Good evening, everybody. This is Jeff Dugas, and I would like to welcome you to tonight's AOSSM-sponsored Sports Medicine Fellows webinar series. Tonight, we're going to discuss the thrower's shoulder, and we have two giants with us. First, we have Dr. Jim Bradley, who is the current AOSSM president. He is el jefe grande right now. He is also the head team physician for the Pittsburgh Steelers, among other things that he does. He is a clinical professor at the University of Pittsburgh and has been involved with AOSSM and the leadership of AOSSM for many years, and he's a good friend as well. So thanks for doing this, Jim. Also with us is John Conway. John worked with the Texas Rangers for a number of years. These guys were fellowship buddies back in the day, back at Curl and Jobe with Neil and Walt Curl, or Walt Lowe, rather, and Steve Jordan and all these guys. They were all together around the same time. John is a shoulder and elbow stud. He teaches and talks all over the world on this stuff. He's recently been on the board of AOSSM as an at-large member, which means we all voted for him. John has a sports medicine practice in Fort Worth, also consults for Rice and Texas Christian. He's a big wig in the shoulder and elbow world and a real leader in this stuff. Great thinker and somebody I have great admiration for. So thank you guys, my friends, for being here. Thanks for sharing this time. And with that, I'm going to let Jim take it away. This is going to be a case-based type of seminar, and we're going to go through a couple of cases along with a lot of information. So we're going to save the questions till the end. We're going to do all the questions in the last 10 minutes. So if you submit your questions, don't feel bad if we don't answer them right away. We're going to get to them in the last 10 minutes of the session, and this is how you submit a question. So if you will do that, go to the webinar panel, click the questions drop-down menu, type your question in there, and we will get to them at the end of the meeting. So with that, Jim, John, welcome, and take it away. Good evening, Jim Bradley. Thank you all for being here. This is the AOSSM Lectureship Series 2010. Let me move forward. Oh, there it is. Now let me move forward. Oh, there. There we go. So my disclosure within the AOSSM website, as you know, these are my buddies here, Johnny Conway, Jeff Dugas, all well and very well known. All this will be in the AOSSM playbook, which will be on the AOSSM website. So this is kind of an involved talk with a lot of slides, but you can always go back to it and look. So this is the potpourri of suspected culprits for disabled throwing shoulder. There's a whole parcel of them, but primarily dynamic posterior shoulder instability, slap lesions, partial cuff tears, and biceps tunnels seem to be taking the forefront. So historically, the disabled thrower shoulder in the 70s, it was outlet impingement. Then it went to subtle instability, internal impingement. Then in 2000, it was scapular dyskinesis, six scapula, GERD, and slaps by Kibler and Burkhardt and Morgan. Biceps tunnels came in in 2010. And then in 15, now it's this anterior arch impingement and subcoracoid fibrosis that John knows very well. So the question is, is what's next? And why aren't our outcomes any better? Because John tells me this all the time. He says, what are we missing? He said, what are we missing? Why aren't we getting any better? So the problem is differentiating helpful throwing adaptations from pathologic lesions causing disability has proven to be very perplexing. Even after 60 years of dedicated research, there's no consensus exists across our profession. And you can see the group of people that have been working on it, and John and Jeff are definitely there. The basic problem is force equilibration. So the shoulder rotates at about 7,500 degrees a second. That's the equivalent of the arm going around 20 times in one second. So at ball release, there's about 1,100 newtons or 247 pounds of force on the arm. The thrower's root causes start, there's many of them, but the kinetic chain goes to all these other causes. And then the issue happens is that the scapular dyskinesis then causes other things. But in the end, what I'm getting to here is this. It's a big mishmash, and it's very, very confusing, and it's hard to differentiate things from the kinetic chain, scapular dyskinesis, microtrauma, motion loss. So we're going to try to go through these systematically and help you somewhat. This is the conundrum that we wrote about. The presence of adaptive capsular laxity, which allows the extremes of motion necessary to accommodate throwing mechanics and paradoxically contributes to many related interarticular pathologies such as subacromial bursitis, bicep stendinitis, partial cuff tears, and impingement, all of which can obscure the efforts to actually pinpoint the cause of the athletic shoulder dysfunction. So here's our first case. This is a 21-year-old right-handed dominant major league pitcher. He's got progressive right shoulder pain and late cocking first. The first thing that happens is he feels like his arm's a little dead, and then the very first thing that happens is it was hard for him to warm up. That was first. Then he loses pitching velocity control. He has no neurologic symptoms. But the problem is he does not improve with extensive physical therapy. So my question now, John, is this hard to warm up? I mean, what sets you off that we've got a problem starting here? So regardless of whether you're talking about shoulder or elbow, that's usually the first sign of trouble is that they have more trouble either warming up or being able to throw the next day than they typically do. Or they'll say my arm is more sore the next day than it normally is. Even though they can get out and participate and do what they're actually doing for weeks and weeks, that's a really early sign that they're getting into trouble. And that's when you really should try to intervene. And that's when you should look at the kinetic chain, not necessarily the joint that's bothering them, because it's probably something other than the joint itself, something else out of line. And if you can correct the correctable kinetic chain problem, you may get the joint you're worried about out of trouble. Jeff, do you see that too, hard to warm up? Yeah. I mean, I think it's – you know, it could be seasonality too. You know, what time of year was it? Is he not stretched out? Did he spend a lot of time in the weight room, you know, and got tight? Now he can't stretch it out. One of the things that worries me about that is you worry about some of the vascular stuff we see too. Yes. You know, when they can't get it loose and they really feel like they've got a dead arm, you know, you're thinking – you said no neurological symptoms, but people say they have a dead arm, you kind of think maybe thoracic outlet. You think, you know, there's other things that may give them this kind of dead arm thing. So I think you always have to have those kind of red herring, those zebras in the back of your mind too. Very good. So shoulder exam, what should I look for? You know, we're always taught to go from the, you know, the toes to the fingers, and we're going to get into this a little more. But it's well – what's well in the literature, this slide basically is for you out there, so when you go back and look at this, this is where you can find