Real brief, so there isn't a whole lot of literature on here, and so a lot of this will be discussion. So this is the case. This is a 42-year-old woman. She's had right shoulder pain one year. She's very active. She's a power lifter and a CrossFitter, and we all know those patients. She's done physical therapy for about six months. She's had injections times two, and she's pretty healthy. She's a muscular individual. She's got good motion. She has some weakness on forward elevation. External rotation is intact, five out of five. She has some groove pain. She has some impingement. These are X-rays, which I think look relatively normal, and then I'm going to let this play here a little bit. So I guess, Mike, anything jump out at you with this MRIs, with this history? For me, usually, with these types of individuals, the females and the young CrossFitters, the active, I always get the critical shoulder angle, based on your exam, so I'm thinking superior labrum, and I'm thinking cup, partial cup, but a critical shoulder angle is going to be key for me with this. There's nothing out there that you wouldn't expect. So here's her critical shoulder. We can kind of get a global view here. Does that change your management in any way here? Has she had the right type of physical therapy, or what's your thought about what her diagnosis is currently? Would you tell me what her PT was? PT, six months, that can mean lots of things. Yeah. I mean a rotator cuff strengthening protocol, impingement protocol. Did the injections work temporarily on her? Yes. Subacromial, I'm assuming? Yes. Both of them subacromial injections. Can I push Mike a little bit? If you see a critical shoulder angle that's out there, are you moving to an acromionectomy laterally? Is that where you're taking us with that? Yeah, if you're above 33, and if you're a CrossFitter, and you're getting, again, you have to separate where's this injection going? Is it intra-rotator or subacromial? If the shoulder angle's above 33, then I'll do a subacromial injection, see what kind of relief they get, and I'll let them ride on that and do the PT. That's very specific, again. But yeah, if they're 35, I'd bevel it. I don't do a lateral acromionectomy, but just coming in, and instead of having this, you can just bevel to increase that without getting into the deltoid fibers. That's been my experience. I've been doing that for a couple years already. Have you done that in isolation? Well, I mean, if this is a POT stuff that's 50% that I'm in there doing this, then this is someone that I'll often throw a scalpel on. It just depends. The acromioplasty lives. It's awesome. And the biceps, of course. We like to address those things. Once you get past 35 years old, I think the literature supports that, too. So, one-year symptoms, good relief, but temporary following the injections. What do you make of this coronal image here? Maybe I'll pick on Jay here. Or Jacob. So, I mean, you definitely see some changes in the cuff, right? So, some tendinosis on the articular side and stuff. She has that degenerative sort of slap, flap there, where some of that fluid is sneaking under the top of the labrum. But I think a little bit, too, when you get an arthrogram on these patients, you don't get to see that biceps, like tenosynovitis that goes down into the root, but it's there because, obviously, that looks down there. Buddy, do you think that's enough to call as a posteter, or is it equivocal, or hard to know? It's not bad. Yeah. You know, but your insertion site is really good. So, that's it. You only have dye dissecting out into that anatomic insertion. And you can go front to back and see if you see more. You do see a little bit of thinning, but, you know, someone that's her age and what she's doing, I would consider that to be normal. And then on your axillary cut, when you go way down to the biceps, you can see some, a few adhesions get low enough. See right there? Back up a little bit. You'll see a line coming from the, right there. So, then you see that coming in on the biceps. You have some, at least, adhesions on the biceps right there. That's really subtle. Regulators don't call that, but when you see that, that's a bit of a problem. Well, so, these are the questions I, you know, have you ponder here. So, is this enough to call a diagnosis? And if so, sort of, what is the diagnosis? Is there, is this, is this an instance in which they're worth trying other non-operative options? Would everyone, anyone consider biologics, PRP, that type of thing? And how long would you try continuing a non-operative treatment before considering surgery? And if you do consider surgery, what are the, sort of, the things that would play a role into what you would do? Steve, is this, is this a type of person that you would take to surgery? Or would you try some other things? And what do you think, you know, what's sort of your diagnosis here? And what, what might your plan be? It's a tricky patient from just a demographic and activity. The way you're describing it. Yes. In my practice, I have, you know, a handful of these women who lift heavy. Like, is she pretty jacked? She's muscular. Yep. So, these patients are tough. Sometimes they'll have some cartilage stuff that you really don't pick up well in the MRI. And then you get in and you see, you know, kind of, you get kind of surprised by some cartilage. You know, primarily humeral head. But if your diagnosis is a likely cuff-based pathology, you know, I think Mike was getting to this with the critical ankle, et cetera. These are hard to get perfect in surgery. So, I tend to do my best to avoid surgery until it's, it's just not working. So, you know, some of the other guys have asked, you know, what was the therapy that was tried? Where was the injection site, et cetera? I probably would, especially if I'm seeing her for the first time, I would probably