An interesting session. I think that it's really evolved over time. We've been doing this for years here and at the academy. And we roll in different faculty members. And I'm really honored. We have such a tremendous faculty with us today. So I think that we can take something from this. The thoughts here are a lot of these are presentations that come into the office and that you see. And they seem pretty straightforward. But as you start to dig a little bit deeper or even get to the time of surgery, there might be some pitfalls that are a bit tougher to navigate and take a little bit more to think through. So our faculty today. Looks like you've got to show Tama over here. It's a strong one. Just experts in the field, Ashish Bedi from Chicago, Chris Camp from Mayo, Jacob Kelsey from Case Western, Ben Kibler from Lexington, Nick Verma from Rush, George Poletta, I don't think George is here yet, from St. Louis, Buddy Savoie from New Orleans and Tulane, JT Tokish, Mayo, Arizona, and Tom Noonan from here in Colorado, and CU and CU Stedman. So our attack here is we're going to do three cases. Each one of the faculty will present a quick presentation of the case and then go down the line and see what each of these faculty members will do. And then they'll show us what we do. And then we're just going to open it up and have a good discussion. And that's really where the gold is in these. So with that said, we'll move forward here. Or just in here, yes, we'll start with Chris Camp. Tom. Let's go to case number two. Normal major leaguer, so a pretty good start. There we go. All right, here we go. All right, so for this first case, so this is a 19-year-old professional baseball player. So this is a kid that was drafted out of high school. Now has one year in professional baseball, so it's shortstop. Bats right, throws right. So he's a right-handed batter. So that means he's here, his left shoulder is his front shoulder, right shoulder is his back shoulder when he's batting. Has a history of left shoulder instability. So he had his first event while batting in high school. And we don't have a lot of details on this. He said it slipped out on him one time. He told the athletic trainer. Didn't have to be reduced on the field. He was taken out of the game, did some PT with the athletic trainer. Didn't get any imaging at all, but was able to return back in one week. And that was roughly a year ago. So this is about a year out from that injury. Has been playing without much difficulty or without much challenge. Now he's playing professionally, so he's in spring training while batting. Has his second event. So let me, maybe I'll pause before I go that far. So second event now, in spring training. So we're in March of the season. So we got him started in physical therapy and went ahead and got some imaging. So maybe I can, I'll run the x-rays, essentially normal, negative. And then I'll let the MRI run here. So axial view, T2 weighted MRI. And we see pretty clear and obvious, I think, posterior labral tear there. Maybe a little bit of posterior chondral loss. Not a lot of edema in the humeral head. We don't see a huge reverse Hill Sachs lesion, which is fairly typical for these. Rotator cuff looks good. I just had these axial images. But that'll give you a little bit of an idea. So pretty clear what the injury is. I think the diagnosis on this one, that part's pretty straightforward. I think the discussion all surrounds the actual injury. So here we go. So there you can see his x-rays, a couple of MRI slices. And this is his second event now that we have this imaging. So maybe I'll run down the panel here and see what your thoughts are. Nick, how would you approach? Maybe just kind of do one minute and have each person kind of speak. So second event, he's in spring training. We know what the injury is. I guess the big question is, do we go to surgery now? Or do we let him try to rehab this now that it's happened twice? Sorry, and so high school and then spring training, was he drafted out of high school? Or did he have a large amount of baseball in between that time? He was drafted out of high school. So what was the time frame between the two? Roughly a year. So had one a year ago, and then one in spring training this year. Yeah, I would say you've got an obvious labral tear that's probably not going to do well nonoperatively in the long term. Having said that, given that we're in spring and that he made it through a season likely having some form of this before, I think it's very reasonable to give him four to six weeks to see if you can re-establish enough stability for him to play to get through what's probably going to be a minor league season, so a shortened season, and then otherwise pull the plug and fix it. But I think in spring, I would give it a shot. OK. Has he had any of the injections or anything like that? No injections. So that's another thing you could consider if his main complaint is pain. Again, I think he's a young kid. He wants to try to probably get through the minor league season. The only thing is obviously having the discussion. If it's going to impact your performance, even if you can do it at that young age, it may disqualify him from being able to move forward. So I guess giving him a little bit of time, maybe trying an injection. And then if he can't, yeah, then I think you probably, I mean, at some point, you're going to have to fix this. Yeah. I agree. Buddy, any other thoughts to add to that? No, same thing. I've had good luck in high school players just rehabbing him through the season and doing it at the end. But as they keep moving up, and some of our college players with badder shoulder can do pretty well. But the higher they go, the harder it is to continue. So if he's only going to play rookie season, it'd be really short. And you could fix it relatively quickly. I think that's reasonable. Otherwise, I think what you're doing is correct. I think we're hearing consistent messaging there. A couple other things to layer on here is that he did his physical therapy with his athletic trainer for a week in high school. So I don't know that he really got a good rehab after that first one. So the thought is, well, maybe if we can rehab him and do a really good job, maybe there's a chance that this won't be a problem. But good chance that it will be. But is there any harm in trying on a bend? Chris, we're throwing around PT as if it's some kind of magic panacea or whatever. And I think if you're talking about PT, then you need to be specific about what are you going to try to do with PT? What are your objectives with PT? How long are you going to give it to try to see if it's going to work? This guy's got an anatomic lesion that's going to create pathomechanics that's going to be very difficult to handle with that bat, no matter how strong the muscles are, how good the scapula is. And don't forget that every time he does it, he's creating more pain that's causing the inhibition of all those muscles. The longer you go with that, the longer the muscles take to get better. And on the right hand view, you see that that lesion there goes to where it involves the posterior glenohumeral ligament as well. So that whole back side's off because he has no support back there at all. So it's just a matter of how many times you want him to have this while he's playing through the season. He can't hit that outside pitch. He can't get to it. He can't pull it. So functionally, he's not very good. So fixing this now, for me, no anatomical loss with the bone. It's a labrum itself. It's not totally beaten up. It goes down the posterior band, all this other stuff. I tend to go with, if you want to, give him three, four weeks of really good scapular control, rotator cuff, all that stuff. But I'd fix it earlier rather than later. OK, JVT? I was actually going to ask the same question about fixing him early, right? Because right now, I don't see any edema. There's no chondral damage. And I think this is a different animal. If that guy lives on this thing, he's probably tough enough to make it through. And the minors aren't going to be quite as demanding. He's going to be batting every day. And if this guy comes back in a year and he's got chondral changes and a little bony edema, I think that's a different animal with a different outcome. So I'd probably jump on this guy early. The other thought, too, along those lines, though, do you think that this is different from anterior instability? If this is a second time anterior dislocation, I think many of us are probably more aggressive to jump into surgery. But what about with it being posterior instability of the batter's shoulder? Does that change that approach for you? I do think they are different animals, anterior and posterior, right? One's a nagging pain. And one's kind of an event where you're stuck and done. So this guy is probably able to hide it a little better. He'll go through. And the problem is, as you guys know, that he'll get in batting practice. He'll do the rehab. And he'll go, gosh, I feel pretty good right up until he doesn't, right? And then you're back kind of to square one. Whereas the anterior instability patient, right, when they have an event, boy, everybody knows it. And it shuts down. And so the decision making is a little bit more clear because those events are a little bit more clear. His posterior nagging pain, he won't anticipate it as instability. And so I think that becomes a little bit of a harder discussion. JT, do you distinguish? What if he's just having pain, but he doesn't report these instability episodes? Is that more favorable for you to let him try versus if he's slipping? I don't think there's a difference in my hands. I know we have this argument all the time about whether it's pain or instability. But I think the pain is a presenting complaint of instability. And I treat it as activity. That is the presenting. The pain is the problem with posterior. And you cannot say, oh, well, it'll go away, or I can rehab. Pain is the reason from the injury itself. I think it's a key concept to pull out there. So for posterior instability, I think pain is probably going to be the more common symptom. And don't forget, pain drives that serratus and low traps. So he'll never get better at the exercises. OK. Well, here's what we did, right or wrong. We let him do PT and try to return to play for a couple of reasons. One, we felt like he hadn't really done much PT his first time around. We thought maybe there's a decent chance. The other thing is it's spring training. So this would have been a different conversation had this been July or August. But because it is spring training, if we do surgery now, he misses all of this season and is ready to go for next season. If we allow him to try to come back and he fails in a few months, we still do surgery in July and August. He's still going to be ready for next season. So the thought was, let's do this. We know there's a higher risk that it may happen again. Let's let you get back out there and see how you do. But I think one of the key is we would define success as being able to play swing without any limitations, no pain, and no apprehension. So we told him if he gets back and he still has pain, even if he doesn't dislocate again, we probably need to move towards surgical intervention. So he was able to do PT, get back to return. But then he played for two months in games without issue. So made it through a good portion of the rookie ball season, but ultimately did have a third instability event during batting practice. So then it became pretty clear, no mystery now. We're going to surgery to fix this. So I'll put some photos up here, and we'll see what the group thinks. Or maybe before I do, let's talk a little bit about the surgical approach before I show what I do. Chris, can I just ask one question to you and to the group? Does player performance, you guys track that as part of this? So for example, this guy could go out, and he makes it and plays rookie ball, but he bats 096. You know what I mean? So I wonder, do you guys follow metrics like that? I