdoor tradition transmission either, uh, except for something like this, we would contact trace being a catcher, not, not so much a batter, but maybe the umpire, for example, when we, you know, in our division, we were, uh, you know, slightly overseeing the, the umpires and referees as well during contests. So, uh, that would be a big point, but, um, mostly to Jason's point, like the, you know, who do they sit next to on the bench for extended periods of time? If that was a possibility to contact trace that the bus ride, the hotel room, because the majority of transmission we saw was outside, um, the field as well. And how about Tom and, and Mike Salazar? Yeah, so I would agree. Um, so we had, um, I was with the St. Louis Cardinals, uh, last year. So we had an outbreak of, uh, 12 players. We really didn't see that through a contact tracing to see any spread through the outdoors. Um, it was mainly, uh, traced back to, um, locker room meetings, uh, travel, different activities like that. Um, going back to the testing and, um, symptoms. Um, so this year and last year, we were very strict, any sort of cold symptom at all, scratchy throat, even if we thought it was allergies as a PCR test, uh, right away, just to jump on that early. Great. Any additional thoughts, uh, Mike Salazar? Yeah, you know, we kind of did the same thing, you know, I agree with, with Thomas, we kind of went the extra mile just to make sure that, that we were dealing with a more COVID case and more flu-like symptoms. Um, so we were a little bit over, over protection as well, just because the resources we had and the ability of to test those individuals at our, at our hands, uh, where we did that just for that case. Um, my question, I guess, to pin out to you as well as to the other, uh, docs at the collegiate level is that when, when did you guys introduce the tromponent, uh, testing in your athletes? I'm sorry, did you say the tromponent testing? Yeah, let me, um, I'll, I'll, I'll actually move on with the case. I know we have a, a, a couple, a couple of minutes left, but, um, so the patient, um, does their, uh, 10 days of isolation. After three days, he complains mostly of boredom, completely asymptomatic. Um, and so we get to the return to play discussion. So given that information and, uh, Mike Salazar's question, uh, what do you do from a cardiac standpoint to clear him? Question to, uh, Jason Womack. Thanks. So, yeah, we, we were, our hands were tied a little bit in the big 10. We were told everyone had to get a cardiac MRI, a tromponent and an echo. So, so we were doing that for in-season all of last year. And, um, when that got lifted, we kind of quickly realized that maybe we didn't need to do that much. And we broke down pretty quickly to just in-office exam, in-office exam and EKG. So that's where we are now compared to where we were. And how about, uh, how about Michael Duncan? Yeah. So interestingly, you know, with this controversy about what to do and what workup knowing that the big 10 was, was doing that extensive workup. In our area, we, we had everyone get an EKG, echo and tromponent. Anyone that had COVID, that was our guideline. And, um, as we evolved throughout the course of the semester, you know, different guidelines were coming out and, um, where we practice again, you talk about standard of care where there's a sports cardiologist, uh, pretty much, uh, in every corner. We were able to have kids seen on day 11 and cleared by the end of day 11 or day 12, depending on the echo. So for us, um, uh, and interestingly, you know, as far as we did order probably about six cardiac MRIs, uh, with one of them showing myocarditis. And, uh, Dr. Liu, what was your experience with, uh, clearing these folks from a cardiac standpoint? Yeah, at the collegiate level at UCC San Diego, we, um, we took sort of kind of a hybrid approach. Uh, we really took into account, uh, severity of symptoms. Um, you know, we use the AMSSM and ACC algorithm to try to delineate between asymptomatic, asymptomatic, mild, moderate, or severe. Fortunately, we had nobody that was severe and, um, depending on either the severity of their symptoms or any symptoms that they experienced upon their return to sport, uh, progress that delineated, you know, what we would order. Everybody did get in a heart and lung evaluation as well as an EKG that was pretty standard and easy to, um, access, but we really only ordered troponins and echoes on a handful of our athletes who had either more moderate symptoms, um, or, uh, upon their return to play, they experienced any cardiopulmonary, uh, issues. So, um, we definitely saw what, uh, the Big Ten and, and, um, what a lot of the other, um, institutions were doing. And as we kind of predicted things were changing, you know, mid season. And so it was, uh, I think we, we felt comfortable, um, just kind of using a hybrid approach with, uh, with not using troponin on everybody. Yeah, I think early on, it was very proscriptive. Um, everybody got a cardiology evaluation. Everybody