All right, great. So, welcome this morning. And like I said, we're going to try and make this a lot more interactive, so please, there's a couple of mics floating around at the tables, and please pass them, and it's small enough where we probably don't need them, and I can just repeat the question for the benefit of – I believe that this is being recorded, so for the benefit of the recording. And so, today we're really going to talk about things around the SLAP, and I think that this is something we'd like to move away for in our terminology, and this ICL is really trying to understand why that is and how SLAP is not a great diagnosis, but rather a constellation of problems that has been misunderstood. So, we've got a great group of faculty. We do have some disclosures that are available on the AOSSM website and the Academy website. And so, I'm actually going to let Dr. Grantham kick us off with the first case. It's a case of his that he'll begin to moderate, and we'll have some good discussion. All right. Good morning. So, my name is Jeff Grant. I'm coming from Lexington, Kentucky. So, this is my case here. A 32-year-old male Amazon employee with left shoulder pain. So, he recently had a new injury, a bicycle injury, where he suddenly went over the top of his handlebars. Terrible anterior shoulder pain following the injury. Occasionally, posterior discomfort. He had difficulty with overhead activity. Really hard for him to go back to work at Amazon. A lot of stocking shelves. Three years prior to this injury, he had a slap repair at an outside hospital. But ever since that slap repair, he's felt tight. Shoulders not felt normal. He never felt like he got back to his baseline even prior to this injury. So, on exam, he had a painful abduction external rotation. We rotate him out to 95 degrees with him in supination. When we pronate him, it only gets to 90 degrees. Abduction internal rotation to 30 degrees. So, he had a positive DLS, dynamic labral shear. So, bring him into this abductive position, trying to shear that labrum. Caused pain. He was tender over his biceps. Negative O'Briens. Being from Lexington, Kentucky, look hard at the scapula every time. So, he did have scapula dyskinesis. When we controlled his shoulder blade, his DLS improved. So, he went through PT. Saw no improvement. Still felt tight. Still felt painful. Still had difficulty with overhead activity. And then we got an MRI. So, on his MRI, on the coronal, you can show that superior labrum. Normal cleft up top. No significant pathology there. On the sagittal, you see where his anchor was previously placed. If you think about 3 o'clock being anterior, kind of 1130 anchor. But a single anchor up top. Jeff, if I can stop you right there. Just a comment. Did he show up with this MRI or were you ordering this MRI? I ordered this MRI. What's the role of an arthrogram, especially in this revision type setting, prior surgery? What's your decision making process there? So, for me, if I'm looking at cuff, older population is pure MRI. MRI arthrogram with subtle labrum pathology. Instability, true instability, dislocation, I'm probably not getting an arthrogram because I think the pathology is much more evident. But subtle labral injuries, I'm thinking more arthrogram. And just, you know, poll of the audience. Who in this situation, when ordering this MRI, would go for an arthrogram in a prior surgical setting? Who would do it primarily if you had concern for this? So, I think most of us would do an arthrogram in revision, and the general majority, excuse me, the majority would prefer non-arthrogram initially. On the screen. Unfortunately, it looks great here. Yeah, it's pretty nice here. Yeah, so essentially, so what I'm seeing is just a single glenoid lesion up at about 1130, showing where their prior anchor was, but really on the coronal and sagittal, no significant pathology. And then when we come to an oblique axial, you can see a little bit of a cleft in that posterior labrum. And so that cleft is that posterior labrum tear. The fluid is getting between the cartilage and that posterior labrum, showing that it really doesn't have a good bumper back there. There's loss of integrity back there. And we like to add an abducted external rotation view, kind of a shoulder internal impingement view, kind of shows where that cuff and that posterior labrum are impacting. And if you look at that posterior side, you see that posterior labrum is sitting deep to the cartilage edge. So it's not really creating that posterior bumper you would like to see. And, Jeff, when you're looking at this in a different patient, you know, in my experience, I've seen that the posterior labral tears, it's not like an anterior dislocation, and especially these attritional wears, it's often very subtle. You know, I don't know how this is projecting for the audience. But it's more obvious, I think, on these cuts than many of them. And we have an MSK-trained radiologist, and they miss it. And so it would be very scrutinized, that MRI. But also I do think the arthrogram helps and the abduction external rotation. And we get an axial oblique view on our MRI. So you're not seeing the labrum on an angle. With the oblique section, you should see it in profile nicely. This axial oblique, it cuts it at a right angle tangent to the posterior labrum. And look at that posterior labrum. It's squared off. And there's a little defect right there. And the whole thing is mashed off the backside. So the other thing is, we talked about this yesterday, is that the main complaint here is pain. Is that right, Jeff? Is it pain? Is it pain that's causing the problem? Is pain, a lot of times these posterior labrum things are all pain. Yeah, so it's a lot of pain. A little bit of stiffness, not crazy stiffness, but a little bit of stain, primarily anteriorly. And so failed conservative treatment, still continued pain. My concern for a posterior labrum tear on MRI, we took him to surgery. At time of arthroscopy, top left, I do all my labrums in the lateral decubitus position, because I think I can see 360 on the glenoid much better. And so 1230, you can see that bicep's coming in, looks good. And then you start seeing a lot of red synovitis following that posterior labrum as it's going from superior to posterior. That superior anchor that was there at 1130 is kind of tucked underneath it on that top left picture. But as we look up at it, you can kind of see where it is in relationship to the biceps. And then if we look down more posteriorly, you can see that subtle separation of that posterior labrum kind of going down into about 730. If we can stop and break here for a little bit of discussion. Obviously, we're already at the arthroscopy now, but would anybody have taken a strategy of more non-operative treatment for this patient? One concern I would have with this, and it's always difficult to figure out, but anytime you've had this surgery, you start to wonder about the biceps itself, right? It doesn't look terrible. It looks like they did a reasonable job on the first lab. You could maybe, on that bottom left picture, say it looks a little over-constrained. Maybe the path doesn't look quite normal. But sometimes I would do at least a diagnostic biceps injection to see if it helped them before I might scope them. I'd say that's not a routine part of my practice. I don't find it all that clinically useful, the bicep steroid injection. You're putting steroid around an inflamed joint. I don't know how diagnostic it truly is. I think another important point now that we are to the point of surgery is the positioning. You mentioned lateral, and I think if you're looking at this and you start to see that posterior labrum, if you are in the beach chair position, and I do all my labral work lateral, if you're in the beach chair position, if you don't move that camera, and you're moving very quickly and you don't move that camera to the front, it's very, very easy to miss that, especially if you don't have a high end of suspicion. I think on this MRI we do, but hopefully as we go forward, we'll see that some of these things can be hanging out and not be readily obvious, and if you're not looking for it and paying attention, that it can be easy to miss. I think that in lateral you're far more likely to see it easily and initially than you are in a beach chair position. Not that it can't be done in the beach chair position, but I think lateral is a little bit more effective. Does anybody routinely do labral work in the beach chair position? I think the general consensus is lateral for labrums, and I think this illustrates one of the reasons why your more subtle findings are more readily identified in the lateral position. So now, here we are. Yeah, so surgical options, right? We can failed slap repair. We can cut the biceps, do a biceps to decis. We could liberate the superior labrum. We could fix the posterior labrum. We could do a combination. It's a dealer's choice as of what the literature shows at this point. And so if we start thinking about what the labrum does, all right? So if you think of the labrum as two sections, you've got the superior portion and you've got the more inferior portion. Biomechanically, the superior portion is intended to be mobile, okay? It is a tension band, and so if the superior labrum is mobile, when the biceps has tension on it, now it becomes a dynamic compressor of the humeral head. The inferior portion, the posterior inferior portion, is much more of a static bumper and a fixed entity. What we've noticed is the true anchor of the biceps to the labrum, or sorry, to the glenoid, is around that 10-30 position. Up more superiorly, the attachment is much more posterior, sorry, medial off of the actual cartilage