could not hit an outside pitch, that guy right there. George, what do you think? I'm not sure. This kid's in rookie ball. What's the short-term gain of trying to get this kid to play two or three months when he's got the rest of his career? As opposed to fixing him, missing a rookie ball season, getting him back to the point where he's healthy and can perform at the level he can perform at. Even if this kid does well for a couple of months, as Ben said, he's not going to perform at the level he needs to perform at to try and move up in the organization. So I think we've got to balance off the short-term gain of getting this kid two months of play versus the long-term gain of really looking at the length of his career. So I agree with Ben. What's the objective of trying to get him back for rookie ball season? And I agree, you could fix him at the end of the season. But if you anticipate you're going to have to fix this kid anyway, why put him in a position where he may not perform as well as he needs to or where he risks further injury, as JT mentioned, condor damage and other issues? Regarding JT's question, I don't know that we necessarily follow metrics. But I can tell you that players batting 400 generally don't sign up for surgery. And players batting 096 say, I can't play like this. But I agree with what everybody said. I think there's very, very few shoulder problems in baseball players that I would recommend early surgery. But this would be one of them. I just don't think they do well. They just keep recurring like your guy has here. And Chris, to that question, if this was a major league guy in the midst of a season where you guys are fighting for a playoff, does that potentially change the metric? And for me, it probably would. I'm just looking at the specifics of this case and this kid. That's a great question. And considering that in terms of the timing of surgery. So to be honest with you, actually, I think more so than their performance or what's going on with the team, the timing of the year has a bigger impact on that decision for me. Because I don't want to put the player at risk because the team's doing well or because they're doing poorly, either way. For me, the decision is based more on the timing. And so if I know that, to me, there's not a lot of downside in waiting two to three months. Because we've got a full year before the next season starts. And I only need six months to rehab this kid. So that is the biggest factor for me as well. And to take the opposite side, I would say he's been playing for a year. There's really no evidence of any chondromalacia or chondral damage at this point. I think he's going to declare within four to six weeks whether he can go or not. So I think the risk is pretty low of letting him give it a try, if that's what he wanted to do. Now, some kids and their agents will just say, yeah, we just want to get it fixed. And that's very reasonable too. But I think that's where the shared decision making comes in. And also, a short change, I didn't give you the exam. I do think that's a big part of it too. If he's got full motion, full strength, and minimal apprehension, it's kind of hard for me to say, we've got to shut you down. You've got to go right now. But if they're really symptomatic on exam, it's looking like they're not going to be successful, then I wouldn't do it. But it can be challenging, very challenging. I've got a question for the panel. Glenoid retroversion, I mean, we probably all look at it. Does that influence anybody's decision making? In general, these cases, this doesn't look crazy. I've seen some of these that have a ton of glenoid retroversion. Does that make you more apt to intervene earlier? So I think there's two answers, if I could, on that. One is an athlete who's been performing at a high level and has a small tear pretty much has been dealing with that type of retroversion for a long time. And I would do as little as possible to change that. And would simply fix the labrum, probably be a little bit more aggressive about operating acutely. Flip that around to a 25 or 30 year old, maybe not athletic, now you have posterior instability, the humeral head is sitting, posterior subluxation, you have glenoid retroversion, that's a different animal. And I don't think we have a great solution to that person when it's a fixed posterior subluxation, because even if you do a glenoid osteotomy and bring it up or put bone, you have someone that's been a certain way for a long period of time, probably had an injury to that posterior cartilage analog when they were younger, and now they have this retroversion deformity. And that's a bigger discussion, a bigger surgery, and a lot more detail on whether you do a glenoid osteotomy or a posterior bone block, or most of us would just try a repair once, but if you do, when they have that posterior subluxation, you can't push it forward, so you have to pull it, which means you tighten the front, so then you lose external rotation. That's not an athletic operation. That's a day-to-day, push the total shoulder down the road operation, not a go back to playing baseball. Different mindset. And Buddy, would you agree those are not just, those are not just retroversion, those are true dysplastic glenoids? Yeah, that's a whole different ball game. I mean, that's not us, that's not this discussion. That's big shoulder reconstruction, where you're really trying to manage everything, and then the rabbit hole, people tend to fall down sometimes, is you wanna make that shoulder normal when it's been abnormal for 30 years. So you can't make it normal, you just have to make it better. Great thought. Well, I'll show what I did here. Please feel free to criticize. So this is the view, so he's in the beach chair position. It's a left shoulder, so we're looking from the back. So glenoid on the right, humeral head on the left. So you can see his anterior labrum, superior labrum are all fine. Biceps looks beautiful. This is the best looking biceps you'll see at this conference all week, I guarantee you. Rotator cuff looks excellent. So here's his posterior labrum. So this seems to be relatively isolated to his posterior labrum. So you can see there is a tear there, probably extending from, we look at it on a clock face, maybe two, three o'clock, all the way down to almost six, maybe about five o'clock. So opening it up with an elevator. So in this one, we're using an all suture anchor that's knotless. So putting the first anchor in at the bottom. And then here you can see sort of where I made that anchor pass. And to me, this is, I think the hard part of this surgery in the overhead athlete is how much of that capsule do you incorporate? Are we just tacking the labrum back down? Are we doing a large amount of capsule? Are we treating like an anterior instability where we're taking a big, massive bite? So maybe I'll stop here with the panel. What are your thoughts here? Jake, what do you think? Is it too much, not enough? Well, I think it's a different story if it's his throwing shoulder versus his batting shoulder, right? So I think if you're doing that on his throwing shoulder, he's gonna be tight. He's not gonna like it. But I think here, it is more of an instability, like a posterior instability complaint. And so grabbing a little bit extra capsule, restoring that posterior inferior glenohumeral ligament will help him. And I think that that's the key to kind of think about when you're doing these is the throwing arm, if it's his throwing side, he's not getting up to the position to throw if you're making him too tight. But I think this is the right move here. Agreed, Ben? The deal's not the capsule. The deal is the posterior inferior glenohumeral ligament. And it attaches to the bone right there at that 5.30, five o'clock position. If you get that, then you got that backside. You don't need to take capsule. If you get that, and then the way you know you got it is all of a sudden PIGHL becomes taut. You can actually see it there. And so you always start down low. You put that in there, and you watch, and then you come back up. Because the capsule is so thin. I mean, back there, that doesn't do a thing in my mind. It's the attachment of the PIGHL, and the really good bumper that you get from the labral tissue itself is the key. And if you say, well, I'll take that big capsule, you may get that bite of that PIGHL as well. We do that, but make sure you got that. That capsule back there is very thin. I don't think you're really helping things one way or the other. And just fix what's torn, which is the labrum away from the bone. Well, good. You guys bring up a great point. So if this is a throwing shoulder, completely different animal, in that case where I'm just doing labrum, if this is an anterior instability event, I'm probably taking a lot more of this. So in a hitter, in a back shoulder, or in their front shoulder, I'm sort of splitting the difference a little bit. You can over-tighten these, and then they have difficulty in follow through, which they can complain about. So you wanna be really careful with that. So there's sort of first anchor, second anchor, same situation, and then third anchor. So we think we used a total of three anchors on this. So there it is at the end. So labrum's repaired, capsule's kind of pulled up over the top of it. So here's sort of the before and after photos. Let's, real quickly, we can run through kind of both. You can see, look, you've got that posterior band taught. At the bottom, yeah. At the bottom right here, see? Yeah, yeah. So you got that, as opposed to that first view, you can see it's absent on before. Right, right, great point. So post-op rehab, so I keep them in a sling with an abduction pillow, which is passive motion for the first six weeks, and then we progress range of motion and strength at week six to 12, keep progressing that. Usually initiate hitting around four months with a hitting progression, and then try to get them back to full swings around six months. But I'll tell you, getting them into games and then getting them back up to their baseline level of play takes a few months for these guys. So, you know, your high school hitters, it's pretty, they sort of get back to their level within six months or so. I think for the professional guys, it takes them a few months. Even once the shoulder feels good, it takes them a while to see pitches and really get their swing back. So I tell them my goal for them for game activity is usually around six to nine months. Hey, Chris, can I ask you about this? You initiate isometrics at week six to 12. I've always been a little confused by that because I know that's most of the therapy protocols, but what are we stressing that you're worried about stressing if you start them early, like today, right after surgery doing isometrics and even some early strengthening exercises? Yeah, it's a good point. Probably is okay. I think for me, part of it is a little bit of fear. And in the professional guys, where I know they're getting good PT and they're seeing them every day, they're not doing anything on their own. I am quite a bit more aggressive about that. The high school kids I worry about a little bit is as soon as you say the word strengthening, they're gonna do their definition of strengthening. And so I tend to be a little bit more careful. But I think if you have access to PT, you got a reliable patient and a reliable physical therapist, probably could start that soon. I think we lose so much by keeping an arm in a sling for six weeks that you can do a ton of scapular work and keep them from losing it on day one after a surgery like this is my opinion. But I'd love to hear the panel say. Oh yeah, that's a great point. I actually have them start doing scapular squeezes and retractions. Literally, we do it before they leave the hospital, yes. We do that and I've always been interested in this because when you do a cuff, you wanna do passive motion, you don't want the muscles to contract. But when you slip in with a scope and you fix the labrum like you did beautifully, you've not damaged any