On behalf of AOSSM and PBATS, welcome to Baseball and Beyond Night 2. 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 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 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, throughout the webinar rather than saving them for the end. In addition, tonight we will end with a longer ultrasound presentation. Now let's get started. We'll begin with Dr. Schickendance's presentation and then hear from our panel. We're going to talk about ulnar collateral ligament reconstruction and the lessons I've learned along the way. These are my disclosures. I think most importantly, it's widely recognized that the technique that we're using is going to get us good results regardless of which method that you prefer. I like the docking technique, but I think it's important for the surgeons in the audience to do whatever technique they're the most comfortable with. My UCL reconstruction, I said, is a docking technique. Other options include the Jobe 3-ply, interference screws, suture anchors, suspensory buttons. The docking technique is the most widely utilized, and that's my go-to for these reconstructions. I like the palmaris, the ipsilateral palmaris, if it's available. Biomechanical studies have shown that it's strong. We know it doesn't have any significant compromise on pitching biomechanics. Other choices would include the gracilis. Just of note, if your athlete has a poor quality or small palmaris on the ipsilateral side, they probably have the similar morphology on the opposite side, so going to the opposite side probably isn't going to help you a whole lot in that situation, and I would recommend using a gracilis from the contralateral leg. I like to use the tenon stripper through a single incision at the wrist crease. Look for adhesions between the palmaris longus and the flexor carpi radialis, particularly in your younger athletes. If you run into those, be quick to shift to multiple small transverse incisions across the baller aspect of the forearm to harvest your graft safely. Once we make a skin incision, we're going to look for the medial lateral brachial cutaneous nerve. It almost always runs next to this big vein that we see crossing the middle of our field. I like to split and don't lift, and I'll explain that to you, and for me it's expose and don't transpose, so what does that mean? I use a muscle splitting approach between the FCU and the FDS, gives us enough exposure to see the ligament in complete continuity. If you've trained and learned how to do the elevation of the common flexor origin, by all means, that's the procedure that you ought to be using. This is what the muscle split looks like. There's a little raffae between the FCU and the FDS, and we follow that. As far as the nerve goes, I expose it just enough to control it, and I only use a transposition if we're having instability symptoms of the nerve. Go distal when distal. What that means is we've got plenty of real estate on the ulnar side, in terms of putting our ulnar tunnels. There's a junction between the sublime tubercle and the medial ulnar collateral ligament ridge, and that's where we're headed for with our ulnar tunnels. You can see the down arrow here pointing to the tubercle, the two up arrows are where the ridge is, and right at the junction between those two is where we place our guide to go ahead and create our ulnar tunnels, and this is ideal ulnar tunnel placement in my hands. This is just a quick look at that. We've got this exposed nicely, that's the sublime tubercle there. The ridge is distal to that. We've got our retractors in. That bottom retractor is very important to protecting that ulnar nerve. We use this little V-shaped guide to create converging tunnels, 3.5 millimeters, again being very careful down below to protect that ulnar nerve. Once we've got our holes drilled, we use a curved curette to carefully be sure we've got continuity of those holes so we're creating a tunnel. We also use that to chamfer the front edge of those tunnels so we don't have a sharp edge. We'll come in with some irrigation, wash out any bony debris, and then we'll use passing sutures through this ulnar tunnel that's going to assist us in passing our graft once we're ready to do that. On the proximal side, we need to stay lateral and proximal. What does that mean? Chris Amad's done some great work on this, looking at where the ulnar tunnel should be. The mistake typically is being too posterior and too medial. We want to be a little more anterior and a little more lateral, so you want to be down in that crease where the trochlea starts off the epicondyle. This is ideal tunnel placement in the modeling study that Dr. Amad did. That's the location we want to put our humeral tunnel. We've got some guides that help us with this as well. This is what this looks like once we get this passed. I'll take you through the actual drilling of this. Here we go. We're going to release our soft tissue approximately here up to the amelial epicondyle, come off of that trochlea down there. We want that little corner down there as our goal for the aperture of this humeral socket. We use this drill with a positive stop. I use either a 4.5 or a 5mm drill to make a socket. We'll go ahead and curette that out. We use this little C-guide to create our exit tunnels for our traction sutures to be used for our docking technique. We use these sutures to pull our graft up into this socket and ultimately secure it over the back side of that. We do have some instrumentations commercially available to help us with the passage of these sutures which can be a little tricky. Once our sutures are passed, we'll then pass our graft and then distally. You can see it coming through the ulnar side and on the proximal side we're going to place a whip stitch. That stitch is going to be ideally to the depth of our socket and then what we're going to do is pull that up in there and pull that off and flip that over. Go for 3 means rather than cut that excess tendon, what we're going to do is fold that over so we get a 3-ply reconstruction. You can see our passing sutures out the back of the epicondyle there on the right and you see our 3-strand reconstruction here on the left side. This is what this looks like when we're finished. We put these in a post-operative splint for 7 days. This is followed by a hinged orthosis we use for 4 weeks. Athletes will wear that orthosis for about 4 weeks or so with the goal of gaining full motion at 4 weeks and then we'll start them on a strengthening program. Thank you. Thanks very much for that, Dr. Schickendance. We now welcome our panel to discuss UCL reconstruction. Thank you all for joining us and Dr. Schickendance, take it away. Thank you so much. I appreciate the opportunity to present that technique. Jeff and Keith, you guys are both fabulous surgeons, tons of expertise here, lots of experience. Jeff, I know you're going to give us a talk later on the internal brace. Talk to us a little bit about your approach and how it differs from mine with regards to doing a reconstruction with a graft. Yeah, Mark. Great talk. Our approach has been using the modified Jobe technique, which is what I learned from Andrews. Interestingly, I learned the docking technique from Alchek when I was a resident. That was actually the first way I learned it. We're so in tune with doing it with the modified Jobe. I think the results are the same. I don't think there's a real plus or minus. We move the nerve because we approach the reconstructions from the backside rather than going transmuscular or intermuscular. We approach it by elevating the flexor pronator mass rather than splitting it. Because of that, we move the nerve. We haven't really seen any nerve issues, nothing that makes us want to stop doing that. That's why we move the nerve is because of the approach we use rather than splitting. It's really kind of dealer's choice, as you know. I think that all of these things have great outcomes. I think the key and salient point to what you said is that the humeral tunnel is really what determines the outcome of these things in a lot of ways. If you don't get that right, you're setting yourself up to fail. I really do think the humeral tunnel is probably one of those things we need to teach people to pay real close attention to as their techniques evolve and their experience with this evolves. They really have got to be determined to get that humeral tunnel in the right spot. Absolutely. I completely agree with you. Mike Ciccotti and others have done some nice recent work on looking at the outcomes from the different types of reconstructions that are done. To your point, and my first point was, do what you're comfortable with. You're going to get a good outcome and be confident in your ability to reproduce what it is that's very good in your hands. On the humeral side, I think the mistake tends to be, as I said, a little posterior and a little medial. What do you think is going on there? Is it a mechanical thing? What are your thoughts on that? I think that there's a tendency as you cut from the sublime tubercle and you split the ligament to air posteriorly with the split. You tend to follow the ridge of the tissue rather than going in line with the fibers. I think it draws your eye almost posteriorly. It's easier to drill a little posterior. You got to want to put it anterior on the face. I think that that's something that we've all, as all of us have talked about this, have seen how important that is. I just think the biomechanics of that, everything seems to be pointing in that direction. You and I have had this conversation a bunch of times. I think that when UCL reconstructions fail, most of the time they fail in the first eight weeks. We may not see it until eight months later or 12 months later, but they fail because they don't heal because the tendon graft isn't able to heal in that environment because it's moving too much, which is usually a tunnel. It's almost like an ACL. If you don't put the tunnels in the right place, the ACL is going to fail. I think that the UCL is similar in that regard. I think you're right. It's almost equivalent, I think, to the killer turn you see with the PCL reconstructions. If you get that thing hanging out there too far, it just creates this angle. It's just biomechanically, it's just not going to work very well. I think we're learning a lot about tunnel placement and anatomic reconstruction. We've got a little ways to go. Have you changed your time to start throwing? I'll be interested in the PT's, John and Brett, what your thoughts are. When do you guys think we ought to start throwing these guys? I think we've actually moved our timeframe back a little bit and started throwing at five months. We feel like it gives us time to get more of the plyometrics done, get more of the strength, the total body strength, and just allows for more healing time. I agree. We tend to err on