edge, and that's what allows for that mobility. So in an overhead athlete, in a thrower, that mobility of that superior labrum is important to allow some humeral head compression, some glenoid-humeral stability, and not over-creating too much tension of that biceps. So what I did was, sorry, go ahead. Could you go back to that other scope picture there for a second to describe a little bit of some of this? I'm sorry, but if you look on there, look on that bottom left, and you see that there's that little cleft, and that probably is that mobility you're talking about, but then on the upper right, you see that that cleft kind of stops, and then you see the application of the labrum all the way down. You see that little split in there. That's the tear, and what happens is right there, that ripstop you're talking about is missing, and if you look at the lower, you see how it goes down there, and it kind of goes around inferiorly, and then goes down obliquely right there. Jim Bradley calls that the lambda lesion. You see it's got those two limbs down there. That whole thing is damaged. It's not allowing the labrum to be the bumper that you're talking about. It's not well attached, and so that's the pathoanatomy right there that you have to address, and you say, well, that doesn't look too bad there on that lower left. Well, that's that upper part that's supposed to be mobile. Now, that stitch is right where it should be mobile, and it's making it immobile, and we just did a study with Tylee's lab that showed that that anchor position right there creates a kinematic situation where the humeral head goes anteriorly and inferiorly because of that compression right there, and so one of the reasons you may have this anterior pain is because that stitch is actually driving kinematics of the humeral head anteriorly, so I think that gives you a better idea of what you see versus what the symptoms are. Well, I know this is a little bit speculative because we weren't at the index procedure, but do you think it looks like that at the index procedure? My guess is yes. I genuinely think we don't do a great job looking posteriorly, and when we do, it's a subtle injury. It's not as abrupt as a Bankart injury, and so I think there's a lot of just debridement of that injury rather than trying to appropriately fixate and create that posterior bumper. Well, I think it's important to acknowledge, too, that the labrum itself is not a homogenous tissue and that it varies in the form of its attachment and its appearance and its function as it goes around the glenoid, and I think that's really important because that mobile superior portion of the labrum is attached differently. It's supposed to be more mobile, and it looks differently, and so if you're seeing abnormalities in the posterior labrum, they're not going to look like your anterior labral dislocation that was an acute trauma, these attritional wears, and even sometimes posterior dislocation in acute setting can be a lot more subtle, and so I think that's really important to really pay attention as you go forward looking at the labrum, noticing that inferior labrum is very tightly knit through the sharpie fibers to the glenoid bone. It does not have a big border posteriorly, and so the way you fix it, the way you approach this problem is very important. You're not recreating a massive anterior bumper like you would with a traumatic anterior dislocation that you're fixing at Vanguard surgery, and it's important. So if you're not looking and if you're not paying attention to normal on your routine cases, I think that you can miss that. So now, who would just cut the biceps? Is there a role for that in this revision? Biceps is over-constrained. They got an anchor there. It's already healed, although... The pain is anterior. Yeah, the pain is anterior. The posterior labrum still can be addressed separately, but do we just cut the biceps? Tinnitus is synonymized. Tinnitus is in the U.S. most commonly. It's a reasonable option as far as what folks are doing right now and say, would it address the biceps tightness? Absolutely. If you don't have the biceps going through the interval, it's certainly not going to be tight anymore. But again, the biceps has a role in the shoulder. So my preference is to save the biceps if we can. So looking at this, what I did was release that superior anchor. Just cut it, made sure that superior labrum still had a cleft, was still somewhat mobile, and so I'll take the arm through internal and external rotations, see that superior labrum can now tension with the biceps motion. Then I did a three-anchor posterior labrum repair from 7-30 up to 10-30, or 7-10-30, trying to create that posterior stability again. I think your picture here, Jeff, highlights an important thing which we were just discussing, is that you didn't create a massive bumper. You repaired the labrum to the glenoid, but you're not trying to over-constrained posteriorly, nor create a massive bumper like you would in a traumatic injury. We also re-established the ripstop. You see the ripstop is this area between the transition between the superior mobile and the inferior immobile, and that point where that suture is, is the ripstop. You see how all of a sudden, now you've got an anchor point for both. So you restored the ripstop and allowed the upper part to move like it's supposed to. So I'll do my labrum repairs with a Wilmington portal. It allows me to get 360 nicely. When I'm doing a posterior labrum, I'm not grabbing capsule. It's just keeping that lasso just right off the edge, and making sure I'm getting underneath to get that, it's almost like a sausage casing, synovium layer over top of that posterior labrum if I can. So at two months post-op, he's got full range of motion. He's got no longer that tightness in abduction external rotation, and his shoulder's feeling better than it has in three years, and we were able to save the biceps. So right now, at three, four months post-op, he's just focused on scapula stabilization. So we get rid of that internal impingement situation so that he doesn't tear it again. He was 30 something, early 30s, right? Thirty-two. Yeah. So if this patient was 42, what do you think in terms of the management of the biceps at that point in time? Let's say he had this repair 10 years ago, and that biceps didn't look quite as good as it did in your diagnostic arthroscopy. Yeah. I'd say, I think, treat the pathology, right? So for me, on his shoulder, the pathology was the immobile superior labrum with a posterior labrum tear. The biceps itself was a consequence of that. So for me, it's fixed the pathology, not just fixed the symptom of the biceps tightness, biceps tight pain. So if the biceps is injured, if I take out that superior labrum stitch and that biceps is torn, because it's been trying to be mobilized through the stitch, consider a biceps tenodesis if there's pathology in the biceps itself. For him, less consequential because he's also not putting his arm through the throwing motion 100 times at 90 miles per hour. So, but, and say, if I can save the biceps, I will. Go ahead. Just technical details when dealing with the posterior labrum, you mentioned making a slightly lower posterior portal, so you can do more work through there. I find that that's sometimes effective, and I also find that sometimes I'm very crowded there. It just depends on the individual. Who here is routinely using accessory portals of five, seven o'clock portals to really address that inferior labral pathology, or the seven o'clock, especially in the posterior labrum? Yeah. I think that there's some really good things that have come on the market for needle localization, that very small needles with cannulization, that makes it very easy to get those anchors in there. I would say, if you're not using those accessory portals, you really should consider adopting them, because they're safe and very effective to get your anchors placed percutaneously if you're unable to do it, or you're just crowded back there, which sometimes happens, especially with the suture-passing devices. There's just not a lot of room back there. So, that can be very helpful. So, questions, comments on that case? Anyone want to disagree? I'm going to repeat that question for the recording. The question was, what do you tell the patients, what are the odds that he's going to be back in 10 or 15 years since that biceps was left intact? Is that correct? And so, yeah, that's why. I don't know the answer to that, like what the percentage that are going to go on to it, because frankly, it's kind of a newer concept to do more posterior than a superior. But at the same time, I think if we have good PT on the back end and we address why he had a posterior labrum tear, right? The humeral head is riding posteriorly. Why, right? Because usually it's because of some tightness of the capsule or it's my shoulder blades going forward as my arms going back, right? So there's a reason that humeral head is riding back there. So if we address that appropriately, he shouldn't be back in theory. Why would you say that? Why would you expect that that biceps would be at— I assume you're going to say that biceps is more at risk because of the two surgeries. Is that what you're saying? Yeah. And— Are you creating that flexible—I don't know how— Yeah. Well, the study we just did with Tylee, what we did, we created posterior labral lesions and then we fixed them. And we fixed them two ways. One was up to that rib stop at 10 o'clock, found that the kinematics of the humeral head translation were back to normal. If we put that superior anchor in there, then kinematics were off. And so the kinematics of the time zero of the repair, the correct repair, were back to the baseline. So once again, if everything else goes well, there's not any extra load on that biceps. Now, this thing—Lancel Clare just did a big study in the—or just reported in the military population, talking about 10 years. He looked at all the all the guys in the military that had a biceps tenodesis and followed him for nine years. 