So welcome, everybody, to the Multi-Institutional Sports Medicine Fellows Conference. Please keep your computers muted, if you would, so that it doesn't interrupt the lecture today. This is being recorded, and it'll be transferred to the OSSM playbook on the website. It'll be on the Learning Management System and available next week. This week's lectures will be available next week, and the ones from before are already on. If you have any questions, please submit down on the chat function. Dr. Dugas and I will ask them at the end. Actually, after this week, on Tuesdays, it's going to be Dr. Dugas' day to be the moderator. And if there's any faculty that we don't catch, we're going to try to unmute for discussion at the end. But if we don't catch it, please just chat us, and we'll make sure to unmute you. So we're very honored and pleasured today to have Jim Bradley give us his talk. He's a clinical professor at the University of Pittsburgh. He's been the head team physician of the Pittsburgh Steelers for, what is it now, 26, 27 years, Jim? This is my 29th. 29 years. He's also a co-director of Greg Norman Golf Research and a consultant for the Miami Marlins, but better known in his role as president of the AOSSM. So we're very fortunate to have him. He's had a long interest in posterior instability and arthroscopy for the management of athletes, particularly this one is a unique topic on posterior instability of the shoulder in the throwing athlete. So without further ado, great honor. Jim, thank you for being here and helping out the fellows. Thank you all. So my job is to talk about posterior instability of the shoulder in the throwing athlete. We've been studying it for a while. I'm going to try to convey to you the lessons I've learned over the last 28 years of research on this. So the definitions, we are talking, we're not talking about locked posterior dislocations. We're talking about recurrent posterior subluxations and posterior capsule labral complex lesions in throwers. There's a potpourri of suspected culprits for disability of the throwing shoulder. And I just show you this because it's going to be on the playbook, so you can always go back to it. But the more common ones are the ones I've lit up. But dynamic posterior instability and slap lesions are very, very common, especially posteriorly, much more than we thought before. The first real important paper actually on repetitive posterior subluxations in overhand athletes was done by my buddy, Jim Taboney. And we did it back in 1993. And we basically said that chronic overuse caused microtrauma to the posterior capsule. You got capsular attenuation. You got posterior subluxation. And then my buddy, Lee Kaplan, looked at the NFL guys. And sure enough, we found that in the overhand athletes, it was usually an indirect mechanism. And then the contact athletes, it was a direct mechanism. Here's the conundrum. The conundrum is 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, and that being bursitis, tendonitis, partial cuff tears, and internal impingement, but all of which can obscure the efforts to actually pinpoint the cause of the shoulder dysfunction in the thrower. Sorry, I got to get this out of here for a second. All right, there we go. So the pathomechanics of the capsule. So the inferior glenohumeral ligament is intimately associated with the posterior labrum. And it creates a compressive force across the posterior glenoid, posterior glenohumeral joint. The posterior band is thinner than the anterior band of the IGHL, which predispose these tissues to specific changes in response to certain mechanisms of injury. So the posterior capsule will plastically deform in response to repetitive posteriorly directed forces. Now, an alternative, perhaps paradoxical, set of adaptive changes have been observed among these overhead athletes because of the unique stresses involved in throwing. So still on the capsule, the changes in range of motion are probably not due to posterior contracture. We've heard that back 10 years ago, posterior contracture is the key. No, I really don't believe that. I think it's a small part, but it's there. But there's humeral retrotorsion we got to talk about, contractures of the CA ligament. Pec anterior deltoid, dynamic muscle stiffness occurs in response to these repetitive strings. And that's thrixotropy, which actually means that chronic repetitive muscular stretching, i.e. throwing, causes decreased range of motions after a single game. And then progressively over a season. And we'll talk more about that. But that better explains the acute changes in range of motions noted after an acute throwing episode. So what about the labrum? The labrum does not, as people say, they say it does not have a consistent anatomy around the glenoid. The superior labrum is very loosely attached and mobile. The inferior labrum is attached and immobile. And these variations have significant implications for glenohumeral mechanics during the throwing cycle. So