here at the risk of knowing full well who's in the room with me, Buddy Savoy and Ben Kibler as well as a number of others, but those two in particular with this particular case may throw some tomatoes at me. But I think it's a really important discussion and one that we have a lot, and both camps think that you talk to one camp in the absence of the other and they're like, I can't believe anybody disagrees with me. So this is, I think, an interesting one. So this is a 20-year-old pitcher at a major Big 12 university. As a sophomore, he throws 95, so he's got some sauce to him, okay? Pains in the front, couldn't work through it, so they take him eventually after he fails therapy and everything else, really good doctor and a good team physician, they take him to a scope debridement of what they call the slap and a partial articular sided rotator cuff tear. They send him to rehab after and he fails that for one year, okay? So this is the picture. This is the actual picture from his scope showing the quote-unquote slap tear, right? And then they injected him after he'd failed all this inter-articularly and he got great temporary relief. So they said, well, your pain's coming from inside your shoulder joint, we're going to take you back to surgery. Again, this is a guy that's a really, really solid surgeon, found that the biceps was noted in the op report to be, quote, pristine, they debrided a partial or an articular sided cuff tear and he went for eight more months and then was referred for a second opinion, okay? This is a guy who's six foot five, he does not have any GERD, he's got actually excellent core stability, he's blessed with having great therapists where he's at, pain in front, everything hurts, Hawkins positive apprehension sign for pain, DLS is negative, pain is worst in early acceleration and follow through. So now we'll hold for discussion, what do you do now? We're a year and a half, 18 months, 20 months into this guy, he ain't getting better. So if you say, well, we'll just do more therapy, I'll tell you the folks at his university are very good therapists and his core is good, his scapula is a little bit of dyskinesis, little differences side to side, I don't know if I'd call it really dyskinetic. He has had an EMG, they're negative, although I agree with you, sometimes that serratus is still dysfunctional and the EMG is normal and then we got to talk about what he might do with that, but that's kind of where he is, yeah, Steve? So they debrided a partial cuff tear twice? That's correct. And pictures of the decompression? Actually, yeah, so the pictures that they sent, it was pretty minor debridement, little flab, maybe something a little, yeah. I'll show them to you in a minute, they have the next one coming. We did, and I didn't notice anything different, but I don't have it in this, sorry? No hookback on the coracoid, his CSA is up a little bit. What about his biceps exam? So biceps exam, he is tender at the front for sure and has, you know, it's a good question to talk about biceps exams, right? So that's actually, let me just ask the group, what is your biceps exam? Because most of us, it's well, he's tender in the front, therefore he's got biceps because I can code for a biceps tenodesis, we're off to the races. But is that the case? In fact, as you guys know, that biceps attaches to that posterior labrum, something Ben has taught me, that it really is an extension of that posterior labrum, so that's why we see biceps issues with pain in the back. But sometimes we'll see pain in the front, so how do you make the diagnosis of a biceps one? Mike Freehill. What's your go-to for biceps? Well, I do all the biceps and labral, so I'll do not only, you know, tenodesis and palpation, but I'll do speeds, I'll do urgeson, I'll do... Okay, so you do speeds, which is never positive, you do urgesons, which is never positive except when it is, and when it is, we can rely on it, but those two don't help you. You do O'Briens and everybody's positive, so that doesn't help you, so now you're back to tenderness in the front. I think that, you know, with the speeds, the main thing is, does it bother you in the front? Does it bother you at the AC joint? You know, those, you can't get either. I think with O'Briens, you need to make sure that they tell you with the thumb up that it's actually getting better. Okay. And you start getting the dynamic shear, you start getting the crank, you start doing the exam that Ben was talking about, I think that's what's going to lead you down that road. To me, the bottom line is, if I have a thrower, and I'm going to get an MR, or I have a question, they're getting an intra-articular injection, because you've got to know, is this truly coming from the joint? Yeah. And if they can go throw after a litmus one, and the