most of these things because we're going to go through some of these. The real problems to me, and I think John may agree with this, is, you know, posture, balance, lower extremity flexibility and strength, lumbopelvic hip complex motion and strength. I mean, I see that in professional golfers all the time, that problem. Core flexibility, stability, strength, scapular position, kinesis strength, and then shoulder stability, kinesis motion. And it's got to be humeral torsion based. We're going to get into that in a little bit. So I put this slide in here specifically for this reason. It's a very long slide, but if you come back and look at this talk, every one of these things John Conway taught me. He taught me that this is the way you look at a shoulder, and this was a long time ago, this whole list, but at the bottom you can see muscle innervation problems, that stuff down there like Jeff was talking about. And also John and I have really, you know, kind of just written on this, about this pec major latissimus mismatch, which we see in posterior instability a lot. So I want to get to shoulder at risk. So shoulder at risk to me, these are the things I look at, and do these things change after throwing at 24 and 48 hours and 72 hours? So, John, these are my numbers. Tell me if I'm wrong or tell me what do you think. So our data differs. So we have a lot of data on this. In fact, we have probably the largest block of data on shoulder rotation and unhealthy flares. And really what our data says is that if you're looking at this side-to-side stuff, non-dominant arm, anatomic torsion less than 30, relative humeral torsion, which you have down here at RHT, outside of 10 or 25, so less than 10 or greater than 25, and total range of motion difference less than 10. Those are the numbers that we focus on. And honestly, for glenohumeral inter-rotation difference, just the side-to-side difference, and glenohumeral extra-rotation difference, just the side-to-side difference, we don't make as much of that without knowing what their humeral torsion difference is with it because I think it really takes you down a rabbit hole when you try to assume whether or not that inter-rotation difference means anything. I'll give you the example I always give. If your external rotation, inter-rotation difference is minus 20, and your extra-rotation difference is plus 10, and your total range of motion difference is minus 10, if you have a humeral retrotorsion difference, the side-to-side difference in your humeral torsion is minus 10, then yes, you're missing 10 degrees of inter-rotation. But if that's a minus 20, then you're missing 10 degrees of external rotation. And so that's a big flip-flop between whether or not you really should be trying to stretch them in internal or external rotation. So here's the guy who's missing, who's got a minus 20 GIRD, as everybody likes to call it, GIRD, but it could mean he's missing internal or external rotation loss based on whether or not his humeral torsion is just 10 degrees difference. And so – Well, give me your slides. They're coming. So wait, just wait. I know you love this. So to me, you know, a total range of motion difference of five degrees on either side is a problem. GIRD greater than 18 to 20 is a problem. Glenohumeral external rotation loss is a problem when normal is 120 to 123. Relative humeral torsion of greater than 17, which we're going to get to. And remember that all of these internal rotation losses, after you throw, it's 8 to 12 degrees initially, 24 hours internal rotation loss is 12 to 15, 48 hours it's 15 degrees, and it's still not back to baseline. It's 72 hours. So let's go with what John was talking about here. This is what John – and I'm going to give you it right at the end, John. So non-dominant arm torsion is called torsion. Dominant arm torsion is called retrotorsion. Those are both torsion in John's mind, and it's very confusing for the rest of us. So that little space, we're going to get to that. So that's called relative retrotorsion. But this is the point I think he's making is this. Absolute non-dominant arm torsion is very important. Now, John, why is that important? So our data has clearly shown, and other people have come along behind us and shown it as well, is that when you have – so when you're born, everybody's born with their arms like this, and in time your arms move forward. Based on how much it does or doesn't move, it determines how much this arm really needs to come forward or stay back in order for you to minimize the risk you have for injury to either your shoulder or elbow. And so the guy that still has a really big non-dominant arm, anatomic – we like to call it anatomic humeral torsion or retrotorsion. It's a gap. It's an angle between epicanthal axis and hero axis. You can call it whatever you want, torsion or retrotorsion. But it's an anatomic angle, and the larger that number is, the more that you have to compensate on this side. So you need to have a larger relative humeral retrotorsion in order to compensate for that. Otherwise, you have a bigger problem. And we have been trying to look at if you have a really big number, what does that mean? How much relative humeral retrotorsion should you have to protect your arm? And people have tried to say if the number is really high, it protects your shoulder. If it's really low, it protects your elbow. But we think it's more than that, and it's probably related more to your non-dominant arm. And we've shown in our large series, big group of guys, that the guys in our group that had ulnar collateral ligament injuries, statistically, significantly so, had a higher non-dominant arm portion. Okay, good. But you've got to measure with ultrasound, right? Right. And I'll also speak to your five plus or minus total range of motion difference. The truth is if you have the same people measure the same guys every day for a week, you're going to get numbers all over the place. All over the place. So we kind of have 10 plus or minus. It's not a five plus or minus. You kind of have to give yourself some room to work. So for us, if you're within 10 degrees of total range of motion, we try not to make too much of that. We try to follow people over time and make sure it's not going up or down. Okay. All right. So what about this? One other question, and then we're going to get back to the case. So there are measuring concerns. Does a contracted pec minor maintain the scapular tilt despite retraction and downward scapular rotation during that scapular stabilization? So I think one of your points is could that cause increased internal rotation values and decreased external rotation values, right? That's correct. Okay, good. So you've got to be careful of that. So this is kind of my take. You guys can point in. My take is if you lose internal or external rotation, if you lose your normal capsular plasticity, loss of stability in any direction, loss of strength or unbalanced force couples like we talked about, pec minor lat, loss of proprioception, pain from even bursitis, and loss of scapular function, those are the things I start getting worried about when I'm looking at these guys. Shoulder mechanics-wise, the scapula is really important, and there's a thing called a sick scapula syndrome. So that scapular malposition, the inferior medial border prominence is the eye in the sick, the C is coracoid or clavicular pain, they get pain in the front, and then you get scapular