Good morning. So first case in the ICL is a Type 8 slap in a pitcher. So he's a 19-year-old college pitcher, he's 6'7", 235, progressive right shoulder pain with late cocking. Feels like a dead arm, there's clicking and clunking in his arm he complains of. His first issue was it was hard to warm up. But all of a sudden his velocity went down by 10 miles an hour, he started losing control and usually high and outside. That's it, they lose their launch window, they go high and outside. No neurovascular symptoms and he did not improve with extensive rehabilitation. So then to me the big three, I always look because I do a lot of throwers, the big three to me are the first thing they do is hard to warm up, decrease pitching velocity, and then they lose control, typically high and outside, sometimes high and inside. So physical exam, you got to go from their toes to their fingers, and you do specific things that we forget to do, you got to do their hips and range of motion, abduction weakness because of the decreased mechanics, they can't throw well. You got to test their quad in both legs, standing balance is a static test we do, single leg squat is a dynamic one for decreased glute medius strength. Then range of motions of the shoulder obviously, total range of motion, internal rotation deficit, external rotation deficit, humeral retroversion, which we need to think about because they're different, pec minor and pec major contractures, which will hurt you because the lat will pull them out the back, and then scapular dyskinesis or sick scapula. So there's a bunch of slap tests in athletes, and the three that we've been working on is called this, we call it the Pit Slap 3-Pack, which is an active compression test, dynamic posterior instability test in throwers, the D-Pit, and then the modification where we block it, and I can show you that if you want, and the Whipple and the modified Whipple, those big three, those are the ones that we've been looking at the most. So here's his physical exam, he's not tender in the biceps groove, which is important because of, you know, you can get groove problems and you can get biceps problems in the groove. That's the thing that worries me the most. His total range of motion was only 160. His abduction was 175. His GERD, he had a 20% glenohumeral rotation deficit. He had no external rotation deficit. We call it the Pit Slap 3-Pack, all of those are positive, they're grossly positive. His positive job relocation test, which is very common in these, and his load and shift was plus two out the back and plus one anteriorly. His Kim and his impingement signs were negative. Strength testing, he had absolutely no weakness, and he had a little bit of protraction of his scapula, which is fairly common. So my point to you is this, there's way too many slap tests, and the issue is there's no single maneuver that can accurately diagnose a slap lesion. So we looked at this at Pit, and these three tests we used, we used O'Brien's test, and then we used this dynamic posterior instability test where we ask them to actually throw, like they're throwing, they hurt right out the back, and then we block them out the back and they stop. I mean, you do the same test, you just put your thumb on the back and block them. You do a whipple like this, they hurt, and you just block them out the back, it's been very successful. So we looked at just the dynamic posterior instability test and throwers, we published it, Tracy Lawyer and Mike Nicolai, and we basically found if that test is positive, single test, that the sensitivity for having a posterior slap is 94%, specificity is 95, and a positive predictive value is .98. Remember that scapular protraction in throwers is common. We published this back in 2005, it's a very common thing to see them look like this. They're a little protracted, but they're not, they don't really have a sick scapula. So sick scapula, he did not have that scapular malposition, inferior medial border prominence, coracoid and clavicular pain is the C, and then there's scapular dyskinesis, and that gives you the sick scapula. The one you're seeing here, that's a sick scapula. So that's much different than my thrower, he did not have one. Our radiographs were this, he had what we call deltoid dysplasia, if you throw a lot when you're young, you get that little step off in the back because it never ossifies, that's really common in throwers. And he had retroversion. So you look at their retroversion, so we did our study with Lesniak and McClincy, we found that normal retroversion across the general population is about 3.4 degrees. Our overall, when we looked at our overall group of people with posterior instability, it was 7.1, but when we looked at pitchers, it was 8.4 was our normal value, which is significantly more than normal. So here's our MRI. I think that, oops, sorry, I've got to stop this here, try it again. If you look through the MRI, if you look at the back, you can see that he's got some issues in the top and in the back, and if you look at the ABRA views, I think I can stop it hopefully