got an EKG echo, high sensitivity troponin. Um, and, um, over, you know, as we've learned more and more in the rarity of myocarditis following COVID, particularly in mild cases, although as Michael Duncan, um, you know, told us that the, the only case of myocarditis that he saw was in someone with mild upper respiratory, uh, illness, um, given the rarity, uh, you know, the, the, the guidelines shifted, uh, quite a deal, quite a bit. And, uh, you know, so right now the current recommendation is if they have any cardiopulmonary, um, uh, symptoms at all, uh, at the time of their illness or during their immediate return to play, um, they should have a full cardiac workup that includes at least an EKG and, um, uh, probably an echo high sensitivity troponin. Um, if they don't have any of those symptoms, um, you can probably get away with, uh, a, a good physical and examination. Um, I think these days, at least as it stands right now, it's going to be tough to get away without doing at least an EKG. Um, but that's, that's kind of where we stand. Um, and, uh, with that, I thank the panel and, um, uh, thank you very much for everyone who's been attending. Thank you all for joining us for this discussion. We're going to go now to Dr. Freehill's presentation and then to our next panel. Hello, I'm Mike Freehill from Stanford University. I'm going to talk about the labrum with emphasis on repair and biceps tenodesis. I want to thank everyone for the opportunity to speak with this great faculty, my disclosures. So slap tears can be seen in any overhead athlete, but usually we think about baseball. Uh, most of the publications on slap tears and baseball come out of United States and Japan, but should we be fixing these in overhead athletes and throwers? And if we do, how do we fix them? Well, we know with regards to the mechanics, the acceleration that late cocking acceleration, deceleration is the time we see injury and likely is the time that this occurs late cocking causing internal impingement was first described by Jules Walsh and tennis players back in the 1990s. And then we saw Burkhardt Morgan and Kibler describe this. And you can see the figures really that twisting of the long head of the biceps peeling off the labrum from the superior glenoid tubercle deceleration is even more harmful. And perhaps this is what's causing the labrum to be pulled off by the long head of the biceps tendon. As that arm goes jutting forward, only being slowed down by the posterior rotator cuff. Now I show the picture of the posterior and free glenohumeral ligament. Why is that a concern? Well, if it gets thickened, we know that that can cause a rotational deficit. It's been associated with pain and injury. Grossman showed us that you have a posterior superior migration of the humeral head accentuating internal impingement with GERD. When we talk about slap tears and throwers, usually this is going to be type two slap tears. Remember we have an A, B and a C type. And now we get into treatment. I bet 90% of the people I see, anyone from young kids all the way to professional athletes will have a sick scapula or scapular dyskinesia if they are presenting with a slap tear. And of course, we'll also see that internal rotation deficit a lot. So my treatment frontline, get the scapular stabilizer stronger, get the internal rotation deficit if it's present, stretched out a bit and really rebuild the core. A lot of non-operative management algorithms. You can see one here. You really want to build up that core, shut them down from throwing. That's the frontline treatment. You don't want to be operating. Why? Because you could be holding the smoking gun, so to speak. I still love this study from Mike Ciccotti and the Jefferson Group, 63% overhead athletes return to play, not great. And this is in great hands usually. Lou Yochum and the Curl and Jobe Group, 12.5% if you did a slap repair and debrided an undersurface rotator cuff tendon tear. So this is very worrisome. We just published this year on really doing a deeper dive into literature and looking at the technical aspects of these papers and how much emphasis was put on a technique. And guess what? It was all over the place. So maybe it's not the lesion itself or the injury, but the way we're repairing it. Type eight slap tears going down the posterior aspect of the glenoid. Ben Kibler's really championed this. You want to repair all that. But I think it's interesting to take Hiro Sagaia's turn and view of this, and maybe we're not doing it right. Maybe we're not emphasizing tacking down that anterior superior area of the labrum enough. This is kind of a no-no in the United States, but it's something to think about or food for thought, if you will. When I think about slap repair, I think about two aspects that I think change the game. Knotless anchors, you can do a luggage tag, and then PDS, I think it's a little more forgiving. Sturdy enough to allow healing, but it has a little elasticity. You look to mentors, Mark Shickendance, obviously, one