muscle around the rotator cuff. So you've done nothing to the muscles. So actually start some more active exercise earlier than passive. I figure if we're stretching, the therapist is pulling on my repair. And I always tell the kids all the time, you're much stronger than my stitches so you can pull it apart. But we start scapular stuff right away and I'll start active motion and isometrics very early and don't let them stretch for the first six weeks or so. Just kind of stop it there and do active exercise from the beginning. Try to work on core. And then when they start to exercise on their own, it's no pushups, no bench press, nothing that puts a posterior force across when you do a posterior. So it's a little bit more aggressive in terms of active exercise because I just don't want them to stretch on the labrum. It's what are you protecting? You're protecting this posterior repair. So you can do scapular plane, this kind of stuff. Nothing here because that's when it goes out the back. So nothing out in front. You can hear scapular control and all that stuff. You can do that very early. And don't forget that every day that you put them in that sling, their muscles are getting weak, every single day. And those poor, stupid low trapping serratus, they get inhibited as well as weak. And now you gotta remind them how to work. And the less time that takes, the better off you are down the road. And when you get it out here, and say, look, I can do right here, but the scapula's right here, then you have not helped him one bit. So early, right here, just avoid putting that strain on that posterior repair. Great, thank you. Well, we can open it up to the audience for any questions, discussions. We got Dr. Freehill running around emceeing. So he'll keep it entertaining for us. So please ask anything you want. While he's looking for me, one other thing I'll mention, I think it can be helpful too, to think about the follow-through for these hitters. One of the things I always talk to them about, if they're a one-handed follow-through person, so if there's somebody that lets go of the bat and does this with one hand, I talk to them about potentially keeping both hands on the bat as they go through this. And I've actually had several players that it's hard for them to make that change on the fly, but when you're taking them through a hitting progression, it's actually pretty straightforward. And I've had most of the players that have this that were one-handed before, will convert to two-handed afterwards. It seemed to do really well and actually feel better with it. We don't have great biomechanics. We're working on a motion analysis study right now to look at the difference of one-handed versus two-handed to see what it does to the shoulder, but I got to think it probably helps. We do that. Our return to hit program has both hands on the bat until they go all the way through, and then they can go back to being themselves. But we do exactly that for that reason. I think that's very smart. One of the reasons they're doing one hand is because they're tight in their hips and back, so if you want them to do two hands, you got to make sure they can do that, which means you got to have good trunk rotation, good hip strength, all that kind of stuff to make it go, because otherwise they're going to go that way just because they can't move their trunk. Sheesh. Chris, just one maybe technical question to learn a little bit from the panel. As I look there, you have, it looks like an accessory posterior portal there as you're mobilizing along the glenoid and the labrum there, and I found that portal to sometimes be helpful for the trajectory for anchors and mobilizing, but it does come a little more lateral and a little closer to the infraspinatus tendon. In this approach, do you change it? Do you try to worry about that more when it is obviously a throwing shoulder more so? But just maybe a little bit of thoughts from the panel. Is this all a one posterior portal operation, or do you make that accessory posterior portal, and what's the risk of that? I'll take that. I go right off the, I cheated two finger breaths and come right off the posterior lateral most aspect of the acromion for that very reason. That way you can do it all through one portal. I go lateral and work from high anterior, or view from high anterior and work anterior and posterior, and to me you usually can. But if you don't do that, you're forced to create another. There's some good, there's two studies in arthroscopy, this is probably 2012, that looks at what happens to the fate of the portal. And as it turns out, they never heal completely, right? Or they scar in. So I think your point about portals back there is a good one, that there may be damage with that. So with that in mind, I'm always a percutaneous anchor guy, because I think that's the only reason you need a positional portal back there is just to get your angle for that posterior anchor. And I think you can do that through a tiny stab incision, all PERC, and then the rest of your work you can do standard. Yeah, I think you can't put an anchor from your standard posterior portal. You're too flat with the glenoid. So if you try to do that, then that anchor, no matter if you're using an all suture, will tend to go between the articular cartilage and the subchondral bone. And you sit in there and then you're back later trying to take care of a posterior significant chondromalacia in an anchor track. So I think you have to do a posterior lateral portal, and I like JT's idea of percutaneous. Just something small, but you gotta have that angle to put the elevator down there and everything else. I do it exactly like you do. And I do, one of the things I find to be helpful, I agree you wanna minimize damage there. So I actually will do, put a needle in to localize it, and then I actually take a knife, go through skin vertically, and then I turn it to go, and I just poke a small little hole through the cuff in line with the cuff fibers. And I allow the knife to be what makes the hole, the hole in the rotator cuff in the capsule, rather than it be the elevator or the anchor or anything like that. So rather than having something blunt do it, I try to shunt it. So if you use a cannula? No, typically not, typically not. For those who do though, do you close the capsule? It was curved. Because we know that capsule's 1 3rd, the width is the anterior capsule. I always close it with zero PDS. I know it's gonna resort, but I worry about, that's what I worry about going too quick with therapy. If that rent continues on towards your repair, so I'm probably a little bit less aggressive to let it heal and also put them in an external gunslinger type, so you're decreasing the tension across the back of the shoulder, maybe that's a little bit too protective. What are your thoughts on closing the capsule? And would it be different in the batter's shoulder versus a throwing shoulder? It's a good thought. I don't think there's any harm in it. Admittedly, I don't. I mean, it's such a small, and honestly, sometimes after you take everything out, you can't, I can't see it or figure out where it is to know. And I'm worried I'm gonna do more damage by trying to go in and get sutures in it. It's a good thought too, it's a great question. We didn't talk about this. Do we immobilize an external rotation when we're doing posterior work? I'd love to hear the panel's thoughts on this. For me, actually, I started doing that, but I've gone away from it because I found that patients hated that brace. They don't use it, they don't use it. And so, I actually don't use it for any even complex posterior instability case. I don't use it because I feel like compliance is very poor. Anybody find that they have success with that? I still use the Ultrasling. It's an external rotation Ultrasling, but honestly, it probably holds them more neutral. It's not true external, but it's more neutral. Yeah, there are a lot of these in-between braces now, right? The traditional gunslinger used to be that metal thing that would truly give them an external, but there now are Ultraslings with neutral rotation wedges that they don't put you in ER, as you pointed out, but they can give you more neutral rotation, which is what I use. I agree. I use the neutral by gunslinger here, but I also use that with slap repairs because I think that putting them in abduction, regular abduction pillow sling, was potentially a big reason why they get so tight, whereas if they're neutral, you've already got them a bit closer. What are you doing slap repairs for, Mike? Type eight, type eight. Plus, even with a traditional Ultrasling, right, some people wear it here, some wear it here, so you kind of just educate them in the position you really want it to be in. Great point. That's a great case, Chris. Why don't we transition to George, and is there any other questions while they're switching over? What? Thoughts on beach chair versus lateral? For that. We were. How about for cuff? Lateral. Beach chair. So what do you do when you got a labor man a cuff? Because you guys that are doing beach chair in one and lateral in the other, you're either, I mean, everybody says, oh, it's easy, it is, sort of, not, right? We might get one of those. Yeah. Okay, this is case number one being presented as case number two. First, I'm sorry, I'm so casual. I came in from out of the country last night and they lost my luggage, so all I had was my overnight little bag with this, and then they didn't, there was a problem with my registration and they didn't believe I was faculty this morning, so I had to pull out an ID and re-register, so I apologize for being late. This is case number one. This is a 39-year-old right-hand dominant Major League Baseball pitcher. Chief complaint, right shoulder pain, inability to throw of about two weeks duration. Now, when I say inability to throw, you'll see in a second. About two weeks prior during a start, three starts prior to when he presented, he said, and this is his quote, I felt something go in my shoulder three starts ago and now I can't throw. He made two additional starts after that, but his velocity was down, he had pain, and he didn't really feel like he had control of the shoulder. He had a lot of trouble sort of with his arm slot and localizing his pitches, so these were his chief complaints. On physical exam, he had a painful arc of motion. He had pain and apprehension with maximum external rotation, both at the side and in the 90-90 position, and interestingly, he had about a 10-degree increase in external rotation with the arm at the side compared to his pre-injury, pre-season, pre-participation physical. He had a positive O'Brien sign, but normal rotator cuff strength. He had a little bit of discomfort with specific subscapularis testing, but no true weakness and no true translational abnormalities on load and shift testing. X-rays were normal. This was his MRI scan. It's a non-arthrogram study. I'm not gonna belabor this. I'm just gonna, let me go back, ask the panel what their thoughts are on this, and the arrows make it pretty obvious. Nick? Yeah, I mean, he's clearly got a posterior labral tear that looks like it extends inferiorly. He's got some internal impingement-type signal in the posterior superior tuberosity. The way you're presenting it makes me think that there may be a capsular component in addition to that. The problem is, at 39, the real hard part is understanding what changed, because this shoulder had structural issues likely going in. There's something that broke the camel's back, and the job is to try to figure out what that is, but a lot of this could have been pre-existing, and now it's just symptomatic, so what's interesting to me is there's not a lot of edema or acute findings back there, so I would be looking at what else is potentially going on that could be this problem. So, interestingly enough, this guy has never had any shoulder surgery, any significant shoulder issues, save for an episode of shoulder pain. Two years prior, he had an MRI, and the posterior labrum looked entirely