And before we get to it, so that we have time to make sure everybody's questions are answered, does anybody have any questions they want to go over before we start going through some cases? So glad you asked that, because that's exactly what we're going to start with. So let's talk about that, because we always talk about surgery stuff, but we never talk about the non-operative stuff. So a guy comes in, you got an MRI on everybody you're suspecting for UCL? If they don't already have one, they probably already have one, they have three. I think if you think UCL by the time they get to us, if they haven't seen one of my partners in the non-surgical world and had an ultrasound or something like that, then they're all getting an MRI. I don't think you always need it. You can almost hear it from the history, but to be honest, 99% of them either have it or they're not going to let you not have one. Chick, what do you do? Yeah, I think an MRI is very helpful. We do all of ours with contrast, so we do intra-articular contrast, we do a specific coil, specific ... We want to make sure we get all the right images. You haven't changed the alignment, so you haven't been doing 20 degree down-coil latency? I would love to tell you that I know the answer to that. I know that they look the way I want them to, but I actually don't know if they changed the alignment of the gantry. But I do know there's a specific elbow coil and an elbow protocol, which I imagine with our guys, they probably do something along those lines. Yeah, John, I don't know the exact setup either, but I do know that I only use ... If I'm ordering it, there's two scanners in the entire Cleveland Clinic system that I send them to because I know that they give me the best results. The worst ones are when they come from out of town, you get these orthogonal views that aren't even ... I mean, they're terrible. Strip mall MRIs. Yeah, strip mall MRI, exactly. You've got to explain to the patient, this is a non-diagnostic MRI, but good luck trying to get another one because they just ... Insurance just ran through the hoops trying to get this one that's now a complete waste of time. Be careful. I think John's point's well-taken. Don't just get any old random MRI scan. John, could you tell the group what you're talking about? It says 3T is better than anything else. It says that contrast in a chronic setting is better than ... There's no question in acute injury you should get a non-contrast MRI. But again, a chronic ligament injury, contrast can give you better information. Not recently, long ago, 20-degree crown coronal bleak images with respect to the elbow were described, and it makes the slices in line with the ligament. That way you see ligament, ligament, ligament, instead of anterior part of the ligament, middle of the ligament, posterior ligament, as you go down, and so what you're seeing is proximal ligament and FTS, and middle of the ligament, and maybe it's all ligament, you're seeing distal ligament and posterior capsule. So radiologists will often read distal tears or proximal tears because of the alignment to the ligament. When you're completely screwed and the tech changes the coronal axis with it, there's no way to tell if you can do it. There's a new paper that just came out called Fever. Flex, external rotation, valgus, whatever, that you have to lay on your side with weight like a 90-degree flex fuse. It's out of Japan, I think. And then they align the slices on each ligament. So it's basically doing the same thing you do on your ultrasound when you do valgus load, imaging of the ulnar collateral ligament in scanner. And the recent data might be interesting to see what we do in the future, but I just wanted to ask what you guys are doing live. And I do this live for a few of our islands. Yeah, the fever thing. Actually, Pam Lund and the Simon Med group out of Scottsdale, Arizona, she's doing that on our players out in spring training. The problem with that is it's painful. It's like the T-List machine. Yeah, it's hard. Anyway, great points, John. If you don't have a good MRI, have them. I agree with you. We have a place that just didn't do a good job when I first started, so I had to educate the techs. I didn't know about the 20-degree thing. I just told them to get the right views. And I've sent people back to them, and they don't have the right views. So if it's someplace around you, you can send somebody back. They won't get billed again. If it's done by a place near you, they can just do a non-billed exam where they can get new ones, because I've had some where you can't even see the ligament at all. So how long are you guys shutting? So somebody comes in, partial thickness, proximal, UCL. How long are you guys shutting them down for? A true low-grade proximal partial injury for us is going to be, we'll start with a two-week shutdown. So if you're down for two, then you bring them back up for two. So that ends up being four weeks. If you're down for four, you bring them up for four. That's it. That's an eight-week shutdown. It's a case-by-case thing for us, based on a lot of other factors. But minimum for us is going to be about two weeks. Yeah, I would say about the same. I think the lower level, the player, the less time it's going to take them to get back, because they probably didn't have as much injury. You get some junior high kid who feels a little pain, and they come in with an MRI, and the next Nolan Ryan can't pitch in this weekend's tournament. So usually it's a couple of weeks. I like the idea of whatever time you're down, you come back in the same program. So we use a plyometric program to see if they're ready to throw. So we always do a week or two of plyos, kind of start with two-handed