the side of five months to five and a half months. Then ultimately, it comes down to the time of year. We try to look at the clock backwards of when is the goal or return to play and do we have extra time. If we have extra time, we go ahead and take advantage of that full time to let this thing heal even more. Jeff, thanks guys. That's great insight. Jeff, I have a question from the audience with regards to tensioning our reconstructions. The question quote is, with regards to graft tensioning, how do you decide about how much tension is enough? I would add to that, in what position of elbow flexion do you prefer to fix your graft? We do ours in about 30 degrees of flexion, but before we tension it, we take it through a full range of motion to be sure that we have not constrained it. I want to make sure that as I flex from 30 to 90 and beyond, that I'm not going to create a lot of tension in that graft. I think that you can tension it 90 degrees or 70 degrees. I think that's an okay thing to do too. You're not going to over constrain it, likely doing it that way. I think we don't want to put these things in too tight. I think obviously you'd rather put a graft in in a way that it's going to be as close to isometric as possible, but you can't capture the elbow with it. I think those people don't do very well and those grafts probably don't heal. I think whatever angle you tension it at, you probably ought to take it through some kind of range of motion and assess your isometricity to be sure that you're not over or under constraining it before you choose your final answer on that. Excellent. I completely agree with that. Completely agree. Brad or John, any other questions or comments before we move on to our next topic? Terrific. Alexander, why don't we move on to Dr. Dugas' presentation on the internal brace? Perfect. Thank you all for that discussion. We'll move on to Dr. Dugas' presentation now. Hello, this is Jeff Dugas. I'm going to speak to you briefly about UCL repair with internal brace. These are my disclosures. While Norwood was the first to report in 1981 on four patients with only two getting back, Drs. Jobe and Andrews both showed basically less than 30% return to play with repair. So these had generally poor outcomes and these were reported by some of the giants and best to ever perform these procedures in our profession. Buddy Sabwa, also one of the best ever, reported in two papers on repair of the UCL first in female athletes then in male overhead athletes predominantly with an average age of 17. 58 out of 60 returned to play at the same or higher level at an average of six months. Unfortunately Buddy's work went largely unnoticed and it wasn't until five years later that we discussed this and had an idea for maybe augmenting repair because we felt that reconstruction may be too much surgery for some of the injuries we were seeing. With the novel construct the internal brace popularized by Gordon McKay we thought maybe we had a way to not have to go through reconstruction maybe we could do something less with a quicker recovery for some of the injuries we saw. So who's a candidate? Well I would submit that anyone who does not have a tissue deficiency could be a candidate for repair rather than reconstruction. The one on the left looks to have good ligament tissue that's evolved from bone whereas the one on the right has very poor appearing tissue along with a large enthesophyte. That person is going to have a tissue deficiency and should have a reconstruction with more collagen added. With Buddy's success as well as a time zero report from some basic science studies we did we did the first patient on August 8, 2013. Since then we've done over 500 of these with several thousand done across the country and interestingly in 2019 25 percent of NCAA UCL surgeries were done with repair with internal brace. We had 17 loss to follow-up so an 87 percent follow-up rate mostly males with an average age of 18. Mostly baseball as you'd imagine with some softball javelin and football. These were about two-thirds high school and the remainder mostly collegiate however no difference was seen in level of play in terms of recovery and return to play. Overall 92 percent were able to return to play at the same or higher level with a KJOC score at two years of 91 which is the same as a healthy major league pitcher who's never been injured. They returned at an average time of 6.7 months. About half had a normal nerve transposition but it didn't make a difference the p-value was 0.3 no statistical difference with or without UCL or ulnar nerve transposition. The location of the tear and the extent of the tear also made no difference so the p-values were high showing no difference in either of these. There were minimal complications we had to remove a subcuticular stitch there was some heterotopic bone and we had to go back and perform ulnar nerve transpositions and two who hadn't and a revision in one all returned to play. Patients tend to achieve full range of motion within six weeks and we begin plyometrics at that point assuming the range of motion is full and painless. The throwing program is initiated after that time frame usually in week 11 with an average return to full baseball or overhead throwing at just over six months. Our group was largely high school and collegiate athletes. The first major league pitcher was done in June of 2016 by George Palletta. He returned to full competition in nine months in major league at 11 months. There has been significant increase among the major league teams over the last several years with more and more people being drafted post-repair with internal brace. I've revised eight of the major league teams that I've coached in the past year. I do use a little bit larger anchor on the medial side. Five have returned to play with the other three less than six months post-op. So my thoughts are that with other ligamentous injuries in the bodies the UCL can be repaired back. The addition of the ultra-strong tape may provide a backstop over time for healing but it is not a ligament replacement. I'm not going to go into the details of the reconstruction. I don't know if the tape is structural or simply a scaffold for healing and I don't think it matters whether you do an ulnar nerve transposition or not. So I have cautious optimism in patients with partial thickness injuries and end avulsions. I don't think this technique will hold up over time in large numbers in people with poor quality tissue or in patients with severe injury. I don't think it will hold up over time I don't think this technique will hold up over time in large numbers in people with poor quality tissue or tissue deficiencies. Although I have done some of these I don't anticipate the outcomes being as good as the good tissue ones. The decision to perform UCL repair with internal brace is an intraoperative one. It should be based on tissue quality and quantity. However the level of play, velocity, age, ulnar nerve transposition or not, location, and degree of tear have shown no effect on the outcomes and revision with repair with internal brace appears to be less complicated and more successful than revision UCL reconstruction. Thank you very much. Thank you so much Dr. Dugas. We now welcome our panel to discuss UCL internal brace. Thank you all for joining us and Dr. Dugas over to you. Thanks Alexandra. Mark, John, and Brett thank you guys again. You know I'm curious what you guys have seen and Ron hey Ron Porterfield thanks for joining us. You know what you guys experience has been with internal brace. I talked to Kevin about this all the time and he he thinks that this is you know just so much easier recovery. I still say it doesn't fit everybody but it seems to fit a lot of people because most of the people we see are are younger and you know there's only a limited number of major league baseball players. So what has your experience been from a PT perspective? John, Brett, Ron what have you guys seen with this and where does it fit in the world that you guys work in? We've had success with them so far. We've had some guys more in the minor leagues that have come back and have performed well. I'd like to see even more of them because the rehab is just that much more accelerated and the results have been so good. So I'd like to see more of them. I'm curious Dr. Dugas on the initial thought was the tears had to be more proximal and are you doing more in either mid substance or distal tears? To me I think the distal and proximal ones are the same. So we saw no difference. So I actually see a lot of distal tears. I don't see a lot of of the mid substance ones that I think are good for internal brace. I've done a few but you know that may be okay it may not. We'll have to see. I think in a pro the proximal and distal ones do just as well. I think they're equivalent. I think first off thanks for allowing me to be on this panel. I'll talk about two that we had last year in 2020. We had two one that was done in May one that was done in September both by pretty astute surgeons in major league baseball and the interesting thing about it we're probably a little more conservative with professional baseball because we allow them you know if they have any inkling of tightness or soreness we kind of back them down a little bit. The awesome thing about the the repair is that the range of motion comes back so much quicker. The thing that's tough to remember is how quick throwing gets upon you at about the four month mark versus about the five and a half to six month mark. But the interesting thing is you know with all the throwing that we do and what they go through as far as like live bps and and bullpens and you know taking time to to mix in all their pitches during the throwing program. They both came out up came back and pitched at relatively the same at the same time frame right around nine months where they were actually pitching in live batting practices competitively and about 10 and a half to 11 months where they were actually pitching at a high minor league level of a competition. Yeah and and you know that's kind of been our experience I think with the college with the high school guys I think the high school and college guys I think we can get them back the high level d1 guys we can have them back in six to seven months. The pitchers you know maybe eight at the most. I think at the pro level you know these guys there's so much invested in them that there's no point in pushing them unless their timeline dictates that. One of the revisions that I did who was interestingly one pitcher of the month in May at the ripe old age of I think 41. So he had a Tommy John in 2011 and we I revised him and I've gone to revising failed Tommy John with internal brace. I think we can all agree that revision Tommy John surgery is probably one of the least successful things that we do in our practices. Mark I know you and I have talked about this