normal. He still had those sort of enthesopathic changes at the humeral head, so there was some baseline comparison, but nothing with the posterior labrum. For a 37-year-old shoulder, it looked remarkably good. So, this is additional imaging from the MRI, and this doesn't project as well on the regular MRI, but Buddy, any thoughts? Seeing that's anterior edema, so you have your cuts this way, and then on your coronal, again, that's subscapularis muscle, I think, as near as I can tell, and then going down in the front. So, I agree with Nick. I think that's more of a lateral capsular tear or a subscap strain, but you said his subscap tested normal? He had discomfort, but he had good strength. Yeah, he had a little bit of pain with subscap testing, but no weakness. By a 39-year-old pitcher, I'm already thinking about treatment, but yeah, I think now you have a strain, maybe a little capsular tear, and now a posterior labrum tear. I agree with Nick. As I said, that's probably been there 25 years, but maybe it's only three weeks. JT, any thoughts on the diagnosis based on this information? I was just thinking I was glad you hadn't called on me for that one. You've got, if you go back one slide, I'm looking at that, and I'm trying to find what the arrows are pointing at, to be honest with you. I think I would be, honestly, I would have probably looked right over that without the exam. Something's changed, though, so in my mind, I'm thinking, usually when somebody shows up and has a acute loss in control, I'm thinking it's an instability episode. They've had a subluxation episode, and that kind of helps it for me, but this guy's older than dirt, right, at 39 for a pitcher, and so then I'm thinking, does he have a partial thickness cuff tear and that he's got an acute expansion of that, but I was a little disappointed I couldn't see that either, so I see what you're pointing at, the anterior edema. Actually, in this case, I'm really glad it's not an arthrogram. A lot of people jump to those arthrograms. I think those confuse things a lot because the edema in the front, I think, is probably your most sort of patented finding, but I'm not seeing anything that's gonna make me jump and stick a scope in him right yet. So this was interpreted by the radiologist and by me with the benefit of the exam as a probable chronic posterior labral tear, posterior superior labral tear, and an acute capsular tear, so that was the diagnosis that this player was given. Thoughts on treatment? You see where we ended up, but George, it's you. I tend to get all plain MRI too, but in this case, would you consider getting an arthrogram at this point? Because you're gonna be able to see eye leak through the capsule if there's a capsular tear. I reviewed this with the radiologist. It's a radiologist that I work with all the time, and he was very confident in his diagnosis. Again, the images don't project as well on the screen as they do on the plain MRI. Combined with the examination and the sort of onset of symptoms, I did not feel there was a need to go ahead with an arthrogram, but this is a situation in which, as you said, an arthrogram might be helpful because you would potentially see extra capsular extravasation of that contrast. George, I would say that we often have the benefit of really good radiologists who are comfortable with the overhead athlete, but I would say nine times out of 10 in the community, this gets read as an inferior subscapular strain, and when you see that, you gotta think capsule because it's almost always the capsule down there. I actually think, this is one of the instances where I think an arthrogram can be really helpful, especially if you've already had a regular MRI, and oftentimes, so although it sounds wasteful, especially on our major league guys, if we do this, we're suspicious of it, don't have it confirmed, then we may get the arthrogram. If you get the arthrogram out of the box, I agree with JT, it's gonna blow up and you're gonna not know really what's going on. It's gonna be hard to make heads or tails. Is that edema? Because you have edema in the subscap because it's leaking into the subscap and you're gonna have it all over the joint so you can't tell. Is it a capsule? Is it an acute subscap strain? So I think it makes it more confusing, but it can be helpful if you already have a non-contrast MRI. Then you wanna say, all right, is this just capsule or just subscap? It might be helpful in that case. And I think sometimes it's helpful to do it delayed because you let the strain signal settle down and then you get some information about whether the capsule has reestablished any continuity. And so, Jordan, and I think the evaluation has pointed out the pathoanatomy fairly well. I guess the question, you got a question mark by the diagnosis. What is driving you to do arthroscopy and what are you gonna repair? Are you gonna wait until you get in there to make it? How much is the posterior labral component causing the problem? How much is anterior capsular causing the problem? Because when you get in there, you may see both and one may not. Like I say, that may be old and you don't have to fix it. So where in the process do you say, before you do surgery, are both of them playing an equal amount? How do you kind of figure that out? So I figured that out in this particular case based on two factors. One, there was an acute change in his physical exam that to me pointed more towards a capsular issue than a labral issue. And the second thing was, in looking at the MRI, and again, I apologize it doesn't project very well, all of the edema, all of the acute findings were anterior related to the subscap and to the capsule. So that appeared to be the acute injury and that combined with his complaints and physical exam suggested to me that that was the straw that broke the camel's back. That's what pushed this athlete over the edge. Buddy? Because I mean, how did you make your decision then on, I mean, really 39 shoulder injury, would you consider non-operative treatment? You know, he's a major leaguer so costs are not that big a deal, PRP or anything like that? Or is this, you feel like this is a tear that needs to be fixed now? And then what is his prospect of going back that age? So how did that discussion? This player made the decision. He wanted surgery, he wanted surgery without too much disclosure. In those two starts after he was injured, he won both of those starts and got his 200th career win. Said at this point, I'm done. I want this fixed. I want a shoulder that's gonna be good for the rest of my life. I don't want to hear about therapy. You're gonna fix this. That makes perfect sense because I would have had a discussion with him about where are you in your career? Are you trying to make it back because at 39, I'm not good enough probably to fix this and be a major league pitcher. So that's why I presented this because this case doesn't illustrate the challenges of fixing this in a 32 or 33 or 34 year old to get him back but it certainly illustrates the pathoanatomy and the decision making with regard to what's chronic, what's acute and how do we handle these acute capsular tears because I think they're a little bit more common than we probably think they are. So this player made the decision and wanted surgery. He had achieved his career milestones, knew he retired, had already announced he was retiring after this season so he decided he wanted it fixed for the rest of his. So you're not loving it. There's no pressure there. It's great. No pressure. So you're not gonna fix the labor in one way or the other. The capsule is what you're in there for. Is that right? That was my decision making was the capsule. He felt a sense of instability in the shoulder but didn't really have true instability. He tried to play some golf, felt I can't do this and he's a big golfer. He wanted it fixed. No question about it. So at the time of arthroscopy this is lateral position viewing from the posterior portal. You can see the humeral head at the top. You can see the posterior superior labrum markedly frayed and macerated. Come in and clean that out. The bottom right is viewing from the posterior portal. This is the undersurface of the cuff. He had some undersurface partial thickness cuff tearing which again wasn't significant in my mind and clearly chronic. And here you can see the capsular tear looking from posterior to anterior. The upper left quadrant you can see that sort of linear defect in the capsule. You can see it on all four of those pictures going sort of from medial to lateral. And this was really almost right between the anterior band of the inferior glenohumeral ligament and the middle glenohumeral ligament. So based on this decision was made to go ahead with repair and you can see the start of that repair in the upper right. You see I'm actually instrumenting from the posterior portal using a curved suture passing device to pass through what I call the inferior or the posterior leaflet. And you can see the suture on the bottom left and then going through the anterior leaflet with a different suture passing device that's more of a jaws biting type to put in that first stitch at the very, very axilla inferior aspect of that tear. I did an arthroscopic debridement of the posterior superior labrum, did debridement of the cuff and then the anterior capsule repair. Here you can see the posterior labrum after debridement. This is viewing from posteriorly. You can see there was no detachment of the posterior superior labrum so it was a simple debridement alone. And now here you can see progression of the capsular tear. I put a total of three permanent sutures in, not tying techniques and closed that defect. So post-operatively, let's assume this is a 34 year old kid. He's got three years left on his contract. How are we gonna rehab this guy? Because I'd like to, Tom, what do you think? Well, it's a challenge because you don't wanna rip your capsular tissues apart but if he wants to come back and pitch, he can't get tight. So as opposed to like a football player that dislocated his shoulder, that'd probably go slow. I think I would start immediate range motion and work getting his full motion back reasonably quickly because again, you don't want him to end up tight. Mike, you seem to be, call it an outlier with regard to bracing and the like following some of these. How would you sling this guy and would you use any type of gun sling or brace or positionally, what would you do with him? Yeah, I'd use a regular abduction sling and I'd get him going a little bit earlier but I think part of this has to do with how you repair it. Are you using heavy number two non-absorbable suture that's used so often or are you gonna use zero PDS? And to me, I like using zero PDS. I think it's a little more, you're gonna get resorption of those knots and I don't think you are gonna, the chances of you over constraining are less. So I think you're gonna get his motion back as long as you don't over tighten them and in one two cents I would throw on top of this that I think is really valuable for the audience I think that we have gotten so much into the posterior with you know rotation deficit and scapular dyskinesia and slap tears that we forget a lot of that early literature that came out of Kerlin Jobe about the laxity that occurs with time with these throwers really stretching out anterior so I'm not so sure that these rents aren't around a lot and we're searching for well that that MRI looks doesn't look too bad or is that a slab or type 8 slab I think these rents it's something to keep in your back pocket if they're just not getting better and the MRI looks relatively clean but here I think is where we go back to the question that buddy asked originally right because it sounds great when you see these and you say what we're just gonna go fix them but the margin for error here is really really small in terms of getting the tension right trying to get it to heal without going too fast and these guys lose a little bit of motion and they're done so I guess the question for the panel is let's