62% of the people who had biceps tenodesis required other treatment during this 10-year follow-up. So doing the biceps tenodesis is no guarantee that you're going to have, probably because a lot of times they didn't do it for the right reasons, but for whatever reason 62 two-thirds of them had other things they that went wrong with their shoulder after they had a biceps tenodesis. So that's not anywhere close to being a panacea. I think one of the other challenges to your point is that we don't really know what the spectrum of normal is. The labrum may be more dynamic in a thrower than it is certainly in me, right? And so I don't think we know what that spectrum of normal is. And sometimes you have to have some potentially pathologic adaptations in order to do what you're doing, consequences down the road, but you know if you tighten up a thrower they're not going to get back. So I think it's a challenge that we haven't figured out. So take a step back here instead of talking about a revision situation, just a primary situation. This is a 23 year old female with left shoulder pain and she was a softball pitcher. She's now had shoulder pain for two years and it's always been anterior and her trainers have always just said okay stretch it out. Her mechanics are good. She was very, very good. She was a starting pitcher. Physical therapy wasn't working and she'd had an intra-articular injection of cortisone that lasted two months toward the end of her senior season to get her through tournament play. Now she's done. She's showing up in my office. But if we just think about this, this history, she's had anterior shoulder pain for two years and physical therapy hasn't worked. You know so Joe, why do you think maybe that the physical therapy hasn't worked for her? I think, I think the, I think we'd have to look at her mechanics and her mobility. I think the, it's hard to know based on this just you know in terms of if you lack her exam, you know, are they looking at the whole body or looking at the lower, lower, the lower legs or looking at the core and their basic form that basically allows us to generate energy from her the ground up. And if she's just throwing with her shoulder and just basically all the force transmissions going to the shoulder, then I think that you know it kind of depends on the quality of the physical therapy. Right and I haven't given any physical exam findings, but when you think about the history and you know a patient shows up in the office. So I've done a whole bunch of physical therapy and it hasn't worked. Well I'd like to know what physical therapy they did. This this patient happened to be in a D3 school in a fairly rural area. I'm not real confident that she's got access to a lot of really high, high quality physical therapy. So oftentimes what I hear is that oh well they, they, they iced me and they stretched me and then we did some band exercises and that's kind of the, that's what you get right, some band exercises. Well I don't know what that means, nor do I know what they're trying to do, how long they did it. And so very skeptical that the therapy was very effective. And again she managed to play with it, but but two years of pain and 21, 22 year old. So she has outstanding range of motion. That wasn't the issue with one exception. She had a pretty significant internal rotation deficit compared to the contralateral side. And she was tender along the biceps and she was tender along the anterior shoulder. She had full normal cuff strength. Pain with just your generic provocative biceps tests. I don't really place a lot of stock in them. But she also had scapular asymmetry and so she improved with stabilization of the scapula. And it's that inframural border that I find is, is often the most common. She had already had an MRI, so here's what she shows up with. And I know that's moving a little quick. Try and run it again, but then I'll go to some static images. But as you can see, her cuff is entirely normal. Cartilage looks good. Biceps is sitting in the groove. Did anybody see anything obvious they jumped out? I didn't on a cursory view, but if you slow down and you look at a few cuts, this is what you see. I don't know. It looks like it's projecting pretty well. Anybody want to comment on that MRI? Yeah. So again, I think we see that posterior kind of slit between the glenoid and that posterior labrum. Just kind of a subtle little signal. I'd say this wasn't an arthrogram, so these can be a little bit harder to pick up when there's, there is no intraarticular contrast, but still, still present. Now primary patient, now she came with an MRI to me, but if this patient was in your office and ordering an MRI, 23 year old, who would get an arthrogram as a primary diagnostic test? On a primary? What about the false positive rate? Anybody concerned about that? So I mean, I'll be frank. I rarely get an arthrogram on a primary case, even if I'm suspicious for labrum, and I think it's because you can see it if you're careful, but it depends on the quality of the MRI. A lot of the MRIs around us are not good quality, but to the point that the the posterior labral tears can be very subtle on that second image on your right. I mean, it's not, there's no full thickness. It's just a very small cleft, so you really do have to be paying attention for it, especially in a busy office situation. So now, what would you do? Send her for more therapy? She's got internal rotation deficit, scapular dyskinesis. She's already done a bunch of therapy. She and her mom is sitting in her office. Where are we in the season? She's done. She's done. It's it's May. She's finished her senior season. She's gonna start work in August. She wants to stop hurting. Pain's her problem, but her mechanics are also terrible right now. She's not looking to play softball more. She just wants to be active and not hurt. She's 23. So I don't know if you're just asking panel members or just asking the audience questions, but I would comment that you're, if you go back one slide, Neal Eltrosh in the adult population, and we just published a paper in JSS International demonstrating that if you see the, there's no point on the back of the glenoid. Posterior glenoid dysplasia is present in most of our injured symptomatic upper extremity athletes, and you end up with this prominent capsule labral chondral hypertrophy that just more easily fractures, fissures, separates with the forces that occur along the posterior margin of the glenoid, and I tend to think that even with a contrasting MRI, sometimes it's difficult to clearly rule out the presence of a posterior labral tear because of chem lesions and the like, because they really do occur, and the other thing is we just published a paper that showed that in almost 200 injured upper extremity athletes, we had a three to four time increase, three to five time more likely to have glenohumeral extramotation deficits over intramotation deficits when you use humeral retrotorsion to correct for motion loss, and so we have all, for three decades, worked to correct 30-degree intramotation differences, whereas in many of those people, if indeed they have a 30-degree relative humeral retrotorsion difference, the motion loss you see on total range of motion difference is actually extramotation, so just to throw a wrinkle into your question, I just thought I'd throw that out because it's more complicated than we, it keeps getting more complicated as we get to know more. Yeah, I think some of the classic measures are less reliable, we do need to focus more on the total range of motion, and you'll see more subtle differences there, and I think that you also see differences in patterns in terms of how that pathology shows up in different types of overhead athletes. The baseball pitcher is different than a softball pitcher because of the arm mechanics, different from tennis, and so it's an important consideration. So here now, who would go straight to surgery? Fair. I did not. I sent her for physical therapy first, but I wrote my own order and told him what I wanted to do, because I wanted to see if she had better mechanics through her daily living and she wasn't throwing a softball anymore, if she was really gonna be symptomatic still. I mean, she's done playing, she's not trying to get back to that, and she's coming fresh off the season, right? It's May, she just finished her season. So I did send her that. She was tight in the front, as they often are, really focused on her core strengthening, which was behind. Again, when Joe mentioned earlier about her mechanics, the number of people who show up in my office as high-level athletes who can't do a single leg squat is appalling. It's neglected, especially in the D2, D3 level, where they don't have the resources that a D1 may, or certainly not like a professional team. So I think that this is very, very important, and that's where my exam starts, is in the core examination for both upper and lower extremity problems. And I give her a steroid dose pack, calm it down, make her a little bit more comfortable as she starts with the physical therapy. So she returns, and actually she feels good, but she still has that anterior tenderness, especially along the groove. And her scapula is not perfect, but it's way better than it was. So now she's back. I think we're talking surgery. Is anybody not talking surgery at this point? She's done what you