dyskinesis, and that's called a sick scapula. And Kibler and Morgan and Burkhardt have shown it, as well as many other people. Now, John and Jeff, are there any special tests you guys do to elucidate this sick scapula? Is there something – is this the test you do? Help us out here. So my way of looking at that is – and I'll just tell you the population that I usually see this in is people that have come off a lot of heavy weight training. So I think that the pec minor and the pec exercise, all those things that tighten the front of the shoulder that cause the scapula to rotate forward, so creating that sick scapula position, protraction of the scapula and downward motion, I really think that it's related to all the upper body stuff that we see these guys do, and then they're trying to throw. So I think it's a condition that we see that's a result of a training regimen that's not great for throwers. I don't think that it's necessarily something you see in people who are training for throwing in an appropriate way. So my way of answering that question is more of a historical question to them of how they got there, because I think that plays into it. If they've been doing a lot of upper body exercise, a lot of front-sided stuff that you should be doing for football but not baseball, then I see that. From a testing standpoint, I think it's important to examine the back of the shoulder to get these guys, especially the ones where you see they've got a little bit of a lower position of their scapula. I would say that this guy's got maybe two sick scapulas, but I don't know if he's a thrower. So I think the tests that you can do have to go along with the history you get. Okay. I would add to that. Jeff's absolutely right, and I would add to that that some of these guys come in with bilateral rolled scapula malposition type pec minors because they do train that way. And it's not an asymmetric scapula only that gets the thrower in trouble. Both their scapulas can be too far forward, and you need to address that. So don't just look for asymmetry. And the other thing is that posture is, without question, a significant problem for a mature athlete because they go play a sport where they do this over and over again. These muscles get tired and fatigued, and they put that muscle in the shortest position it possibly can be in for the next 12 hours of the day. And these muscles tighten up. If you were a sprinter and I tied your heel to your butt, every time after you went out and sprinted, you wouldn't be able to run anymore because your hamstrings get too tight. So there are multiple reasons why that scapula gets rolled forward. It's their training. It's their posture. It's their genetics. There's a whole lot of things that come into that. So look at them as a whole, upright, and make sure that their shoulders aren't sitting in front of their chest, bilaterally, symmetrically, and start your game there. Okay. So we're going to move on to the case. So one of my points is going to be to the fellows out there, there are way too many slap tests, and that there's no single maneuver that can accurately diagnose this as a slap lesion at all, one single maneuver. So, okay, gentlemen, these are the tests that I've been using. All right. I tend to like those tests, but is there any other test out of that group that you guys use consistently that will help you with a slap? Okay. John, nothing? So my five are Whipple's, O'Brien's, Dynamic Labral Shear, Biceps Load II, and ABAIR. Those are the ones I do routinely as my labral test, my superior labral test. Great. And there's no question that there's overlap for those and any others, and there's no study that shows that any single test or group of tests statistically, measurably, reliably, can document that you have a slap or that if you have a slap, it indeed is the cause of your pain. And for me, the subacromial injection is the best test you've got for a slap because if you have an MRI that shows a slap and you inject the subacromial space and all their pain goes away, that slap is not the cause of their pain. We're going to get there. This is what we've done at Pitt. Okay? These are the three tests. We call it the slap three-pack. The O'Brien's test, the Dynamic Posterior Instability Test, and the Whipple's test we're going to talk about. We found we just finished our study on this. Okay? So this is John doing a Dynamic Posterior Thrower's Instability Test. He's asking him to throw. And when he asks him to throw, his arm goes there and the patient says the pain's right out the back. And then the modification is to block that with your thumb. But this is what we found out. We found out that just by doing that test alone on a bunch of our patients that we're publishing this in Sports Health, that you have a 94% sensitivity, 95% specificity, and a positive predictive value of .98 that you have a posterior slap. We're just going to go through the radiographs. When you say posterior slap, you're meaning type A slap, or are you talking about just posterior superior? Posterior superior. Two Bs. All right. So this is the gentleman, and I'm just going to go through these quickly because we have other stuff to do. This is the thrower's shoulder. When you see that rounded in the back and you see they have retroversion. We did our study. Our control group was 3.4 in retroversion. Our overall posterior instability group with slaps was 7.1. This is bony retroversion. And the pitchers were really worse. They were 8.4 routinely on the ones I had to take care of. But you want to look at the control. A normal population is about 1.1 with a standard deviation of 3.2. So these are both very statistically significant if they've got posterior instability or they're pitchers with posterior instability with slaps. All right. So please be careful on MRIs. We're not going to go over them. But in this MRI, the first one is basically a meniscoid MRI, the typical meniscoid thing. It doesn't go into the body of the superior labrum. The next two are definitely slap tears. But the radiologists are going to read these and say, oh, that's a slap. No, it's not. That is not a slap. That's a meniscoid lesion. So be careful what the radiologist says. Okay. Can I ask you a question about that? Oh, God, John, you're slowing me down. I know. The one on the right has an immature superior glenoid margin. So don't be tricked on that. Sometimes the superior labrum still has high signal in it in a 16, 17-year-old kid. And sometimes that's not a slap because that's immature skeleton. So don't get fooled on that either. Okay. This is not a 16-year-old kid. Okay. These are JC's rules on MRIs. I love these rules. These are the rules he taught me. If you want to operate on a throat or shoulder, get an MRI. But if you get one, don't treat the MRI. Second rule, you can't see the pain on the MRI. Third rule, are the findings the cause or the result of the primary problem? And then lastly, the one I love the best are, are the MRI changes beneficial, adaptive, or purposeful changes? So you've got to make that determination. But the number one thing is you don't operate on the MRI. Gentlemen, am I on the right track here? 100%. Thank you very much. Okay. Next. I'm just going to go through it. This guy has a slapped hair. We don't need to go through that because we want to move along. What about this, John? This is something that really worries me. What's that? That's glenoid osteochondrosis. That's a bad