that's one of my least favorite operations to do and I think the outcomes are just horrid but I think I've been happier with repair as a revision to reconstruction and reconstruction with a revision to repair. What's been your thought on that? You're on mute Mark. Yeah Jeff I completely agree. You know I think I think what's going on here is clearly that internal brace is is supporting the the native ligament or the reconstruction and you know Keith talks about this a lot. You know that that that that that brace seems to to allow to allow us to let that ligament really heal beneath you know what's going on there you know structurally with with the with the tape and with the internal brace and you know he's been doing some work with these hybrid reconstructions with with a reconstruction with a graft and and the internal brace and and it makes a lot of sense to me that we're doing that. What what what what are your thoughts on on combining a a graft and when would you maybe consider doing a graft plus an internal brace in the same setting? I've been asked that a bunch. I've done it once and and I did it because I felt like the tunnel on the ulna was not as competent. I just drew it was a native ulna and I drilled a tunnel and I just didn't wasn't sure that his bridge was it seemed like it was just small and I really wasn't comfortable that the bridge that I had between the tunnels and the ulna was was great so I overlaid it with an internal brace and and he's fine. So I think it can bail you out of some bad bone issues you know too. I want to I want to bring a question to John and and Brett as well. Brett if you have thoughts. You know John when when we're putting these people into range of motion we're putting them in a brace we're starting a range of motion earlier we're getting the range of motion back quicker they're feeling good. We I have a problem with the weight room with these guys. They want to go lift weights you know four to six weeks after surgery and I'm always telling them do not lift weights upper body except for your band exercises until you're done throwing. How do you guys handle that with the level of throwers you're dealing with? These guys are used to being in the gym. How do you handle these guys when they just are dying to go lift weights? I tell them that's the worst thing they can do is lift heavy upper body stuff after after these kind of things. We try to load the that's a great question. We try to load the the joint and the ligament isometrically initially and then we try to involve more manual technique or manual resistant versus just getting in the weight room and getting after it. We tend to err on the side of caution as well and the team approach between our strength coaches and and our our rehab professionals we're able to you know just guide them through the the right channels and the right process but we tend to do more manual resistant and some more proprioceptive techniques just to again load the tissue load the ligament and the repair but not stress the repair. I'm always impressed with how I say the same three things to patients when they start their throwing program and I make a point of saying number one I tell them to always throw to a target even when you're 120 feet away make somebody stand there and hold a target because if you don't when you get to phase two you're going to throw the ball in the dugout. Number two I tell them to throw on a gentle arc we're not throwing on a straight line even though you can I want it on a gentle arc but I want the arc to be the same as you back up through the phases of the throwing program that way the only variable is the effort you're giving and then I tell them to do their band exercises after they throw fatigue their shoulder after they throw not before and then when they're done with that go for a run or get on a bike to flush out whatever lactic acid they got. So what else do you guys add to those kind of instructions what are your what are your words to your players what's the advice you give your guys when you're telling when you're taking them through a throwing program we got about a minute or two to go. I'll try to be quick we try to warm them up and actually load their arms before throwing but not to the point of any type of fatigue so we we advise them to get the tissues activated we don't do a ton of aggressive stretching or anything to the shoulder or elbow before unless that's absolutely necessary but we try to actually get them more active and and better properly prepared to throw the baseball prior to throwing and then following we ask we do our maintenance strengthening arm care program. Got it well guys Mark any final comments from you? No it was fantastic Jeff thank you so much your experience and your wisdom on this is literally groundbreaking you are literally changing the way we think about and do ulnar collateral ligament surgery and listen I know you're humble about it but seriously it's really been revolutionizing how we how we handle this so thank you so much for all your contributions. Thank you I appreciate that. You're very welcome. Thank you guys thanks everybody for participating and Alexandra I'll turn it back to you. Of course thank you all for that discussion next up we're going to move on to Dr. Verma's SLAP presentation and then to the next panel. This is Dr. Nick Hill-Verma director of the sports medicine and shoulder surface at Rush University Medical Center and Midwest Orthopedics at Rush in Chicago and I'd like to present to you today the treatment of superior labral pathology in the overhead throwing athlete. My disclosures are available through the academy's online disclosure program. The case that we're presenting today is an 18 year old right hand dominant pitcher and outfielder with a history of right posterior shoulder pain which has been recalcitrant to an extensive conservative management program including medications injections and physical therapy. He's able to hit but he reports posterior superior shoulder pain with throwing particularly in the cocking phase of the throwing motion. Radiographs are seen here the patient is skeletally immature but approaching skeletal maturity but otherwise no abnormal findings noted on diagnostic x-ray. MRI scan is seen here and one can appreciate evidence of a posterior superior labral tear with cystic changes within the greater tuberosity and potentially a small undersurface rotator cuff tear which is typical for these internal impingement lesions. The surgical procedure is next demonstrated. We begin with the dynamic shoulder examination. This is with the patient out of traction the scope in the posterior aspect of the shoulder. We're in a lateral position and we can see here as we bring the arm into a typical abduction external rotation position one can get a true appreciation of internal impingement with the abnormal contact between the humeral head and peel back of the superior labrum with undersurface tearing of the rotator cuff. This is the true internal impingement lesion. Diagnostic arthroscopy is then performed in this case the patient had preoperative bicep symptoms with temporary response to a biceps injection and therefore concomitant biceps tenodesis was performed and here we are examining the labrum within the shoulder and one can see a significant anterior superior labral tear. And as we move the scope to an anterior superior position, we can see that the tear extends posteriorly, which in my experience has often been associated with increasing pathology or lack of response to conservative care in these patients. The next step is to actually perform the repair. As stated earlier, a biceps tenotomy has been performed based on preoperative biceps symptoms. The bony portion of the glenoid is lightly decorticated using a bone-cutting shaver to allow for a bleeding bed to heal. At this point, a 7 o'clock portal is established and all suture knotless anchors are placed in a percutaneous fashion in order to repair the labrum. The repair begins at approximately the 530 position at the distal extent of the labral injury. Sutures are passed through the labrum only, avoiding any significant capsuloraphy that may reduce range of motion, which can make return to throwing extremely difficult in these athletes. The repair is performed sequentially, placing anchors every 5 to 7 millimeters. And as we move more superiorly, we switch from a curved suture-passing device to a crescentaric suture-passing device to allow the appropriate angle of insertion for the anchors. Here you can see the completed posterior aspect of the repair up to the 11 o'clock position. Next, we place anchors into the superior aspect of the repair using a Wilmington portal, which is placed just off the anterolateral edge of the acromion. And we can use a spinal needle, which is placed through the divisor portal in order to pass and retrieve sutures through the labrum superiorly. In this situation, because of the extent of the tear anteriorly, which appears pathologic in my opinion, I elected to proceed with an anterosuperior anchor, but take great care to make sure that we do not incorporate the coracohumeral ligament or the superior glenohumeral ligament into the repair, which may significantly reduce rotation, making return to throwing extremely difficult. Sutures are then retensioned. The knotless construct allows for a very smooth interface between the labrum and the articular cartilage, which will limit any significant articular injury as the patient returns to high-level throwing with contact between the humeral articular surface and the sutures. An open biceps tenodesis is then performed, as has been demonstrated previously. Postoperative rehabilitation is demonstrated here, and return to throwing is generally initiated at approximately five months. Thanks very much for your attention. And thank you to Dr. Verma for that presentation. We now welcome our panel to discuss SLAP. Thank you all for joining us. Dr. Verma, take it away. Thanks very much, guys. Hopefully we have our panel with us. I don't see them popping up. There we go. Welcome, Mike. So, I'm going to start with you, Joe, and I'm going to ask you, is Joe on with us here? There we go. So, you know, one of the difficult decisions that we have for any of these athletes is trying to make a decision about when surgery is indicated for the SLAP lesion, right? We get MRIs on all these players, probably 70% have some, quote-unquote, labral pathology that the radiologist identifies or the surgeon identifies. So just walk us through, you know, what is your recap algorithm, and how do you get to that point where you say to the player, you got to go see a surgeon because we're just not going to get through this without some operative intervention? You know, I think for us, and especially for me, you know, over my, amazingly to say, 20-something years in the game, that answer has kind of changed in a lot of ways. It feels