basically, the superior or the labrum functions differently in response to this throwing stress. The superior biceps and labral complex functions as an organ of tension or a tension band. And the inferior labrum is an organ of compression providing a bumper. And Bain was the first one to explain this correctly, we think. So if the segments remain linked, the two together function as a tension band stabilizing the glenohumeral joint, which resists translations, especially in significant ranges of motion near the end. It deepens the glenoid cavity and it increases tension across the posterior band of the IGHL. So the superior labrum can still function as a tension band as long as the inferior labrum is intact. So some degree of superior labral detachment or what I call the good slap, may be the price that is required to achieve this maximal caulking that you get. So this is a new article that we just put out. And I gotta thank Andy Sheen and Ben Kibler and Johnny Conway. We all got together on this because we thought it was important. But what you can see is the superior labrum actually attaches to the side of the glenoid, about three millimeters off it. Where the inferior attaches directly to it. So the superior is mobile. It's the tension's controlled by the biceps, which confers this dynamic stability or tension band. The inferior is fixed. It's static compression effect, which acts as a bumper for the biceps tendon and the rotator cuff to push against. That's normal. And by the way, there's a lot of free nerve endings in that labrum. So when it goes bad, what happens? So you get symptomatic, you lose the posterior organ and compression is now compromised. When the labral tear extends from the biceps anchor now into the posterior band of the inferior glenohumeral ligament, that causes flattening of the labrum and inter-substance delamination. It's very clear cut when you look at it in arthroscopy. So that pathologic cascade ensues as the tension band becomes incompetent, then you get the decreased effect of the capsule labral bumper. And then now you lose tension in the posterior band of the IGHL. And what you do is you lose, there's a loss of concavity compression. You lose edge stability. You start, as Neil Elytra says, you start ratcheting or like when you ski and it kind of rattles along instead of making that good edge, that's edge stability you need. And then the worst part is you have increased humeral head translation. And if you see where the little arrow is there, that's where it starts and it splits the capsule. So there's three groups that we talk about. The first one, Shane Soroya and I talked about in 2007 and we took that off from Burkhardt and Kibler and Craig Morgan. So you get a tight inferior capsule or a glenohumeral internal rotation deficit. You get repetitive microtrauma after ball release, progressive tearing of the inferior labrum like you can see on the pictures. You have mechanical symptoms, not when you release the ball, but during follow-through and instability is not predominant. And this is a small subset, I think. The second group is much more common. We talked about it, Ben and I, in 2016 and 17. And what it is, you get a 2B slap tear and that extends posteriorly, which bisects the posterior labrum into two distinct bands. As you can see the picture to the right. One extending into the capsule and the other one that follows the glenoid labral junction. So you see the two in there split and you lose the tension band. Here's the issue though. You've got to repair these both together and to the labrum or and to the glenoid from top to bottom, or it will not work. So to further, I'm going to try to reiterate this a little better now. So you have a mobile tension band. So the superior tension band goes into a fixed inferior labral organ of compression. When the slap tear disrupts the band, the tension band, it propagates and you have three distinct problems. The superior labrum cannot function as a tension band. The inferior labrum is mobile. So you get no compression and the inferior labrum and the posterior band of the IGLTL loses this concavity compression. It looks like this. There's two tears, but the one tear you want to look for is the one I'm showing you right there with the arrows. So not only is it off the glenoid, but it's right split into the capsule. It looks like this. Orthoscopically from the back, it looks like that. There's that split. If you look from the front, which is a little better, that's what it looks like. And here's what it looks like when you see it. It's very distinct from like football players and their kind of instability. This is a very distinct pattern. The third group that Johnny Conway taught me about back in 2016, we started talking about it is dynamic posterior instability, which we think is much more common. So the pec major has, they're both internal rotators, the pec and the lat. The pec major is an anterior vector. The lat's a posterior inferior vector. So these two