asked, she still hurts? She did not have any significant laxity. She was not a hypermobile person, no Beaton findings. So you're planning on surgery. Where are you going to tell the patient? What's your strategy? Joe, what would you do? She hurts in the front too. You know, I think it's a little bit like the last case, where you want to look at what's inside the joint and decide what's pathologic, right? Because if she's had enough symptoms and that now the biceps is affected, then I think you have to, I think it behooves yourself to do something to the biceps as well. But I think this comes back to the posterior labrum and being the bumper. And if you're not treating the pathology and your biceps looks perfect, I think it's reasonable to repair the posterior labrum. So is anyone going into this operation with a greater than 50% chance of performing a bicep stenodesis in the back of your mind, thinking I'm more likely than not to perform a bicep stenodesis? Good. So in terms of this, when you're thinking about this, positioning I think is really important. Is there anyone who would advocate for positioning in beach chair in this instance, given what we've talked about before? And it's fine if that's your preferred surgery. I just think you have to be aware. So again, I like to position these lateral. And if we look at it and we look at the biceps examination, you know, she was hurting in the front, but her biceps on exam is totally fine. Her shoulder is a bit synovitic, but I don't see any, you know, synovitis along the biceps tendon, at least none of any significance. But what you do see is this tissue. And now if you're looking from the back and you're moving quickly, you could just say, oh, well, there's some hypertrophic tissue, a little bit of degenerative labrum, and just clean that up with a debridement. But then you notice that the probe is falling in there. I'm not pushing very hard at all. That posterior bicep, or excuse me, that posterior labrum is not well attached at all and fell off really easily there. And so again, she hurts in the front and yet she's got a normal biceps. It's because she has no posterior hanging. There's nothing holding that biceps. The whole biceps labrum complex is loose off of the labrum going posteriorly. So as you do that right there, you're pulling, you're putting tension on the biceps, but it's not attached anywhere down there. So that's, in my thought process, is why you're getting the biceps pain, because you're putting a lot of tension on the biceps because it's not anchored where it's supposed to be anchored. That whole back side's bad. That rib stop's gone. And so it's not attached anywhere from that lower level right there all the way out to her biceps attachment right here. There's nothing attaching well. So it's just kind of sliding back and forth. And I think in the next series of images and videos, you can see that that labrum's off from 7 o'clock up to 10. And so looking at this, mobilizing that labrum, and that labrum had a lot of delamination and everything, but as you start to bring it back down and fix it, it's not too bulky. And so three-anchor repair from 7 to 10, but no further, and leaving that bicep superiorly a little bit more mobile. And she got better. Six months later, she was back to doing all of her regular fitness activities and no anterior shoulder pain whatsoever. Again, stabilizing the posterior labrum. And on these, I do tend to close the capsule carefully on the way out, especially on my posterior labral repairs. I don't know that that's really necessary. I think there's some debate. Does anybody routinely close that posterior capsule? Again, in the atraumatic session, atraumatic injury, or no acute trauma, I should say. Yeah. So this is kind of a compare and contrast, and this fits a lot more like Jeff's first case. 26-year-old female shows up. She'd had an initial injury nine years ago. She was a high school volleyball player and had some sort of maybe a subluxation injury. It's not really clear. The history's a little fuzzy. But she was diagnosed with a slap tear and underwent a slap repair. Now, the op notes aren't there, and they're long gone, as are the images. So I'm not really sure what that was, but she said she then returned to play. And she was okay for a few years. Then she had a recurrent injury three years ago. She was playing recreational volleyball. She still likes to do that. And she had a second surgery, and there they did something to the labrum, and then he did a biceps tenodesis. And as far as we could tell, the indication was a failed slap repair. She never got better. She's had continued pain since her second surgery. She's been to physical therapy multiple times. This person lives in a more rural area, so the physical therapy is highly variable there. So I don't know what they were doing. But she's also had two steroid injections within the past year, and none of them had sustained improvement. Her exam is pretty decent. She had inter-shoulder pain, coracoid tenderness, biceps tightness, but really, really very bad scapular dyskinesis. And she often had difficulty even with the overhead motion. It was very dyskinetic. If you stabilized it, she could bring her hand up overhead fairly easily, and her pain decreased. It didn't resolve, but it decreased. And so it was very significant. So if we look at these x-rays, anybody, Mary, want to comment on these? See anything of interest? Yeah, nothing profound. This isn't meant to trick. This is just nothing too obvious. And so if we look at her MRI, again, this is southeastern Kentucky MRI, so it's of limited quality, and they didn't run very many sequences. But you can see that she's got posterior labral injury, she's got anterior labral injury, and this is a really not a very happy shoulder. Some remnant in the biceps groove, hard to know exactly what that is. But here you can see that there were a couple of anchors placed. It looks like there's been surgery that was performed anteriorly and posteriorly, but it's really unclear, and there's certainly nothing inferiorly that was done. So the history is pretty vague, but there doesn't seem to be a biceps in the joint, and she's got anterior and posterior labral injuries, with some questionable chondral wear. Again, the MRI is not great, so it's a little hard to say. So what would you do at this point? She wants to play recreational volleyball, symptomatic in her daily activities. She works as a teacher, so it's not like she's got a heavy overhead manual labor job or anything like that. Joe, where would you start with her? I still think it's a good idea just to ask like what they were doing in physical therapy and see exactly, you know, what the quality of it was. I think you never go wrong with going down that path. I do think this is, you know, the quality of the tissue and the MRI shows that, you know, she definitely has a ton of pathology, but I think, you know, it behooves you to try in that sense to figure out what was available, and if they can at least correct some of those mechanics, I do think it might be a little bit easier after surgery as well. Yeah, and I think no matter what, I've already had the conversation with the patient that no matter what we do, nothing is going to be a slam dunk. You're two surgeries in, you've been hurting for two years, and first surgery was questionable in its indications to begin with, so, you know, there's been problems, didn't say that part, but there's been problems that have been created, and, you know, you have to have a sneaking suspicion that perhaps some of them are iatrogenic, and so who would start, show of hands, with physical therapy? You're prescribing physical therapy and controlling a lot more now than whatever she had done previously. Yeah, I mean, that's where I started. I mean, she has a really ugly exam. I'd like to see how much better she can get, how her symptoms go, and what's her demands are. And the studies show, like, a return to play after biceps tenodesis is not 90% like an ACL. It's 60, 70% at best, probably more like 50%, and so she's kind of, if she's already had a biceps tenodesis, she's already kind of set up to not thrive in the overhead position with high-level activity. I don't have a great explanation for that. I mean, normally they'd be loose, but she still was, and still hurts. I mean, still attached to the coracoid, and there's, and she's dyskinetic there, so I did send her for more therapy, the usual Dospec and anti-inflammatories, really focusing on her scapular control and posterior chain strengthening. Again, she was hunched over, she's tight in the front, she's got, you know, terrible posture like so many people do who are not focusing on that. But I said specifically, I don't want them doing overhead strengthening, because what happens a lot that I hear from some of these physical therapy places who don't treat sophisticated shoulders, they just start treating them like they're at the end of a rotator cuff repair, and they want to strengthen their cuff, and they think that's the problem. That's actually probably exacerbate her problem, and that isn't what I wanted her to focus on. And so she comes back six weeks later, she's getting better in terms of her mechanics, she's got no real improvement in her pain, but she looks on exam better from her scapular control. It's not fixed, but it's going in the right direction, but she still hurts a lot, and she's still frustrated. So now, same goals, where are we gonna go? Is anyone not going to arthroscopy at this point? So I think now the question is, what's the plan when you go in there? Biceps should be gone according to the MRI and according to her history and the incisions, and you know that she's got some labral