like very early in my career, it feels like we were very quick to jump into surgery, and the older I get, the less we really want to jump into that. So where we are now, I feel, becomes multifactorial in a lot of different things, basically looking at what has the pitcher done? Has anything changed in what they're doing? Have we added any kind of external forces, anything in a weightball form? Have we changed who they are, given them a new pitch? As we know, we're all dealing with the release cams, we're dealing with the labs. So looking at everything from that standpoint and stripping them backwards. Looking to strip them backwards and go with a non-operative management, see how they do. If they get to the point where they're feeling good, we may try and add some things back. If we add some things back, and we find that maybe there was just a, as a lot of us know, we come in with a lot of different programs. So taking the gross mismanagement some guys come to us with, what they believe is above average management, they end up doing well. By the time we start to add things back, we see failures. Then we talk to them again, go non-operative rehab again, maybe orthobiologics to the equation at that point in time. And if they can get back to the mound, try and encourage them to stay where they are, to not go through the surgical management. If they're insistent on adding it back at that point in time, you end up face-to-face for us with Dr. Eaton, just talking through and saying, look, we've hit a dead end. We've tried non-operative management multiple times, we've gotten multiple opinions. We've taken you through long toss program, we've taken you through mound progression, we've taken you through lives and you continue to fail at the latter point of the rehab. We start to hit that dead end where if they can't compete at the major league level, minor league level, or they can compete, but they're not the same pitcher they previously were, you kind of hit that decision point. And I think that's the one that we all dread is where you're sitting face-to-face in your office and you know that they can't compete and they can't defend themselves on the mound anymore. Yeah, I think it's a great point. Number one is the pendulum is completely gone from one extreme to the other, right? When we first saw slap pathology, we thought we got to fix everything. And now we've kind of gone the other way, which is we don't want to fix anything unless we absolutely have to. So I think that's what I'm hearing from you is exhaust everything you can because labral surgery is no fun for the surgeon or for the athlete. So Mike, one of the things that we have a hard time deciding of at surgery is, first of all, what's pathologic and what's normal. Some would claim that slap pathology is adaptive to allow for increased rotation. How do you decide at surgery what is an abnormal slap, what needs to be fixed? And as I showed in the case that I did is some of the decision that's hard to make is where do you start and where do you stop? Do you just do the posterior? Do you do the top? Do you do the front? I think you're muted, Mike. Yeah. Yeah. It's a great question. You know, we talked a little bit about it last week as well. I think that this is where it gets tricky with the throwers. You made a great point of not doing a capsule or if you're not grabbing capsule when you did go posterior and Jim Bradley talks a lot about that as well. It's different with a football player than it is with a baseball player. If you tighten that up, you're in trouble. I do think that with those type eight slaps that go down the back, that you do need to repair that. You know, I think that Hiro Sagaia has some great points about that anterosuperior region and do you tack that back down? You don't over tighten them. As you said, you don't want to tie in the corcohumeral or the superior glenohumeral ligament that would probably over tighten. But perhaps tucking that in just a little bit might be a good option. I think that you presented it well. You're going to exhaust all conservative management. Joe laid it out perfectly. I think that this is a totally last ditch effort in my hands. Yeah. I think you make a good point, which is for me, one of the hallmarks of any type of surgery in the overhead throwing athlete is you can't do anything that's going to cause them to lose motion. If these guys lose motion, it's pretty much the end of the game in terms of them getting back to throwing. So I'm very thoughtful about where I'm putting anchors and how I'm passing sutures to try to be motion sensitive when I do this. Mike Reinhold, the elephant in the room, obviously, as I showed this case, because I did a biceps on him and that's kind of the new hot topic. You know, in the older patients, obviously we've moved towards doing tenodesis as our primary option for management of the slap, but it's still highly controversial in the overhead throwing athlete. Can you give us some of your thoughts on experience in managing patients post biceps tenodesis? Do you think it's an always, I shouldn't say always, do you think it's a never event? Do you think that we can take the biceps and still get patients back to throwing? And what about other sports, meaning non-baseball athletes? Are there other sports where we have to be similarly concerned about taking the biceps? Yeah. I mean, I must say that our success with patients with a tenodesis, I wouldn't say the tenodesis has limited any potential outcomes that we could have. So what probably happens is if somebody needs a tenodesis or their shoulder is so significantly flared up that they have that much pathology, they're probably further along down that line where probably their outcomes are going to be limited anyway. So for us, I don't think you adding the tenodesis is going to change our rehab significantly or their outcomes from what it normally would be. You know, I always go back to what, you know, Dr. Andrews always says in meetings where he says, you know, somebody put that biceps there for a reason. They probably need it to pitch. But for me, I mean, I'd prefer not to take it off unless they definitely had to. But by all means, an older person that's in significant pain or even somebody like a general population patient that's not an overhead athlete, yeah, if that's a huge source of pain, then we can certainly do some things to build dynamic stability and function around the shoulder and get by without that function for sure. Yeah, you know, I've been relatively successful knock on wood with with removing the biceps when it's clinically indicated. I don't do it frequently in the overhead throwing athlete, but if they have pain anteriorly, which is relatively atypical for slab pathology, they respond to a biceps injection. I don't hesitate to take it because I worry about it being a persistent cause of pain and I haven't seen negative consequences significantly. I do think that we obviously need to learn more about what the role is for the biceps and throwing. The medical literature right now is very limited because most of the reports are in patients undergoing revision surgery or salvage procedures, and I don't think we can equate that with a primary procedure. So a lot to be learned with with regard to the biceps. Joe, we got about a minute less, but one last question for you is we've seen a lot of movement now towards biomechanical analyses or motion analyses and trying to determine either pre operative treatment and or post operative return to throwing. Are you guys using that routinely? And you think we should be looking for those facilities for our younger athletes in the communities? Do you think it's helpful? Well, it's funny, like right now as we're talking, we have actually on staff two biomechanics with the Rays. We just hired another one on full time and we use it, I mean, extensively as far as trying to get a baseline with our pitchers before and as well as as well as after. I think that the more we've gotten into it, there is a stronger comfort with how to use it. It isn't a constant tweak, tweak, tweak. It's getting that base and then seeing where they are changing, be it from mound to mound or in game, the breakdown we get from our biomechanics, just the little things. So I think, yeah, there is definitely a draw to pitchers trying to find those facilities. My concern becomes, do all of those facilities truly understand the overhead thrower? Do they all truly understand the major league pitcher or minor league pitcher, just the competitive pitcher? And are we overcorrecting to the point that maybe people are ending up at champion sports med or other places such as that, just trying to pull them back to the norm and keep them on the mound versus the constant tweak that, unfortunately, I think we're seeing in the industry that's landing people in yours and Dr. Freehill's offices more and more. Yeah. Yeah. So I think two great points. Number one is the way that we often use it at the major league level is to have a baseline and then look for quote unquote, what changed, which I think is very helpful, especially if you have an in-season athlete with pain. And the second point is, unfortunately, we're in a period where there's a very significant lack of standardization, where we have a high, a hard time really normalizing results from a given center or a given report that may be in our hands. But I do think there's going to be a lot of value in the future of this quote in vivo analysis to help us understand how to better treat these patients and when they're ready to go back or, or maybe biomechanical or biomotion issues that may be ongoing that are correctable to keep them out of the operating room. So a lot to learn on that front as well, gentlemen, I want to thank you for your time and we'll move on to the next session. Thank you to everyone for that discussion. We're going to move on to Dr. Verma's tenodesis presentation and then to the panel. My name is Nikhil Verma, Director of the Sports Medicine and Shoulder Surface at Midwest Orthopedics at Rush and Rush University Medical Center. And I'd like to share with you today the technique for open subpectral biceps tenodesis. My disclosures are available through the Academy's online disclosure program. When considering longhead biceps tenodesis, we need to keep in mind the anatomic considerations in that the longhead biceps is composed of an intra-articular segment measuring approximately 3.5 centimeters, but also a longer and more prominent extra-articular segment measuring about five centimeters, which cannot be seen arthroscopically, but may be a cause of anterior shoulder pain. As a result, multiple different techniques for biceps tenodesis have been proposed, but we prefer a subpectral tenodesis to maximize our fixation strength and also to eliminate the vast majority of the biceps, which may be a cause of persistent shoulder pain if tenodesed in a more proximal