of the chairs of this meeting, and Javier Duralde. And I've taken aspects, not that they do the repair exactly like this, but I like to go through the body, I like to use PDS, and I like to use knotless. Jim Bradley has also emphasized these aren't football players, the throwers. We're not going to do a posterior capsule, or if you like I'm doing in the video above, we're just going to repair the labrum back. I don't think we put enough emphasis on the physical therapy and the sling. You want an extra rotation brace so you can get back into that position. With regards to biceps tenodesis, I only do this in failed slap repairs at this point in time. It's a good argument, it's good to talk about. I think Tony Romeo's work has now showed us as well, they just don't get back with a biceps tenodesis to high level of throwing. So really have to have some caution there. If I do do a biceps tenodesis, it's with a double loaded all suture anchor that's only a 2.3 millimeter pilot hole. So in conclusion, you want to exhaust conservative management with slap tears. It's still the gold standard, but are we missing the mark? Are there other things or other ways we should be doing this? With regards to tenodesis and throwers, you got to have caution only in a revision setting. Thank you. And thank you for that presentation, Dr. Freehill. We now welcome our panel to discuss shoulder labrum repair and bicep tenodesis. Thank you all for joining us and Dr. Freehill, take it away. All right. Thank you very much. Again, I'm very thankful for the opportunity to present today. So in five minutes, it's a lot to cover. Obviously we're really concentrating on superior labral pathology, but the first point, and I hope that what got across there is regardless if there's a slap tear or not, frontline treatment is non-operative. We really got to concentrate on the scapula. We've put emphasis tonight on the core, the hip, glenohumeral range of motion, obviously, but I think we've also touched on the fact that we need baselines. You need to look at baseline hip rotations, baseline glenohumeral rotations, and see are people coming off of their baseline or are they worsening throughout the course of a season? And then, you know, regardless of if they have a slap, you got to get them back to where they should be. My second big point here is, you know, we talked so much about the elbow and the success that we have, but we have to remember the UCL is a static stabilizer. And although you can think of the labrum inferior on the equator of the glenoid as being static, I think when you talk about the superior labrum, at least as it relates to throwers, it's a dynamic static stabilizer. You really need some play in that. It's more meniscal, if you will. And that's why I highlighted how I do those repairs. I'm not saying it's right, but I think that if you do have to get to the point where you have to pull the trigger and do that, do a slap repair, that, you know, you want to not over tighten it or over tension it. And that's what that publication that we had recently was about. I just think that maybe the poor results that we've seen over time is just we've over-constrained that labrum and it can't get back to that hyper-externally rotated position that allows them to function at an elite level. Sal, what are some thoughts you have about that? Yeah, Mike, I think I agree with a lot of the things that you said. I think that was a nice concise way of presenting that material. I think that the biggest thing for me, and I know we have some experts on this that I would like to hear more about with Mike and Joe on this, but, you know, I will not fix a slap tear unless I feel like they have, the scapula is controlled because I really feel like, you know, they've done studies in the general population that show 70% have a slap tear that are asymptomatic with their shoulder. And I think that that just shows that this slap tear sometimes, I think, is our way of saying that we know what's wrong when I think that this is a kinetic chain problem that may start lower than the shoulder, but at least at the shoulder level, the scapula is the first thing. And I think that by fixing the slap tears, I think that, you know, you're taking away this adaptive feature that these elite level throwers have with external rotation. And I think that honestly, I think with Segoia's paper, I think that the interesting thing with that is not that they fixed it anteriorly, but that they just debrided it posteriorly. I think that even shows you more that maybe that's what helped. And I think that's because, you know, if their scapula or if the rest of that kinetic chain is off, they're going to be, they're going to, um, they have a pipe, uh, tight posterior capsule, they're going to be, have that posterior superior, uh, lack of clearance and as we know, that's essential for these throwers. So, um, you know, I agree with what you said there. I just, I try to avoid operating on these as much as, as much as possible. And