try some additional stuff. I would try to hone the therapy a bit. Maybe something intra-articular, whether it be a steroid versus a biologic, just to kind of see if there's a response to that. Okay. You know, kind of just, you know, you don't move past, you know, certain things on the first date, so to speak. Because you know that perhaps it's going to be pretty tricky in recovery as well. Ben, you had mentioned sort of what kind of therapy she was getting. And what were you sort of alluding to with that? A lot of these fitters are so looking for certain definition of certain things. They get so imbalanced. They get so tight, so loose. It's amazing, a lot of those can't stand on one leg. There's, all that stuff is based on the scapula. He didn't tell me anything about the scapula, about where it is, what it's doing. So, you know, put your hands on them, move them around, see if you can change. If she's had PT and you do all this stuff and it doesn't make any difference, then PT is not going to help. But you have, there's so many other points to this, but they'll all get tight here in the front. So they're all going to be tight in their pec, they're all going to be, their lats are going to be all out of whack. So there's a whole lot of things you can look for to add to your treatment that's different. For example, a lot of times I'll see a patient, I've done PT and I don't want to do any more. I say, okay, here, I take a $10 bill out of my pocket. I put it down and say, if any exercises we're going to show you, you've done before, that's your $10 bill. So far, it's still in my pocket. So there's a whole bunch of other stuff to do before you get around it. Because really, the MRI didn't, you know, she probably does have rotator cuff disease, but really, where does that fit in there? So in biologics, once again, what are you trying to do with biologics? As far as I can tell, there's nothing that can really be helped that much by that. Yeah, no, I mean, I think this is a tricky scenario, right? Because nothing is completely obvious. This is a high level person, very hard to kind of meet their expectations. But for the sake of kind of going forward, because I think there's more discussion here. So let's say we've addressed all the things that Ben mentioned, physical therapy as well. She doesn't have any crazy deficits in her scapula core. And she has the positive impingement sign. She has weakness. She has some bicipital groove pain. I'm going to actually do something unconventional. Before you get to that, my table voted to inject her again and let her just keep working out. Don't touch her at all. So what we said was, these people are going to go to the gym and keep working out no matter what you do. And so you don't want to operate on them until they come back and go, I can't work out anymore because my shoulder hurts really bad. It's very positive as opposed to, you know, it hurts a little bit when I do my TRX part of it and I'm swinging my back. Should I stop doing that? No, you should do whatever you want to do and keep working out. And when it gets really bad, come back. So buddy, so let's... You're out of your shot, right? Right. So let's pretend... Once a year for 10 years. You've got 21 years. So let's pretend that she wasn't referred to you, but that is a person that you saw for a year and you've done therapy of injector twice. You'd still... And she's begging you. She said, Dr. Savoie. Option one, live with it. Option two, do another shot. Option three, I can operate on you and put you in a pillow sling for four to six weeks and you'll take six months to get back in the gym. What do you want to do? And they pick option two almost every time. Well, so let's say she picked option three here. Okay. And so I'm going to jump to this just because... You may never work out again. I want to jump to this just to show you before we discuss what to do here. And so this is the intra-articular look. And so you can see sort of the cuff pathology. You can see some redness going down into the bicep. So I'm going to now jump back here. And so she picked option three despite Dr. Savoie's best efforts. And there are, I think, a variety of treatments here. And I think maybe I will pause here so that the tables can talk about this a little bit and then we can talk about what to do. Are you going to debride this? Is this a space for a biologic patch? Do you do an in-situ posture repair? Do you take this down and repair? And what do you do with all the other concomitant issues? Do you leave the biceps? Do you do subacromial decompression? And then how does your rehab protocol change for all of these? Can you put the scope in? Five minutes. Yeah. Okay, so you're thinking something that's enough of an injury. What do you call it? What are you saying? Doing something. In this particular patient who is already demonstrated that she's going to be over the top for most of this stuff. What are the pros and cons? I think we're going to have to bleed it. We've got to show her, you know, that we've cleaned this up. That on that upper left, there's some junk that needs to be cleaned up. I forgot about that. But then you see that delamination of that upper right. And, you know, that's a cuff that's really on the edge. There's no doubt about that. But if you try to put these pieces together, either by taking that out or just, you know, make it tighter. That's what usually happens. Certainly in a brawl, you can't do that. And what about her biceps? Biceps is kind of angry. To get my biceps, I'd probably still do surgery. I'm pretty aggressive with her. Well, what she's doing, she's having problems with her biceps, because she doesn't feel good. That's the only one. Every person needs a bicep. There's somebody that doesn't. Yeah. So, probably get a bicep. What are you going to do with her biceps? I'd be between. So, I'm just in general not a giant