pain's completely gone, you might be on to something. But if it makes no difference to me, you're barking up the wrong tree. So I want to get Albert's opinion here, but remember, this guy did have an intra-articular injection, and it did relieve all of his pain. Does that help you with joint versus biceps? Right? Because you guys know 100% of your intra-articular injections get into the bicipital groove and get out there. So then, are you any closer to getting, because that's what they did, did an intra-articular, they went back in, biceps was pristine. Albert? Well, Jay, this is like a, everything's kind of a political, right? You showed the pictures, the superior labral region looks kind of okay. I would try maybe an ultrasound injection into the bicep sheath a little distally. Okay. And see if he gets relief from that. Just see if it's a biceps problem or an intra-joint problem. Okay. Ben? Two tests for biceps that were not mentioned. One is, we wrote this up, it's called an uppercut test, and it has a likelihood ratio, which is higher than speeds or uricans. It's basically, you take the arm and you have them push up, and you put the hands on, it's a sudden movement like that, to see if you have pain in the groove. The other is this biceps tightness, get your arm, if you want to get the maximum length of the biceps, 90 degrees of abduction, this position, all the way out here, pronate. This puts the most length, and they'll hurt a lot of times, right along either here, right, here or down on this spot right here, means that the biceps is tight. This is a, we use it on throws all the time, this is a very, very good test to talk about biceps being a little tight. McCarty from Colorado has described another one where you bring the arm into extension and pronation to sort of stretch that long tail of the biceps. I'll be honest with you, I've looked at all of them, and I can't make one that I can hang my hat on. I can't. I'm like Mike, where I'm like, I'll do all of them. So there's 15 of them. I think there's a race between the people who named biceps tests and the people that named COVID variants, and the bicepses sometimes win on that one. So really tricky, Steve, and then we'll move on. Bicep was normal, so he hurts a little bit with the belly press, but not dysfunctional and can do a lift off and hold it. Doesn't hurt with that one. Anyway, so maybe I'll move on, Michael, just to kind of move along. So that's taking Albert's good advice. We did an ultrasound guided injection into his bicep sheath. These are the pictures from his previous surgery, and you can see that cuff don't look so bad, right? They did a beautiful job of debriding it, or it was pretty minimal, one of the two. Gus, sorry. When did you inject the one? So he got an injection with lidocaine and with a little steroid. With what little steroid? Kenalog 10 has been our sort of go-to, okay? He says, I'm normal. So this is what we did. We have Chuck and Ellen at our practice. This guy came to see us when I was in South Carolina, and Chuck and Ellen brought him up, evaluated him, brought him in. We injected him. They took him out and through 20 minutes afterwards because he flew up from out of state, and he said, I feel normal. So to your point, I think we've got a diagnosis here, right? So pain returned, though, after that. Went back, tried to do some more rehab. Now what? Are we at surgery? How many of you take him to surgery at this point? Oh, there's no takers. Oh, I would. You would? And what would you do? Because I think I have a recording on my phone that you'd say, you've used the term never, so I'm hoping you'll go the other side of it. No, I'm kidding. You're going to go to surgery with him. What are you going to do? I'll be an exception. But you said he's been in two years of therapy. Yes, sir. And I don't have a great treatment algorithm for distal biceps stenosis. And that's where it looks like you're taking this, right? So that it's tight and it's outside the joint. Either that transverse humeral ligament, I don't think it's at the labrum. I think it's outside the joint. He has anterior pain. Never described any anterior subluxation. And because I do sometimes do jobs, the anterior capillary repair for a thrower to investigate the pathology. So that's truly it. That test would make it. Then you're looking at a bicep stenosis. Help us understand, buddy. You mentioned Job's anterior capsular reconstruction test. You guys know this. He described it and actually relieved pain in everybody. Not a high return to throwing in pitchers. But how do you make the decision of doing that procedure in a young baseball player as part of the surgical solution here? So it's an algorithm of looking at superior labrum, posterior inferior, anterior subluxation and preputation. If you have anterior