I'm curious to hear what Mike and Joe have to say about the scapula and how they approach slap tears from, uh, from a, um, uh, rehab standpoint, cause that is the most important treatment for this. And I, let me, and I'll throw a question out there for Mike Reynolds as well, because of his work on the, on the weighted balls and everyone, you know, most people on this call are seeing patients and athletes that are, you know, come up with this conundrum. What their kids working with a weighted ball, trying to get the get, get rich quick with velocity. And Mike's done some great work on that. I'm wondering, Mike, you, do you sometimes think that there could be a threshold, uh, that kids especially are using too heavy of a ball and they're getting too hyper externally rotated and that's almost driving these types of lesions. Yeah. I mean, I, I would say based on our research, I think what we found with the mechanism with weighted balls essentially is that they increase layback, they increase external rotation of the shoulder. They do it acutely. They do it chronically over time. Um, and you know, you wonder how much is too much, you know, we, we see often players will have an increase in velocity initially, then they'll plateau. Sometimes they'll even get worse as their window of adaptation kind of opens. And if you really think about it, like neuro physiologically, the only way that that can happen, um, just use one session I'm throwing is we get some sort of desensitization of the proprioceptors, right? So the, the ability to protect the joint almost goes away, just like when we stretch the hamstrings. Right. I don't think we increased fascicle length in, in one static stretching session. I just think we desensitize the ability to prevent that stretch reflex. So what we're probably happening, we see happening is probably that. And, and, you know, this, this whole, you know, you talk about the concept of static and dynamic stability with this is we're increasing our, our, or decreasing our static stability or increasing our static instability over time with this, so that allows layback that allows velocity, but at what cost. And I think that's what it is is we don't have the dose. So, you know, oftentimes it's very easy for these athletes that we've talked about the importance of hip core, scapula, or shoulder strength, right? We see these athletes that aren't prepared for any of this and then all of a sudden they start overdosing. So yeah, it's definitely a combo that we don't like to see. And Joe, anything that you're, you're seeing when the athletes come in and, uh, you know, that they might have slap pathology that you're really focusing on. You know, I think I've come to the point where it feels like everybody has some former sort of slap pathologies. And we've come to accept that obviously, as they've progressed from the amateur to the professional, to the major league side and all points between where it doesn't matter, they are, as Mike was talking about, they're all chasing the gold goose, the weight balls are a part of it, consistently tweaking mechanics as a part of it. I think sometimes getting out of what makes them special as a part of it. And that's been a big part of a learning curve for me is I think sometimes there's such a high level of mechanical alterations, sometimes inning to inning, sometimes year to year. And I've had players that have made alterations and have almost been on the tape and they've said, no, no, no. Let me go back to who I once was. And they've continued to pitch healthy. So I think sometimes getting out of that norm, what's given them that layback or what's given them that freedom. Sometimes they, they look to almost either push it or we end up in surgery. And I guess a question that I've long had, and I wouldn't even know how to really approach it outside of really turning to, you know, Mike Ronald, somebody who does a lot of research or turning to our director of performance, Joe Myers, who does a lot of research is how much, when you end up taking care of the slap tear and everything that goes with kind of tightening up that inherent laxity is humor retroversion, not being accounted for as far as what gives that layback, how we're looking at that under, you know, ultrasound measuring dominant to non-dominant and what they're used to and what they're trying to attain and how is that translating down the chain and how much is that something we should be looking at prior to getting into surgical intervention? Yeah, for sure. That's a great question. And we, we could talk about this for a long time. My, my personal thought on the humoral retroversion is we know that the proximal humerus fices is going to de-rotate during development. So it's highly likely you're not going to become an elite level thrower if you start throwing later in life, right? So you've almost independently assorted who's going to get there and who's not. So in my mind, although it's good for research if you have a baseline, retroversion is not