right there. No, I can't stop. Hold on. Let me try to stop that again. Sorry. It's just hard to start. No, it's not going to start again. Try it again. There you go. If you look at the back and the ABRA views, you can see right there is the problem, which is fairly common. If you don't get abduction external rotation views, you miss it most of the, well, some of the time. So I listen to John Conway, he's my buddy for years. I call him the Conway rules on MRIs. So if you want to operate on a throat or shoulder, you get an MRI, but if you get one, don't operate on the MRI because you can't see the pain on the MRI. Are the findings the cause of the result of the primary problem, or are the MRI changes beneficial, adaptive, or purposeful changes, which a lot of times they are? A lot of people throw with, you know, good slap tears, which we'll talk about. So here are your treatment options for the tables. Do you inject them with steroids? Do you debride them alone? You do a slap repair? What technique do you use? Tendinotomy, do you do that? Or do you do tenodesis alone, and where, and how, and why? Those are your questions. Hey, Jim, where are we in the season? It's right at the beginning of the season. He just came through, and he's draftable, because he's going to be drafted. This kid was drafted, he plays for the Cubs now, he's in there, he's at the major league level right now. This case was two years ago. All right, I'll give you one more thing, just one more thing. So this is our pitcher, draftable pitcher, start of the season, control issues, velocity issues, kinetic chain issue, no kinetic chain problems, and it looks like that. That's the lesion. Pardon me? It's too early for a case that hard. This isn't that hard. We see this all the time. Okay, gentlemen, so just a few things here before we do the last table where you guys are all going to discuss whether I did the right thing or not. So here's our pitcher when we get in there. That's his peel back. So when you put him back there, you take him out, you take him off the thing. I do the lateral decubitus, you start putting him in a pitching position, and you can see this obvious peel back of the labrum, and that's a telltale sign. The other thing is, if the biceps invaginates, if it goes down, straight down, that's a bad sign too. So if you treat them, what would you recommend? Surgical knots would be knots or knotless? I think I'd get a vote on... All right, knots or knotless? No, no, who's going to do cortisol on that stuff first? Yeah, okay, who's going to do cortisol? So I'll do that. Okay? We would do that. Okay? Especially if he's at two lane at the beginning of the season, we don't have a lot of pitching depth. Okay. That's not an answer, buddy. That doesn't count. Okay, so is anybody going to Tina Deese the guy? Is anybody going to cut the biceps? How about fix the biceps? Is anybody going to do that? No one's going to do a slap repair? Traditional 12 and 1. Is that what you're talking about? Slap repair, meaning? Meaning a type 8 slap repair. The ones that go the whole way down the back. Oh, no, that's what... You didn't show it the whole thing. I'm going to get there. That's where the muscle is. Yeah. All right. So are you going to do knots or knotless? I mean, typically knotless has been shown to be much stronger than knots, and knots have been a problem in the past. I mean, when I started, when I was doing knots, I mean, four times a year I'd be taking squeaky knots out. And then are you going to use tape or suture? I would recommend that you use a tape and make sure that the tape is polyethylene on the inside and polyester on the outside, because polyethylene does not incorporate. And you can get streaks along your... I've watched... I've gone in there and looked at them. They get these streaks along their humeral head. So polyester, the body likes that, and it'll cover it with cells. So I typically use that. You can go pericutaneously, which I'm not a big fan of going back and then forth, but I know John Conway does it, and a lot of guys that do a lot of throwers do it. I use a small five millimeter cannula right through the body of the rotator cuff, not the tendon, but the muscle. I've done it for years. How much do you take in a thrower? You can say what you want, but what I do is on the top I take very little, and I don't mess with that gutter, because if you mess with the gutter up top, you've screwed them. They've gone from a major leak to a minor leak. And then down below, anatomically, it's on the face of the glenoid, so we put it on the face. It's on the top, it's on the side of the glenoid, and at the bottom it's the face of the glenoid. Where do you put it? Simple or vertical or horizontal, I use just simple stitches. I don't use mattress-type stitches. That's up for debate. And I never do a capsuloraphy. And I always close the posterior portal, because it's a stress riser. So the posterior portal, I was doing revisions, and people would come in from other places, and they'd have this big hole in their posterior capsule. That's a big stress