one. Right. So guess what? That's what it looks like in the back, doesn't it, when you look in there. Yeah, but that guy doesn't have a posterior wall. On that MRI, that CT where that was, that posterior wall is all gone. Well, I cheated a little bit. This is the one, the picture I had of one, all right? But there are ways to fix that, right? You can bone graft them. You can put those little bony spikes in the back when you have to. But the point that I'm trying to make is when you see that, that's a bad actor, and you've got to be really careful. Am I correct? Right. Good. All right. So remember. Because a lot of people miss that. The radiologists miss that. Their posterior is superior. The radiologist won't call it most of the time. You have to look at your own MRIs. You have to look at them carefully. And if you see some signal change in that posterior superior glenoid, it's certainly worth looking back at your X-rays, and sometimes getting a CT, because you don't want to be surprised when you get in there and walk out and have to show the parents this big hole from a piece of cartilage you took out. Okay, so just to make sure we can contrast here, Bryson Lesniak has shown us that he works here at Pitt, Major League Baseball pitchers have a slap tear, but yet they can throw very well. Tony Mineachi, 80% of asymptomatic mature pitchers have MRI changes, 45% of them with a labral tear. And Dave Littner has told us that, look, the results of surgery on repair of slaps and throws is inferior to non-op care. The point is sometimes it's not the problem, but sometimes it is, and that's what we're getting to. Okay, so I'm going to go through this a little quicker, because we're moving with time here. So what is the role of the biceps labral complex? That's the question. There's multiple papers out there that says that the short head is for elevation, is balanced by the long head, which is a depressor, and if you cut the long head or release it, you get 50% migration superiorly. Alexander has shown us that the long head is an effective overall stability of the glenohumeral joint. Anteriorly, its stability is 46.2%. Inferiorly, 73% is the effect of the long head of the biceps. But Habermeyer studies the best. If you do a slap repair with an intact long head of the biceps, that will stabilize your glenohumeral translation. But after a biceps tenotomy, there is no effect of a slap repair on the glenohumeral joint. So stabilization effect of the superior labrum is basically dependent on the long head of the bicep. So this is my quote, and I want you to tell me if I'm right or wrong. I said, In throwers, the biceps tenon and superior labrum acts as a secondary stabilizer for rotation and translational stability at the extremes of motion and is a weak head depressor. Jeff, am I on the right track here or not? Yeah, I think so. And basically what you're highlighting is the difference between good slap and bad slap. You know, I mean, it all boils down to that. I know. But that's what you're highlighting. So, yeah, I think you're on the right track. Okay, good. Okay. So, John, what do you think? I think you're absolutely right. I think it helps control the head on the glenoid as they throw. And it helps guide the head as they throw. Okay, great. Okay, what causes the pain? Is it Tommy Vang's nest that told us there's a lot of free nerve endings? Or is it Neil that says the edge loading, it's an edge loading problem. So, as you ski and you jump on that ski and you carve your turn, that's much different than shattering down the hill as you make your turn. So, I mean, I'm in Neil's camp and I say, look, this is edge loading of the labrum. Am I on the right track here? So, I think loss of rotational and translational stability creates a problem in the shoulder and can particularly cause pain on the back. I think you really have to have a really beat up superior labral biceps complex for you to have pain. And I think that the majority of the time when you're having pain, when you see superior and posterior labral pathology, a lot of it's coming from the subacromial space. And I believe that because even when I know they have instability or a significant superior labrum that I think is part of the problem, by injecting subacromial space, the majority of them have greater than 50% of their pain go away. So, yes, I think there's pain and I think they have some pain fibers. And I do think that the bumper effect and the superior labral tension band effect that occurs provides some stability and loss of that stability can cause pain, but I don't think that those are necessarily the pain generator most of the time. Okay. So here's what we talk about all the time. Good slap bats, like Jeff just said. So is the slap tear a purposeful, beneficial adaptation allowing labral mobility, humeral elevation, external rotation, velocity and better performance? Or is it a pathologic process causing translational and rotational micro instability, pain and loss of performance? So the way I remember it and the way it's called stamp BR. So a good slap to me, and John helped me with this a lot, a good slap is the subacromial injection helps. The tissue is good. In ABER, the labrum rolls back. It does not peel back. The margins are chronic, smooth, and compensated. The patterns are typically a slap one or two B. The biceps tunnel is not tender and there is no rotator cuff tear. Jeff, is this what you think of a good slap as? Right on. I agree completely. And, you know, I also think that you have to look at this on a timeline. You know, we see these things in one moment or when they're in our office. And so is it possible that all of these images, these good slaps are, you know, good at the time. And then maybe they get a little bit of progression from that point. And they were fine for all these years. They adapted. These are adaptive changes that allow them to throw. And maybe they have one moment or one pitch or one season or whatever, and it gets worse. And they tear off a little bit more. And that good slap goes to being a painful good slap or even a bad slap. But, you know, if you tie those things down, you've undone the adaptive changes. So I think, unfortunately, a lot of times what we see is these timeline problems with these good slaps. They've been adaptive. They've allowed these people to throw for a long time. And maybe some little incremental change in that is why they're sitting in our office. And how do we know? And what do you do? So would you both agree that you have to have a mobile superior segment to throw well? Yep. Don? I think that a lot of throwers have to have a mobile superior segment to throw well. Okay, great. To Jeff's comment, sometimes it may not be what changed inside the shoulder. It may be something that changed in the kinetic chain that altered the equilibrium point in their shoulder so they can't tolerate. That's right. Yeah. One of the take-home points we're making is you got to look at the chain all the time, right? Because little changes in the chain make big changes in the shoulder, and the shoulder may not be the issue. It may be something downstream, right? That's right. Okay. So a bad slap to me is the subacromia injection does not work. The tissue looks bad. The labrum peels back. It does not roll back. It has acute sharp tears that are uncompensated. It's typically a 2A, 3, or a 4. The biceps tunnel is not tendon, and you typically see a rotator cuff tear. John? So my only comment