location. There are several advantages to a subpectral approach, including a distal technique, reduces incidence of persistent postoperative pain, subpectral fixation increases strength and fixation stiffness, it avoids poor quality proximal tendon disease, and it allows access even in cases of rupture or distal retraction. Multiple bone fixation options exist, and either a suture anchor or a bone tunnel screw fixation option provide high levels of fixation strength with no difference in biologic healing between inlay and onlay techniques. Surgical procedure is now demonstrated. This is a patient who's undergone prior labral surgery. He's placed into a lateral decubitus position, and we retract him to a 30-degree semi-supine position. I prefer a axillary fold incision for improved cosmesis, and you can see here the incision which is made over approximately 3 to 4 centimeters. The first step is to identify the interval between the pectoralis major and the short head biceps. The pectoralis major crosses the wound obliquely, whereas the short head biceps is a longitudinal structure, and the first step is to open the fascia overlying the short head biceps to allow for exposure of the long head biceps and retraction of the interval. Here you can see medial retraction of the short head biceps and further identification of the distal fascia, which is then open to allow exposure of the long head biceps. Here you can see the actual muscle and fascia overlying the short head biceps. Next, we place our retractors. The pectoralis major is retracted in a supralateral direction, generally using an army-navy, and the short head biceps is retracted medially, generally using a Hohmann-type retractor along the medial border of the humerus with care to avoid placing the retractor within the substance of the muscle, which can endanger the musculotaneous nerve. Once the retractors are in place, the long head biceps is easily palpated and removed with a curved hemostat. Next, further exposure is carried out to identify the medial and lateral borders of the humerus, as well as the base of the bicipital groove. Our preference is to perform a fixation using an all-suture anchor. This allows for a very small pilot hole, generally in the neighborhood of 1.5 to 1.6 millimeters, which allows for adequate fixation strength while minimizing the risk of post-operative fracture. The anchor should be placed proximally to allow for suturing to be done within the tendinous portion of the biceps rather than the muscle portion. We then identify a position about 10 to 15 millimeters proximal to the muscle-tendon junction. This can be approximated using direct measurement, as well as simply placing tension on the long head biceps and approximating the appropriate location to start suturing when tensioning is applied to the biceps itself. The suturing is done using a single limb of the suture in a crack-hour fashion, moving distally over a course of approximately 3 centimeters, coming across the tendon, and then moving back approximately towards the tendinous end. Once the suturing is completed, we can then take the opposite end of a suture from the anchor and place it in a simple configuration through the biceps to be used as a pull stitch. We then remove the proximal portion of the biceps, and we use our pull stitch to deliver the biceps against the humeral cortex. The pull stitch is then used as a post, and we perform standard knot tying in order to secure the biceps with an appropriate length-tension relationship. And final palpation confirms that the biceps is adequately fixated. Here you can see the cosmetic nature of the incision at the completion of the procedure. Thanks very much for your attention. And thank you for that, Dr. Verma. We now welcome our panelists to discuss. Thank you all for joining us. Dr. Verma, over to you. Thanks very much. Jeff, I'm going to start with you. You know, anterior shoulder pain can be a very nebulous diagnostic in terms of lots of different things that can cause it, very hard to come up with a firm diagnosis in terms of biceps, AC joint, capsular problems, labral problems, et cetera. What I haven't really seen, though, is people talk about conservative therapy management options for the biceps. If you've got a patient with a suspected biceps-related pain pathology in the front of the shoulder, what's your approach to the initial conservative course? You know, obviously, we like to look at the kinetic chain, and then we also like to look at the range of motion of the shoulder, how it's operating, how loose the shoulder is. We try to do, you know, if you talk about specific exercises for the biceps itself, we look at doing eccentric work and isometric work with the bicep, along with tying in supination and pronation, because it's crossing both joints to make sure that we're trying to get real activation of the tendon in the positions that the baseball players are. So we'll also get up into 90-90 of the shoulder. We'll also get into 90 degrees of flexion of the shoulder. As long as we're not creating symptoms, then we feel like trying to get them in as functional a position as we can and load appropriately is probably the best course of action to try to really treat that area. Yeah, Ben Kibler has talked about the biceps tension and trying to unload tension on the biceps, and I think some of the maneuvers that you just talked about probably accomplish that as well. Salvatore, can you talk to us about your decision-making regarding when atenodesis is indicated? What are your go-to preoperative tests? Do you use injections, ultrasound guided? Is it just palpation? Do you use tension signs such as speed or Yergesen maneuvers? How do you go about that? Yeah, so, I mean, especially in non-throwers, based on a lot of the work that you did, you know, in dealing with slap injuries, I'm treating pretty much any symptomatic slap that I see, even in a relatively young, active population with biceps tenodesis for the most part, regardless of that anterior pain. But for those, I do like to utilize ultrasound guided injections. If I think it's more slap related, I would, you know, intra-articular injection. And then if I think it's biceps groove related, then bicep ultrasound guided injections. And, you know, I think that it has worked really well. And I think that, you know, for me, other than really throwing athletes and really pitchers, I've gone to really treating most slaps that way and I've really seen good success and much quicker recoveries from that. So I have a couple of questions for you regarding that. One, how aggressive are you with rehab afterwards in terms of letting them move? I know some people, you know, if they feel like they get a good tenodesis for that, they don't really restrict patients too much. And I know others, like myself, I still kind of keep them for about six weeks from doing any real active flexion. Curious to see, you know, what you do for that. And if Jeff, if you have any comments about that also. Yeah, so as you know, you know, the biceps procedures are often associated with concomitant procedures. So at times you're more restricted by what else you've done in the shoulder, so to speak. But if I'm doing an isolated tenodesis, you know, the fixation strength shows that we've get generally around 200 Newtons, either with a screw or solid anchor fixation. So I'm pretty comfortable about letting them progress through passive active assist and even active range of motion over the first three to four weeks. I do think we need to restrict resisted biceps activity for the first eight weeks. You know, at the end of the day, a tenodesis is largely to maintain the length tension relationship, avoid cramping, prevent cosmetic deformity. And so I think if you've gone through the process of actually doing a tenodesis, then I think you want to make sure that you give enough time for that to heal. But by the eight week mark, I think we can progress with strengthening and then kind of allow them to return as the rest of their rehabilitation progresses. And the tenodesis is pretty much healed. Jeff, any experience in rehabbing isolated biceps tenodesis and what's been your experience? Yeah, you know, we like to get the motion moving as fast as we can. Obviously it depends on the physician, how comfortable they are with what they've performed in the surgery. We don't like guys to sit because, you know, from a physiological standpoint, one week, two weeks, they're already losing 10 to 20% of their muscle mass. And so if a guy hasn't been prepared well enough before he goes into the surgical procedure, we're really getting behind the eight ball for him on trying to get him to rehab. We like getting into the pool as soon as we can. And we are motion, motion, motion, and just trying to get guys to be able to have their brain, understand moving their joint in space as soon as they can. And like you talked about, Dr. Verma, we don't like to necessarily push the resistance so much. We're just trying to get movement happening. And then we really try to work on getting the scap to move and getting the scap stronger. So I think that's a good comment for the surgeons in the audience, that when you're choosing your fixation method, especially in these younger athletes, I think you do want to go with a method that allows you enough fixation strength that you're pretty comfortable with early, at least passive and active assist range of motion, because for, especially for the overhead athlete, as we've discussed, the loss of range of motion can be really hard to overcome. Guys, you know, in the older population, we have lots of debates about tenotomy versus tenodesis. Salvatore, any tenotomy experience in these younger patients, or do you think that's just something we should stay away from for the, say, under 35 crowd, who's looking to go back to a higher level of sports? Yeah, I think that, you know, tenotomy is pretty much out of the question for a lot of reasons. I mean, you know, and the cosmesis is one of them. I mean, you can't, you know, undermine that too much. But also, you know, I think that we have good fixation techniques with tenodesis, whether you like to do it arthroscopic or subpectoral. And I think that, you know, especially with, you know, you do get some, even though the outcomes have been, you know, when they're looking at these, you know, overall populations, the outcomes haven't really been any different. I think if you really had an isolated group of young individuals, now that we're doing more tenodesis for slap issues, I think you would probably see a difference in outcomes in younger patients, in terms of satisfaction scores and everything with a tenodesis versus tenotomy. So I really wouldn't consider that too much in that, in the young throwing population. And, you know, I think that, you know, we're still at the point where we're not really doing tenodesis in this group other than if they