riser. You don't want to do that. So here's what I did. At the top, it was very small. At the bottom, it was more on the face, because the natural glenoid, the labrum inserts on the glenoid and the top on the side, about two millimeters off the glenoid. Once you get below the equator, that's an organ of compression. It's on four millimeters on the face of the glenoid. So I think people, when they fix them, they're not fixing them the way the normal anatomy is. This is up for me. I'll throw it out to the audience. The role of the superior labrum and biceps tendon in athletes, this is what John Conway and I wrote. In throwers, it acts as a secondary stabilizer for rotational and translational stability at the extremes of motion, where the pitchers are. All right? It has proprioception. It's a weak head depressor. That's out in the literature. Here's the issue. The top is a, and Ben and I have written about this, the top is a mobile tension band. So the tension band and the inferior labrum is an organ of compression. So mobile tension band at the top, organ of compression at the bottom. Problem is, as the slap progresses down into the posterior inferior glenohumeral ligament, you get three problems. The superior labrum does not work as a tension band. The inferior labrum is now mobile, no compression, and the inferior labrum and the posterior glenohumeral ligament loses the concavity compression, which you absolutely need, so the head starts wandering around. We've written about that. So Conway and I came up, we call it a lambda tear. If you look to the right, at the bottom, there's a split in the glenolabral junction, right there in the posterior inferior band, and then there's a split in the labrum itself. And Ben has taught me this, you've got to fix both. So you've got to fix both of those at the same time, or it doesn't work. So we call that the lambda tear. We introduced that back in erudicus. So when it goes bad, you get symptomatic. The posterior organ of compression is compromised when the labral tear extends from the biceps anchor into the posterior inferior band. That causes flattening of the labrum and or inter-substance delamination. You get pathologic cascade ensues. The tension band becomes incompetent. It doesn't work at the top. And what happens is you decrease the effect of the capsular labral bumper posterior inferiorly and you lose tension in the posterior inferior band of the glenohumeral ligament. And all that adds up to this. You lose, the tension band is altered, that you get altered glenohumeral rotation because of that. Decrease rotator cuff concavity compression and bumper. You lose edge stability. You get scapular protraction and then you get the posterior translation. So that's the sequencing as it happens, as it splits down into the posterior band. It looks kind of like, wait, I'm sorry. If I can get this to play. I don't know here. So this is one of them and you can see the posterior band. When I lift up on the cannula, this is one of my pictures. You see the posterior band is right there and it's incompetent. So just so you, I want you to think about this. We just finished this study. So I looked at Javier's. He had 280 sequential cases and almost half of them were posterior because everybody tells you in athletes it's anterior. And then Ben came out with his and his was also posterior. His sequential cases of 167. So those two things, we've been saying this a lot, that in athletes it's different. So I said, we're gonna finish this. So from 2005 to 2022, we did 765 patients for instability. 64% of them are either posterior labral repairs or posterior inferior labral repairs. And when we took the athletes out of it, all right, just only the athletes, it was 74% of my athletes had a posterior inferior lesions. So we then looked at the throwers, the baseball, softball, quarterbacks and javelin throwers. We had 600 and 468. We had 222 pitchers in that group. And basically our total revision rate for doing these repairs was 6%, which I will take every time. So just one last thing. A long time ago, we wrote good slap, bad slap. Most of these players have a mobile lesion up there. I mean, a mobile superior labrum. So that's a purposeful beneficial adaptation along labral mobility, humeral elevation, external rotation. It improves velocity and performance because it allows them to externally rotate more. But then it can become pathologic and that causes translational and rotational micro instability. That's what the superior labrum is good for in throwers. Then you get pain and you get loss of performance. And that's kind of what happened to this guy. There's 10 types of slap tears. The most common ones we see in throwers are type 2B slap tears, where it's just starting to tear at the top. Shane Schroyer and I wrote about this in 2007, and then it splits. And when it splits, it becomes a type 8 slap. And when it comes down and does that lambda split, then you get into trouble. We've written about it in multiple areas. And that's kind of what the tear looks like. It kind of splits at the top and goes like