This is a lot of fun. You all have participated last year. I know you know what I'm talking about. All right, so I was asked to do this first case here. This is a 24-year-old pitcher. He has an eight-month history of increasing shoulder pain as he tries to throw. Pain's mainly on the posterior aspect of the shoulder, posterior joint line. It hurts worse than a sharp with abduction extra rotation. There's a little click and catch. He noticed that he's wild high. He really is arm side high. He cannot bring the ball down. He's up in the strike zone. He's had the therapy with injection, rest, and it helps his symptoms. But then as soon as he starts throwing, it hurts again. His physical therapy helped a little bit. It was mainly rotator cuff exercises with a little bit of core stability. But he really couldn't get where he wanted to go. So his exam here, he's got a little pain here in the front. He says, but mainly it's the back. Scapula, shoulder blade, posterior joint. If you look at him from behind, you can see a little bit of prominence. But I want you to watch as he starts raising his arm. Look how he loses the intermediate border of his scapula as he tries to control that. See how it sticks out. It just sticks out both on the way up and the way down. So it means he doesn't have control of that very important motion. He's got impingement with forward flexion. If you look at his exam, he has weakness of his hips. If you do one leg stability, he corkscrews. You see, he doesn't have very good stability. This is a professional baseball player. Doesn't have much hip or core stability on either side with the left being a little bit worse than the right. This corkscrew, this three-dimensional torquing in all three planes. So he doesn't have that good stability that we need to have to throw the ball. Once again, he doesn't look too bad here. No atrophy or anything of that nature. You do this what's called scapular assistance test, which allows normal motion of the scapula to control the intermediate border. And he has no pain, full range of motion, relief of his symptoms. He does have tightness of internal rotation. He also has a little bit of weakness in forward flexion that is improved by scapular retraction. So if you stabilize the scapula, once again, in retraction, you increase his demonstrated forward flexion strength. So he's improved. He doesn't have any pain there. He has tightness of internal rotation that you can see pretty easily here as you take his arm into the abducted position. He's very, very tight in internal rotation, maybe 5 degrees of internal rotation. So he also has a DLS test, which is positive. This is how you do the test. It's for posterior labral injuries. You put it into the abducted external rotated position, shear down, hurts right on the posterior joint line. You can retract the scapula, get the glenoid out of the way, and you change the symptoms, relief of symptoms. So that's the case, very briefly. So discussion for you guys. At this point in time, do you have enough information to initiate treatment? If not, what else do you need? If so, what is the content timing of what you're going to do? And how are you going to check back with it to see if you're going to make any progress? And then what are your other treatment options? OK, have at it. Way too much, way too good a discussion, I understand that. But I think we're going to have to move on here. So let's talk a little bit about what are the key points on here? History here in exams is crucial. What does high arm side mean? What's that mean to you, if this picture says that? First of all, you've got to ask that question. It means that he's not controlling. He's not on top of the ball. He's losing it. His kinematics of his kinetic chain are not working well. So there's something wrong there. Stephen Thomas has shown us a whole bunch of stuff what's wrong with this. So history is very, very important. And then where it hurts, what he's had done, obviously, is very important. Exam, look at not only the pathoanatomy. We tend to focus a little bit, oh, that shoulder's bad. Look at why the, he also has pathophysiology and mechanics as well. You've got to know some of this. We spent a lot of time on this last year. Imaging, everybody's going to want to see it. But you've got to look for the posterior labrum. How do you do that best? Physical therapy, you've got to address the demonstrated deficits, which means you need to identify the deficits you need to address. Five, six weeks is usually going to be enough time to figure this out, if you want to give them that time. And then surgery, you have to look more, less at the slap. We're going to talk about this this afternoon, more at the posterior labrum. So key point here, external rotation. We know internal rotation is bad. External rotation is also bad. And the other thing is, remember that you don't throw the ball this way. You throw the ball this way in pronation. We just did a paper, Sports Health this year, that there's 10 degrees difference between this ability and this ability. This being tighter is how you throw, which means if you can't get back here, you end up doing bad things to your shoulder as well. So look at this, do a pronated external rotated exam as well as just a regular. You'll find about, in 80% of the players, 10 degrees less. We found this very interesting. On the left is your standard axial view of the posterior labrum. You see it's cut tangentially. You can do what's called an oblique axial view, where you look exactly tangential right across the posterior labrum. Here's the difference. This is the same patient, same cut, same everything. Here's what you see on the axial view, maybe. Here's what you see on the oblique axial, cutting it exactly tangential. So think about using that as you think. Optimize range of motion, internal rotation, pec minor stretch, external rotation stretch, and then this pronated stretch, where you put the arm all the way back in this position here, stretch it out this way, come forward, stretch out. So you gotta do all those different maneuvers. You saw this kid got the medial