on that is that you can have a bad slap without a rotator cuff tear, but the rest of it's absolutely true. And I think that the acute rotator cuff tear, I mean, the acute slap in a thrower is always bad. You don't have a slap. You dive on the ground. You got a slap. You make a hard throw and you got a slap. They didn't get there slowly He's not gonna tolerate that that acute slap is probably the primary indication for me to operate on a slap But beyond that it's a crap shoot. Okay, we're going right back to you John a type 2a slap. Is that a bad slap? Yes Why is that a bad slap John? Typically traumatic number one if they have a type to be it It means the middle buddy here like leave it came off and it's kind of it occurs with instability only that it doesn't have Happen without trauma it could have happened throwing not commonly It's probably diving on the ground diving into a bag but in my experience when I see that it's typically a traumatic event and It needs to be fixed But you gotta be careful. You gotta be careful because you start fixing the front of the superior glenoid labrum the superior labrum You're gonna digitally lose extra rotation. This is an obvious one. This is your slide you gave me That's an obvious tear the middle glenium ligament Which you fixed and you did a little trimming like you usually do and that's where the superior to middle goes We all know that and then you use your suture anchor Techers and technique and fix this and reduced it But that I agree with and I think the take-home point for the fellows is stay away from the anterior Superior labrum if you can because there's a lot of variability up there and throwers so Andy Sheehan and I and John and Ben Kibler just wrote a big article in the journal and what we come up with is the Normal labral anatomy the superior segment from the equator up is a mobile segment It's controlled by the biceps tendon It confers dynamic stability to the system the inferior below the blue part below The equator is a fixed static compression effect Which acts as a bumper for the biceps and rotator cuff to push against that is normal And even if you look at it under and with H&E staining you can see the bottom is really fixed and the top has that Little cleavage. So what I'm saying is the top of the labrum inserts on the side of the glenoid Not the top not the face the inferior labrum below that inserts on the face of the glenoid about three to four millimeters So that's where you need to put it. So this is called slap extension. We've talked about this in the academies John and I and Ben Kibler and Andy Sheehan. So the top is a mobile tension band the top of the Of the labrum. All right, this it's a superior tension band the inferior labrum is a fixed organ of compression when the slap tear disrupts the Tension band as it propagates so as a slap goes down it propagates into the the fixed organ it becomes a problem There's three problems that happen from that the superior labrum can't function as a tension band the inferior labrum is now mobile and you can't compress it and the Inferior labrum and the posterior inferior glenohumeral ligament lose this concavity compression Any so it the split happens right there where those arrows are. It's very just I'll show you it This is what it looks like arthroscopically There's a big split there, that's what it looks like statically on your right But if the next one is going to show it better that that splits in the middle is a problem and you got to fix those So when it goes bad Point out that that tears off and a Y pattern So it runs along the glenoid at the glenoid chondral interface But then crosses over the labrum out into the capsule along the posterior band and that's a classic pattern for throwers poster instability pattern right so When that's what it gets symptomatic the posterior organ of compression is compromised when the labrum tear extends from the biceps anchor Into the posterior inferior band that causes flattening of the labrum and in their substance delamination The pathologic cascade ensues as the tension band becomes incompetent There's the decrease effects of the capsule labral or bumper posteriorly inferior and there's decreased tension in the posterior inferior glenohumeral ligament and all that adds up to is Please come there loss of concavity compression and edge stability and then your humor head translates. All right, so We're back to you two now So it doesn't matter whether this is major league college or high school started the season trouble warming up Control issues velocity issues. No kinetic chain problems. Those are the those are three images gentlemen Am I on the right thinking about these are the ones I may want to fix fix them Yeah, that's so that's a peel back. That's not a rollback. That's a split in the label Johnny you agree looking at bone I mean, it's yeah, the bottom rock is a traumatic avulsion The the bottom right is clearly peeling off and the top goes down to the bottom, right? So those are the ones I've been looking at. So this is our guy Here's the slap extension right there that we talked about. That's what you want to look at Treatment options and pearls. This is all I want to get to so I'm gonna go through them all and I want each of you To answer all these questions and Jeff I want to start with you What treatment would you recommend so if surgery knots or knotless if knotless is it tape or suture If what kind of tape do you use because it makes a difference pericutaneous versus a small superior cannula How much of the labrum do you take? Do you take the whole way around it or you just do half like you've talked talked to me about Where do you put it on the glenoid and is it simple versus matlet mattress sutures horizontal or vertical? Do you ever do a capsule or a fee and what do you do with the post to your portal Jeff? Why don't you start? Definitely surgery definitely knotless. I use all suture anchors the the one five and one six arthrax all suture anchors They are a suture not a tape I do both percutaneous and cannula depending on what I'm trying to get to So if I'm if I can get to it through a cannula I do I always tell the fellows don't make portals You don't need if you need a portal to get a good angle get a good always get a good angle I take a labrum only I don't want to pull up capsule, especially in a thrower. I'm not trying to tighten the shoulder I'm just trying to put the labrum back because if you take capsule you're taking you this is a princess-in-the-pea Kind of a situation in the thrower you tighten that thing up and the princess isn't gonna sleep let alone throw So you can't pull it up there I want it on the angle of the cartilage. I don't want to put it up on the face I don't want it down on the neck. I want it right on the corner I do simples and I do lots of points of fixation. I have the blessing of working in a hospital setting So if I need to put ten of these things then nobody's gonna give me any grief for it I don't do capsular fees and throwers and I don't close the posterior portal I haven't had any I haven't had any real issues with that I know you do But I haven't had any thoughts about that I've seen this talk a couple times and I've thought more about it since I've seen it But I have not gone to closing the foister portal. Okay, John Transcutaneous no cannulas not less. I like tape. So I'm still using anchors. I Will remove some of them in this void labor with the top I don't remove labor