subluxation and preputation, you can put the scope in and that's where the problem is. And I think we have to address the location. And when you're talking about anterior subluxation, are you talking about a little bit of apprehension in this position? Job's has anterior augmentation and relocation. He's got to get to 130. He cannot get to 130 without pain and you relocate him and he still goes to 130. Then you just got to, I mean we're all surgeons, you got to figure out where that pathology is. Is that gird? Is that slap? Is that anterior? Jim and Jimmy and Hawk for the longest time would do a little thermal in the front. That's right. Or put a PDS stitch in the front. So you get a little bit of tightness but not too much. If you do too much, then they can't actually rotate. This is what we're all here for. That's the elegant surgery where you put it all together and put it back. You're describing biceps and that test is very significant for it. JT, do you have any new imaging on this guy? We did. The MRI was pretty normal, pretty nondescript. So biceps on the MRI? Biceps on the MRI. Had a little fluid around it, but nothing too crazy. What about the capsule? Everything looked okay. The guided injection I think is helpful. When I do a biceps, I'm usually injecting inter-articulately because I don't use ultrasound with that. I'm confident in the joint. I know it's hit the biceps. I thought we went with an ultrasound guided injection in the sheath because we were trying to, and we did it standing up so we wouldn't get it in the joint and try to make sure that we didn't confuse the two of those, although I think you can. Next question, JT. My table wants to know if you did an ultrasound of the biceps and saw either increased blood flow, tenosynovitis, or stenosis. You can see that on ultrasound? Yes. My MRIs are always negative. They are negative, right? It looks horrible. You see it sometimes, right, buddy? Yeah, you can see signal in the biceps in an MRI. Sometimes you look at it. Yeah. You really got to look at it yourself. It's the cuff patient that we see biceps pathology in because their biceps are ripped up. Those young patients, man, I don't think, I don't see it much on an MRI, but on an ultrasound I think we do better. We're lucky we have great ultrasonographers at our place. So the arthroscopic biceps, you know, as you know, groove pain, susceptible tendonitis, if you will. It says pull the biceps in the joint or goo, and others have showed us that you only get about 55% of that. This is what he looked like actually in the surgery when I took him back intra-articularly, but I would tell you that we don't see the whole biceps with this. And I think Steve O'Brien has taught us that, you know, this zone two injury that Buddy alluded to where it's outside the groove below and above the pec. So below the transverse humeral ligament, above the pectoralis major, they found that 18% of the time that was their only lesion. So this is him. So this is him on the left. That's the most representative picture. And then this is me after I've taken the sheath down. You can see the big sort of chunk of biceps that's in there kind of going forward in the subdeltoid space. And that did not look unusual in the MRI at all? Nope. I mean... You can see it on the ultrasound. MRI, you really got to look at it. It's hard. I feel like these young kids almost never have any findings of MRI. Yeah. MRI is always a little bit of this, a little bit of that. Okay. So now what do we do? How many are going to debride this? Actually, I think that's on my next slide. Debridement alone. Let's take a vote. Tenotomy. Tenodesis. Oh, everybody's going to do a tenodesis. Okay. How many of you are superpeckers? A few superpeckers out there. How many of you are subpeckers? Way more subpeckers than superpeckers. Huh. Okay. So this is what I do. You can see his falciform ligament of his... This is transverse humeral ligament. You can see his pec major coming in. I happen to do it super pectorally. You bring it over the cross. You make two grasping stitches around the biceps in the subdeltoid space right in zone two. So we're below the groove just above the pectoralis major. Now I do all this with an all soft tissue anchor, but in this particular kid, this is his surgery. We use two sutures here and then place an anchor in because I think onlay is just as good after you prepare it. Important to me is we do this before we cut the biceps interarticularly. That way I know that his tension is assured. We've got the tension and the length right. It does cost you to have to go back into the joint and take out the remnant of the biceps out of it on that regard and kind of go in from there. So his outcome, just to fold this up, he did return to pitch for a year at his previous level went back up to 