take your case out of this what's been the experience with treating these initially non-operatively we've had anecdotally reasonable success in the non-operative setting initially I don't know what your experience has been George my experience has not been as favorable treating them non-surgically quite honestly and the literature doesn't there's not a lot of literature but the literature will review briefly doesn't support non-operative treatment as being very effective from a technical perspective I agree but this is a longitudinal sort of tear in line with the anterior band of the inferior glenoma ligament so as long as you don't take a huge plication I don't think you're really going to over tighten them yes you have to be technically careful but re-approximating that capsule and I think the mistake that I've seen guys make in the past when I've seen some of these cases as revision guys go in there with their shaver they try and shave some of that capsule quote-unquote roughing it up and they make a huge hole in the capsule that they're they're trying to close I basically take a little arthroscopic rasp roughing up the capsule I leave those frayed edges there and I take a small small bites and just close it sort of anatomically buddy any technical I think I think what you said is perfect you want a very sharp passer you don't want to take away any tissue and then you're not trying to double breasted or over placated because the tendency is to think the capsular tissue especially when you get into the middle of the anterior capsule it's not as good as the haggle part or the part by the labrum so then you want to get a bigger bite so you get a better suture but that's completely the wrong thing to do you get close to the edge you pass your stitch tie one see how much it comes tie a second one I love the three stitches I would usually combine what you and Mike do where I would put one pretty much non-absorbable stitch in and then put a PDS or something like that above and below it so I get less irritation in the capsule and then mobilize them like this but I think those are small bites close in you can't use some big passer that's really thick so you want something something small very pointed that you can pass your stitches without damaging the rest of the capsule and without creating a rent in the capsule as you know when you try to pass through it if you have a big retriever as you go through it you're actually creating another hole and you'll make that split worse so this is very precise very careful and what I do is I'll put that first stitch in and then I'll take the arm out of traction and move it and make sure I have extra rotation then I'll put a second stitch in and see where my tension is that also helps guide my post-op rehab because I can say you can go this far early without putting any tension on the capsules and we can start moving them a little bit earlier because I don't want it to come apart should take four to six weeks to heal and then we start stretching so that's a good point and intra-operatively I took him to the 90-90 position after each stitch was put in to make sure he could get there I did not take him past 90 degrees even though he could go past 90 degrees and use that as my sort of check rain for post-operative rehabilitation so I kept him in a sling for six weeks but he came out and did active and passive external rotation to 90 degrees at the side passive external rotation to 90 in the 90-90 position and began early isometrics but did not exceed basically neutral or 90 degrees in each position for the first six weeks the other point buddy in using a large passers if you create a small hole and then you over tension that capsule when you put them an external rotation you'll you'll tear that capsule further and now you've got Swiss cheese you're trying to put back where you go back it's really hard then to try to fix it so I'm sorry go ahead Mike no no I just want to ask a technical question are you guys doing this be sure or lateral this was lateral for me yeah so lateral just technically how do you take them out of that traction and then put them back into that traction so there's I use an arm holder that has a loop of you know heavy rope that comes off of it I just disconnect it I hold them down here the whole arm everything's sterile just moving to 90-90 in the lateral position and then hook him back up to the to the suspension crane I think I think your point of keeping the shaver away from that is really important so I always tell my residents and fellows whenever we're doing any instability case but especially when there's a capsular issue if you touch that capsule with the shaver that goes away really fast really dumb and and and then your capsule or the resident and yeah both and then the other thing is and we talked about a little bit with Chris's case I'm not I don't love passive motion unless you know the therapist really well I like a little bit of active assist because then they kind of protect themselves with these if you're if you go if they go to a therapist you don't really know obviously he's probably going to somebody who's really great but if they go to a therapist you don't know or you're kind of they're in out away from you out of your system you know that they really can kind of try to push these a little too much and so the athlete will protect themselves if they do a little bit of that active assist and I agree I mean you got to give them the parameters in terms of not going past 90 but but even within that little bit there you want to kind of let them protect themselves and go ahead you got got to throw in my plug for the scapula if you do an external rotation the scalp is here then you're just you know you're getting here but you're putting too much tension make sure all those exercises you do passive active is that you start from here to go to here rather than because everybody's here and now you put an extra strain so any of your exercise make sure that the first move is scapular traction then move your arm passively or actively to get that way you don't put that extra going around the corner stretch she's you're sitting there at the end you got any comments with regard to rehab you know I echo what what everyone one mentioned I think one of the challenges that I found with these particular capsule tears and maybe I'll answer a little bit with a question is when you have um you know an arthroscopic view of this is there certain patterns you're looking for I didn't hear much about the possibility of an open repair in these settings are there some findings that you see in terms of the direction of the tear or associated pathology if there's an associated rent at the labrum or more of a pull off from the humerus that makes you convert to an open repair in this setting so in my experience with overhead athlete throwers these tears that I've seen are typically these longitudinal tears and a classic haggle is not the pattern that you see so I've been able to repair these arthroscopically but the way I actually consent them as arthroscopic possible open but I've not had to convert one of these true longitudinal tears like I'm showing you here to an open procedure buddy I will tell you when I went through my beach chair phase that it's almost impossible to get to the anterior inferior lateral capsule it was for me in a beach chair position it's easy as it can be in a lateral position so if you think you have a capsule or tear even if you're an obligate beach chair guy you should you should turn them on their side so you can get to that area because otherwise you're not going to get far enough distal quick quick question we all tend to stop at 90-90 when we're looking at the capsule but in a lot of these pictures they have they'll have 120 degrees of extra rotation on their on their you know you know start of the year exam and in this this guy may have got to 130 after you did that and so how do you know if you don't stress them all the way in the OR past 90 so I'll answer that the downside of stressing them all the way and tearing that repair outweighs in my opinion just getting to 90-90 and making sure that they're not over constrained in my experience if they can get to 90-90 then in good hands we are usually successful in getting their motion back that's anecdotal based on my 26 years of experience with these but now I move them to 120 and and disrupt that repair I I don't have much left to work with quite honestly so what I do is I'll take them all the way I'm just watching my repair so I put my first in and you know when you get them to here 90 and I'll just keep going until I see the tension seem like it's gonna be too tight to tear and then I stop so I'll take them as far as I can but I know where they went on my EUA and so then when you're doing a repair you're just trying to make sure you get them pretty close like if I'm doing a label repair I'll take them to 130 and make sure they don't impinge I want to get all that motion back so if you can't get them too close to let's say within 10 degrees of their EUA do you take your stitches out and redo it so I'll either I'll either add another stitch and then take that one out I will because I have small hole so I don't mind and I can I can hit the same hole again and just tie it a little bit more loosely I think I over tension him so I think if it's too tight I take that stitch out you also can't forget the interop factor too so I think 90 90 you know in this position I can do this right now there's not a camera in my shoulder and it's not full of fluid and so you know if you put a instruments in there and you pump it full of fluid obviously that's gonna distend thing so you're dealing with the rotation plus the distinction as well so I think that it's it's not uncommon if you can't get it to the to what you'd be able to get within the exam on an anesthesia that's probably pretty typical and maybe we should be shooting for something a little bit less because we've got it distended with instruments in so here's what the literature will tell us there's only two papers dealing specifically with the overhead throwing athlete this was the first paper from dr. all checks group at HSS this was 10 years ago small group these tend to be in the older throwing athlete generally in their early to mid 30s all presented with anterior shoulder pain and an inability to throw no patient had an acute traumatic injury MRI made the diagnosis in four out of five patients one of these was an incidental finding at the time of arthroscopy three out of five had arthroscopic repair two out of five had an open repair at that time for return to their pre-injury level mean was over a year average or the range is 8 to 18 months I didn't include it here but all of these athletes failed a course of non-surgical treatment ultimately ended up with surgical treatment a more recent paper a year ago from dr. Ella trash and dr. limp of osty out at curl and job this was 11 players eight major leaguers one minor leaguer two college players you can see their positions there again generally an older group although they did have a couple of young players that skewed the mean 11 out of 11 had a posterior superior labral pathology and rotator cuff pathology couple required actually concomitant cuff repair or labor repair they followed these for an average of three and a half years again all of these failed an initial course of non-surgical treatment they showed statistically significant improvements in the cage occ and sane scores and a hundred percent of these athletes reported a high degree of satisfaction all of these were treated arthroscopically without any open repair required again long recovery time frame of about 16 months you can see an average they're as short as seven and as long as over two years and they got 10 out of 11 players to a return to play so the literature would support that actually the return to play is relatively high it's a very long time table and again in this particular case that I presented this athlete had met all of his career goals had already announced his retirement