this. We have two publications on it. And I showed you that. So I always say this, so if three experts agree, they're probably wrong. So now it's open to discussion. Did we do the right thing? Did we not do the right thing? Do you teen a decent? Do you not? Do you cut it? I have a question. For that lambda tear that you said you need to fix bolt, but you're just incorporating it in. Yeah, so you fix the top and then you incorporate the bottom. Ben? The posterior inferior glenohumeral ligament attaches to the glenoid between 6.30 and seven o'clock. They showed this in the study. So you put that anchor down there at seven o'clock and you get both the glenoid and the posterior inferior band right there with one good stitch. And then you can watch, you can see the tension develop in the posterior band. You can actually see it become taut again. You know you've put it in the right place and you've got that posterior anatomy the way it's supposed to work to keep that from going out the back. That's right. It goes here. Shoulder goes back that way. You got to have something back there to keep it from going back that way. So the thing that we've been looking at is this balance between the pecs and the lat and the back. So they're both internal rotators in the arm. What happens a lot is the pec gets contracted. So the pecs vector is anterior and still an internal rotator. And the lat is posterior, but the lat is way stronger than the pec. And when the pec gets contracted, the lat pulls it right out the back. The other thing about when you do the surgery, the first stitch you put down there, you go to the inferior band, the posterior inferior band, just make it, it doesn't have to be a big stitch. The first one at the very bottom doesn't have to be a big stitch. But the second one is the one where you pull it up. So I put one at the very inferior part and then the next one up the band. So the very inferior one, the first one down here is, you don't take a whole lot of tissue down there. That will hurt them. The next one, you can take the tissue and you just recreate the band as Ben said. You can see the band. You can actually see it. We good? Jim, can you comment on, I think Ben was hinting at this. Do you use anchors anterior to the biceps as well? No, I hate that. I'll do anything not, because all the anomalies are that upper quadrant. You know what I mean? High glenohumeral. The only time I ever put an anchor there is if I have a high middle glenohumeral ligament and it's lifting off, going like that. I usually see that in gymnasts and swimmers. I don't see that usually in throwers, but I will do anything to stay away from the anterior superior quadrant in a thrower. Just limiting biceps external rotation based on what you want. Most people who are stiff after ligament repair, I think it's that. They're amazing. Yeah, I tell my fellows that all the time. You want to stay away from that. And I can say, the two people that I see it in all the time, they'll come in with a normal MRI and they've got the signs and symptoms. And when we go in and move their shoulder, that high middle glenohumeral ligament is just lifting right off the face. And that's when I have to do it, but not very rarely in throwers. Yes, sir. Bob. So in the vignette, GERD was 20 degrees. How long do you work on that? All the time. Before you go to the operating room or you do not work on it? Do you care? No, so I do care. So most of the time we can get them out of the GERD, but, and I said years ago, I never do that, but I can tell you that I have gone sometimes and they have a 20 degree GERD and they don't get better. I fix the labrum. I go to the capsule and about a five millimeters off, I'll make a small split in the band and let it heal. Cause I can't, they're not going to get better if they've got GERD, but I'll do that maybe twice a year of all these guys I've done. So that's very rare for me. Most of the time we, I mean, most of the young kids I see with elbow problems have GERD. I mean, that's the first thing we look, we just go right to their, they can ask Albert, we go right to their shoulder cause that's mostly what the problem is when they have that elbow pain. JT. How do you evaluate your GERD, Jim? Cause I mean, GERD is GERD is GERD, right? So a lot of that's retroversion. If you're not doing bilateral radiographs or CT scans, 20 degree GERD can be incredibly normal in a professional picture. So help us how you, help us understand what you differentiate between bad GERD and normal. So, so we use the, we use the ultrasound in the office with, we've got an ultrasound now. We use the, the, their humor retroversion and we test it against the other side. And that's our starting point. And then quite frankly, if you stabilize the scapula really well, you can tell the amount of GERD. I, I, I have, I don't have a problem doing that, but you're absolutely right. Cause some of, some of that is normal, JT. And you know it, but that's as good as I can get, but I know I have to get rid of it for them to get better. How can they be loose and tight at the same time? What