going to change the bones healed. They are where they are. So I think that in my mind it's more of a soft tissue issue, but you might have somebody that's at risk that because they're not, they don't have a lot of external rotation at baseline. Not retroversion. Retroversion is what it is. Correct. I'm saying retroversion pre-surgical and then finding when you come out, where are you in your max layback? Has that changed? Then what they end up doing is trying to recapture what they can't do. We ended up putting weight balls in their hands and then you've got a whole mess on your, on your hands when it starts translating down to the elbow or they start mechanically altering who they are. I think as far as SLAP, we see that we can address the scapula. We can address everything, but just from a non-operative management, that is our ultimate goal is to try and get through it without surgical intervention. Yeah. Those are great points, Joe. All right. Thank you all very much. We are moving on finally to Dr. Weber's presentation and then to our last panel. Thank you. Welcome everyone. My name is Kathy Weber. I am the director of primary care sports medicine at Midwest Orthopedics at Rush, Rush University Medical Center. I will be presenting a hamstring injury case. I will be presenting a hamstring injury case. Unfortunately for my team, I could have picked from numerous hamstring injuries that occurred this past season. I have chose this particular case as a learning platform. This is a case of a 24 year old male professional baseball player who was running to first base. He landed awkwardly and felt a pop. He immediately experienced pain localized to the right proximal posterior thigh. He was helped off the field. He was immediately evaluated in the training room and acute treatment was initiated with rice, rest, ice, compression, and elevation. He was placed on crutches. The following day he was seen in our orthopedic office and evaluated. His physical examination revealed that he ambulated with a preferred stiff leg. He had posterior thigh, minimal bruising. There was soft tissue swelling and muscle spasms. The medial side of the tendon appeared intact. However, the lateral side was less defined. Pain was elicited with hip flexion and knee extension along the proximal tendon. Radiographs were obtained and were unremarkable. An MRI of the femur was ordered. His MRI revealed a high grade partial tear of the proximal common hamstring origin. As seen here on the stero-coronal view, his semi-membranosis appeared intact. The biceps femoris long head was completely torn and retracted two to three centimeters as seen in the above images. The stero-coronal, T2 axial, and T2 sagittal. So where do we go from here? How do we treat this athlete? Do we treat them non-operatively with a number of the options shown here, or should this athlete be treated surgically? What are the pros and cons of each of these treatment options? What are the potential complications? What is the return to play timeline look like for these treatments? The panel will discuss these points. I know there are numerous teams evaluating their hamstring and conditioning programs after the plethora of hamstring injuries that we're seeing in this past season across the league. They're exploring the best preventable options moving forward. We all want to be proactive, not reactive. We'd like to keep our athletes on the field and without injury. Next, the panel will discuss the various aspects of treatment and prevention of hamstring injuries. Thank you very much, Dr. Weber. We now welcome our panel to discuss hamstring injury, rehabilitation versus repair with return to play. Thank you all for joining us. Dr. Weber, over to you. Great. Thank you. I know a lot of teams had a lot of hamstring injuries this year, which is not an unusual thing for these high explosive sports and running, but we also see in other sports. Those individuals that are in our audience, hopefully you'll learn from some of the things that we'll take home from this case tonight. First of all, the case of the athlete that I presented was a proximal injury. We all know that that's not the most common acute injury. We typically see more of them in the myotendinous region of the hamstring. Unfortunately, this year we saw both proximally mid and distal hamstrings on our team. What I'd like to do is start with a discussion of this athlete's injury. I'd like to talk to, have Mark, I'd like to, I'm really interested in your thoughts in regards to this player's injury specifically, what do you think the management options are for this player? Well, Kath is, first of all, I think of this list of distinguished panelists, I'm probably the least qualified as a shoulder and elbow surgeon, but happy to chime in, you made a great point. A complete proximal rupture like that, even though you still had some semi-membranosis attached, is a rare injury in baseball. That's the type of injury we see in our water skiers, getting pulled off the dock, pulling