injuries, so lateral position. Her shoulder's irritated, it's angry, there's been some done there, but look, it's like they missed the labrum when they put that anchor in or it retore over time, hard to say. There's a lot of scar and irritation around this. So what's the strategy now in looking at this? I think you'll see more here in the back in a second. And I've got another picture in a second. But if you look inferiorly here shortly, I think it's on the next slide, actually. That's very interesting right there. See that stitch right there? That's the problem with doing a slap repair. There's an anterior superior stitch that was put in there that's totally torn loose. It wasn't that one o'clock stitch right there. I'm going to do a slap repair, and there's the problem with the term slap, I think, as well as whatever went down there inferiorly, too. And then now we're looking from the superior lateral portal where I use that as my viewing portal. But if you look down from five to seven, she actually still has intact labrum there. And look at how useless this anchor was. I just twisted it, and it fell out. I mean, it wasn't doing anything, probably hadn't been doing anything for a very long time. And I don't know at what stage that single posterior anchor was placed. My guess was that that was in her second operation. But if you're looking in here, I always start repairing from the back. That was that seven o'clock portal I mentioned. I find that that's very helpful. You can get low, and you can start working there. And so start repairing the posterior labrum. Now, she doesn't have a biceps tendon to worry about, but I'll still stop at about 10 o'clock. I'm not really dealing anymore with superior, especially since there's no biceps there. And then start working on anteriorly. That's the five o'clock portal that was there to start bringing that up. And then in going through that, I mean, her shoulder joint's ugly. You see the cartilage damage that's there. That labrum was scarred way anteriorly, and it wasn't doing anything. A lot of scar tissue there to mobilize and start to bring up. But here you can see, I mean, it's been restored. Tissue looks pretty crummy. So does her cartilage. But she now has a semi-normal in appearance in her labrum. And so she did get better after that, when she had her labrum stabilized. Any comments on that strategy? So my slide, I talked about the labrum being a bumper. So I think this case also illustrates the attachments of the inferior glenohumeral ligament. It attaches. There's an anterior portion, a posterior portion, which go to the labrum. So without the labrum being competent anteriorly and posteriorly, she's got no inferior sling. So every time she's overhead, that humeral has gone back, but it's also going down. She has no static control of that glenohumeral joint. So that repair restored that. And when I say considering return to volleyball, I don't have high expectations for her performance. But she's at least to the point where she feels comfortable enough to try. You know, volleyball is not that high of an impact sport, and she's not playing competitively, right? It's a recreational thing, so you're talking about maybe once a week. I'm not too concerned that that's gonna accelerate her cartilage symptom in a stable shoulder now. It may hurt, and I tell her that, you may not be able to do it, you may not perform as well as you did, but I certainly don't think that there's any harm in trying. And I find that most of these people will just self-regulate if it's painful, it's there. But again, if it doesn't hurt and it's getting worse, we wouldn't know that anyways, which is, I think, one of the challenges. And if we move more abstractly, when we talk about the development of post-traumatic arthritis, regardless of whether it's in the knee or the shoulder or whatever, it is a silent killer. And so there is a chronic inflammatory catabolic process that's going on that is below a pain threshold until it's not. And by that point, it's typically too late. And I think that's one of the biggest challenges that we face in dealing with any particular surfaces. There's a lot that's going on that we never know about until it's pretty far gone, and we're talking about some major preservation or salvage procedure or replacement for that matter. Yes. What are your restrictions in rehab and how long do you expect that to last? The question was, what are the restrictions in rehab and timeline for return to play? So I think this case is a little bit atypical, revision setting, ugly counterwear. But when we talk about that baseball player, I actually tend to move a lot of these people pretty slow because they tend to be younger. And so I'm not too worried about them getting too stiff. So I'll keep them in the sling, let them chill out, do general range of motion exercises and that sort of thing so they don't get stiff. And I'll start periscapular exercises very early on. But then at six weeks, I really focus on motion, but I don't let these people perform strength training until three months, because I really want that tissue to heal. I want their motion to be normal. And oftentimes I've found, especially that people who start strength training early get stiff. And so that's what I don't want. I want their motion to be normal and stay normal and then start strengthening at three months. And then if it's contact athlete, I prefer if at all possible I'll keep them out of contact until six months post-operatively, especially if it's a football player and you're dealing with more of like a traumatic posterior labral tear. Again, this is a little bit different from anterior labral pathology, but I think the principles actually overlie in terms of the rehab very well, because you're still trying to get that labrum to heal, whether it's on the front or the back. So does anybody accelerate faster than that for their contact athletes when you're talking about a labral repair? Like I said, my general, the longer, the better, but I prefer a minimum of six months. So in moving on, and hopefully we venture into a little bit more controversy with this one. This is a 44 year old male, left-sided shoulder pain, 20 year army veteran, and he's now working a desk job. So he's been active in the military a long time, but he's out now and he's had shoulder pain without clear trauma. And it's been going on for more than six months, anterior pain, overhead pain. And he'd done some sort of physical therapy with the VA within that past year. It's a little bit unclear. Physical exam findings, nothing crazy. He didn't have a positive chem test. He's got pain with dynamic load and shift. His scapula is a little dyskinetic, but not terrible. And here's his x-rays. Jeff, anything notable on this? Nothing jumps out to me. Yeah, again, no trick questions. Seems to be pretty normal to me. He didn't seem to have arthritis and significant cuff pathology, anything that's obvious there. MRI was scheduled, but still pending when he saw me. So that decision had already been made. So at this point in time, I sent him for physical therapy because I had no imaging and it was still pending. It's typical process when they're moving out of the VA. And so now he comes back to the office. The steroid dose pack helped. Physical therapy has been helping some, he feels better. Still symptomatic with overhead activity. He's still got some nighttime pain and some pain interiorly. And here's what his MRI shows. So again, he's had a consistent anterior pain. Anybody want to comment on that MRI? Hopefully projecting okay. So the biceps is sitting in the groove. I don't see any clear evidence of sling compromise or something along that. Again, 44 and he's been worked hard with his shoulder during his time in the military. But you see posteriorly, and then this is almost, I would almost equate it to like one of the ghost signs on the meniscus when you look at that. The labrum's there and there, and then it's suddenly not, that's a concern that that tissue has very little integrity and is not doing its job. Yeah, one of my other partners, Dr. Hester calls that one on the far right there almost a W sign or that, see that ridge right there? That's a sign of a delamination of the internal structure of the labrum. It's split longitudinally, not necessarily torn away from the bone, but it's just split longitudinally because of constant delamination and compression shear across that backside. And I think that's exactly what I wanted to highlight is that these look different from a traumatic, like an acute traumatic tear. These are attritional tears with attritional wear. And I was very fortunate, you don't get this lucky very often, that the sagittal caught the superior bicep. They were complex, all in one cut. And to me, that looks pretty good. I don't see anything majorly concerning there. And you can see that on the coronal as well. All right, so now what? We're doing more therapy, we're gonna do an injection, or are we going to arthroscopy? So surgical discussion, we're gonna go to arthroscopy. Here's what we see at the biceps tendon. So thoughts on that. What do you think about his biceps tendon? Again, 44-year-old guy, right? So it's not the 25-year-old athlete. Hurt anteriorly, consistently anteriorly. What do you think? Do we do anything with that? I mean, to me, it looks pretty healthy. There's maybe a little bit of irritation as it gets ready to head down in the groove, but pretty minimal. And I don't see anything obviously wrong with that anchor. And so. Mm-hmm. Biceps is entirely normal. Good anchor point. There's nothing that's going to put extra tension on that, you know. So cutting it is not going to change your symptoms at all. And so again, I'm viewing posteriorly