and go to one-handed. If they can't do a one-handed plyo, they don't need to throw. So rather than just saying, go out and pick up a ball, because that can be a little bit uncontrolled, and you can end up getting a little worse, we always have them do a little bit of plyo work before we put a ball in their hand. Yeah, we do too. And for those who don't know what plyo work is, that's where they've got the ball, and they're throwing it into the trampoline or using the body blade. They're up in that 90-90 position. They're reproducing the throwing motion. And a low level of valgus stress across their elbows, what they're doing. We do exactly the same thing. And what do you guys tell them? So for those two to four weeks that you have them shut down for, you don't have them throw, what do you tell the therapist to work on? I always tell them for the first half of it, just go be a kid. Go get a tan, go do some running, go learn how to be a real baseball player, maybe hit, do something different. And then for the second half of that rest period, we'll get them into some plyos. Make sure their range of motion is full and painless before they start plyos. They do a little two-handed, progress to one-handed. And you can do that, like we said, if it's maybe a total of a two-week period. So you may do all that in a week. And then go to one-handed. And if they can do a one-handed plyo, they can start their throwing program. Yeah, I think it depends somewhat too. It can be seasonal as well. You're going to handle somebody in-season a little different than an off-season thing. And you do see injuries off-season as well. If you pick up deficits on your physical exam outside of the elbow, such as a reduction in total range of motion of the shoulder, a little tightness in their posterior capsule, scapulas down a little bit, a little tightness in their hip, something like that. Have them work on all of that, get all that tuned up. It's great to have an athlete that you find some of that stuff on because you really feel like you can do something for them from a physical therapy standpoint. So I have them work on that. I have them keep their cardio up, keep their core work going, keep their fitness going if they're in-season. So that when they're ready to pitch, they're ready to get out there and actually do it. So that's how we approach it. Ned Chick, you mentioned PRP may or may not be beneficial. Are you using PRP in any of these guys? It's hit and miss. It's a discussion that we have with our athletes. We're doing it ultrasound guided. Our approach to our higher level athletes has been, in addition to the MRI, we're doing a dynamic ultrasound and looking at the ligament, looking at the gapping. You get a different feel for the ligament, I think, with the ultrasound than you do with the MRI. Those that have a reasonably stable ligament that's got a low-grade partial proximal injury, if they have the conversation, they understand that it's painful, that it may not add to their recovery. We'll go ahead and do that. I have primary care sports docs that do that. As an orthopedic surgeon, I don't do that. I'd say probably 50-50 that we're using PRP. We were using some other stuff, a placental tissue matrix that the FDA put the kibosh on recently. So we're not doing any more of those. We've got about 50 of them in the pipeline that we're following along. So we'll see how that turns out. I think the studies that have been done on major league level, I think it's no better than 50-50 whether it's going to work at any level. I think proximal definitely better than distal. Like Mark, we don't do them. We have the primary care guys do them. I think, to me, it's more of a seasonality thing. So I think if you do a PRP injection, you're looking at 90 days. You've got to rest them for four to six weeks, then you've got to do an interval throwing program. So I think if you say PRP, you're saying 90 days before you're back to full go. So that wouldn't work very well. You're not going to talk them into that this time of year. So in July, if you tell them 90 days, and they're not going to know the answer until October, you're going to find very few people that have an interest in that. April, we don't really have a hard time talking them into that because they're not really going to miss anything they haven't already missed. And they're not in danger of missing any season they're not already going to miss. So I think that seasonality really plays into whether I'm going to recommend or even consider PRP as an option. I think that's kind of become the most important part of it for me because it's basically a 50-50 success rate in our hands. What do you think, Josh? That's a great point. I was even going to ask you before I saw your hand. So at the biologic meeting yesterday, Bradley gave a log on it. That's actually something everybody asks. So I want to ask you guys more specifically. Do you recommend leukocyte bridge, leukocyte IV, highly concentrated, activated, unactivated? Do you think it matters? One shot, two shots, three shots. You had a big comment about blockers. This is what I agree with. Do you treat the acute injury guy who just had an injury last week differently than the acute guy who's had a problem for six weeks and been trying to fight through it? Do you treat the high school kid differently than the college kid? So I think they're doing... Like I said, we don't do it. So our non-op guys are the bright, ultrasound-guided PRP geniuses. And in their minds, PRP heals everything. So they'll inject this about anybody with PRP. They'll do a brain injection with PRP if they thought it would help. I think they're doing leukocyte-rich for the UCLs. For intra-articular things, they're doing