So now we'll devote about 7 or 8 minutes to discussing biceps, labral pathology, subscap tears and then we'll regroup. And I think the hardest part of my presentation was the patients. I'm doing an MRI of a tear and the therapist is not going to be able to tell me. And that's when I think you need to spend a lot of time with them and going through the literature and telling them almost everybody who's been doing baseball has a slab tear and they didn't have surgery. And so really getting them to do the therapy really do not help operating on them if they had surgery. I do, I mean unless someone doesn't want to, I want a positive response. I want to hear that even for a week I had pain. Even just the lighting from the injection gave me an afternoon of pain relief. So that I really know that that finding on the MRI is correct. Because if they have that finding but that's not really the source of pain and I operate on them, then it's not really pleasant. But I agree completely. I always start treating my patients with slab tears conservatively. Many times they'll get better. And it is important for them to have that buy in, to do the therapy, to be committed to that. And then if they're still symptomatic like we saw with Julie's case, then absolutely moving forward with surgery and whether that's a tinnitus or a repair combination. I think it depends on the age of the athlete and their activity level and whatnot. But we are seeing very good evidence in the literature and I'm sure you guys have seen these studies of younger and younger patients being treated primarily with a bicep stenodesis rather than a repair. So even in their 20s. You know it's interesting, my partner takes care of those gymnastics teams. And all the men who do all of, you know, they're in the rain. They all have slab tears. And when they become symptomatic, they can't participate anymore. He used to do slab repairs on them and had prolonged recovery. It was difficult recovery. Not great return back to play. And now an 18-year-old gymnast who's doing biceps stenodesis. And then he, because he actually has a guy that he did a slab on one side and then a couple years later did a biceps on the other side. And the recovery and the return was so much. And there's no deficit. There was no downside. Yeah. It's pretty impressive. Yeah. You know it's really hard for me to repair something. Yeah. It really is. Yeah, so we do, we'll use an ultrasound. We'll charge it with our injection. Because I really do feel, I think if you're going in the joint, it's going to go down the groove. Oh, I think so too. And I've seen our guys, you know, we have non-ops that are ultrasound certified or whatever and they do all the ultrasound injections. And think about it. This is how I think about it. When I do a total shoulder, there's a lot of times I'm trying to find the groove. Is that the groove? Is that the groove? And the space between the sheath and the biceps is so thin. And sometimes we have a difficult time calculating if we want to open up the groove or if we want to be able to get the biceps out. And I'm thinking, so are they really getting the needle into the sheath in that teeny space? And I don't know what to make of the response to that. So I would do an interjoint. I don't know about you. Yeah, no, same. I would do an inter-articular injection. Yeah. What do you do in your practice? Well, the overhead response is not so prevalent in Singapore. Most of the overhead response I think is in the back. Right. So most of the time, it's complicated to start a business, and the decision whether to teach or not is up to a team. So basically it's up to the teacher, and also the actor in front of the camera. So if it's a tight screen platform, then it's quite an area that we need to focus on. Otherwise, a tight one, it takes a lot of time, especially in a young position. I think that's so far in front of me. And then what about technique? I'll open this up to you guys. What you see at Toledo, but in terms of, if a biceps tenodesis is going to be done, what approach are you using? What technique are you using most often? Or does it vary depending on age, etc.? You can do a unicortical though, so you can do a unicortical button. Yes, that also works really well. And always. So if they're doing a biceps tenodesis, they're always doing open subpec. I was going to ask you, Julie, just in general, so you presented a subpec there, but if you're going to do a biceps tenodesis, does the technique vary a little bit depending on the age, demand of the patient? Yeah, I mean, I might have an older patient, you know, we call it a godmother, which isn't very nice, but someone who is just not very muscular. If they had a tenotomy, they wouldn't even be able to tell. But I have found that now, I don't do a tenotomy on anybody, because they just get angry, and it's just not worth it. So I tenodeson into the upper arm, and I just take one of the sutures through it, and if it fails, I don't think anybody's going to know. But as far as that patient knows, I fix it. But I do a subpec in anybody