and the last thing he was interested in was a 16 month rehab and recovery time frame but I think the point here is you've got to counsel these athletes that they're looking at a long timetable for return that there's a relatively high return to play rate but this is something that's going to be somewhat arduous for them in terms of a course to recovery so Mike I think open it up for questions or Georgia hopefully second paper did they comment at all on like whether they got past their level because I think one common theme in shoulder surgery and baseball players is you can usually get them back to where they were and so you'd rather operate at a major league player but I mean getting people past where they are is a whole different animal so you operate on a single a player and they typically don't make it to the pros so so this group Neil and ors group this was a series that was done over the course of I think eight years so the earlier cases didn't look at the same sort of return to play metrics that we look at currently so I think given that the timetable over which these players were collected it was hard to say and they just used as a as a outcome metric return to the same level of play but I think your point is well taken and we're looking at these outcomes with a much finer tooth comb now in terms of all of these performance metrics as we discussed even in the first case yes sir question great case when you start your throwing program for these folks if knowing it's gonna take a year at least well let's let's just go down the line here just give me a month number you start at three months four months six months nine months Nick start of a throwing program I think it's the problem here is they're getting their motion back right and especially because they're already older athletes to begin with we're just gonna present a challenge so I would let them start as early as six I think realistically most of them start around the eight to nine month mark yeah same six of their motions there we just did a study surveyed major league and minor league trainers on when what their criteria for returning and one was time one was range of motion but there's a huge subjective component it was everywhere from these were just general return after a surgery anywhere from six to nine months but yes it does take that time and then you have to progress very slowly starting off with and then building up it if it's gonna take you 16 months get better six months that means you still got another 10 months to try to throw so I don't know if six months is reasonable in that situation maybe eight months might be more reasonable Chris yeah same six months Tom it's also six months 18 but I don't think we have any good reasons for it you know it's healed the tissues healed right so then in my mind I don't think a time thing matters so much I think it has much more to do with their mechanics we don't want to put them on a mound and have them have jacked up mechanics and go back and reinjure that's what we're all afraid of but I don't think six months is some magic thing I think once once you know that once you feel the capsular area is healed which probably is literally really six to eight weeks then I'd get them back into range of motion and and if that's two more weeks great and hopefully I've been doing isometrics and scapular strengthening so I get them back there and then I get them on the mound and start and so I guess I would say I'm a lot more aggressive in that regard I don't look after a major league team I probably be a lot more cautious if I did right but but for the younger collegiate athlete and everything else I think that's a mantra we all follow without a lot of good evidence and I think we can we can get them back to throwing a lot faster as long as they're as long as you have somebody watching their mechanics to make sure they're not breaking down JT that's a very good point so what does that mean that maybe 16 months is we're babying them a little bit too much you try to get I think maybe if you if you're talking about now you're talking about getting them to throw or good and I agree mechanics and you got to hit the slot and a lot of the stuff and then does it take nine months of throwing right and I think it's actually detrimental to have a pitcher out of the game for 16 months lots of bad things happen to all kinds of areas of the body so I think that's an issue that we could really look at this group and you guys in the room could really help us answer if that's just one of those things we've followed for dogma for years because we don't want to be the one to screw it up and I think our therapists with it with a good therapist I'm blessed with a couple of really good ones a couple of them are in this room who who I trust implicitly that can that I think can watch and manage that patient and I think we're I think we have a lot to learn in that area so I think it's actually a level thing for those of us that are doing a lot of high school kids and college kids then your margin for error to getting them back on the field is a little bit easier and minor league professional and certainly much much easier than a major league professional so I think that length of time if Neal's paper was mostly professional athletes then it's gonna take longer a college kid you don't want to take them out of their sport environment for 24 months I mean that's just a bad thing for the kids I raised sons if they're not playing ball they're going to jail and I don't like bailing them out so so for me with my kids I'm gonna try to make them back to the next season so whatever time frame that is you know Chris talked a little bit about everything has to do with timing and especially with baseball and softball a lot of it is timing and you say well look you're not gonna play summer ball but in the fall we're gonna start your return to throw program and that may be at four months because I want them ready in January and I want to get him back in the team that's their show certain environment that's what keeps them going and so I think that's critically important and different than a professional player where where you have a higher ceiling to achieve in this one we just want to get him back on the field I think it's very different we haven't heard from a she shit just one one comment I wanted to make George I'm a little bit echoing JT's point I think there's more and more literature right from the lower extremity literature now making its way to the upper extremity that the tissue healing part of this right really isn't this six months and the only literature I'm aware of in terms of return to play with the shoulder that's looked at strength is in the anterior instability contact population from or in another group that shows when we return to play as of course there's still a significant deficit in deltoid strength there's some new studies that are coming out that are doing volumetric analysis of all the muscle groups around the shoulder girdle and I think probably this big challenge if you look at the preliminary data as there's a significant atrophy of all the periscopular muscles in the deltoid and that's what's happening somewhere between four to sixteen months it's probably not protecting your capsular repair that's really the issue at six so I think part of this is really recognizing the complexity of that which is much more difficult than looking at quad deficit you know after after any injury I think the other part of this too is this highlight this discussion we're having underpins the challenge with overhead athletes and throwers too and so one of the things is yeah I agree the capsular repair is well healed before six months and definitely before 16 months your high school kid as buddy mentioned they don't necessarily care how they feel they just want to go pitch and though they'll go out there and pit as soon as you say you can pitch they'll pitch it doesn't matter if they've warmed up they've done anything they will go and they might they'll probably be okay the professional pitcher it's very different it is their livelihood and so they won't throw until it feels right and they're much less likely to work through pain discomfort they're very dialed in you know they're hyper acute hyper aware so it's much more challenging and they also know that in order them to get back to that level they've got to have a certain amount of motion certain amount of strength a certain amount of dynamic stability so that's what I actually tell any anytime we do a shoulder repair of any sort whether it's labrum capsule cuff anything I let them start throwing was in the at the professional level as soon as they have full motion full strength and appropriate dynamic stability which we assess through a battery of tests that generally takes about four to six months after some sort of repair but it depends if they can achieve those things faster than we let them go but if not but you're right the key is even if they're not ready to throw how do you keep them engaged how you keep them moving those muscles how can you simulate a throwing motion you know whether using you know two-handed plow balls one-handed plow balls whatever to try to prevent that atrophy but it is a little bit challenging because the bar they're trying to get back to is much higher and then it usually don't feel comfortable throwing until they've checked all those boxes all right the awesome case we'll move on to the third one dr. Kelsey from Cleveland you know while they're switching the other thing I would say though is it just this just speaks to the severity of the injury for these caps are problems right nobody's holding these athletes back for 16 months this is tough recoveries they often have stiffness injections medrel packs shutdowns I mean this is the athlete struggling to get back and so that's a discussion you got to have with them and your front office when these injuries occur because they're not straightforward in nature buddy I want to hear more about the beach chair phase that you went through and if you were going through something or need any support and with it so we can talk about that after but so I'm Jay Kelsey I'm from Cleveland Ohio thanks for having me and and listening to me talk so we do all have probably some disclosures so I'm gonna present a case it's a little different of an overhead case because it's not a professional pitcher but it's a it's a 24 year old male soccer goalie is a semi-professional and he had noted pain when he was sort of reaching for saves for a long time but then started having pain when he was throwing and really with soccer there's there's a couple different ways that that goalies and soccer players will throw a lot of goalies will kind of throw with the straight arm he was more of like a baseball pitcher type of a thrower when he would throw the soccer ball so so when he got up into that abducted externally rotated position he would have pain he would localize it deep and posterior and he also had pain laterally and and pain with a lot of his rotator cuff testing and and I say he failed non-operative management we have some really good overhead physical therapists that kind of got everything normalized and and dr. Cooper I know you'll ask about his scapula and it was moving nicely and so that really wasn't wasn't the issue at that point and so it did not get any injections or anything but but really failed some pretty good PT and so when we're examining him his motion was okay on that side but his big his big issues the big deficits were he had pain with Job's testing a little bit weakness he had pain with that sort of posterior labral stress pain with that resisted throwers and and you know kind of slap signs though Brian's and then the big thing was when he got up into that abducted externally rotated position that was when all of most of his pain kind of got to a point where he really felt like he couldn't throw. So on his MRI, and I don't typically get arthrogram studies on patients. I do say if you want to operate on somebody, getting an arthrogram helps because then you'll probably