have, like you mentioned, bicep specific pain. So I think going to that next step is not something I'm doing right now. Yeah, I would agree with you. I mean, I think you do have to be very cognizant of the perception of the athlete. The cosmesis is real. The cramping or fatigue discomfort can be real. I think the tenotomy studies are hard to extrapolate to a younger, more active population. And again, you know, Tony and Romeo and I have presented or published our results in tenodesis in large groups. And with the exception of the overhead throwing athlete where the data still is not clear, we've had very good success in getting patients back to sports, even as young as 15 or 16. And along those lines, you know, Jeff or Salvatore, Jeff, I don't know how much experience you have you're a baseball guy, but one of the areas where I find a lot of anterior biceps pathology and pain is the windmill pitcher. It's a very different motion than the overhead throwing athlete. And I've had good success, you know, not that I want to emphasize myself as a windmill pitcher position, but I've had pretty good luck with tenodesis in that population. Any experience with that Salvatore or Jeff, any thoughts on the windmill motion versus the overhead? Let's start with you Salvatore. You know, it makes a lot of sense and I don't necessarily have experience with it, but, you know, I agree with a lot of things. And one of the questions I was going to have for you is, you know, the study that we have in baseball players that you guys did with biceps was only 17 people. So I was just curious to see if you had, you know, I'd like to see what longer term outcomes are with tenodesis even in pitchers, because I think in overhead athletes, I think we're very against it, but I think the, I mean, you know, if you look at our outcomes with slap repairs, they're just not very good. So if it's not something you ride to breed, which I know Mark does a lot, and I agree with, you know, as a very good treatment for a slap issue in a thrower, I think that a tenodesis as we keep going may be something that we use for a lot of these throwers, but it makes sense when you're having, you know, and I think that that also adds to some of that anterior instability or micro instability that some of those type of throwers get too. And I think that that puts more pressure on the biceps and it would make sense that a tenodesis in that group would be effective, so. Mark Shickendance, I think you're online. I'm gonna give you the last question before we go to the next session. Thanks guys. Fabulous discussion. Very controversial topic, as you all know, and I appreciate all the great insight. Nick and Sal, I've got a question really kind of for both of you. So when do you consider repairing a labral tear and doing a biceps tenodesis? And what are your indications for that? And why would we do that if we're getting the bicep out of there to take care of the labrum, but we're gonna go ahead and fix the labrum anyway? So I'll start, Mark. You know, I think that's a great question. And we did a biomechanical study a while back to try to figure out what is the role of the biceps versus the labrum. And I think the reality is for most pitchers that where they get off track in the shoulder is when the ball doesn't stay centered in the socket. And if they've got an abnormal translation, it leads to that abnormal contact between the posterior superior hemohemal head and the glenoid, and they start to get deeper rotator cuff pathology, sometimes even bony pathology is relation to that. What we've seen in the lab is that if you do the tenodesis, it doesn't change, it doesn't worsen the translation, but it also doesn't correct the translation back to normal. And so I think particularly in those tears that extend like the one that I showed earlier, posteriorly, I think you've got to fix them because it's a translational problem. You know, you had texted a question earlier about the good slap versus the bad slap or the adaptive slap. And I think the ones that are challenging are the ones that are truly relegated just to the superior labrum, where you could argue that maybe it's just a pain generator and probably all we need to do is to clean those up. But I think if you get extension of the tear beyond that superior labrum area, where you're going to lead to translational abnormalities, those in my hands are ones that I fix. When do I add a tenodesis? You know, in general anterior shoulder plane is relatively uncommon in my mind with slap pathology alone. So it's in those patients that have extended as Mike Reinhold suggested, where they now are having biceps pain in addition, and they've got a positive response to the injection and they have significant complaints along the groove. And those are the ones that have been tenodesis. I can't tell you that I've got evidence to support it. That's just been my anecdotal experience in decision-making process. That's great, thank you. Sal, what do you think? Yeah, I think that, you know, one of the theories that, one of the things that you taught me is that there's different ways that these throwers have pathology. And I think those ones with that anterior micro instability where they're a little loose in the front, just like the windmill type pitcher or something like that. I think that they get some of those more anterior, that more anterior cuff pathology, and it's not that typical internal impingement type posterior. I think that that would be one where I would, if I was gonna do a tenodesis, and I think it would be an effective treatment, I probably wouldn't do any kind of slap repair, but I agree with Nick that when it extends posteriorly, you have that true internal impingement type situation, and you have that posterior labrum issue associated with it, or in a posterior labrum tear that's unstable, obviously, that would be a situation where I would fix it. But if it's just redundant tissue posteriorly, I would just clean that up, because I think that's what, I think the best outcomes we have from slap repair are the ones from Saguaro where he basically fixed it, put a couple stitches anteriorly and debrided the posterior labrum. So, I mean, that would be how I would approach that. And I think at this point, Mark, that in the revision situation, we pretty much all decided that tenodesis is probably the right option. To Jeff Dougas' comment earlier, the only thing worse than revision UCL surgery is revision slap surgery. So, that's a tough nut to climb, but I think the biceps generally goes in that situation. No question. Well, Nick, listen, thank you for tackling a very, very difficult and controversial topic. You're really at the head of this in terms of our understanding, and we really appreciate your time and your expertise. So, thank you so much. Thanks for having me. Alexandra, let's move on. All right. Thank you all. Now let's go to Dr. Nazarian's elbow ultrasound, and then to the panel. So, let's start. All right. So, hi, I'm Lev Nazarian. I'm professor of radiology at Thomas Jefferson University in Philadelphia, and I'm here to demonstrate the ultrasound evaluation of the medial elbow in a pitcher. So, we constantly are seeing patients who are pitchers who have medial elbow pain, and we sort of have a checklist of structures that we look at under ultrasound, and ultrasound is very well-suited for this because not only do we get very high-resolution pictures with the ultrasound, but we're able to put things in motion, for example, to do valgus stress maneuvers on the elbow, which we'll show you in a minute. So, I'm just gonna go through a very simple checklist of the structures that I look at in the pitcher with medial elbow pain. So, we place the probe, and for ultrasound, the probe or transducer should be a linear probe, so the top of the probe should be flat because transducers that are flat like this tend to give us the best resolution and the best wide field of view in the near field, and since many of the structures we're looking at are very superficial, we want to make use of this probe configuration. We take the probe, and we place it first on the medial epicondyle, and what I'll now show you are the landmarks and the orientation. So, I've oriented the probe so that where this arrow is, this side of the screen is superior, and this side of the screen is inferior. Now, the next thing we're gonna look at is look at the bony acoustic landmarks. So, this is the distal humerus on the medial aspect. So, this is the medial epicondyle. Here we have the trochlea, and here is the sublime tubercle of the ulna. So, here would be the joint between the ulna humeral joint would be this space right in here. So, if we go back to our bony landmarks, and what we can do is we can decrease our depth, meaning we can really look very superficially here. What we're seeing here is the normal signature of a tendon anywhere in the body, alternating hyper and hypo-echoic lines, which represent the common flexor tendon from its origin on the medial epicondyle. We can see that this is a very normal-looking one. I can scan back and forth to make sure there's no focal abnormality, but in a normal situation such as this, it'll be nice and parallel fibers, no disruption, no thickening, no calcifications, no tears. From there, we can then move more distally. Now, notice how the echo signature is changing here from the compact fibular pattern of a tendon into what we call the pennate architecture of a muscle. So, these are the flexor pronator muscles here, and we can scan back and forth, and we can look not only for muscle injuries, but we can also focus on the musculotendinous junction where a lot of injuries occur. And so, we can then turn the probe perpendicularly to get the orthogonal plane and come up. Now, I am superior here, and this would be anterior on the patient, posterior on the patient, and here are the individual tendon bundles that are attaching to the medial epicondyle. Then I'll slide distally on the arm, and you can see each one of these tendons going into their respective muscle as we come down into the forearm. So, we can get excellent resolution to see what's going on in these muscles, the fascia, and the tendon as well. Now, if we go back to that original picture where we were focused on the medial epicondyle, we can now go sort of one layer down, so to speak, and in order to do this, we can increase our depth again, so that we're seeing farther down in the image. And notice this structure here. This is the anterior bundle of the ulnar collateral ligament. And you can see it sort of has this arrowhead shape. It attaches here to the humerus deep to the flexor pronators, and then you can see it as it then narrows to attach to the sublime tubercle. And so, it's this structure. It sort of looks like an arrowhead-type structure, and then deep to that, there's usually some fatty tissue, sometimes you'll see a little bit of fluid undermining the