leukocyte-poor because you don't want to generate that inflammatory cascade. So they're doing the leukocyte-rich. They're doing one shot. I have seen them do two shots. They've got a small series of eight or ten of those. Didn't seem to think it made a difference. In the UCL, now I think in the MCL, the knee, probably a different deal. Hamstring, maybe a different deal. But in the UCL, I don't think they've seen a difference. And like I said, they're doing it. And I think one of the things that we haven't really talked a lot about, we're talking a lot about the actual biology of what goes in there. I think where the actual tip of that needle goes makes more of a difference than some of those other things. So I actually think that some people are not actually getting to the deep part of the ligament, where the pathology is. You've got to get in there and see that tip of that needle, get to the deepest part of that ligament, and then start injecting as you come out and really cover the area where the tear is. We've got to be very specific where the tip of that needle is to make a difference. To me, I think that's actually more important than one shot, two shots, stuff like that. Yeah, I mean, we could have a whole, obviously a whole ICL on biologics. I'll just jump in with regards to the technique. I think Jeff is right. I think technique matters, and that's why we have guys that do this all the time, doing our injections. And the other thing that my guys will tell me is that they think that there's, in a more chronic situation, let's say you have an acute or chronic situation, that there is scarring between the flexor group there and the ligament, and they'll do a little hydro dissection of that area, and you can watch it sort of separate. They think that that's of some value as well. So in addition to getting the PRP where it needs to go, as you back out, you do a little fascial dissection, is what they're calling it, technically, is what they're doing. Whether or not it makes a difference, I don't know, but they seem to feel like it does. I don't have much else to add to that because I don't do them, again, our primary care does them, but I also tell them a week before and a week after, no anti-inflammatories, no ice, just try not to blunt the inflammatory response that we're creating. But that's not what you guys recommend across the board. Most of the time you're not recommending PRP is what I'm trying to get to. You have to know what you're doing if you're going to do it, and you're not recommending it to this audience. Yeah, I think it's 50-50 at best. Best case scenario, it's 50-50. I agree, and I think you're less likely to do it in a younger athlete. Personally, I wouldn't recommend doing it in a high school athlete. Don't you find it's easier to shut them down after you've PRP'd them? Oh, you do. I know, but you can't shut them down with partial PRP. Jeff's point is extremely important because it's very aggressive non-operative treatment. I mean, you're committing them to three months. Yeah. We asked some people to try to form some consensus statements about what to do about non-operative treatment and operative treatment and things. Some of the stuff basically that Chick talked about is what we kind of focus on for non-operative treatment of these injuries. The orthobiologics, again, may help, may not. Data probably doesn't show that there's any particular regimen to use. We probably got to look at this a little bit more. And then when to begin a throwing program, like I said, shut down for a few weeks, and then once they're pain-free and asymptomatic, usually I bring them back and I test them before I let them start throwing, and if they're negative, then I'll let them start a return-to-throwing program. I think that's a really important thing. If you get used to seeing these elbow patients, and I've actually had to kind of go back to a little bit more of a dogmatic approach to these things when I see them back. If you don't examine the shoulder when you see these elbow patients, you're going to be surprised at how much contribution there is from the shoulder, how much loss of motion there is, weakness, things like that, kinematic stuff. And you may be setting them up to fail again by just managing the elbow. I've been very impressed over the last few years at how much shoulder loss of total arc of motion there is in these players. It's exactly right, and you know, it's fun to walk into a room and start your exam on the contralateral shoulder, and they're here for their right elbow, and the first thing I look at is, they're here for their right elbow, and the first thing I look at is, they're here for their left elbow, and the first thing I look at is, they're here for their right elbow, and the first thing I look at is their left shoulder. And they're like, you know, what's going on here? So it's a great point. In Alabama, they think we're hillbillies. What the hell is this hillbilly doing? And then the other thing, you know, John and Tim understand the importance of this as well. John's talked about a lot, you know, just the kinetic chain. I mean, you know, internal rotation deficit of their dominant hip, so we got to try to address that. Tim has a comment. Before we get out of here, I want to know the difference between the throwing program to prepare and discipline and the reconstruction. Earlier you start throwing, typically four to six months with the reconstruction. So we get, we usually do 18 to 20 weeks we start the throwing program with the reconstructions. I know Stan has really gone more to 24. I mean, they've gone longer. I don't think people are going less. I mean, at some point we were all trying to do less and now everybody's kind of in that, you