find something to operate on. But for these, if you get a good MRI, you can usually see enough. And for him, so he had this posterior superior labral tear that extended inferiorly. He had this paralabral cyst posteriorly. And then he did have this undersurface cuff sort of signal there and a little cyst and his greater tuberosity. And that kind of matched with his exam and the pain that he was having laterally and with rotator cuff testing. So before we go on too far, so this was kind of my diagnosis. So posterior superior labral tear, partial thickness articular site, and supraspinatus tear. But if we go, you know, I'll leave it on the picture here. If we kind of go down the line and what your thoughts are and how you manage this guy. So he feels like he cannot play because of this. And while he's only semi-professional, it's very important for him to do it. It is not his livelihood. So he has a normal job during the week. Actually, he's a soccer coach, so he's still throwing and doing things. But it's really important for him to be able to get back to throwing. So if we can just go down the line. I'll start at the far end with Ashish. Yeah, if you've exhausted everything here, Jake, I think it sounds like it's headed towards a discussion about a potential surgical treatment for him. You know, it doesn't sound like from your exam you're concerned that this paralabral cyst is causing any infraspinatus weakness, but I might have a low threshold to get an EMG to see if that's in fact a symptomatic cyst that's causing weakness or just more a cyst related to the tear. And, you know, without getting, I guess, too much into the arthroscopic treatment, I guess it depends on the appearance intraoperatively, but this would be one that I would be prepared to decompress the cyst, probably through the tear in this case, repair the tear, stay posterior to the biceps anchor so I wasn't incarcerating that in any way, and probably debride the partial thickness cuff tear and do little more. I'm always prepared in these patients to chat with them about the possibility of a biceps tenodesis if I see something intraoperatively, but that would probably be my surgical approach if he was headed there. Yeah, JT. Yeah, I would agree. If you're heading to surgery, I think the cyst becomes important to me. I know that there's late data and literature that says that you can ignore the cyst and repair it and it will resorb. It's not been my experience in many cases, so I know it can happen, but it doesn't always. The other thing I would say is I learned a long time ago that I am increasingly frustrated when I try to go through the tear because you get to the shelf of the glenoid and you can't get there, and so you open it up and then you put your elevator in there and then you get a little blush of something and you go, see, we decompressed the cyst, and I was lying to myself. That's just true. So I think these are true ganglion. Look on the MRI here. That is multiloculated lobulated tissue, and I don't think going from, at least in my hands, I can't get back there enough, so this requires me to either approach this either through the subacromial space, but what I do, Kevin Plancher described a way to get to the spinal glenoid, release on that, so it's just an extra portal posterior, but it's eight centimeters and four centimeters, and you can go right down on it, and sometimes you see these things and it's like a wrist one where you shell out the grape, and they can be that big and that compressive, so that would be my approach. Would anyone do anything differently with the cuff? Anybody be more aggressive than just a debridement if he's having pain with his cuff? One other thing I would mention, real quick before we get to that, is I think, especially if we're in season, and I don't know what we've done for nonoperative treatment, but I would definitely consider maybe injecting this shoulder as well. I think there's a good chance that that would, A, at least get him through the season, or in some cases might potentially be definitive too, so that would be another thought, and we've had some success with ultrasound-guided aspiration of these cysts, and then intra-articular corticosteroid injection can be helpful when they're loculated like this, it's a little bit less successful, but I think that's at least worth the discussion of having with the patient, especially if they wanna keep playing this season. I agree, we did talk about the injection, and he was pretty adamantly against it, had some buddies who had had bad experiences and whatever, but I agree, I think in season especially, it's a good way to kinda get them through. Yeah, I hear what you're saying about he's failed non-op, but I mean, this is like every major league pitcher's shoulder, and most of them do fine, so I guess I really would lean on for intra-articular injection and therapy, I just don't see why this couldn't get better without surgery, but. It is a little bit challenging, so one of the benefits we have in our professional athletes is that we have baseline range, George showed that in his case, he knew what the baseline external rotation was, so he had a comparator. We don't always have that in these athletes, but it would be nice to know, has he lost external rotation, or does he have an internal rotation deficit, is there something that's correctable with PT? Then, if you've corrected all of those things, and ideally, if he'll try the injection, that's failed, then you're sorta stuck, but I think those are things that we haven't really talked about, but definitely things to consider. Yeah, he did go to one of our really good overhead PTs, who kinda normalized all his motion, and really had good strength, and when testing him, he did not have any infraspinatus weakness, a sheesh, but yeah, I mean, this was a true, I agree, I think the failed non-op, when they come to you, and they say they've tried PT a couple times, I always get them with our specific PTs that I know and trust, and kinda want some metrics before we talk about surgery, but for him, that's kinda where we obviously ended up going, so any other comments or suggestions? Two, so two things. One is, a lot of times when you have a cyst like that, the top branch of the suprascapular nerve, where it goes around the spinal glenoid notch, comes up high, and the first place you'll notice some atrophy is right beneath the scapular spine, the very top of the infraspinatus, and if you have them with their shirt off, put the arm in 90-90 position, and then resist external rotation in one versus the other, you can usually see that there's a little bit of a change in the infraspinatus on the affected side. For him, I would aspirate that cyst, and inject that area, and see if it made his symptoms go away. Talk to him about an intra-articular injection, but I think that's a major issue, that at some point, if you don't correct it, we'll start putting pressure on the nerve, and then you'll have a problem, and I go subacromial, and follow the spine down, and use tuber tractors, but I think, to me, where that cyst is sitting is a concern, and in a young person, I don't want that muscle atrophy to develop, and it not be correctable, so if he didn't want an intra-articular injection, fine, but I wanna take care of that cyst first, and then that would push me more, that didn't work, to doing more of a surgery, but my big thing would be to decompress the cyst, and I agree with J.T., you can pop it from inside, but if you really think it's putting pressure on the nerve, even if you did that, that tissue's gonna stay where the nerve is, you have to go clean off the nerve. Did you do a steroid injection, or a PRP? How's that, do you do an anti-steroid injection? Yeah, I just wanna put a needle in that cyst, and decompress it, so I don't care what he wants after that, I'll do whatever he says. If he wants to play for a PRP, great, not a problem, whatever you wanna do, but I want that cyst to go away. If you haven't treated the alcohol, one of the positive factors of the cyst, how often do they recur after aspiration? Do you have any information that alliges with that? Because my experience is they recur quite frequently. At least 50%, yeah. Yeah, I wonder how dependent that is on the quality of the ultrasonographer that's doing the aspiration as well. And I do wonder, and we don't know, but I think particularly loculated cysts are probably more likely to recur. I think if you've got somebody who's questionably getting into the cyst, or can't go into the different components of it, that may affect that as well. So I think if you have a really good ultrasonographer that can get in there and get after it, that probably improves the chances. At least to me, anecdotally, we've had a number of these that go away and they don't come back. So I at least feel like it's worth a shot. George, to your comment, there is a reasonable-sized series from the NFL Combine where you get the benefit of imaging often of a shoulder that's asymptomatic at that time. And in that group, athletes who had had one of these cysts aspirated during their collegiate career but then had had an MR at the Combine, the recurrence rate was north of 60% in that population. How many asymptomatic ones did you see, Ashish? At the exam at the Combine, the conclusion was a small percentage of those who still had some infraspinatus weakness. Those were, of course, another level of concern. But the remainder were all quote-unquote asymptomatic. But still, 60% recurrence rate across all. All right, so again, this is kind of that internal impingement patient, right? So he's getting that peel back of his rotator cuff that you can see on the MRI, that undersurface articular-sided tear, and that sort of posterior superior labral tearing and the associated cysts. And I agree, I don't think you can really do it through the tear, and so I make actually a tiny little mini open and excise it like you would like a ganglion cyst right there and kind of split the infraspinatus fibers longitudinally to get there. So this is not what you wanna do for the cuff, is to restore their footprint. So if you're fixing these through this arthroscopic transcendent repair, you're gonna restore their impingement, right? So this is something that you really don't want to do. He's been peeling back that cuff for a long time, and even though it's symptomatic, you don't wanna put it back where it goes on the footprint. And so you're gonna over-constrain the shoulder, and they're gonna lose that ability to get into that abducted externally rotated position. And this is kind of just the way I think about it. So they need to get into that abducted externally rotated position. They get internal impingement. They get this partial thickness articular-sided rotator cuff tear. And if you fix the rotator cuff and put the footprint back, then you're just giving them internal impingement again, and they'll be back not feeling great. So there's gotta be another option if you're gonna do something with the cuff other than just to breed it. And so just kind of break that cycle. So this is what I did. And, oh, lost my, okay. This is what I did. And, is it flashing here on the screens? You guys see it? Okay, okay. So I did talk to him about the cuff, and that there may be options to take care of the cuff, not fixing it with anchors, but other things. And so I did a posterior labral repair. This is what it looked like when we went in there. I'm not sure why that kind of slid over there. One second, sorry guys. You had me tell bioinductive implant. Can we talk about that for just a minute? It disappeared. You can't see my labral repair for some reason. There's a little bit of an issue here, sorry. So I promise my labral repair here looks almost as good. I think JT's probably, he's got his foot on the switch. He's unplugging it and on the bioinductive implant. He doesn't like where I'm going with this. JT's doing it. Yeah. So my labral repair almost looks as good as Chris Camp's, I promise, but it's right behind that other picture there. And then his undersurface of the cuff looked