man of awesome parents, so I usually don't do that. I'm more of a take-it-down kind of thing, or take-it-down-with-parents, or board-collections, I'm not doing it. But, interested in the idea of, we would do a sexually-dedicated fellowship with Lynn. Probably more blatantly, don't ask me about it. But, we would start to do retention patches sometimes. So, I personally haven't, because I cupped it. But, I mean, a lot of it's industry-driven, but there's a lot. There's some data on the... I didn't... And that's because, that's over-repairing? Like, with two acres or something? Yeah. Okay. Improvement in the wall. Okay. And, in her, I mean, that honestly may be a decent option, because with that, you're not going to lock her down as long as you would as a repair. She'd get back in the gym quicker. You actually want her to start moving again quicker. So, come October, you can really think about putting a patch on top of it. Right now, I'm going to take it down and probably do a one-on-one double wall. But, I don't think... I don't think I can take it down all the way. I think I can put a slice in it and just kind of get in there and take it apart. It doesn't allow it. And how do you rough it up to repair? It's hard to do, really. Like, from your anterior portal? Anterior portal. I can sometimes get to it. Do you get, like, a shaver? Shaver. Or do you do, like, a little ball rack? Shaver. Or then, just do my little, I guess... Oh, go ahead. Slice right here. Right now? Yeah. I think I'll clean up and repair it. He said, maybe after board collection. I would really think about doing an anterior patch on it. And biceps? I'll just do an anterior... I'll definitely do an anterior t-cutter, biceps, and a knee cyst. Just talking about that. I think that's what I'll probably do. I suck at that guy. I don't know. All right. So, back to this case. So, I'm curious, you know, to see sort of what the discussion was with this. So, maybe JT, I'll start with your table. And what did you guys discuss here? Yeah, we agree that this is a tricky patient sometimes, right? And we know that agreement doesn't change things over the course of time. And this is a gal that's got a degenerative problem, not an acute problem. And that should all make us a little nervous about taking her surgery. But we're here, and all of us get into this position. So, we like the idea of a patch. We're not real crazy about xenograft patches, although those that use them know that the literature does support, you know, placing a versatile side of one for an articular side of tear. It's performed fairly well, although there's new data out with increased levels of stiffness, et cetera. The human dermal allograft patches that are available to kind of augment this cup, so that's kind of our thought, is we biceps tenodesin and augment. And then the human dermal allograft patches are emerging as a possibility for that. They've been compared to the xenograft patches and shown to be better, at least in the dog model, but no direct study, you know, clinically. And then finally is a newer technology that we're using where we're taking that biceps that we cut out and turning the biceps itself into an allograft or into an autograft patch and putting that in as a cuff support for augmentation on the top. So, biceps tenodesis, use the patient's own tissue, create a patch out of that, and put it on the top of the cup. So, my question for you is with that approach, what is your rehab protocol for us? Because there isn't really a lot in that space. And so, you know, one would say one of the benefits of this is not to mobilize for a long period of time, but there's really not a lot of literature to guide us in terms of when do you strengthen, you know, when do you let it go back to activity, and so if you're going to go that route. Yeah, I think that this is one of the advantages of the augments versus takedown and full repair. If it's a takedown and a full repair, but then you've got a long time, you've got to trust that and protect it. With the augments, I think you just have to get it to where it's going to stick and not move independently, right? So, I think you can move them much faster. So, gentle range of motion right away, and then we usually start a full range of motion right around the three- to four-week point, and strengthening is about six weeks. Buddy, is this a person that you would do, or I don't know what your table had discussed, but is this somebody you would use the, you know, a collagen bovine patch for? No. No, I think there's too much damage. On your left picture, your poster ligaments that stabilize your biceps are torn. You have tendon left on the footprint on that picture, and then on the right picture, even though you've treated some of it already, you don't have normal tendon. Yep. And so, one of the things we do is we read back until we see normal tendon in order to do a posture repair. You know, we voted for takedown and completed just because the quality of tendon, at least on the pictures, was pretty poor. So, it's a longer recovery. And I think you have tinnitus in the biceps at the same time. And your third question was a decompression, and pretty much all decided that if we looked up top, and it was pristine and normal, and your critical shoulder angle wasn't above 35, we would probably leave it alone completely. If the critical shoulder angle was 38, 39, we might double the lateral side, but that's the most important. Now, if this was debrided and you did see healthy tissue, is the go-to here an in-situ posture repair, or do you think that's more, or would you still take this down? So, my table voted to take it down and fix it. For me, I do a variation of Pascal Wallo's inverted mattress stitches. And so, I would do, because I can pass my sutures, struggle with PDS, really obliquely so I don't over-tension. And I would leave the normal tendon alone