do you mean loose? Don't you think GERD is mostly a bony adaptation? No. Is that a capsular issue? No, Ben, go ahead. It's a cap. To me, it's capsular. The, the number, the individual number is less meaningful than the result of the reaction of the muscles to the throwing motion. So our measurement of GERD is pre to post-throwing. And when it changes more than 12 degrees, more than 10 degrees, and we know that that's a bad sign. But the numbers on bony, 30, 13 degrees across the board, several studies. Anything more than 20, that's why we picked 20 to start off with back in 2003. Cause it was more than that. And it turns out that's a pretty good number that you can usually get better. And it's, it's a muscular component as well as a capsular component. And those things will work out with therapy. You've got two good therapies. Those will work out. So that's his thrixopathy, he'll tell you. I think we gotta be a little careful though. We, we measured the Rockies for seven straight years in spring training on all asymptomatic baseball pitchers. And we found that GERD was wildly variable in patients without any issues, right? I agree with you. That's why that single measurement doesn't count. Yeah, so it's a longitudinal thing. And we measured the same time of day before they threw. We did that with the Royals, we moved to Astros. And we found that that was very consistent. We measured the same time every day before they threw. Then we measured it's, we were able to get them as soon as they walked off the mound. We measured them then. Just help us then, what pushes you then to do a release, right? Cause that was very popular back in the early 2000s. I've never done one. I've never done one. Never done one. Never done one. Because you get a good therapist to work that out or it becomes that 15 degrees, which, you know, okay. I've never done a poster release. So if you look at Ben's study, if you haven't done it, he did 50 innings pitched, right? So if you do 50 innings pitched and then he measured them. And they started out with an internal rotation, no internal rotation deficit. And then what happens is the first day they've got 15 degrees, the second day they got 17 degrees. It takes them about till the fourth or fifth day to get back to normal. But the problem is during the season, the starting point changes. So you start here at the beginning of the season and in the middle of the season, you're starting here. So it makes it harder and harder. So that's kind of the point that people don't realize. You don't start at the same point beginning of the year, middle of the year. I mean, Ben, right? Yeah. Okay. We measured at the end of the season and it was off. You know what I mean? That same five days, it was set down 10 degrees. You're exactly right. How do you counsel this guy that's like returned to play timeline and growing? Four months. Well, I have a really good guy, Tom, but we have a book, a little pamphlet, and all the stuff is in there, the exercises and everything. But at four months, we start him on a throwing program. At six months, that throwing program, he's off the mound. And then we watch his velocity and we videotape him. And then we see, because a bunch of these younger kids have the hitches in their giddy-up. They're not, you know, they're releasing the ball way down here. They're not covering the ball in the back. They're opening up their pelvis. There's all these things you look for. And most of the younger guys, it's a mechanical problem. This guy didn't have a mechanical problem. He just was throwing like 93 miles an hour. And we had him, but he was back pitching in six months and he was drafted. And then he went to the minors one year and then he went to the majors. Jim, where was your superior anchor on that guy? It was right behind the biceps. You do not capture the biceps. You can't do that. 11 o'clock? It's behind the biceps. The one thing that you never do is you never strangle the biceps. So 11 o'clock is a good point. JT. Just two other questions. One is we saw some fraying on the video there on the cup side. Could you help us understand how you address that and what would be your trigger for putting a repair stitch in that? And then secondly, do you go back and recheck your abduction external rotation after you fix the top of that labrum to see if you've restricted motion? Second question first. When we're done, we look at it. We take them out again and we look at it. I do the best I can. Second of all, the only time that I fix a rotator cuff in a thrower is when the cable is involved. Most of the time that's fraying because the rotator cuff has five layers. That's the bottom superior capsular layer. We usually just debride it. And I can tell you in this past year I've only done two cuff repairs with a slap like that. Most of the time I do not. I debride them. The cable's intact. So look at the cable. The cable's intact. You don't have to do anything. All right. Good? All right, thank you all. Thank you.

19-year-old

college pitcher

shoulder pain

slap tear

range of motion

muscle weakness