right now. I haven't moved my camera yet. I will in a second, but you can, again, you can see if you're moving quickly and you're not using an anterior viewing point, you can really glance over that. So now with the camera in the superior lateral portal, you can see that this is a delamination. And I'm sorry, I don't have video on this one, but the labrum is not as profoundly irritated and degenerative as the prior two cases, but it slid off. It doesn't have that bulk, and you can see the fissuring there from that delamination. And so again, my strategy here is to bring that labrum back up without creating a tight posterior capsule. So I'm just fixing the labrum back to the glenoid, and I think Jeff highlighted that on his earlier case. That's really what we're after there. And so I'm just belaboring a point. Can you just pull, okay, a 44-year-old guy, how many would fix the labrum by itself? How many would, no matter what, do the biceps because he's over 35? And that was why I selected this. I'm sorry, I kind of glossed over that point. And that's why I selected this case. I glossed over that point. So he's in his 40s, and I fixed the labrum. Did I just commit heresy? Can anybody tell me why 35 was established as the cutoff point? Is there any data that says at 35 years old, after that, you don't need to fix the labrum? It's military data, so it's not overhead necessarily, but once again, does that mean that biceps is in there? Don't touch me, man. I'm okay. There were several good studies in the military data that said 33, 32, 35. There was a statistical difference in how well they did with slap repairs, and so they used that as a cutoff, and so that's why they went to that. But Bradley's got some emerging data right now that shows that you can repair superior labrums much older, and it really has to do with whether or not it's a truly traumatic event in which you can repair healthy tissue back, or it's tissue just needs to be cleaned up, and you need to just be debriding it alone, or in some cases, you need to be doing a biceps tenodesis. But that's evolving a lot right now, and so that number is not hard and fast. Unfortunately, in a thing we're doing right now, looking at indication of biceps tenodesis, that becomes almost a knee-jerk. 35, do a biceps tenodesis, which to me, in this case, shows that you've got to use your head sometimes to figure that out. Correct. Mm-hmm. Yeah. Injured shoulder pain, but when you're looking at that tendon, I'm not seeing a reason to cut it. So no, I left alone, and so far, so good. Came back to have his chronic tennis elbow done on the other arm, so he must have been happy enough. And this is just a belabor point, so move this very quickly, but this is a 22-year-old male pitcher, college baseball pitcher, right-hand dominant, eight months of right shoulder pain, difficulty pension. He'd already failed his non-operative treatment for biceps tendonitis and scapular dyskinesis. He did have better training staff and better physical therapy, and so he's got mild anterior shoulder tenderness without any appreciable biceps subluxation on exam. And he did have a positive dynamic load and shift, nothing crazy on his internal rotation deficit. Again, his total range of motion was symmetric, so I don't even know that that's relevant. And a little bit of scapular dyskinesis. Here's his MRI, and moving a little quickly on the side there, but on the static images, see how well this projects, but his biceps is in the groove. It's not flattened, it's not appearing that the sling is compromised. And again, this is very different from, like, your sling compromise in a rotator cuff patient, right? This is a 20-something, but if you start to look here, you've got very, very subtle findings on his posterior labrum. A little bit of flattening, a cleft there, and then, you know, is this, what is this, maybe an early Bennett's lesion? Maybe that's developing there, unclear as to what that is. He's got profound posterior glenoid dysplasia, and you see that exostosis that forms his elliptic sticks out, and it's fragmenting and breaking down. And you may call it a Bennett's lesion, but if you really look at the plane radiographs with them shot parallel to the glenoid and slightly off-axis to the central line, you can see that that's really just a flare off of a dysplastic posterior glenoid, and you end up with this big, again, capsule labral chondropertrophy that is unstable because it can't withstand those. You just look, draw a line along that line on the right side. You can see the humeral head wants to fall right off of that, and that's with any type of press exercises or overhead throwing type exercises, the humeral head moves back and there's nothing to stop it. So, normal biceps. So the question is, you know, we're fixing this posterior labrum, and he'll be better for a while, but if he keeps doing what he's doing, do you think we're gonna be right back where we started, given that he has an underlying bone morphology that I'm doing absolutely nothing to change? This is a soft tissue operation, so do you think that's the wrong long-term answer? Here you can see that's very similar to the softball pitcher, but that seven to ten o'clock area where it's delaminated and off, and so he was repaired. So again, anterior shoulder pain, normal biceps, labrum's great inferiorly, but don't repair past that ten o'clock spot. So, move on. Mayor, you want to take the lead on this? This is one of your cases. Yeah, I had both in there. We've got some time and flexibility, but they're just a little bit of a different flare. Yeah, so I'm gonna do a couple cases, and I guess, I don't know how closely I looked at the posterior labrum, but I'm starting to feel guilty about this. Which one do I do to go forward? Yeah, I've just been using the arrows, but yes. So, this was a 20-year-old college shortstop from a small school, a small Christian school near Lexington. No pro aspirations or anything, but just finished his sophomore year. He's barely able to throw, considerable loss of velocity. He was able to finish the season, can hit without any problems. So, he's had two prior surgeries. At age 17, he had a slap repair in his hometown. Some improvement, but difficulty throwing. At age 18, he had a reluxe scope and debridement. He's never been pain-free with throwing and gradually getting worse. So, he had good motion. Total arc of motion, as we've talked about, was equal with no GERD. Some pain with abduction external rotation. No signs of instability or apprehension. I didn't mention any posterior loading findings, so it's possible he's had something going on there, but seemed to have kind of some slap-type symptoms and biceps-type symptoms and good strength. No obvious scapular problem. So, we got an MRI. I'll put my glasses on, but I guess given the theme of the day, I probably should look at his posterior labrum pretty carefully, but we did not see anything obvious on his MRI, if I remember. So, we talked about whether we should do physical therapy or surgery. The thought process was that he had a lot of biceps pain. Probably today I might do a diagnostic injection. If you don't like steroids, you can do it with some arcane and re-examine him, but he basically tried everything. So, we did a reluxe scope and I picked this case mainly to show what can happen when the biceps gets over-constrained, even with a relatively well-done slap repair. I didn't see any problems with how they did it. This was done in the beach chair only because I had already planned on doing a biceps tenodesis, and Lyle Kane tells me it's just fine to do it lateral, but to me a subpectral tenodesis is easier to do in the beach chair position. The next slide, or next couple slides, you'll see that that slap did look pretty good. You see this, anybody see what's going on there with the humeral head, just from throwing for a couple years after a slap repair? In my mind, once you see that chondral lesion about the humeral head, that's a sign that the biceps is over-constrained and is rubbing against this humeral head there. Can everybody see that? Do I have a pointer? It's on that. Yeah, there we go. All this stuff here, like this humeral head is basically missing cartilage, and to me that's a sign of a biceps problem. It's either windshield wipering, or you may even have a tiny bit of upper subscap problem there, and he's got some synovitis. I mean, if it's over-constrained, it's gonna be tugging on that sling, right, in addition to the cartilage. It's gonna be wearing out the biceps sling. Correct. So anybody have any thoughts on, would a poster stabilization help with this kid, or once you see that as a time to do something with the biceps? Any thoughts in the room? I would try and salvage that biceps by mobilizing the anchor. You know, we saw an example of that earlier. Yeah. I think, my opinion, this is a little bit different. I've never done that. It actually looked pretty good. I'd have to say the one you did, that it kind of sprung back to look like a bicep should look. I've done that a couple of times, and they get better, but I don't think they get back to normal. I think the damage to the humeral head is the problem. You see, that used to be called not arthritis, but I didn't think it was as much not arthritis as constraining, just like you're talking about. I think it's much more of a constraint issue, because you've taken this thing that's supposed to be mobile, and you've anchored it down, and so everything just just robs right up in through there. So these these pictures show a little better. I really can't argue. Those are the, you see those two sutures on the left side. I can't really argue that they've done anything wrong, over-constrained anything. It