them at the back bottom I put it I try to restore the anatomy and like you said the posterior lab max it comes off the glenoid rim So I put it all under the blood rim, but I try really unless they're just grossly unstained I try to just put the labor back without tightening the posterior capsule But I want to try to see a little bit of the line the posterior band and then fear glitter humor ligament Recur where I put it, but I'm not trying to see any tension in the posterior capsule and I do close the posterior portal if It's bigger than three millimeters if I've just gone through the same hole that my scope portal went through and I've been able to work through that the whole way and it's well away from the glenoid rim I won't close it and if it's any bigger than three millimeters, I close it Yeah, it was traumatic posterior spilling always So I went not unless why because it's faster lower profile higher pull-out strength More consistent tensioning and may better restore the meniscus anatomy of the labrum So that's why I went to it and the papers there will support that treatment Meniscus rim debridement. I typically debride the meniscus rim. I think you two fellows also do that Anterior repair for instability only so if I have a high medical any humor ligament That is that I think is going to cause instability because it's torn anteriorly I will go anteriorly to repair that that's the only reason I'm going there unless I've got an unstable buffer complex there and then Biceps crossover. I do not cross the biceps ever in throwers. That's the kiss of death for me You guys agree with that? Totally. I try not to touch the biceps in a thrower My question to you either is these are both my cases All right. Do you do? Circumferential like that but not grabbing the gutter or do you do like half of ones like Jeff was talking about? So Jeff you like that half thing, right? We kind of want to go right behind the labrum. So I really want to grab labrum and not capsule I don't want to roll it up on the glenoid So and I think it depends on where you are on the labrum and what that individual labrum looks like And I also want to point out something that you guys will both agree to Do not touch the capsule in the sulcus in the gutter stay away from the gutter The gutter is bad, right? Okay good. We're going moving on Okay So Neil had a great paper But basically what Neil said that with rotator with return to play after slap and rotator cuff pathology is far less than throwers With then isolated slap repair. So if you have a cup with it He had a twelve point five return to these elite throwers versus an isolated. We had 80% now So he's a rotator cuff with the eye. Wait a minute John I'm getting to you rotator cuff pathology is a major contributing factor to failure of slaps is what he said But we're getting to you John. We looked at our posteriors and throwers and we found it didn't make a difference So we just published this Justin Arnott published it with me There was no difference in patient reported outcome measures with return to sport for throwing and we didn't find that So the real question to us was well, what the heck is going on? So this is the issue in Neil's the throwers were elite They were older with greater rotator cuff disease and associated pathology especially bursal and anterior arch subacromial space Pathology John we're going to get to you thick cork Oh capsular ligaments increased internal impingement and finally anterior Capsular tear which you see on the right. That's the terminal result of Neil's guys. Okay, so Isolated slaps causing symptoms and elite throwers is very rare probably adaptive changes So look for other pathologies. Is that a true statement? So In the neary paper and Neil will will admit this they did not routinely look in the subacromial space and We looked at a series of 50 They were elite. They were either they were minor major league players or a few college kids in it, but they're fit They're elite level players That had rotator cuff tears and 87% of them had Hypertrophic hypervascular bursa thick hypertrophic hypervascular bursa So if you leave that alone It doesn't just go away if you go from having a half millimeter thick bursa to an 8 millimeter thick bursa You don't clean that out Some of them will reabsorb it but a lot of them won't and so you'll struggle coming back because it's like wearing four pairs of Socks in your shoe. It's just too too much junk in there So I think if I think it's in that neary paper They have cleaned out the subacromial space and every one of those throwers a higher percentage of the throw of the slaps with rotator cuff Might have gotten back and there are other papers that have been published that look at slap repair with subacromia compression Whatever you wanted to find that that had a higher percentage return So what I'm hearing is you got to look at that anterior arch, right? Because there's a lot of there's a lot of fibrosis that happens there. Yeah, you look there right you look in the front, right? I'm sorry. I'm reading a question. I'm trying to find a question here. Never mind. We're passing you up that Ours were younger We had no pros less rotator cuff disease and we left in 50% involvement and we had no rotator cable tears That's why I think ours did better. All right, so Midterm results we're going to go through that the throwers actually had more pain decreased function Decreased return to sport at 6.6 years, but they had a very high satisfaction. They were pretty happy We looked at it and then when I really looked at my started switching the knotless So I want to get through that second case. We don't have a lot of time. I'm gonna go quickly This guy's got biceps tunnel disease. He's a college catcher And my question to you guys is biceps tunnel disease John, why don't you tell us this is a bunch of stuff? But this is a real entity So what used to be everybody had bicep tendonitis and then we poofed that for a long time I thought nobody had biceps in eyes, but we're not other Really six or seven things that can cause inflammation in zone one two or three of the biceps tunnel as Explained to us by Sam Taylor and O'Brien and some others, but you can get tendonitis tenosynovitis hypertrophy partial tears delamination ruptures and this is a different set of Pathology than the old guy with biceps tunnel disease So just be aware of that and you can have instability at the aperture, which is not that common in the throat But we occasionally see it inside the joint You can you can't see really remarkable changes where the bicep tendon gets incarcerated and just chewed up and turned into layers That was a that was a baseball player. This is a baseball player There's a softball player that you'll see tend to come in along the way. Those are real things We see in 20 18 year old people. How can it turn into delamination? it's because that tendon gets ground up in the Aperture of the biceps tunnel as a result of their throwing mechanics and their pathology and their anatomy So we do see biceps tunnel disease and that the line I always use is you can't treat superior labral pathology of biceps Biceps tunnel surgery or vice versa get into there. Okay, I use these tests But the one that I like is Ben Kibler's test He taught me that the speeds test with the uppercut test. I seem to be able to isolate these bicep tunnel problems Is there any tests in there that you guys like Jeff? What do you prefer one test over