scapular border. It's just not working. You gotta control it with all kinds of exercises with scapular retraction, stabilization, using your hip and core together, using this as a combined activity. This is one exercise here. You call it a crew. Do these eccentrics. Take balls of different weights, do eccentric component. Each of these has a different weight. And then you also can do the integrated hip and scapula, where you extend and then eccentric for external rotation. A couple of papers we're gonna talk about this afternoon have shown, recent papers show that slaps only make up seven to 8% of all the labor and muscle injuries that you're gonna see with your arthroscope. Huge number of posterior involvement of some kind. Posterior superiors, 48% in our group, 47% in that, two groups doing the same study, not knowing the other one was doing it. Came up with exactly the same results. So this is food for thought. It's posterior is where the injury is, not superior. So current concepts, two main types of clinically significant. We got this slap eight, where it goes from the superior on around the corner, all the way down low, all the way across there. And sometimes it'll go actually into the inferior glenohumeral ligament. Second is an isolated posterior. You see a lot of shear. Don't debride, clean this up, but you gotta repair it. This is delamination, and this is like a meniscus, and it controls hoop stresses. And you've got to control that delamination when you see that. And then multiple criteria for completion. We can talk about this all day long. Nothing above 1030. Make sure you get the good bumper. Make sure that you, this is back when we were doing stitches, make sure that you get this posterior glenohumeral ligament. And make sure you don't hogtie the biceps. Comprehensive exam, entire labrum, address all areas of the injury, be aware of the biceps overtightening, and specific criteria for completion repair. So that's what we did in this guy. Unfortunately, he required surgery. He got back, and he's playing now. So, yes. That's awesome, but so what, at what point would you separate jumping into surgery, regardless of what you see on the MRI, because we know that a lot of the MRIs are gonna look like that. So from your, when are you gonna say we need to do something? We did a paper on that. We took everybody that came in with the inclusion criteria of the labral injury, put them in the groups identifying physical therapy. At five weeks, we had them come back, and we had basically two groups. We had one group that was doing well, other group one. Of this group right here, there were 25 of them. 24 were not doing well. 24 of them eventually decided they wished for surgery. This other group, 26. Only two of them wanted surgery. So about five or six weeks, you can use it. And you have to have some improvement. You gotta, you gotta have stability. You gotta control the scapula. Five or six weeks is what we use as our criteria. I wonder what all the experts and everyone that's here doing that would say that you tell an athlete, or tell the parents of the athlete, how long it's gonna take when you have that array of deficits. How long's it gonna take you to rebuild your core and balance it and to get your scapula dyskinesia controlled? Okay, so, and so for me. Can you stand up so everybody can hear? Since you asked. So for me, I think the key on Ben's exam was that he improved most of his symptoms with scapular assist. And so if that happens, I tell them it's a 2 3rd chance. Normally, my younger athletes, 25 and down, it's basically four to six weeks that you should see improvement. So I'll put him in therapy. You said he'd already had a shot, so I wouldn't do that. I'm kind of just telling him to do everything non-operatively, come back in four to six weeks and see if your exam has changed. If the scapular assist is negative, in other words, the symptoms remain, despite me controlling your scapula, then I just tell them it's a really bad sign. We should try it anyway, but it's unlikely to work. And yours seems like it was about 50-50 hours. It's about 2 3rds. And maybe we're doing the younger patient population, but about 2 3rds of them get well and never have to do anything. I mean, if they come back and go, I don't even know why I'm seeing you. You're seeing me because you're lazy. And about 1 3rd come back and there's no change at all. I mean, and those people are really easy. You don't have to tell them any surgery. They tell you. And so 2 3rd, 2 3rd. I had one 18-year-old high school pitcher in March. Exactly that situation, got him better, went through the season, got a D1 scholarship. Came back next March and said, how you doing, how are your exercises? Oh yeah, those exercises, you forgot. That means you gotta keep them up. Yeah. So the rehab piece is important, obviously. How many of these athletes are either coming in with an MRI already before they've seen you? Or what you're seeing if you're talking through this, are you getting MRI? Are you telling them, look, the MRI may show something, but we're probably not gonna make a judgment at this point in time based on it. You know, it's hard to have that conversation. I'll walk in with an MRI. I haven't slapped hair on any surgery. So these are long conversations. Yeah. And then tell them, everybody has slapped hair. Talk about David's work and everything else. That's it, and then you show them what's wrong. And the key is that you have to fix what's wrong. And if you get better, fine. If you don't, we'll fix it. But fixing it, the explanation I get is you started throwing when you were five years old. And your body has made some adaptive changes over the next 15 years. And if I fix you, I'm taking you back to where you were five. It's gonna take you a long time to re-develop those adaptive changes in the world. You're better off not having surgery. So that's my explanation, it seems to me. I agree, the rationale to get surgery is obviously the time it takes for them to recover and get back to normal. So are you getting an MRI? Let's say they don't come in with an MRI in that