ligament that comes out from the underlying joint. So, that's the ligament right there. Now, this is, again, a nice, normal-looking ligament with a nice, compact fibular pattern, similar to a tendon, with slightly different orientation. If we go into the short axis, we can find that ligament. So, again, here's the tendon, and now we're gonna look deep to that, to the ligament in the short axis, and we can follow that all the way down as well. But in truth, the long-axis view gives us most of what we need to know in terms of evaluating this ligament. So, I use this view, usually, almost exclusively, scanning anteriorly and posteriorly to make sure that I've been through the entire ligament. Now, notice that when I go even more posteriorly, we run into another structure here, which is the ulnar nerve. And we will be able to evaluate that ulnar nerve in a moment. But first, what I'd like to do is demonstrate the valgus stress maneuver that we do for the ulnar collateral ligament. First, we can measure the ulno-humeral joint here with this cursor placed on the trochlea, and this other cursor placed on the ulna. And this is a very reproducible measurement we've been doing for years and years on thousands of people. And this happens to measure 3.4 millimeters at rest. Then we can then have valgus stress placed upon this ligament. This can be done mechanically with a device such as the Telus device, but in our clinic, we usually have somebody perform valgus stress in usually about 30 to 40 degrees of flexion, and they stress it to maximum. So, I'll have my young colleague here, Dr. Harwood, come over. I usually like to do this with the individual standing. So, if you could stand up, please, and hand him your arm. And then I scan here from the medial aspect, just like we were before, and so I will get pairs of views. So, here is without stress, and we're going to, again, measure this joint before we stress it. So, it's coming out here at 3.3 millimeters. Okay, now go ahead and stress it, and tell me when you're at maximum. Okay, freeze it, you can relax, and then I'm gonna measure that again. So, what was 3.3 at rest has gone to about 4.3 with stress, so about a millimeter of gapping. And we usually say up to two millimeters is normal, but the other thing we also want to do is compare to the other side, because some patients have loose ligaments. So, if somebody has, let's say, 2.5 millimeters of gapping, but also gaps 2.5 on the other side, that may be normal for that individual, whereas if somebody has 2.5 gapping in their pitching arm, but only one millimeter on the opposite side, well, that's more than one millimeter difference in that delta. So, we look at that delta, the difference between rest and stress, and we compare it on the right to the left, and if that delta is greater than one millimeter, we find that that is abnormal, the difference in the deltas from side to side. So I want to make that clear. We get rest to stress measurements. We subtract them and get the delta value. We do it on the contralateral side, get that delta value, subtract one from the other. And if that difference is greater than 1 millimeter, it usually means that the pitching arm is abnormally lax. And that's pretty much stood the test of time. So we find that to be very, very useful. The other thing, too, is I usually get 3 and average them. We do 3 valgus stresses and average them. And that's because what we also notice is that with the first valgus stress, the pitcher's often guarding. And we have to teach them they have to relax. So the first stress is often they're scared it's going to hurt a lot or something. Once they realize it doesn't really, then they usually loosen up for the next couple. So we get 3 and average them. And that's sort of our standard. The last structure that we always make sure that we look at on the medial elbow is the ulnar nerve. For the ulnar nerve, I have the patient bend like this. And what I'm trying to do here is I take the probe. And I want to bridge two bony landmarks, which are the medial epicondyle and the olecranon. So we'll make a little bridge there. And when we do, we're going to see a structure that is the ulnar nerve. And I'm going to get it. I'm just raising your arm just a little bit here. And we'll use more gel. You need a lot of gel for this view. And if you raise, yeah, perfect. OK, so what I'm doing, so again, I'm bridging the two bony structures. And I'm going to fix the gain. So I'm going to make it a little brighter. And when I do that, you're going to see a structure here that has what we call a fascicular pattern. I'll turn long on it. And you can see this structure here. So these are the fascicles of the ulnar nerve. We can follow it more distally into the forearm. But the bottom line is that this is a structure that is different from a tendon. You can think of a nerve as more, it looks sort of more like a bundle of grapes here rather than the more compact fibular pattern you would see in a tendon. So again, there it is in transverse plane. Here it is in longitudinal plane. And his is nice and normal. When it's enlarged, you'll see it even better. This, by the way, happens to be the posterior bundle of the ulnar colloidal ligament, which sort of sits on top of. And then here is the medial epicondyle. So then we test for ulnar nerve subluxation by having the patient flex. So go ahead and flex slowly. And we look to see whether that will perch up over. Notice it does not actually come up over the medial epicondyle. So this is not subluxating. Bring your arm back into the extended again. Good. What we do notice is when he does flex as well, do it again, is that the medial bundle of the triceps is going to come over. So I take a peek at that too right here. Because another right here, because one of the things that we will also identify sometimes is the triceps snapping over the medial epicondyle, so-called snapping triceps syndrome. So we want to look at two things. Does the ulnar nerve subluxate? Does the triceps snap? And that view is good for both of them. Then I can focus on the nerve itself and cross-section, follow it distally to the region of the flexor carpi ulnaris. And that's usually what I'll do for pitchers, especially those who are not complaining of ulnar neuropathy. But it is important, because if somebody is going to, we have had instances where people have had Tommy John surgery. They had either snapping triceps and or subluxing ulnar nerve that was not dealt with. And then they ended up having to have a second surgery. So this is something we find is very important to evaluate pre-op. And of course, ultrasound is going to be the way to do it, because you're not going to find these pathologies on MRI, because they're dynamic. Now, we do have a volunteer who wants to show us your, we have a plant in the audience here who has told us that he has a subluxating ulnar nerve. And so we want to, is it worse on the other side? All right, we'll see. Just lift your arm just a little bit. OK, so now, here we are. And extend all the way out, because it's actually with subluxated, even with that little bit. All right, so what we're going to do is we're going to show you here. Here's his ulnar nerve. And here's the medial epicondyle. Here's the olecranon. Now, watch what happens when he flexes. Do it slowly, because it's going to really go. And there it goes. It just snapped over. So it wasn't even slow. It snapped. And now, as it comes down, it's going to snap back in. Right there. See how it snaps back in? So now, we can see that dynamically. No other way to see it. And we'll ask, do you have any ulnar nerve symptoms other than the snapping? None. OK, so there you go. So it's a normal variant in you, but may not be in somebody else. OK, so that's basically the ultrasound evaluation of the medial elbow that I do in somebody with medial elbow pain who's a baseball pitcher. And thank you for your attention. And thank you for that presentation, Dr. Nazarian. We now welcome our panel to discuss the ultrasound. Thank you all for joining us. Dr. Nazarian, take us away. Hey, well, thank you. And Mark, if you want to take us through here. I can absolutely do that. Thank you again for that demonstration. And I do want to save time, because we do have an ultrasound demonstration for the hamstring. But I'll throw it out there to Alex first. Where does ultrasound fit in to the diagnostic algorithm for a pitcher with medial sided elbow pain at your institution? So first, thank you all for having me. For me, it depends on whether I'm dealing with a young athlete or more of a collegiate age or professional athlete. And I really start evaluating with an x-ray first, make sure there's no little elbow or there's any other obvious structure damage. And then once I see that there's nothing there and that's clear, then I'll start looking a little bit more in with the ultrasound. And I'll look at the pendants a little bit more and make sure they're attaching correctly. And then I'll really evaluate the ulnar collateral ligament and then see how much laxity they're having. And just like Dr. Nazarian said, I'll really look and see if they're gapping. And then really, I usually go back to your guys' paper. You guys did one in 2003, and then there was another one in 2014. So I usually go back to those for my numbers. Great, how about Chris? What are your thoughts with regard to the utility of ultrasound versus a MR arthrogram for the elbow? Yeah, again, I think it was well said in a presentation where ultrasound is great because, first of all, it's point of care. So you're able to give real-time feedback to the patient or athlete that you're seeing, which is very helpful, especially in a lot of your pro or high-level athletes. As far as comparing, the other thing is dynamic exams. So you can see gapping that's associated with any ligament that's damaged. You can see the subluxation of the different nerves or tendons in the area. I still, you know, arthrograms obviously have a role, for sure, when you start thinking about other intraarticular structures. There are times when, again, the ultrasound is also operator-dependent, and I'd be lying to tell you that that wasn't the truth. And so there are times where, depending on what the elbow looks like chronically, that the ultrasound images don't show up as well as you'd like them to. And, you know, going forward, obtaining the MR arthrogram would still be necessary. Great. And, Raj, we will get to you with the hamstring, but I just wanted to touch base with Lev. Just can you comment on kind of the role of ultrasound evaluation for elbows in our organization, the Phillies? What we do for the Phillies is they're complementary. So just about every pitcher will get both. They'll get both the MR arthrogram, which, again, will be great for the intraarticular pathology, osteochondral lesions, bone marrow edema, more sensitive for loose bodies, et cetera. But then we