the other for biceps tunnel disease? I like an ultrasound guided injection. That's my best test What about physical exam? Come on John? So for me, there's a big difference in a throw between having zone one biceps total pain and zone two biceps Total pain having zone two biceps total pain pain bothers me having zone one biceps total pain does Okay, we're getting to that. So your point is well taken. Can you treat biceps tunnel disease with superior labral surgery? You can't you can treat biceps tunnel disease with either rehab or biceps tendon surgery. Do you agree? Agreed. Okay, great. Okay. These are the zones one two, and three Articular margin to the distal subscap distal subscap to the proximal pec major and proximal pep Major distally. Those are the three zones and the no man's lot. No man's land is zone two all right, so This tunnel gets impinged. I'm going to go a little quicker because we're running out of time, but this tunnel gets impinged Through this long arc and that's what happens to it. And these actually are John's slide right there That is John's cadaver study. All right, remember there's scarring down there stenosis, there can be loose bodies and Taylor is shown as Sam Taylor at 70 or 47 and 90 49 percent of the biceps lesions were not visible Arthroscopically, so you got to look for it You can you can also get this little instability. You see the tendon you can get biceps instability down there. Very subtle This was a volleyball player. I think this was John's to Remember the frequency of tunnel lesions there. This is Sam's Taylor's work. You all should read this It's very common scarring instability stenosis tears loose bodies and vincula what I'm getting at This is the thing that bothers me when you throw the leading edge of that subscap Just is like a like a razor on the on the on the biceps right there when you go into that throwing motion right there Hey Jim, I think this is a really important point these videos highlight the idea that Subacromial pathology can cause what we all think might be intra articular biceps tunnel pain Look at how tightly opposed these tissues are in a thrower through their range of motion to the CA ligament The subacromial space the bursa and all those things So John's point and the whole point about injecting subacromial to see if you get relief from these things Is it was a really valid one in these videos showing this are really kind of highlighting that. Yep That that video shows that the biceps tendon continues to move proximally and distally Regardless of the position you have your arm in because it's changing its relationship to the shoulder I hope your neck is tight. Then you get additional compression on the Biceps tendon that leads to that zone to biceps tunnel tenosynovitis and that's why I worry about it in zone two more than one Okay, so, you know treatment you can stretch them early motion zone to tunnel steroid injections Like Jeff talked about modify their weight training. I mean do any of these really work? Yeah, yeah, okay good, okay, so my concepts I'm going to move through this we've already gone through that So if you're going to t2d somewhere you're going to do it So this is what I put out there and you guys can comment. I don't do Tina licenses. I hate them Transfer to the coracoid that works for great for Steve O'Brien doesn't work for me zone one Steve Burkhardt I've done that a lot works very well for me in zone one Some people don't like to do that zone two and three But those options probably won't consistently work for all surgeons taking care of high-level throwers So you're going to have to make your decision up So some surgeons will need to decide whether they're going to do it in zone two or zone three me. I like zone one I'm very used to being up there and I've got good results there I just wanted we've got hardly any time left, but let me just go one thing So we do subpeck, but we get at the very bottom of zone one We're at the real bottom of that that paleo impactor Alice that covers, you know the groove So we're looking to pack up We're really at the bottom of zone one or maybe at the very upper border of zone two right at that Junction, okay? I'm gonna skip through this and go to one slide Because I want the questions to be answered Because it's all about it's all about rotator cuffs in them. Oh I want to go back to that. Wait a minute. So This is is this treatment statement true the throwers pasta partial articular-sided tendon abulsion is Probably well tolerated as long as it is less than full thickness Contained within the rotator crescent and both the rotator cable and anchors are intact. Is that a true state? Yes The statement because it's a good reason not to fix those things All right. Well, I'm going I want to go to I want to give them some recommendations because they can go through this talk Yeah, I'm going through this. This is don't fix it. The reason is not to fix it There's the reasons to fix it Which we'll get to but I want John to go over the new paradigm that we've been working on. Okay, so You know how deep is too deep how wide is too wide? What about the cables which are very important? Do you fix slaps and cuffs at the same time? I do all the time. These are our old guidelines This was what our old guidelines John and I had a talk many years ago. We had these guidelines Okay, the John I want you to go over these these are our new guidelines you have less than five minutes All right. So if the rotator cable, there's not a cable that runs from front to back If you're opposed to cable is torn fix it if you have an anterior supraspinatus tear It's caused by one of four or five things if it's greater than it's less than 50% to breed it But make sure it doesn't involve your anterior rotator cable It's greater than 50% repair. It is transcendence more method if you have a posterior super Supraspinatus or upper infraspinatus tear the classic throw response to lesion It could be less it could be 80% depth 90% depth as long as the rotator cable anchors are Okay, leave it alone. If it's near full thickness You can either complete the tear if it's almost all the way through or if it's not do a transcendence repair But use a 50% footprint restoration and dines work show that that works If you have opposed to your supraspinatus upper spinous tear with D lamination Don't try to fix that whole thing If it's really good quality tissue and deep to stabilize that front margin and that's where you stop Okay, so This is a this is on the website Wait, I'm gonna get that I'm at the end The bursa is on the website what to do with the burst is going to be on the website because I want to get to The questions just a few things you got to know Please read this article about elbows and shoulder injuries and adolescent players Because age height playing multiple teams pitch loss the arm fatigue Pitches per game and innings pitch per game are clear risk factors These are not risk factors showcase participations games per year training days per week pitch type Shoulder external rotation total shoulder range of motion and these are not conclusive yet. Okay, so I just want to thank my mentor I'm sure John's mentor who taught me more about throwing than anybody was. Dr. Frank job So I got it. You always got to give credit to your mentors. Thank you all very much questions One of the greatest gentlemen that ever graced our profession. He was a gentleman among gentlemen So with that I will say thank you