setting. Typically, you're not gonna get imaging and try rehab. These are baseball parents and softball parents. They basically tell me what they want. And I tell them, have you get an MRI and mark the remedy. You want to wait a month and see if this works. And you don't have to get one. It's not gonna change more than an MRI is gonna plan on surgery, not to plan your treatment. Yeah, you tell them the data. MRI, you go to baseball camps and you got 100% positive MRIs. And remember, it's a two-dimensional static interpretation shadow of the anatomy. And that's all it is, it's nothing more. I'd be interested, George, Steve, some of you PTs. Yeah, we talk, oh, PT's very important. You need to hook up with a good PT. They need to know how to do these things. George, you all try to keep them going. How do you train these people to understand the hip and core and the scapula and everything? Well, as you said, you start with TLS, which is total leg strengthening, because of the test results. Then you go to core, then you go to scapulothoracic strengthening exercises, both concentrically, eccentrically. Plus, I think another thing that's often missed is the endurance factor or fatigue factor. And when you look at the number of throws, and it's been shown very clearly in the literature that when fatigue occurs in the overhead thrower, that increases the incidence of injuries. I think that's a neglected area all the time, even with good therapists. And then, of course, then head out to the physical TAS, total arm strengthening. So I think it's an entire kinetic change in that concept. Start with your foundation, TLS, total leg strengthening, core, scapulothoracic, then into the arm for TAS. And it's a comprehensive approach. Yeah, Gus? In my experience, those patients with the scapulodyskinesia or the motion, they may or may not get better symptomatically, but I've never sent anybody to physical therapy that had a scapula that was winging, and then all of a sudden, after six weeks, it came back, and it wasn't. So what's going on there? You can definitely increase their core strength, and you can definitely increase their range of motion, but I've never had that scapula come back normal. One of the things is when you ask a patient, and they say, I've been in therapy for three months. This is what Steve and I are saying, right? I've been in therapy for three months, it hasn't helped. How many times has your scapula been taken back? Well, none. How many times have they watched you exercise and put a finger on the scapula? If you shouldn't send them off for shoulder rehab, you're not gonna get any better with that. Yeah. We have all kinds of things going on. No, but you guys have patients that have scapulodyskinesia, you send them rehab, and six weeks later, their scapula's normal. I've got a video on my cell phone right now, Gus, if you wanna see it. We had a patient yesterday. For example, a patient just two days ago, I've been doing scapular rehabilitation for six weeks, I mean, for six months. What have you been doing? I've been prone airplanes. No, that's not scapular rehabilitation. It's what George was talking about. But yes, you can get, now, it's visual, so you observe it, and you say, well, but if you, you can get them better. Now, do you get them pristine on the other side? Maybe not, but you get them to where they can do that? Yes. You gotta do the right exercises, though. You gotta really, really gotta spell out. You were very quiet. Well, you might just, might work. I just, I just, I just assume you gotta stay up here. Finish up. And then taping, do you like that taping? I like the taping. The skin gets raw, we tell them, we give them some exercises, posture assurance, all that stuff, and we were just talking at a table about some serious exercises that you can do to sense it. You know, not just pinching your shoulders back, squishing on a wall, telling them to look in a mirror, because when they come in, you know, you took Mom, sitting right in front of them, and you said, look at this shoulder, because the video then showed, as soon as you look at that guy, you go to the shoulder, down and forward. That's his resting position. And the simple explanation is, you got a pain in your shoulder, you're gonna pull it in, that's the body's natural response. Play baseball, softball, you gotta fix that. And it does correct, but they've got to specifically target serratus exercises and posture correction. You gotta stretch out the pec minor. If you don't do that, you're not getting any better. The flip side of it, not to monopolize this, is if they don't get better after six weeks of therapy, could you have an isolated serratus policy when you're softball players, you really think about that, which means you wanna get an EMG, and that electromyographer has to understand that you wanna look at a serratus, the super scapula nerve, and we always tell them to look at the spinal accessory as well as the long thoracic spinal accessory, super scapula. If the super scapula nerve's getting pinched by the dyskinesia, then you may have to decompress that as part of your surgery. You'd be amazed how many people come in and you do that test, and all of a sudden, that's positive, and they'll say you have very poor recruitment of the serratus. Maybe it's a little bit of compression. It could be different things, but, you know, and then the treatment after, you know, they're talking, but if they really don't respond at all, then you have something else going on. Not to carry on any further, because this is not a strength issue. This is an activation issue, and so you can do strength all you want to, but if you don't activate them with hip and core scapular attraction, and it's an activation situation, with proprioception, taping, touching, this is an activation issue rather than a strength issue. So Mike has asked, if you're a faculty member, we're gonna ask you to rotate clockwise. Just stand up and go to the next table so that we can mix you guys up a little bit as we introduce this next case. I certainly am.

shoulder pain

pitcher

throwing

shoulder injuries

physical therapy