pretty crummy. And so, and he had the cuff symptoms. So for me, I did put something on top of it to address it. And this is the bioinductive collagen implant. And I'm sure I'm gonna get a little beat up for this. So if you guys can weigh in. And JT, you wanna go first? Well, you've put this implant on the bursal side of the tissue. And we do that because we aren't technically able to put it on the articular side. That's the reason everybody puts it on the bursal side. To treat an articular sided pathology problem. And I know the data from this shows that you put it on the bursal side and you get this increased thickness and it magically heals the articular sided tear, which as Steve Burkhart once told me, requires me to suspend my disbelief. And I think you're going into a space where a guy has had no troubles. I know the data on the patch is okay. I just look at this and I say, you've got an internal impingement lesion that you've debrided beautifully. You've handled this posterior superior tear. And I guess I would look at that and say, I just don't understand why one would go there. Well, I think it's a good thought. And I totally understand the rationale behind it. I agree, the primary issue here, fixing the labrum, debriding the rotator cuff tear. But there are these tears that, I think that these athletes tend to tolerate, 25% loss of the footprint thickness, maybe even up to 50% and tend to do well. But there are times when you get concerned where maybe they've got 75, 80% of the footprint uncovered. They're sort of borderline. You don't wanna do a formal repair. Maybe if you just thicken the tendon up, it's gonna be okay. So I do think that there's a role for it somewhere in there, but I don't know that we know that answer quite yet, or at least I don't. I'm in the school of, I'm in JT school. I think that this adaptive change might not be correct, but they're basically developing a defect in the cuff with tissue loss. And the ones that, for me, are more problematic are the ones where there's some intra-tendonous delamination and they have sort of a split between it that goes medially. And those are the ones that I will sometimes consider closing down. But if you advance this articular-sided cuff tissue to the footprint, you're basically making up for a tissue defect. You're shortening the length of the cuff. And I think that this is adaptive in most cases. And I would take a minimalist approach to it, like you do, at least in terms of the cuff pathology. Yeah, I agree. And I'm not putting the footprint back, right? So the footprint we're leaving, that I do not put anything on the articular side for this reason. Dr. Kepler. Yeah, Jacob, the question I have is how much are you dealing with anatomy and how much are you dealing with pathomechanics and function? I mean, because you're so fixated on he's got this anatomical problem, got this anatomical problem, without putting them together into the clinical symptoms. Why is the guy's, Craig Moyer, why is he on the end of your arthroscope? And most of the time it's because the pain, like we were talking about before, and this impingement. But once again, you got him better. I mean, you got his scapula and everything in good shape. And then you still had to fix that. Now why, the rotator cuff is a co-traveler. I agree with JT here. The problem is that the problem with the function is the labral injury, not the rotator cuff injury. And so I would go to where the pathoanatomy is, which this is where, unless you can really tell me that that undersurface rotator cuff injury is creating his symptoms. And I don't see there's a lot of literature that says that, I don't know. But you're looking at anatomy and say, well, we've got to fix everything. Anatomy, we showed the last case, he didn't fix all the pathoanatomy. It was great, you didn't fix that labral tear. And what would you say if, let's say you have the same posterior superior labral tear here, you fix that. And then on the cuff, let's say you've got a 90% thickness. That's a different case than this one right here. I think it's different. In that situation, I think you have to do something. You can't advance it. I think I was talking with the guys about the MOON program. Turns out that a lot of times we can get by with pretty significant rotator cuff pathology without trying to repair it. Because you can't make that normal. You can't even make it physiologic most of the time. But you can, if you get the rest of the stuff okay, get the mechanics working okay, that rotator cuff kind of goes where it's supposed to go. Now, this is not the usual one we see, which is the thrower. But this is a thrower, so you got to treat him like a thrower. And you don't fix very many of those. So where I struggle is, I think if we're talking about articular sided tears, in a throwing population, if up to 50% of the footprint is uncovered, I feel pretty comfortable just debriding that and leaving that alone. If it's 100% complete tear, that's a bad day, but we got to fix that in a lateralized position. But it's sort of that 50 to 100% where I don't really feel great. I don't know that we have a good option. This might be an option. I don't know where the cutoff is. You got to tell me, I don't know, how did that get that partial tear? Did it get, was it tension? Is it compression? To me, it's compression. And so you get rid of that compression, you can fix all you want, until you get that internal impingement compression out of the way by fixing the labrum, so that, we just did a study where the posterior labrum, the humeral head goes posterior, and it goes posterior, it's going to impinge. So you fix that, get your scapula, then that, whatever's causing that rotator cuff problem will be lessened in terms of the pathomechanics. So let's go back to, this is a soccer goalie, not a pitcher, and your physical exam at the beginning said his cuff was weak and painful to testing, if I remember correctly. Painful, not weak. Painful, not weak. So you know, if you have pain there, and you think your physical exam showed cuff symptoms, and then the next question would be, what does he like to do besides semi-pro soccer? Because he's 24. He's a coach. So that's what he does. He throws. So he's going to be out there all the time. So then you're looking at it and going, well, what are your options here with the cuff? You could microfracture the bed. You know, you could try to put a PDS stitch in side to side, not really going to help. You know, we don't really have good evidence on that patch for throwers with partial tears. But again, you extrapolate that you're in soccer, not in baseball. He doesn't have to have this 130, 140 degrees. He can certainly turn his body and swing the ball and get back. So I think if you're looking at someone in this sport with that pathology, I think you can get away with doing a little something to the cuff. I don't think there's any harm in putting the patch on. I personally don't use it for partial under surface tears. I use it for a whole different thing. But I think there is enough literature evidence to support it, right or wrong. But I agree with everyone else that fixing the labrum, getting that cyst out is probably the most important thing. But you don't want to be back in a year fixing his cuff. You know, because he went to go lift weights or do something. I probe these from the outside with a spinal needle, you know, just kind of feel what the cuff tissue feels like while I'm looking at it from the under surface. And for him, it was really thin there. And while it was probably about 50%, maybe a little more once I debrided it, even the stuff that was there felt really thin. And so that was kind of where I felt like doing something was an option. It makes sense because now you're regenerating a little bit of tissue and there are a lot of different ones, patches out now, but you're regenerating a little bit of tissue. You had thin tissue. You're trying to build a little bit more tissue to protect him down the road. And you checked it. I mean, you put a spinal needle through it. So I think if nothing else in this particular case, I think it's a very reasonable thing to do. Now if he's a quarterback or a pitcher or a softball pitcher, I wouldn't do it. But I think for this case, I think that's a good decision. We have a couple minutes left. We have any audience questions? Yeah. Dr. Toth, if you could more clearly explain how you get at that cyst, your technique. Yeah, so I think the cyst is too far back behind the shell for us to get to. Now you can put a needle in it, but I worry, like Buddy was saying, it's a grape sometimes, these things. It's amazing how the wall is. So there's two ways you can do it. Either you can go subacromially, and as Buddy said, you can follow the spine all the way down. Most of us will get a little nervous because as you're pulling the supra and the infra apart, so he mentioned in passing retractors, and I think it's a really important point that is second nature for Buddy because he's a freak show arthroscopist, but many of us don't think about that. It's difficult to get there without damaging the muscle without retractors. So a little retractor in there to pull that apart, and you can follow it right down to the bone safely. I think sometimes that's all you need to do, and it shows up. It's almost like, you've seen this, Buddy, but it's almost like you do this, and this little baby pops up in there. It's awesome. It's really kind of, it's beautiful, and then you kind of take it out, but I think sometimes that the cyst will hug the bone a little too much for me, and I worry about that superior branch of the suprascapular nerve because I don't see it well from the top because it's coming in from under. So because of that, I choose to go like a spinal glenoid notch release. So I'll take two portals. One's four centimeters from the tip of the acromion, and one's eight, and I look through the eight, and I work through the four, and you just hug the lateral edge of the scapula as you come up, and it'll take you right there, and now I'm working from below the nerve where it inserts in the muscle, and so I'm totally safe there, and then you can just kind of pull it out of the way and then deliver it and get rid of it that way. And we'll tell you that the anatomy at the spinal glenoid notch is not consistent. When you do a suprascapular nerve release in the front, 99% of the time, you have CC ligaments, you have your suprascapular notch, and the ligament is right there, the artery's above, and the most variety you usually see is a bifid nerve where one limb goes over the ligament. In the back, it's very inconsistent. There's a plexus of veins that sits there. The spinal glenoid ligament is not consistent, so it's not like you can drop right down to it and it'll block you from damaging the nerve. So, and then the nerve, as JT said, stays high. Once it comes around, it stays high on the infraspinatus and sends branches, and that top branch is really small. And you really gotta be looking for it. And I'll put a retractor in, two switching sticks, and I'll use one through an advisor portal and pull the supraspinatus anterior, and I'll use one from the back and pull the infraspinatus down, and that makes the nerve hug the spinal glenoid notch, so it's sitting right there. So then you can dissect down, and whether it's a slap repair where they got too much capsule, you can release the capsule, but then the nerve is sitting right on the notch, but you gotta look for it. All right, well, that wraps it up. Some great cases. I appreciate all the faculty's participation, and thank you for coming. You know, please give us a review so we can learn from this and make it even better, and we appreciate your participation. Have a good day. Thanks, Michael. Put it together, man. That's a great case.

shoulder injury

overhead athletes

surgical intervention

rehabilitation

shoulder instability

capsular tear

posterior labrum

arthroscopic surgery

rotator cuff tear

bioinductive implants

post-operative rehabilitation

individualized patient assessments