know, what does a month difference make? On the repairs, and this is really where I think we've learned this, remember with the repairs, we're not having to go the process of ligamentization. We're not taking a tendon and asking it to become ligament. We're taking ligament and asking it to heal. So it's already ligament. It doesn't have to do that stuff. So we do six weeks in a brace. We start a plyo program. We do two weeks of two-handed plyos followed by, with gradual progression to the operative side, followed by two weeks of one-handed plyos with increasing intensity. And we start the throwing program at the beginning of week 11. So after 10 weeks. And the program is shorter. Toss is about eight weeks. Eight to nine weeks. Phase two. You know, mount stuff. Same basic program as another eight to nine weeks. So the total recovery time is about six and a half months. Unless you have a reason that we need to not be that quick. So we won't really shorten it. But, I mean, anybody I operate on, like, in June, there's no point in having them ready to be game ready in January. They need to be game ready in February or March or wherever their season starts. So we will always take advantage of that extra time and not push them to be game ready for an extra month of the year or two months of the year. Because then you're just taking chances. So, if I'm hustling, if I do it in August and I'm hustling, they're going to time out right about game time when they're ready to pitch. But anything before that, I'm taking as much time as I need to ramp it up. Exactly the same. I mean, it's exactly the same. So we're almost out of time, but I want to throw one case at you guys. I'm glad we had the discussion. So this is actually a guy, Ahmad had operated on him back in 2012. He was a professional baseball player at the time. Had a UCL with the Palmares. Got released. So he's getting a little older now. He's kind of going down in his performance. Having some elbow pain when he's throwing. Can't really localize where it is. Got shut down for three weeks. Put him on some meds. Then he came to see me. Range of motion sticks. So he's 35 degrees shy. Getting fully straight. Flexes up to 120. His UCL exam was normal. And I lay them flat and I crank on their elbow when I'm examining them. He had no pain with anything I did to his UCL. But had basically arthritis type symptoms and had issues with flexion and force extension. So these are his x-rays. So you can see a bunch of heterotopic bone that's formed. Not only around the UCL, but also anteriorly at radial fossa. So this guy has arthritic symptoms in his elbow in addition to a UCL issue. So tried to shut him down a little longer. Get him to throw. Couldn't do it. Gave him a steroid injection. Did okay from it for two to three weeks. Felt much better but couldn't get back to throwing. So we got an MRI and basically the MRI is here. And his UCL does not look great on this MRI. Now granted it's a lot of other stuff going on in this guy's elbow. So but the fibers still to me are going in the right direction. I think the UCL is still competent. So I didn't think this guy's symptoms were really UCL. I thought they were mostly his arthritic symptoms. You can see here he's got some osteophytes that are formed kind of over the radial fossa there. And then posteriorly he's got some stuff going on in the lacunar fossa. So he's got a lot of stuff going on. And I had talked to Dr. Mazzi to make sure that his nerve wasn't transposed before and you can see his nerve still sitting in the back. So his nerve had not been transposed. And so this is kind of what I thought the options were for this guy. How would you guys treat this? What would you do? Does he have nerve symptoms now? No nerve symptoms. Really? With 35 degree flexion? No nerve symptoms. That's interesting. Progressively slow over time. To me this looks like an arthritic elbow not an unstable elbow. He's sort of at that part of his career and that exam, those x-rays and that MRI I think are screaming degenerative arthritis. I don't think I'd do anything with his ulnar collateral. I think I'd address his joint. I was ready to move his nerve if he had symptoms. You might want to do, you know. I got to think that's coming with that flexion contracture. But you don't have to do anything about it now. I would scope that and clean it all up as best you can. I don't think you're going to gain a whole lot of motion. You might gain a little bit. That's a tough problem. That's a career threatening issue for sure. And he's starting to decline in his career. He wants to get back but he's clearly on the downwards spiral. Yeah, I agree completely. I don't think that you're going to make him better by doing a revision. You could have the same problem when you, a key question about whether you move the nerve or not, because a lot of times some of that heterotopic bone will be in the cubital tunnel that can prevent extension if you have previously moved the nerve. We haven't seen it as much with the nerve in its typical location. So I think if you're gonna scope it, you wanna be able to look around that medial gutter and make sure that it's free and be willing to open it up or take it out and move the nerve, because you obviously don't wanna be shaving over there. But you can see some of that heterotopic bone on that posterior medial side. But I agree, I would try to do that through the scope, take off some of that tip. It even looked like he was getting a little bit of an olecranon stress fracture in one of those images in the mid-portion of the olecranon. So I think if you decrease that CAM effect and get him maybe 10 degrees more extension, that may be where he lives anyway. You know, and he may be fine, and