who has definition, who cares, who cares what they look like. And for me, it's just so quick. And I just find you have to stop the technique. For me, it's kind of annoying, it's kind of fussy, and I've seen so many fail. So many of my partners fail. Issues with the screws. One guy lost a screw in the joint. And I'm like, no, I'm going to quickly refit. I don't find that the fluid makes a difference at all. I don't think it has an impact either. No, I really don't. I think it shifts your incision. So what I've found is if you do a big scope, you initially have an incision here, and that incision just shifts it. So I can make it even more medial, and then it hides in the axilla when everything calms down. All right. Everybody, I think we're going to take a couple minutes now to do our discussion. If you don't mind, sorry to break up the great talks that you guys are having. I think we'll mix it up a little bit. Let's start over here actually with John and Nick and see what you guys took away as the main discussion points. Sorry, the mic is Julie. Would you mind sharing the mic with them? Or you can grab it. Julie's not sharing. I guess our first conversation was around the biceps tendon. I think we have a little bit of a mixture of how we manage it, where we manage it. It seems like you can do it super-pec, sub-pec, either way. I think people are having good outcomes with how they do it. We talked a little bit about throwing athletes and slap pathology, a little bit about the pathology that goes along there. A lot saying that a lot of our slap patients, that seems to be kind of fading away, and our throwing athletes a little bit, we're not seeing as much of the pathology and focusing on one of the most recent comments here from Nick, who certainly sees a lot of these. Talking about when we do see them, a lot of it comes from overthrowing, especially in our younger athletes, and poor kinetic chain core strength. So kind of focusing on the whole picture there to get it back. Great, yeah, very important. Brian and Tiger, let's go back to you guys. We talked about having the partial subscap rupture, or small fulcrum rupture on top, and then the biceps pathologies. Do we take the biceps every time we do a subscap repair? I think most of us do take it. If it looks pristine, we may leave it. But a lot of us, if we fix the subscap, we typically take the biceps. A lot of these are related to chronic pathology. The second thing we talked about is the slap tears, and whether it's bicep tinnitus as a first primary treatment for somebody who's a thrower or athlete. Do you think we're still erring towards the slap repair? Maybe Brian does the tinnitus off the bat for younger patients, for throwers? I think to characterize it in that way may be short-shrifting the conversation, but we were talking about the presence, where the symptoms are, what their provocative exam is, and I think the best terminology I've heard is the biceps is like the thermostat of the shoulder, and it really can be inflamed in many different settings. So excluding those, looking more at those type 2a or any extension of the structural problem into the biceps, I would probably lean preferentially towards the tinnitus. Great. Thank you. Julie? I'm paying attention now. So we talked mostly about just different indications. They don't have as many overhead athletes in Singapore, but for the young ones they have good results with slap repairs. And then how to do the tinnitus, arthroscopic versus open, and the reasons for that. And then a lot of the conversation I think was do we even do slap repairs at all? What is our threshold? Is it getting lower and lower? And also we talked a little bit about tenotomy, and our experience, my experience with doing tenotomies and the patients, why they're not very favorable of tenotomy, and when do we do subpec versus something different based on the patient. Okay. Excellent points. Sarah and Steve? So we spent most of the time talking about season 3 of The Mandalorian. I haven't watched it yet. Don't spoil it, please. So I think we started, one of the participants at our table commented that they were at a previous ICL this week, and a discussion of what do you do in the overhead athlete? Can you do a biceps tenodesis? And there was general consensus that you shouldn't do a biceps tenodesis in the overhead athlete, which I think based on the conversation here, I mean, there are times when you have to do it, and there are times probably where it's preferable to do it, and I think there's generally increasing data in that area. So we kind of talked about that for a while. We talked about how a slap tear is a very heterogeneous group. There's a bunch of different pathologies there and kind of how you address all of those. And then we actually spent a lot of time just talking about how you execute a tenodesis, you know, do you do arthroscopic versus open and fixation and things of that nature. So we spent some time talking about that. Great. Excellent discussion.

biceps

labral pathology

subscap tears

surgery

conservative therapy