that hamstring off, that proximal hamstring like that. At least in the general populace, if you get more than two centimeters retraction of that proximal complete injury, you think long and hard about maybe operating on that and fixing that because if that goes on and scars distillate, gets the sciatic nerve involved, it can be much more complicated down the road. So again, not being a hip surgeon, but I think that that needs to be in the discussion as to possible treatment for this injury. This is a nasty problem for sure and rarely seen, I think, in baseball. And I'm very interested in hearing my colleagues here who've had experience maybe with some of these injuries. I've not seen a proximal like this in one of our baseball athletes. It'd be interesting to see if anybody else on the panel has seen these and had some success either operatively or non-operatively getting these athletes back. That's a bad problem you've got there. Agreed. Lonnie, you've got a lot of experience in this world. Have you had any of these athletes at Cleveland? Thanks, Kathy. Have not actually. Had one way back in the day in Cincinnati as a free tendon injury that was repaired and eventually returned to the sport at approximately six to nine months. I'm assuming this case was eventually repaired as well, but as Dr. Chigudan has outlined and as you outlined, not all that common of an injury for us. Now, hamstrings, on the other hand, the non-free tendon ones are a little more common for us and exciting to talk about, especially in the preventative realm. Exactly. So we'll get to that in a few minutes. I want to bring in Dr. Hicks and let's change the scenario here because we're talking about baseball, but this is not an uncommon problem that we see in sports medicine clinics are these chronic proximal hamstring injuries. This one obviously has a pretty significant injury with the one tendon being retracted. But what are some other options for individuals not in the baseball player, but individuals like the weekend warrior or the marathoner who's coming in with these chronic complaints approximately? What other treatment options conservatively can you offer them? Are you on? There we go. Unmute. Sorry. That's okay. Good question. We see this often in a lot of our weekend warriors, even some of our basketball players who have had sort of these chronic hamstring, like, you know, tears, partial tears, tendinopathies. And usually when they become chronic is usually where we come and play a role as far as non-operative treatment and sort of trying to advance, uh, improve upon their symptoms. I think acutely there's not, you know, you do a lot of the eccentrics and hip strengthening and things of that nature that sort of help more long-term. I'm a bit of a stickler about putting steroid around a tendon in an acute phase, which I think most of us probably would agree with, but I think to answer your question, Dr. Weber, chronically, there's been good data that's starting to come out, um, with PRP injections, um, and this is again, more with chronic injuries where you can have, you know, build up a scar tissue in that area, hamstring feels sort of chronically tightened or sort of stuck as some of what our athletes will tell us. Um, PRP is now sort of coming out as a good option, um, for more chronic hamstring issues where you go ahead, I do a tenotomy procedure where I sort of try to restart the injury phase or an acute inflammatory phase with the, with the athlete, poke a few holes in there and drop some PRP in there. And it's usually a full sort of six to three months recovery phase to try and get them back slowly into, uh, some of their more athletic endeavors, including like running and jumping. Right. Um, and I would agree that, you know, um, I do that as well. Um, you know, we use PRP and, you know, in the, in the bellies, et cetera. Um, you know, the hard part about the PRP is that the literature is very, um, um, controversial. There's some studies that show that it may be effective, some studies that doesn't, but I think as, as a sports medicine physician and team physicians, we're trying to get those players back. So we're looking for that, uh, for whatever we can to help them. Um, has anybody on this, um, call had any experience with, um, the angiotensin receptor blockers and any of the hamstring injuries? I haven't personally, it's in the literature. I don't know if Mark or, or even any of that, um, uh, PTs or trainers, have you guys had any of the initiation of that in some of your players? Um, no, I've had no experience with it. I'm, I'm, uh, I've heard of it. Um, but I, I, um, we've not used it. Right. I mean, I think that it's, it's, you know, really new. I haven't prescribed it's off label, obviously. Um, and so I just wondered if anybody, any of the teams were using that at all. I think, um, I think Ed Snell from the pirates has some experience with that, if you're really interested. Okay. Um, the other thing, um, if we look at, you know, muscle tenderness and, um, muscle