definitely I would not revise him. Anybody else? Revise? John? What test did you do for the elbow nerve? Why wouldn't you get a good imaging study with comparison nerve conduction losses if you think it might be a problem? I didn't think it was a problem, based on his history and his exam. So I know the imaging's a little concerning. The only reason I brought up the nerve was just to, to Ahmad's point before, if you're gonna scope the elbow, know where the nerve is. Just wanted to show that his nerve was in the back, but he had no nerve symptoms. And I usually do 10 L's at the elbow and then an ulnar nerve compression test at the elbow. And then I'll check two-point discrimination if I'm concerned about it. Yeah, so I'll keep it flexed and then hold pressure over the ulnar nerve. Is it long or really more of the triceps? And back, posterior medial? And if I'm trying to figure out, is it just what you're doing here? Is it posterior medial abdigement? Is it, of course, could be a lot of different things. Is it underlying ligament insufficiency? And there's no question that ligament's high signal. Proximal, posterior, front, and the ligament has wide signal. He could have some underlying ligament insufficiency. It's not just like the case that they presented, where that ligament was horrible and he had no ligament pain. We've seen that. So, in a guy where I'm thinking the ligament might be a problem, the nerve might be a problem, I'll still get a nerve test. But sometimes we see coliform nerve neuropathy. It's a great indicator. And sometimes something as simple as managing the nerve to take an old picture, we're not having to try and change all that by going to the back of the elbow. Because when you get to the back of the elbow, where do you stop? How much are you gonna clean out? Is that, once you get into that joint, are you gonna, what are you gonna try to accomplish? Are you just gonna try to move a loose body? Or are you gonna really recreate the electronic fossa and remove all the spurs? You're doing too much, suddenly now that ligament's gonna see more stress and you already saw a high signal. So, I'm not telling you I know what to do, but I would love to hear what the rest of you guys think after that test. Well, I like, I have never done that test, but I will definitely start doing that test now. I haven't done it in pictures. So, I went with the elbow arthroscopy debris manipulation part here. And actually, once he was asleep, his motion got a little bit better. I think some was mediated by pain. And then to your point, I do always try to go around and sometimes I'll put a switching stick in to help push the medial capsule out of the way so I can see. There I have to create an extra portal in the back just to be able to get that switching stick in. So, I went in the front, went in the back, took out a few loose bodies and actually manipulate him. And I'll, similar to if I'm doing an elbow release and free the soft tissues up anterior and posteriorly, take the trocar for the scope and run it up the anterior humerus and posterior humerus and try to get everything off that I can. And these pictures suck, I'm sorry. But basically, we wound up with almost full motion interop, so he's about five degrees shy of getting fully straight. Had him up to 135, not full flexion, but 135, which I thought was fine for him. And so, he's started his throwing program around five weeks and progressing well so far. We'll see if he gets back. He's playing for an independent team out in Utah, but he's on progress to get back. So, I don't know. I didn't, you know, honestly, he didn't have the nervous symptoms. I didn't really consider moving it like I do in my, it's funny, because in the arthritic elbows that I treat with the elbow releases, I will move the nerve a lot. But in the picture, sometimes I'm a little less aggressive, but I probably should have done a little more. How old is he? 26, 27? So, to the panel, how much you got, how many of you guys really tried to get zero in a guy like that, or just try to get rid of the stuff that you think might be too much? I would have settled for 10 to 15 at 35. Yeah, I would too. I don't think he can get zero. To your point, John, he's probably lived there, Jeff's point. He's probably been living there for a long time. I was happy with five. Yeah, for sure. Yeah, that's great. Most of the guys, particularly the ones who are 28, 30, the less you do, the better. You're just trying to find whatever you think is really tempting, and get out. But that's, I mean, it looks like he's doing great, so you're obviously doing what I think so far. Yeah, that was, so we'll see how he does. Shaq brought this up before, just location of tear. This is a guy that just saw me, almost a complete distal tear. I was gonna bring up your basically imaging studies. When do you guys try to treat this complete distal tear in a 17-year-old high school pitcher who is now in July, who I saw literally two weeks ago? Would you try conservative treatment in him at all? Or would you just say, go for a repair? I would tell him that it depends on what he wants. Does he play other sports? If he's a football kid, and he says, look, you know, in Alabama, if you have the choice, most of them are gonna say football's slightly above faith and family, you know, and especially if you're a Roll Tide fan. I mean, that's the highest level of aptitude in Alabama. So, you know, you gotta talk to him about what's important to him. If they want to be a pitcher, or they want to be back for next season, with that MRI, I would tell them you gotta, we could try to manage this non-surgically. You're not gonna know for 90 days, and even then, you have a chance that you could re-tear it. I would