looks perfect. Now maybe, I guess you could make the case, though, that normally you might have a cleft under that biceps, and they've over-tightened the slap in that way. You know, everybody's, every time you scope a shoulder, it's different as far as the degree that there's a cartilage that goes over the edge, and maybe they've basically over-repaired it, but I really can't make any, have any qualms about those two sutures there. I don't think it was necessarily, you know, maybe now we would say the anterior one's a little too close to the biceps, but it's fairly reasonable. So I took the stitches out, and I did a biceps tenodesis subpectral in this case. And, you know, to the point about whether guys can come back from biceps tenodesis, if you've got a kid that's got pro aspirations, and he's a pitcher, I mean, I would have a long talk with him. I think the data there is probably is 50-50. For getting an infielder back to play, you know, recreationally or lower level college for a year or two, I think it's got to be a lot higher than that, if the biceps is the problem. So he started a throwing program at four months, and played another couple years as an infielder without any problems. I think one of the questions is that I think the problem was the first surgery, and why did he have that repair? What got him there, and what was the pathology at the first finding? Of course, we don't know because that was two surgeries ago. I don't have pictures of the poster later. I'm going to have to go back and look at those from a couple years ago. But, I mean, while the anchors in principle from what the practice was at that point in time, I agree, but I think that perhaps that practice is wrong. And that's really, I think the take-home point from that is that he shouldn't have that first surgery done the way he did. Not to say that there wasn't a labor problem, but it wasn't there. Do you have another one? Because I think this one's kind of a, it's something different from what we've talked about. What's that? Yeah, we do, but you can go through this one. The main reason I picked that one is just because I thought it was one of the best examples I had of the humeral head starting to be changed from, this is the same one as the other one. Do we have that second case or not? Is it on there? Yeah, we have more behind this one. Okay. Yeah. Just keep going? Yeah. Not the same one? Yeah, just keep flipping back there. Well, we have more cases, so that's okay. We'll keep going on that one. The actual one we just left there, that needed it. Didn't make it in correctly. Jeff, you want to talk about this one? Because this is a good talk about, maybe a slightly different strategy in treatment. Yeah, so this is a 28-year-old professional baseball player, high-level minor league player, which right on the cusp of the league, came to us for a second opinion. A lot of anterior shoulder pain at ball release, decreased velocity and accuracy. And so this is, I think, February timeframe, aspirations to go play in the World Baseball Classic in Japan that year. So he's got a history of arthroscopic rotator cuff debridement, prior PT, throwing programs, PRP, everything's been thrown at this, still having these limitations. When we examine him, he's got an internal rotation deficit. He's only getting to 10 degrees when he's abducted. He's got tight biceps. And so again, we like to look at the biceps when we're abducted, externally rotated, taking the arm from supination to pronation, because all these guys, we throw a baseball in pronation. We don't throw it supinated, but we're always checking abduction, external rotation and pronated position. But that, sorry, when we pronate it, you see how much difference the biceps is playing in the rotation. Negative speeds test. On his labral exam, positive DLS. But again, putting his scapula, retracting it, his pain improved. And type one dyskinesis, meaning as he comes forward, that inferior medial border's tipping forward. So again, that internal rotation deficit, it's really hard to decelerate and internally rotate if you can't get there. So your shoulder blade has to then compensate for it. Well, and can you go back to examining the biceps and the tightness? Because I think that's an important, and maybe even demonstrate, because I think it's kind of a nuanced strategy so that you can demonstrate how you find that biceps and what the arm position is when you do it. So if you think about it, when you're throwing, you go here. And when you're cocking, you're here. And so Mike Howell, who's our throwing guy, said, you know, there's something different. And so he said, how do you always measure external rotation? This way? Okay. So he said, why don't you measure it this way, which is what, this is the capability it is required to get back here. So you measure it this way, and you measure it this way. And we did it in professional, we did two separate studies, and found that 10 degree difference in 80% of the players. So that this right here is tighter in external rotation. Now, so what? Well, that means that if you're going to cock, you either have to do this, horizontal AB duct, or you have to do this, or you have to accept it. And so you get this capability, and you can get this back here, but measure it this way. The other thing is, this is really highly associated with elbow pain, to this tightness and pronation. So it should be a very important part of your evaluation to do it this way. Todd, I know you do it. Is that reasonable? Is that what you found? And actually, just because it's kind of cool, Jeff, you want to talk about the images on the screen? Pictures on the right side of the screen is a show motion capture system. So there's a onlay system that you can just put on the skin to watch shoulder motion through the full arc, sorry, scapular motion through the full arc of shoulder range of motion. So you can compare the asymptomatic side to the symptomatic side, and watch how, is it getting some posterior tilt? Is it externally rotating as the arm's going overhead, or are we getting compensatory changes? And so we've been using that to... So symptomatic was the green, and the good side was purple, you see that? Right. Variation in the scapular. So yeah, the dominant arm has much more variability. Those green lines are all over the place as we do repetitive overhead motion. And we're just doing simple flexion and simple abduction. We're not doing any throwing motions. But just with repetitive overhead motion, his dominant arm, where he has more control of, in theory, is a lot more variability than his non-dominant. When that guy saw that, he says, that's what my slot feels like. I can't get my slot. It's like it's all over the place. So he recognized those patterns as being, I can't get that slot to throw the ball with effectiveness and velocity. And so he comes with outside MRI. We see a partial articular sided tear, some posterior labrum signals, just a simple small cleft in the back. And so he's previously had debridement. He's still symptomatic, still having limitations. So in trying to just wrap it up for the patient, I'm telling him he's got some dyskinesis and internal rotation deficits and biceps tightness. And these are all kind of going along with internal impingement, creating some difficulty with velocity and control. But the nice thing is, we did get some improvement of his symptoms when we messed around with his scapula positioning. So when we get him, so when we do the DLS and do a dynamic labral shear, we'll see if it's painful and then we'll hold them in retraction. So we're getting that glenoid to externally rotate and then we'll repeat it. And if pain improves, we're a little bit more optimistic about things. And so just looking at what is internal impingement, why are we injuring that posterior labrum and that articular side of the cuff as we're throwing a baseball? It's that extreme position, the abduction external rotation position puts those structures at risk. And so the main things that are contributing to this impingement is dyskinesis with that scapula going forward, a posterior capsule tightness and glenohemorrhagic horizontal abduction or extension. And so that's why we test the DLS in both positions. Yeah. And that's just going there. And so I'm talking about your conservative treatment. I mean, this was non-operatively treated, right? So like the biceps was contributing and the patient does have some posterior labral pathology, but this was managed non-operatively. Successfully. Right. And so yeah, timing of the season, he's contracts, he's trying to play in a world baseball classic and everything. And so we talked to him much more about the conservative side of things rather than shut him down for an entire season with repair. Plus again, you don't know what physical therapy he's had before. He's in a good system, we respect their system, but again, we approach things a little bit differently and a lot more scapular based. And so working with our physical therapists focus highly on that kinetic chain, right? Working from the ground up, make sure he's got strong hips and core, working on those glutes and then working on getting that scapula stabilized. And so part of getting that scapula to calm down is getting that internal rotation deficit address, having more flexibility at that glenohemorrhagic motion so he's not compensating through his scapula, but then getting good scapular control, focusing on the serratus and the low trap. So we're winding down and intend to leave some additional time just for discussion, but I think some of the take-home points from today is that just because you have anterior shoulder pain doesn't mean that you need a surgical procedure to address the