belly injuries, you know, corticosteroid injections have been, um, utilized. There's been literature, you know, strongly from the NFL and its use. Um, um, I'm assuming, um, teams have had that experience. Um, any, um, thing from, uh, the Astros, have you guys had to use corticosteroids in some of your hamstring injuries? Um, not, you know, we're not talking about the proximal one. Jeremiah, um, we, we have not today. We've not really used that as, um, any of our, uh, treatment methods so far. No. Okay. All right. So, um, I want to move on to a little bit, um, and talk about kind of the rehab process. Um, I'm going to come back to the case in a few minutes and say, tell you what happened. But, um, you know, I think rehab and prehab or prevention is really kind of where I think we're, we really need to, uh, drive this conversation. Um, what are the, what are you guys doing? Um, uh, Brooke, um, I know you just published an article with, um, actually Michael, um, on, um, kind of the, the, uh, off season conditioning. What are you guys looking for in, um, making the assessment and trying to, you know, design programs to really help us prevent these types of, uh, injuries, uh, from occurring. Um, there was a really nice paper from Timmons talking about, um, short biceps and more fastball length and weak eccentric hamstring strain. So for us, I think that's going to be the biggest component. I think obviously where we see the injuries the most are high-speed running. When you compare high-speed running to other forms of exercise activity, um, it's really, if, you know, if sprinting is a hundred percent hamstring EMG, the Nordics are maybe 70%. There's nothing that really comes close to sprinting. 70%. There's nothing that really comes close to sprinting. So I think it's a combination of those two things. Um, you've got to have a good eccentric hamstring program and you've got to have a good, um, thoughtful buildup for the sprint program. Um, so I I'd say especially eccentric hamstring strength too, because. Um, just reflecting back on the research concentric exercise actually been shown to shorten fastball length. Um, so we really need to hammer eccentric hamstring strength and then build that up prior to getting into intense sprint work. Um, Todd, what's your, what's your experience on, if we'd say we have a, um, you know, grade two, not a severe tear. What, what is your kind of rehab in the training room, getting them back? And what do you, what's the typical timeline for, uh, those types of injuries to get back to full back, um, baseball activities? Thanks, Dr. Weber. Um, that's kind of a loaded question there, but you know, depending on the position, depending on the expectation of the position, um, and the timing of the season, uh, those are a lot of factors that go into the timing, uh, in general grade two, uh, hamstrings, uh, muscle strains, uh, four to six, six to eight weeks, depending on the severity, depending on the level, uh, depending on the level of training that, that has led up to the injury. Um, and, and what we're, we're challenged with most at this, at this juncture, I think is really aligning expectations of workload for our athletes and making sure that our athletes, as, as Brooke just mentioned, that we can do all the strengthening in the world, but if those, if it's not strong enough and the expectations aren't matched up with the workload, we're going to continue to have these, these chronic hamstring injuries. Right. And I think the other problem is, is that, you know, once I've had an injury, they have an increased risk of potentially another injury. So that timing is really critical, but it's, it's a difficult balance and there's so many components to that. So I concur with you. So I want to get back to the case. So, um, this player, um, obtained two opinions and both, um, opinions, uh, recommended surgical repair. So we underwent a right endoscopy, uh, endoscopic, uh, proximal hamstring repair with a minimal open incision with an ischial burpsectomy. Um, he went through post-op rehab. Um, he's now, uh, been, uh, continue to progress to strengthening reconditioning and he's transitioning to great graded return to baseball, uh, related activities and expected to return to full baseball activities for the 22 season. So I, you know, I thank all of the panelists, um, not just for this one, but for all of them, I think it was very helpful and informative. Um, and, um, I look forward to hopefully having a hamstring free injury year next year. Thank you all so much for that discussion and a big thanks to all of our panelists and presenters for their work on tonight's webinar. Thank you to our attendees for joining us and participating in baseball and beyond. If you haven't already, we encourage you to register for next week's baseball and beyond night two webinar by going to sports med.org. If you're interested in CME, you can click the survey link in the chat to complete the evaluation. 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