say 95-plus percent of those people are gonna elect with the shared, you know, decision-making discussion to have it repaired acutely, and they want to get it on tomorrow. Mama wants it done. She wants to know if you can do it on Sunday. As soon as you can get it done, they want it done. Same thing? Yeah, absolutely the same, and you're right, Jeff. You wouldn't do it on Saturday, because that's football. Yes, that's football. We couldn't do it on Saturday. Right, so he's on for next week, and this is to Shake's point about some of the studies he's done about showing basically the high failure rates with complete distal tears, much higher than low-grade proximal tears, and looking at, you know, in their study of who basically was operated on, if you're looking at complete tears, especially distal tears, if you look down there at those three Bs, nobody did well with non-operative treatment. They all got operated on. So, Matt, we've talked about this. There's a book coming out on the elbow. A lot of the people in this audience have contributed to it, so if you're interested in it, you know, definitely check it out. There's also a new app coming out that I thought was pretty interesting. It's like an Instagram for surgeons that you have to have an MPI number to take part in. You can put cases up. Is this one of your things? This is, it's not mine. It's somebody else that developed it. They just asked me to help with the orthopedics part, so we'll see how it goes, but it's called Surgeon. It's coming out soon, so. Cool. Thanks. Any other questions that you guys have before we break? All right. The last case, the distal one, repair or? Repair. All the time? 100. Yeah. Yeah, I'd repair that one. Good ligament, 17. No issues before the acute injury. Acutely different, couldn't finish the game. I'll say that, you know, we can send them for both, and we're probably a little bit over 90% accurate predicting that based on MRI, but it speaks to the limitations of MRI, so I always tell people, you know, you're asking me to make a decision beforehand based on an image and somebody who read it, and your MRI was done in a strip mall, and you gotta let me make that decision when I'm there, and I've had a few people lately say, at pretty decent throwers, like I had a kid this week that's a 98 to 100 kid, and he's got a fifth year that he's eligible for, and he basically said, I have to pitch next season. If I can't pitch next season, I might as well just go to grad school and be done. So if I'm not pitching in March, I don't need to have this operation. He said, I don't care what it looks like, and I was like, okay, I mean, fine. I mean, I work for you, dude. I'll do whatever you want me to do, but, you know, if it fails, obviously we can go back and recreate it, but, you know, we can revise it, and he said, I don't care. I need to be ready to pitch in February. Okay. We'll see how it pans out. Yeah. Can you speak specifically to where you're looking at, intraoperative ligament, change of ligament, intraoperative is a separate thing. What does that mean? So, you know, you see some of these things, and it looks like the ligament is just not good tissue. It's just gelatinous crud with holes in it, and it's thin, and it's, and, you know, trying to get that to heal back to bone and become a ligament tissue, they need more collagen, so I always describe it as, is there a tissue deficiency, either in quantity or quality? Do they need more collagen? If they need more collagen, they need a graft, and you can't expect that fiber tape, well, I would not expect that fiber tape to overcome a sizable tissue deficiency. Can it overcome a little bit? Yeah, probably, but I don't think we have enough knowledge to know how much of that it can overcome, so I think when you look, especially at the distal end, when you see some of these things, and it is literally just patchless, gelatinous, stringy crud that is never gonna become ligament tissue, and you think sewing this down is not even that good of an experience, they need a graft. Yeah, John. Oh, you've got another one, yeah, here. Yeah, I'd like to hear your thoughts on the management of a flexor pronator mass that fails non-operative treatment, either in isolation or along with a UCL injury. So I think that's particularly hard. It's very different than on the lateral side, where you can cut through the tendonitis or tennis elbow, and you can see a tear over there pretty easily. On the medial side, there's so much muscle layer that having a medial flexor tear, it's almost hard to find it. You can cut through that flexor mass like we do when we do a muscle splitting approach, but to find that tear, I think it's challenging to even find those things. So what I've done is I've kind of made two or three longitudinal splits in the fibers of the tendon to try to identify where the pathology is and get down to bone and make it bleed, put an anchor in if you think you need it, like a little 1-4, you know, all suture anchor or something like that. Use something really small, you know, plus minus the UCL stuff. So those are pretty rare. I'd say maybe one or two a year I'm managing the flexor pronator stuff. But I think the flexor pronator's hard because you can get talked into some things on MRI that are tough to find when you're looking at it with your bare eyes. Yeah, I try my best to avoid operating on those that are not complete. I mean, if you've got a complete avulsion, which is rare, then I think you're obligated to do a repair. That situation is a great one to hand off to my primary care sports docs. I mean, they get all excited about looking at that with the ultrasound. They can say, oh, you can see the little defect here? You know, and let them do their