biceps. And you can generate that with a slap repair, you can generate it if you ignore biceps tightness, but biceps tightness in and of itself does not mean that you need a biceps procedure. And so looking at that posterior labrum, looking at the mechanics, understanding if and why they're tight, looking at the posterior chain, the core strength, all of that really plays into these athletes here. This is not a rotator cuff biceps, that's not what we're talking about and that's not what the purpose of this is, but we'd caution against, I know there's data out there and unfortunately some of the faculty couldn't be here that helped support that data, but caution against performing a tenodesis in an athlete, especially an overhead athlete. I think you really need a very good reason to do that. And the point that I think we've made today and hopefully take with you is that anterior shoulder pain is not that indication. So we've got just a few minutes remaining. Any questions that we didn't address, any controversies we didn't highlight? Yes. If a patient requires a biceps tenodesis, what is the criteria for the biceps tenodesis? The question was if a patient requires a biceps tenodesis, what is the criteria for fixing the labrum? I'll be frank, I haven't gotten there yet. I haven't seen that patient, but that patient that had the over-constrained biceps that may or may not have posterior labral pathology, if that patient had posterior labral pathology, I would fix the posterior labrum and tenodesis the biceps in that scenario. That failed slap girl that I showed was on her surgery. She got better by fixing the labrum. Tenodesis the biceps only did not solve her problem. So I would not leave a known labral injury alone. So my extreme case example, an Ehlers-Danlos patient who had a slap repair, lost motion. She got stiff with a slap repair. And because over-constrained the biceps, there was a lot of scarring around the biceps. So that patient cut the biceps with a labrum repair because Ehlers-Danlos needs all the stability they can get. I've seen a lot of those patients. And two ways, you see them after they've had the biceps and then continue to have symptoms like that because the labral problem is still there, creating that loss of control in the humeral end. But if you see somebody, now the reason why the data of saying you can't do a biceps tenodesis and a labral repair at the same time is because they get stiff is because they fixed the labrum up kind of high and they didn't take care of the way they're supposed to take care of the labrum itself. But if they've got an anatomic lesion and you can document it by a DLS or whatever your test is for a posterior labral injury. And you see that preoperatively and then at the time of scoping, you see all that stuff. You gotta look because like I said, sometimes you do little splits, but that is a loss of the attachment of this labrum, which is supposed to be completely solidly attached. It's a bumper from 10 o'clock all the way around to about 2.30. And if you see those little splits or cracks or that's fraying, if you debride those, all you do is make the instability worse. So a lot of times you'll have a biceps that's damaged and you have no choice but to do that. But if they got the posterior labral injury, you've gotta do that as well. The thing that bothers me the most is now some people are saying that the presence of a labral injury is an indication for a biceps tenodesis. And I don't think that's a true way of addressing most of these patients. So you gotta figure out what the clinical presentation is. But if you have to do a biceps tenodesis, fine. Let's get rid of that pain for real. You've decided before surgery that they have those symptoms or you see the time it's all split and damaged and synovitic and everything. But you gotta do something in that posterior labrum because that is an anatomic limitation to humeral head translation. If you don't fix that, then you're just asking for more trouble. There's a very interesting study in this journal that you all read. It's called Clinical Biomechanics. But this guy by the name of Klimt, and he looked at the stability ratio in the glenohumeral joint, which is the ratio between the amount of compression force, amount of tension, I mean translation force. And he found that if you do a biceps tenodesis in baseball throwers versus football throwers, basketball shooters, they did a soccer throw in, all those other, that baseball itself, the stability ratio is so badly affected by biceps tenodesis, that the rotator cuff cannot compensate. So the title of the paper is, you shouldn't do a biceps tenodesis in a baseball thrower. Because you lose that stability ratio, which is key to that high level capability in throwing. Yes. So the question is to repeat for the recording was, what do you do in terms of creating a rip stop when you have a superior labral pathology and a buffer complex? Is that correct? Did I... Yeah, so the biceps attachment is not anterior, right? It's much more posterior. So I'm not touching anything anteriorly. I'll clean it up, but I'm not going to anchor anything anteriorly. That concept of that, it ends at about 230. So anything above that, unless it's, you know, I know in the past, well, got all this extra mobility and everything like that. And that may be the case. If you've got true pathologies all frayed, then maybe you want to clean it up a little bit. You've got to be careful above two o'clock that you're tightening the biceps too much. I think part of it too, depends on why you're there in the first place, you know, what pathology got you there. So you're seeing this arthroscopically, but like, why are you in that shoulder in the first place? Cause that can help guide it as well. And, you know, I mean, I think these principles go to, if you talk about traumatic labral tears that progress to like 270, you know, making sure that you respect that biceps tendon as you fix that 270 degree tear, not going up to 11 and one o'clock with your anchors, you know, in that setting as well. So I think the principles move beyond just addressing posterior labral pathology. Any other questions in the last couple of minutes? All right, great. Well, thank you so much. Can I ask the attendees, was this helpful, this information presented helpful to your understanding of these problems? I mean, this is kind of new stuff. Did it, did you have a light bulb index or you want to throw tomatoes at me, go ahead. But the idea that the slap is the problem, I think we're trying to get away from the idea that the slap, which has anterior posterior, trying to get away from the idea that that's the reason why so many throwers have problems. I think a lot of the data now shows them the location is mainly posterior and maybe we need to look a little bit more closely at the posterior when we're talking about slaps because it turns out that the mechanical, biomechanical data from a slap injury is that you get a little bit of anterior translation, but not much. But if you do a posterior thing, then you got a lot of translation posteriorly. So I think that the problem in the thrower is more posterior than it is superior. And just look and see, just add that to your thought process. In cases that represented a lot of posterior damage, the end uterus looks very good. What was the generator of pain at the time of the injury? That's a fantastic question. What's the reason why they have pain? And it appears, I was talking with Ty Lee, who's a fantastic biomechanist, just yesterday about that exact question. We feel there's probably a tension component that is pulled back side. If you look at it, the biceps runs from here all the way back and it goes through the labrum down posteriorly all the way to the posterior inferior glenohemal back. So that whole area, if it's loose, if the labrum is not, the central part is not right, then you got tension capability on either side of this. And it appears to be tension, maybe a compression component with that shear like that one case was shown. But there's something going on back there that creates the pain. The study, Dr. Alexiev from Atlanta did a study that paralleled the study that Dr. Grantham and I did, which showed that about 70 to 80 percent of all the injuries to the labrum that require surgery, arthroscopy, are all posterior. And he found that the presenting complaint was pain, as opposed to the instability, which is the anterior component. And so the pain is probably a component of this posterior translation, which does occur in there for compression. But I'm pretty sure it's mainly tension along that whole area all the way around there that creates the problem when you get out here or when you get back here. There's just stretch, just pull on it. All right, thanks so much. One final question. So you're closing it, can you explain what was wrong with that? So I don't, yeah, I made that comment. So I just close my large capsulotomy with a simple suture to re-approximate. I don't tighten it as you would for an instability. But I do have a reservation because that posterior cannula can get pretty big right near the area where I just repaired. So I'm not trying to tension it. I'm just trying to make sure that that stays. Because in the sling, they shift around. They're going to place tension on that. And I just want it to heal back the way it was. I use five millimeter cannulas, and I've not repaired a capsule. And I've not seen problems. Great, thank you so much for coming out Saturday morning.

shoulder issues

SLAP lesions

shoulder mechanics

shoulder pathology

shoulder terminology

shoulder pain

bike injury

labral shear tests

MRI

arthroscopy

scapular stabilization

physical therapy

surgical interventions