gentlemen for doing this as our both of you We have let's see the questions tab I am not seeing. Oh, it's got to be in the chat. Okay. Uh, I Don't see any questions at the moment Okay, here's one Would you do a surgery on a good slap tear that improves with subacromial injection? within three months of that injection No Well, if you can make them well without operating on them, that's the right answer you don't operate on anybody that you make well with Rehabber with or without a shot What do you guys feel about using you know cortisone if you do a subacromial injection and and it doesn't get better you do an Intraarticular injection they don't get better and you end up at surgery Are you waiting six weeks before you want to do that because of the risk of something not healing if you think you're going to Fixing a labrum or cuff. What do you think the effect of the cortisone is on non non healing? So so I do not inject throwers joints with any steroid I will inject them with platelet-rich plasma because I've seen some of them work It's it's helpful because it's a natural anti-inflammatory natural antibiotic and a very good pain reliever I will inject the subacromial space with steroids, but I wait six weeks before I go anywhere near their shoulder I'm gonna operate on Will you do bicep injections? Oh, yeah, I'll do bicipital groove injections with 1cc only and most of the time it's a diagnostic thing Okay John Oh The really big papers that have looked at rotator cuff and post arthroscopy Procedures that have infections are done come out of large Large Data dives in insurance company system So you have thousands of cases and give you that data and a lot of them are older people So, I don't know if you can really apply that Point-four or six percent increase infection rate to the young population number one But I tell my throwers if I give you a steroid shot I can't give you a I can't I can't scope your shoulder for four to six weeks and the data varies depending on who You're looking at one study says four weeks. Another one says three months. And so Where do you where do you go with that? I think that most of that data is coming off of older people and if you look at that data It's hard to know whether or not some of those things say they got a shot after their surgery And so you don't really know whether or not they had an infection already. That's how For me I say four weeks Six weeks if I'm concerned at all, but that's my line. I did not inject the shoulder joint with steroid I have injected plycus in the elbow of a steroid, but I try to stay in the plyca I do use I have used PRP in the elbow on a number of patients and I've rarely ever used it in the shoulder another question How do you manage? Here it is, how do you manage scar persistent pain after a zone 2 tinnitus? Or how do you manage anterior shoulder pain after tinnitus both questions Well, I can tell you Bert. I can tell you Burkhardt's results. He had 1040 patients he had a 4% Reoperation rate and 0.4% Worse for the biceps, so I don't have a lot of experience with that John I will let you answer it. I've been pretty lucky with mine So JP Warner's follow-up study on that says if you don't fully decompress the sub across the biceps Tunnel all the way down to the back Secondary anterior shoulder pain and then at Burkhardt study is a really nice study and they had virtually no anterior shoulder pain after that so it's really interesting looking at that data and then you look at look at Taylor and what others have said where you miss 40 some odd percent of the Pathology in the biceps tunnel if you don't open it up the the bottom line is I do a zone 2 biceps tunnel tinnitus aka modified Caspari Weber and I actually when I quit using screws my biceps tunnel pain really dropped down I don't know if that's a Part of it or not. There are all sorts of reasons why somebody still may have pain for me I really try to clean out underneath the coracoid and see the Short end of the biceps all the way down to the back when I do a biceps tinnitus because I personally think particularly in the younger Athlete that scar beneath the conjoined tendon contributes to some of the pain in the front of the shoulder So one of the points I think we should make is that anterior arch that we showed in those videos Is really important to clean out and and people don't look there enough That's the next place that we go right John am I Jeff? That's where I'm looking. I agree Alright last question and this is from me We'll finish with this We've seen a significant decrease in shoulder injuries at the highest level of baseball and an associated Increase in elbow injuries over the last say 10 years We're not seeing the level of rotator cuff injuries and labral tears that we saw You know 10 to 15 years ago Why do you think that is is it related to the training regimens? And and where how do you think we get that information down to the colleges in the high schools? Well, I'm cheating because I have a specific guy that I will send most of my high level throwers to and I think it's the Rehab and learning about the force couples and going through the kinetic chain going I mean a lot of my guys have hip problems. It's not their shoulder You fix their hip their shoulder gets better So the base I think the reason that the pitchers are is because the velocity is going up It's directly proportional to the tears so the kids can throw harder and they rip their ligament I think it's a it's I think it's a velocity issue You know you getting that I got kids that are in their high school that are throwing 90 miles an hour, right? I'll tell you if you look back to 1990s and now I spend a Three times as much time with a player and I operate on a third So I spend a lot more time figuring out what's really wrong with them and then I operate only about a third of them and whereas before I operate on most of us add anything on there where I operate on it and I never looked at their kinetic chain and Our outcomes are as good. I think that word I think that in a good center You're saying kids evaluated better and treating with conservative care and put the hands of talented therapists I say this all the time. I'm only as good as my trainers and my therapist. They're really what make us successful because we can whether we operate them or not in the end they have to end up in the hands of a talented Therapist or athletic trainer in order to be successful with their rehab right on I think the thrower shoulder is a tough spot if you can avoid it avoid it With that we're gonna say thank you. These guys are Giants Jim and Jim and John two good friends and people I learned from every day I continue to appreciate the work that you do and Really appreciate you guys a lot. Thanks for doing this. Thanks for your leadership, and we'll be talking to you soon Everybody have a good night the next one What's that Just said nice job. Oh, thank you. Thanks, Jim The next one will be Next Tuesday, June 23rd. This will be a foot and ankle one with past president Ned Amendola and Ken Hunt From the University of Colorado. They will be talking about some sports medicine foot and ankle stuff. So Thank you guys. Very nice very much. Have a great night. Thank you guys. All right. See y'all. Good night night You

thrower's shoulder

Dr. Jim Bradley

John Conway

shoulder injuries

biceps labral complex

biceps tunnel injuries

slap tears

rotator cuff injuries

kinetic chain

comprehensive approach