magic, you know, whatever it is that they're doing there. I don't think, to Jeff's point, you know, even on the lateral side, we're not operating so much anymore. But the trick on the medial side, operating on medial epicondylitis probably isn't a real good idea. John, last thing. I want to comment on two things. Most MRI on the planet uses an elbow range of motion brace. In the first half of the period, the Grand Kings published a nice paper a couple years ago that showed that range of motion braces provide zero protection for the iliopsoidal ligament. And you put a range of motion brace on a kid who now feels like he has armor. Why do we, the first question is, why do we use range of motion braces instead of just a normalizing with some type of an arm normalizing? Because the truth is, it doesn't, we're not trying to block their motion, really, or unless you are, because I'm not. And then the second question is, your comment about that's when you let them hit. If a guy has an acute ligament injury, I typically let him hit while I let him start to throw. Do you guys let him hit before you let him throw? So there's two questions. And then, let me comment on this real quick. I do see guys hit a golf ball and pull the entire contra-inflected tendon off, and they'll retract, and they don't come in to see you until six months later, and there's a giant retracted defect in the, I see it, so that's probably what you're talking about. Not exactly. I see independent players. So, it's your player. It's the 26-year-old who had the over-collateral ligament infrastructure, by you or any of you guys, and does okay, but he had flexor-proteator problems at the same time, that never got better. So, the two things you need to think about that it is. One is, if he actually has a defect, we're not going to be able to manage that, is I harvest the medial endoskeletal septum, because I really would take this, you get a three centimeter graft, and you clean it up really well, and you take a 2.4 super tag, or some other anchor, and put it in right at its origin, which is anterior to the FBS. So, the kind of flexor-proteator is anterior to the FBS, and then you pull it distally, and you kind of pull it up into the tendinous supraluminous, so it's titianid, and you pull the rest of the confluent tendons back up to it, and you sew all that together, and it recreates a kind of a flexor-tendon, and I've had massive defects that we've repaired that way, and that works. The other thing is, if you don't have persistent flexor-proteator in the muscle mass chain, and a guy after restructuring, and you run into something out there, think median nerve, because it's probably a median nerve trap, because if you're hurting here, and you're trying to deal with that, you're pointing to a median nerve. And then again, I'd like to hear your comments on the brace and the pattern. I use a brace. I use a brace. I hate putting people in splints, because invariably, it gets nasty when they take a shower. I get questions from my office. The brace is just easier. I do like locking them up for a week, because I like the idea of getting seven days of healing in, letting everything calm down. If you take the dressing off, and you start messing with it, those arms look like they got run over by a truck, and the mommas and daddies are all nervous. And again, my office is getting pinged with a bazillion phone calls. So putting them in a brace, and wrapping them up for three to five days lets a lot of that settle down, let the therapist see them. I think in terms of hitting, I'm talking about a hinged elbow brace that we can lock. I use the Don Joy one. I do think it's important on that brace to put the straps as far up the arm. The one that sits right at the crease, you wanna move that one up, because you'll get some nerve issues from swelling if you don't. In terms of hitting, if somebody's being treated non-operatively for a strain or a partial tear, I'll let them hit if they don't have pain. Post-operatively, I let them start hitting when they start throwing. So if they don't have pain when they're hitting in the non-op course, I don't care. Because my feeling is if it doesn't hurt them, they're not hurting it. I don't think we know the amount of valgus that goes on the UCL yet with hitting. I think we have to try to figure that out. Pat McCullough had a poster at AMSSH or something, looking at that, and basically showed that there wasn't a lot of valgus stress that the medial elbow sees on the top hand when you're hitting. The bottom hand actually saw more valgus load, which to me was counterintuitive. So we're actually trying to reproduce that in a biomechanical study in Jersey to see if that works. So the hitting thing, I'm with Jeff, if it doesn't hurt from a non-op perspective, I'll let them hit. From a UCL reconstruction perspective, I'll usually let them hit if they care. Most times they don't, but if they care a week or two before, I let them start throwing. With, to Shake's point before about the paper, getting back sometimes a month or two, depending on their level in hitting in a game before they throw in a game. Yeah, with regards to hitting, I ask them what's more important to you, hitting or pitching? Almost all the time it's gonna be pitching. So I let them throw first, just to kind of get going. And I say, look, return to hit program, return to hit progression is quick. You know, you can get back to full speed hitting pretty quick. It takes a lot longer to come back from throwing. So I like to start them throwing first. So when you hit a pitch on the inside of the plate, you have greater flexion, and you're having to tuck your elbow in more to get to the ball and to the greater valgus. The reason I