95, completed his college career, did not play beyond this. So a little bit of literature here. This is the study that ruined everything. So he's looking from the top world. You're going to do that. You actually can do an acute pec repair for that same. Yes. You can look from the top down and you can see the whole groove all the way down. You can see the pec coming in. You've got a great view of the biceps all the way to the bottom. So if they're not being, on your physical exam, when you palpate under the pec major tendon, then that's the technique. I use an all suture anchor. I do it right there at the top. I think because it's anatomic. I agree. Right there. So that seems to work pretty well for that. So my camera is in your standard lateral portal. And my working one, the ablator, is in the standard anterior portal. I want everything to look normal for our guys so that you get those two down and it takes a little while to kind of get comfortable with that anatomy. But once you do, it opens up a whole world for you, including subscap repair, lat transfers, all this crazy stuff, and including this particular thing for releasing biceps. We should talk. Anyway. So JT, real quick. So was your rationale there? Is that how you do your tinnitus for everybody? Yes. Okay. So the damage did not go, like the tendon looked pretty healthy once you got to that spot. It did, yeah. Were you worried a little bit about fracture if you did a subpec? It sounds like you don't do subpecs. I don't do subpecs probably for the reasons for fracture, but I do a soft tissue all suture suture anchor. So if you're going to go subpec and do that, I think you're fine. And I'll share a little of that data with you. This was the study that ruined it for us, that really all of us thought maybe the biceps tinnitus is a good idea. And I know Ben's starting to twitch here, and I'm sure he'll have comments, but I don't think we should do biceps tinnitus in all throwers or even many throwers. But I do think there's an indication for it, and I think this is that kit, if you will. And this is what they found. They looked at the results from 2010 to 2013 in all patients in Major League Baseball who had tinnitus. And it was cool. 80% returned, but only 17% of pitchers returned. So a lot of it got a bad name, right? It was like, oh, my God, we're back to the drawing board now. What do we do? But interestingly, those of you that have followed this in AJSM this year, they relooked at the data from 2014 to 2017, same database, et cetera. I think we as surgeons may be getting better about who we're selecting and which ones we're selecting out. But take a look at this. Their return to play for everybody was 86%. Now, they didn't return to the previous level only 50% of the time, but pitchers returned 100% to play with the biceps tinnitus. So maybe better diagnosis, maybe refined techniques, et cetera. So certainly a better option. So that's where we are with this now. There are lingering questions. Check out this by Chris Ahmad in terms of the role of the biceps in the throwing athlete. Many would say this is a critical stabilizer, a dynamic stabilizer, especially in the thrower. And others would say this is a source of pathology. So is tinnitus a viable option? So the real question is there. I would just direct you toward Ben's excellent work this year, published in Arthroscopy, taking a look at the disabled throwing shoulder. As you know, he's done this since 2003, updates every 10 years or so. And several of you in the room helped out with this article. It's a great two-article section. But just note this quote, that the biceps plays an active role in dynamic glenohumeral instability by potentiating concavity compression of glenohumeral joint. So certainly that group, our group, felt like that's an important thing. Yes, sir. Question. In terms of pitching, returning to play, you'll get some pitchers that are starters and some pitchers that are relievers. So has anyone looked at looking at a starter versus a reliever? Because I think that you can do a tender thesis on a starter, but do they come back to being a starter? Yeah. It's a great question. So when they talk about, that's captured somewhat in the return to previous level of throw. So that 50% number that says only 50% of them got back to their previous level, that includes those starters that ended up in a reserve or in a relief kind of pitcher. But they didn't stratify those out. Remember, these are 17, groups of 17, 18, 19 pitchers in each group. So a little tricky to get to your question, but bigger study would be good on that. So ultimately, this lets us get to the question of, should we cut it or should we keep it? And how do we decide? Thanks very much. Good luck.

shoulder pain

surgery

biceps issue

intra-joint problem

diagnosis