and do a tension band repair like that. Probably two, maybe three inverted mattress stitches, and one or two lateral, and they're still pristine. So since there's intact tendon with that type of technique, in a sense with any in-situ technique, do you move them quicker, or do you change your rehabilitation protocol? Yeah, great. Gus? I just wanted to ask, you guys are talking about looking at, quote, normal tendon versus abnormal tendon. Paul Southey did a nice paper where he showed that we're inherently not really reliable on that. So, what's your definition of what a normal tendon looks like? Just white. Meaning the shaver won't eat out. What? It's really simple. It's whatever the shaver won't eat out. So, you put the shaver on it, and you just start shaving, and if it doesn't take anything, that's normal? You shave, and if the shaver goes all the way through, it's a bad tendon. It's like the Supreme Court said with pornography. So, anybody, any other table here that decided they wanted to do a PASTA-type repair here, or not? I don't know, Steve, would your table, what did your table decide to do, a takedown, PASTA? So, I was at JT's table. Oh, okay, okay, got it. You know, I think a PASTA repair, honestly, in this setting, this is a tough patient, right? So, you try a bunch of different things, and a lot of times you have trouble. I think one of the benefits is you can rehab a little bit more aggressively, because you're not taking it down. Just like JT said, with an augment on top. So, I don't think it would be unreasonable to try, but I do think that this is a tricky patient to get that type of repair to work. If it's more of like a delaminated-type therapy, you see something like you can use. You can do an incision repair in that setting. Yeah, Albert, I think the last of your questions, occupation, desires, you need to talk with the patient. But if she's going to do what she did before, then our table voted for an augment. An augment. For several reasons. Yep. One of them is the anticipated load, return to activity. And I actually agree with JT. We can do it with biceps, tendis, because she's not an overhead thrower, so we'll do it. Well, actually, that brings up another point. So, if you do a tenodesis with a patch, are you going to change the recovery in any way, or still let her move the same way? Same way. Same way. So, let her do an augmented, accelerated protocol. Yeah, the biceps, tenodesis doesn't change our rehab. The cuff does, for sure. If you repair a cuff. Okay. Albert, I think the thing that's interesting with our table, I think all of us are in agreement with the tenodesis you would do. But what Gus brought up is the important part, and this was brought up by Lyndon at our table. I think it's a great trick. Make sure you mark it just like you did there with that, and then go up when you're in that subacromial space. And as we talked about, remember Clark and Harriman, that's great work. There's five layers of the rotator cuff. And we forget that, you know, four and five, the more articular side, it's just capsular tissue. It's not that great a tissue. If that tendon up above, you're not eating through it easily, as we discussed, then I think it's better to augment it. If you take that down, or do it in situ, in my limited, compared to my colleagues here who are so experienced, this patient tends to get really tight. They'll get tight in a second. They will get tight in a second. So this is what her subacromial space looks like. And so nothing changes here for anybody else's plans. You know, Albert, when they talked about the original postures, if you have a – so if it delaminates where the articular portion truly abulses, hence the term postures, then I think that's amenable. But I think the partial undersurface articular side and cuff tear is rarely an abulsion. It's more like this where you've got tension tissue loss. It's gone. So you've got to grab what looks like normal tissue and bring it over. That's not the articular side. That's just the remnant of the lost tissue. And I think that's probably why we've gotten in trouble with tightness over the years is that we've said, oh, I'm going to grab that because we can, and you bring it over, and it's not the articular side. It's tendon loss. I think, JT, that's a really great point. And I presented this case because this was very early in my practice, about eight years ago. And so I'll show you what I did. And she ended up having an okay outcome, but I think that's a great point because that tissue is not evolved. And most of the time, this is degenerative tissue that's retracted. And so this is subacromial space. I didn't sort of change the plan. I decided to do an in situ repair, and this was, you know, years before we had the possibility of, you know, the patches. And so we used knotless anchors here. And again, I think this goes to the point where when you're trying to get into that good tissue, it ends up kind of bringing that medial side way, I think, not anatomically onto that footprint. It's a fun surgery, right? And you can, you know, kind of tighten this, and you put it through, and it looks like you have compression. You go back in. I did, you know, I would have definitely addressed the biceps as well, but I didn't at this time point. I thought she was young and active, so I left it. And, you know, I think the issue is that she did have initial stiffness, and I moved her, you know, right away. But again, I don't think that's an anatomic repair, to be honest. And so I think my vote these days would be I would either take that down and repair it, or I would consider using a patch for this as well. But she went back to her crazy stuff, and so far I haven't heard from her. So, yeah. Any last thoughts or anything like that? All right. Perfect.

shoulder pain

labrum pathology

impingement

surgery options

rehabilitation protocols

biologics