know that is, suppose they can take a ruptured leg event during a pre-season game, and he couldn't hit. What he couldn't hit was an inside pitch. He could hit everything else, but he couldn't hit an inside pitch. Yeah, but he couldn't hit an inside pitch anyway. I mean, it's... It hurt him. He couldn't catch it very well. He couldn't catch it cold. I've always said, if I'm gonna let him hit early, I'm gonna hit outside of the plate, to the opposite field only. And I'd love to see you get this study done, because that's a great idea. I'd love to see whether or not there's... That is a good idea. ...other players on the outside of the plate too. That is a good idea. That's a great point you make about bracing, John. I think a lot of it is just, because that's what we've done. It's just what we've done. It's kind of what folks expect, and maybe someone like you needs to lead the charge and say, listen, folks, we don't need to be bracing these things. Well, I think... But the first one that goes bad, they're gonna ask you, why didn't you put them in a brace? I think with the repairs, so Kevin will tell you... I've never used a brace. I use 10 days of splint, three weeks of sling, I've never used a brace. Kevin will tell you that the repairs, they get their range of motion back so much faster. He says if we don't put them in a splint, they're doing too much. Or if we don't put them in a brace, they're doing too much. So he almost feels like he's got to slow them down. Yeah. For dislocations where I really need to protect them, we have a thing, you can make it what looks like a cast, cast-made hard glass. There's a polyester material that looks just like hard glass that's flexible. You can have your O.G. make a cast that is split down the middle, and it opens up like a cast, but when you close it, it's now rigid. And so if you really need to immobilize somebody, you can use a polyester cast that your O.G.'s can easily make. So if you really want to lock somebody up, that's the way to do it, as opposed to a yucky cast, which is pretty terrible. Everybody knows that. The problem with braces, for me, is they all move distally and actually rotate. And it's really hard to keep them in the right spot. So if you can't walk to your office, the hinge is right here. I mean, do you guys not see that? Yeah. Yeah, all the time. Same thing with the knees. So I'm just curious, because everybody uses a brace. I just don't know why we all use a brace. It's just what everybody's done. You need a better brace. The various producing brace. Six weeks. Total, total, right? Total. For the day of surgery, yeah. Yeah, but they're unlocked at two. I would bet that probably most of them don't wear them six weeks. Let me ask you one other question. Neil published a paper a long time ago about pain and pros coming back to a third program. His paper said 50% of the guys who make it back will have pain at some point during the third program. How do you counsel people going through the third program with regard to pain? How are they supposed to respond to pain? And what percent of your patients do you think actually have pain going through the third program? I don't think it's 50%. In my practice, I think it's a lot smaller than that. And I try to keep them out of pain. So I think a little soreness, a little stiffness may be expected. But if you're having pain while you're throwing, something's probably wrong. How do you modify the program? Do you tell them to take days off? Yes. Walk it back. Is it a three-level walker? Yes. What are your recommendations? I tell them, typically you're gonna take a little break. If you're concerned, you're gonna take a break, right? And then I back them up. And it depends on how long they've been not throwing would determine how far you back them up. So if you shut them down for five days, let's say they hurt themselves or start to feel pain 150 feet, you back them up to 120 feet and start there again. If you shut them down for two weeks, you may wanna take them all the way back to 90. The other thing I'll tell them is, so I think the key question is, does it hurt while you throw or does it hurt after you throw or in between? The other thing I'll ask them always is, what are you doing? What are you doing besides throwing? How much weight are you pushing? Are you back in the gym? Are you lifting when I told you not to? So I always tell my people, no upper body lifting when you're in a throwing program. Do your bands, but I do not want you doing Olympic style lifting, get away from the freaking gym, especially these high school and college kids. And I always point out to them, Jake Arrieta does Pilates and most of the pitchers in Major League Baseball look like they could skip a buffet or two and they're soft in the middle, but they're giants in their back, their ass and their legs, but they're not lifting him. The Major League Baseball has figured out not to lift heavy upper body weights in their pitchers. That's how we've seen, I mean, all the Major League Baseball docs, the team docs and the strength and conditioning guys have gotten on the same page and we're not seeing the shoulder stuff we saw 10 years ago. And so it's really been a windfall of good things not having that. So I always tell them, you got to quit doing all this gripping, grasping stuff and get out of the weight room and quit trying to bench press in the middle of your throwing program. It's a great point. I tell them, look, we're not trying to field a weightlifting team here. This is a baseball team. All right. Thanks guys.

orthopedic surgeons

elbow injuries

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platelet-rich plasma (PRP)

UCL surgery

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