get the ultrasound to look for the gap as the ligament is functioning, and also to look for these other pathologies, such as the ulnar nerve subluxation or snapping triceps. So basically, they're done in a complementary way. Sometimes one's done first. Sometimes the other is done first. When I do it, I try to read it independently of the MRI so we have two different data points. But that way, we're able to get what we think is a comprehensive evaluation of every pitcher. How important is it to have a baseline for these folks? Well, we do like to have a baseline. In fact, for many years, I've gone down to spring training to do the minor league players and then the major league players who are symptomatic. And it is nice because midway through the season, if somebody gets injured, you know what they look like in spring training so you can tell if there's been an interval change. That being said, we've done so many pitchers over so long that even if we don't have a baseline, we know usually if we're looking at an abnormal amount of gapping. Great. Well, thank you. Why don't we move on to the hamstring demonstration, and then we'll wrap up with the panel discussion as well. So hi, I'm Lev Nazarian, professor of radiology at Thomas Jefferson University Hospital. And I'm going to be talking now about examining the hamstring. And specifically, since we're talking about baseball players, proximal hamstring injuries being more common, I'm just going to focus on how to identify the proximal hamstring, tendon, and muscles to be able to look for pathology. So first of all is probe selection. So because a lot of the athletes that we're going to be seeing are very muscular, you're not going to be usually able to use the same probe that you use in an elbow on a hamstring. So what I usually start is with a curved probe configuration. What the curved probe does, first of all, is it has a lower frequency. So in ultrasound, lower frequencies penetrate deeper. The one thing you give up is a little bit of resolution, but you've got to be able to see the structure. If you use something that's too high frequency, like I was using in the elbow, then you may not even see your target. So I'll start with a curve. This is 5 megahertz curved probe. The next thing is, like anything we do in musculoskeletal ultrasound, is we want to see the landmarks that allow us to identify a structure. And so we usually use the bones. So I take the probe. And I want, as usual, use a good amount of gel there. And then I'm going to take that probe, and I'm going to place it on the area of the ischial tuberosity, which is right here. So let me show you. So bony structures on ultrasound, they'll be bright, and they'll cause what we call shadowing behind them. So this is the ischial tuberosity, this curvilinear structure here. Now, if you look carefully, you're going to see a tendon here in cross-section. But if you look even more carefully, you're going to realize there's a plane between these two components, because this part is the conjoined tendon between the biceps femoris and the semitendinosus. And if we go out more laterally and deep, that is the semimembranosus tendon. So we're going to see very carefully the insertion site of this common tendon onto the ischial tuberosity, looking for any tears, fluid collections, calcifications, et cetera. Now, we can look at the transverse plane as we are here. But then we could also turn longitudinally. So when we turn longitudinally now, we're oriented so that the head is to the left and the feet are to the right. So this is the ischial tuberosity, the bright bone that's shadowing. And here are our tendons, the conjoined tendon, the semimembranosus tendon in long axis. And we have the normal fibular pattern we expect from a hamstring tendon in these tendons. But we don't have to stop at the origins. We can then follow these tendons down to the musculotendinous junction. So now we're starting to see muscle, the pennate pattern that we associate with muscle right here. So you can see the tendon going into the muscle here. And here is the muscle starting right over here. And now we can then look at the muscles and see if there are any muscle tears as well. So we can examine the tendon origins. We can follow the tendons down towards the musculotendinous junction and then look for any musculotendinous injuries. But don't forget the orthogonal plane. So we'll come back up to the ischial tuberosity again. And here it is. And now we're going to follow these tendons down into their respective muscles and look for any injuries. And when you see these very bright planes here, these are fascial planes that separate the muscle bundles from each other. And often, tears will occur adjacent to fascial planes, these bright lines. So I look very carefully at the architecture of the muscles and for these fascial planes. And then for no added cost, you get to also see the sciatic nerve, which is here. So this is this structure right there. So we can actually follow the sciatic nerve up all the way to the ischial tuberosity. In fact, we can follow it beyond to where it comes below the piriformis. And then we can also follow the sciatic nerve down. It's really more of a landmark than anything else. We don't make a lot of diagnoses of the sciatic nerve, but at least it's a structure you're going to run into. So it's important to know what it looks like. Once again, we can look at the texture of the muscles. We can look at the tendons themselves. We could look for tears, tendinosis, calcification, fluid collections. If it's acute, we could look for hematomas, tears, which will appear as disruption of these echoes. And more chronically, will look like scar tissue, which will often be usually bright and may even see some shadowing. Scar tissue can sometimes shadow the ultrasound beam. And then we could just follow right down the thigh as far as you need to follow it based on where the symptoms are and where you suspect the injury to be. So that's really the basic way that we screen the hamstring, tendon, and muscles for pathology. Thank you very much. And a big thanks to you, Dr. Nazarian. We now welcome back our panel to discuss hamstring ultrasound. Now that my butt is internet famous, let's chat about where the role of diagnostic ultrasound is with regard to where it fits in with the diagnostic algorithm. So to Raj, where do you guys use, at your institution, where do you use ultrasound? Where does it fit in with MRI? Do you get both? Do you do one versus another? Talk to me about where ultrasound fits in for you. Yeah, so similar to what Alex mentioned previously with the elbow. So first thing, we'll get some x-rays. We'll take a look and see. Particularly on the young athletes, we're looking for an avulsion injury of the bone first. And if basically I see that and there's evidence or suggesting maybe some retraction over there, then I'll usually go to an MRI. But if there is an acute injury that happens and the x-ray looks pretty unremarkable, then usually I'll put on the ultrasound and take a look over there. What I'm looking for is basically a complete tear and also retraction, degree of retraction, hematoma formation, things like that. And generally, if I have any concern that there may be more than 2 centimeters of retraction over there, then I'll go ahead and proceed to an MRI from that point. Yeah, any other comments from the panel with regard to diagnosis? I think that the, at least with our organization, we have an ultrasound unit in the athletic training room. And when an acute injury is suspected, we put the ultrasound on right then and there. Of course, depending on who's covering that evening and whether or not the, again, the ultrasound is very operator dependent. So if someone there has ultrasound skills, we can do it right then and there. Oftentimes we move toward an MRI in any event just because that's what we do. But it's really nice to be able to reassure someone in the evening before an ultrasound or to tell someone that they have a significant injury right then and there. Mark, I'd also like to add that although I agree that MRI is primary for this, for interventions, it's very nice. If you have a fluid collection to drain, if you have a biologic to deliver, et cetera. So I see ultrasound with more of a, it has a diagnostic role, but more of an interventional role in the hamstring where it can be very useful for that. I would agree. Just to sort of add to everybody's comments, I think diagnostically, when I'm thinking, if I see an obvious sort of muscle belly tear or even muscle tennis junction, if it's fairly obvious to just based off of history and physical exam, I think ultrasound just sort of solidifies things. Obviously, as Rajiv stated, that if it's anything greater than two centimeters retracted and we're thinking surgically, then I think shooting an MRI makes a lot of sense. But a lot of the times you can sort of move forward, especially if it's not operatively managed with just an ultrasound within the muscle belly. Great. And Alex, I think we're gonna pass it back to you and thank you very much for your time. And I thank you to the panel. Thanks, everybody. Thank you. I was just gonna say also that, you know, the population that I'm dealing with mostly a lot of high school athletes and underserved population, and they don't have access to MRI or finance to be able to pay for it. So that's something that I really utilize ultrasound for. Quickly, I don't have it in the training room, but I do have it in my office and I have it in both of my offices. So that makes it really easy for me to get a high school athlete in pretty quickly. So it's a great utility for that when people don't have the resources to be able to go above and beyond. Thank you. All right. Thank you all so much for that discussion. A big thanks to all of our panelists and presenters for their work on tonight's webinar. And thank you to all the attendees for joining us and participating in Baseball and Beyond. If you're interested in education credit, you can click the survey link that I'm gonna post in the chat to complete the evaluation. CME and CEU will appear in your account within a week and you can access it by going to sportsmed.org, logging in and then clicking My AOSSM and My CME. If for any reason you wanna look back at this content, a recording of this webinar will be available to you by the end of the day on Thursday. To access the recording, please go to sportsmed.org, log in and click My AOSSM and then My Meetings. And finally, all of this information will be emailed to you in 24 hours. So don't worry about remembering it all. Thank you again for your participation and have a great night.

open subpectorial biceps tenodesis procedure

shoulder pain

rotator cuff pathology

longhead biceps tendon

superior glenoid

sutures

anchors

rehabilitation

ultrasound

elbow injuries

hamstring injuries

baseball players

panel discussion