vector forces have to cancel out. Or what you get is if you get a weak or tight or inactive pec major, the anterior vector, then that allows the lats, which are very strong, to pull the humeral head right out the back. And that can occur with or without a labral tear. You don't have to have a labral tear to have this happen. All right? Here's the key. There's pain just at or before ball release. That's what we found, that these are different. They're not in full follow through. It's right at ball release that you usually get these. Let's talk about the history. Posterior is significantly different than anterior, especially in throwers, posterior instability. It's insidious onset. You can have a slap event, but in my thing it's not that common, maybe 30%. Vague complaints of posterior pain. Clicking and popping is really common. You want to ask for that. They have anterior or posterior pain in cocking and ball release. The first thing I usually see is, do you have a problem warming up? And that's the first thing they'll tell you. They can't warm up. And then what happens is they lose velocity, control, endurance, and recovery times. All those things happen, and you got to ask them specifically in the history. The physical exam is also different. It's just not the shoulder. First of all, you got to go from toes to the fingers. Anybody that knows anything about throwing knows that the kinetic chain is everything. So you start, I mean, typically I'm going to go through a few things I look at, but the hips range of motions and abduction weakness, you have decreased mechanics, you get shoulder problems. If you have quad strength problems in the landing leg or the push-off leg, you got problems. Tests you want to think about are the standing balance test, which is a static test for the hips, the single leg squat, which is a dynamic one, and it'll show quad weakness. They'll just collapse. You got to know how to do total active and passive range of motions, internal rotation deficits, external rotation deficits, this new thing is humeral retroversion, which I'm going to talk about a little more. I want you to start thinking about. You got to look at the pec major and minor for any kind of contracture because they're there more than you think. And then obviously Ben's taught us all about scapular thoracic dyskinesis and six scapula syndrome, which is another thing. So I'm just putting this in here. So if you ever go back and look at it, this is kind of the checklist we go through. Every one of these things we'll go through in our throwers to make sure all of these things we look at. And a lot of the time, if you get them early enough, they're not going to get a slap because they've got a nice mobile slap that's up there that's a good slap. And if you can correct these problems, then you know what happens, you don't operate on them. So what values do I really worry about? Well, I learned this from Kibler and I've learned it from Kevin Will. So side to side total range of motion differences, anything greater than five either way is a problem. Side to side GERD of 18 to 20, that's two standard deviations above. Side to side external rotation deficits, anything less than five, because remember that normal external rotation of throwers should be 120 to 123, and then they should lose internal rotation, but still have 180 degree arc. This is where the problem comes that I think is much confusing. Relative humeral torsion. So there's humeral torsion and there's relative humeral torsion. Relative humeral torsion is when you compare the dominant arm, throwing arm to the non-dominant side. That's a big deal because of where you start and where you end. So we're gonna talk a little bit more about this. But the other thing I want you to remember is that internal rotation loss after you throw acutely is eight to 12 degrees. At 24 hours, it's almost up to 15 degrees. At 48 hours, it's still 15 degrees. And at 17 hours, it's still not back to baseline. So there's multiple studies that show you, you lose that over the season. So you even get worse during the season as the season goes along. Here's Ben Kibler's work from 2012. And you can see this is early to the end of the season. And you can see that you lose external rotation. You initially gain it, then you lose it. Then you lose internal rotation late. That's the purple. And you lose total range of motion. That happens over a season, all right? There's multiple articles on this of other athletes and other professional sports. They're baseball players, you know, both professional and college has been looked at multiple times, as well as handball players. They've all have found this glenohumeral internal rotation deficit, which is sitting out there to your right. This is what I want to kind of tell you. I want you to think about, because this is a little bit complicating and I have trouble with it too. So are we causing posterior instability with our physical therapy by stretching the back instead of the front? John Conway and I go back and forth on this and we discuss it and we're trying to figure it out. But just give me a little bit of time for this. So the problem is we measure the athletes at 90 degrees, but they don't throw at 90 degrees, they throw at 70. We measure them supine. The scapula is not controlled or it's malpositioned. So what does that give us? And what about when do we measure? When they're not throwing posterior, when they're throw just acutely, or how long after the throw should we do that? So the term we should talk about is not humeral retro torsion. We should be talking about humeral torsion and it's a relative torsion. You take the dominant arm minus the non-dominant arm, it's a negative number and that's the number you want to look for. So one example, I know it's a little confusing, but just kind of bear with me. So if you have a glenohumeral internal rotation deficit of 20, and you have a glenohumeral external rotation of plus 10 in a thrower, and your total range of motion difference is 10, then if you have a relative humeral torsion, and this is by ultrasound, you got to get your PhD or your physical therapist to be good with ultrasound, of minus 10, then you have a 10 degree internal rotation loss. However, if you have a relative humeral torsion of minus 20, you now have a 10 degree external rotation loss. So what most would say when they look at this is that the patient had a 10 degree GERD and should be treated with internal rotation recovery stretching. Clearly, the addition of relative humeral torsion would redirect the therapist to do external rotation stretching. So just be careful you're not stretching out them posteriorly and you're causing the problem, not helping it. So that can cause posterior laxity and posterior instability. The physical therapy, some of the things we've been working on at Pitt are these things. It's called the D-PIT, modified D-PIT, Whipple, modified Whipple, and circumduction test. Cause it's very hard to determine it, but those tests, we've done some more research on and then we'll talk a little bit about it now. If you wanna talk in the discussion, I can help you. This is the Pitt three-pack, okay? So it's the slap three-pack, type eight slap, active compression test is positive. The D-PIT test is dynamic posterior test is both positive when you can modify the D-PIT and they can make it go away by blocking it with your thumb in the back. And all that guy is doing is throwing, pushing down like he's gonna throw and I'm just blocking him. The Whipple and modified Whipple tests are the same. Here's some better examples. So circumduction test, you're gonna have a problem with this guy, okay? That guy's going right out the back and he's relocating, okay? He's going right out the back, here he goes and he's gonna relocate. That's a problem. That same guy, if you look at his shoulder, look, he just drops out the back in neutral, just drops right out the back. That's gonna be hard to control. So here's Conway doing the posterior thrower's instability test. He's gonna ask him to throw, guy's gonna push down real hard, all right? And then right there, he goes out the back and the guy says, and John says, well, where is it? And where does he point? It's to the back, not to the front. So we looked at that Tracy Lawyer and Michael Nikolai looked at it for us. And this is what we found just that test alone is that for posterior instability and slap instability and throwers, it was 94% sensitivity, 95% specificity and it's positive predictive value is 0.98. That is still pending in sports health. It's not published yet. Joe Myers and I looked in 2005. You gotta remember that scapular position is protraction is very common in throwers. So increased protraction is common in healthy throwers but when you get weak posterior muscles and they get inhibited, remember that lat can pull that thing right out the back because the lat's very strong, all right? So protraction is normal. So to see a picture with that, you know, I'm not really worried until I finished my exam but that's really not an uncommon thing in a picture. Beware of scapular dyskinesis. You know, Ben Kibler is gonna show you here in this video. This is courtesy of Ben. When that arm drops, you see it just go out the back. Well, there's three types of kinesis. They're not pathologic specific but this is what I've learned from Ben, not from me because I had to call him about it multiple times to figure it out. You know, when you get a posterior instability sometimes your shoulder and scapula are really smart and they are gonna protect that shoulder from going out the back and what do they do? They then have, you get scapular dyskinesis and the scapula lifts off and it keeps the head in place. The only way you can fix that, because I talked to Ben about one specific person that no one would operate on and I finally operated on him probably about eight years ago. It completely went away as soon as I fixed it. So physical exam findings that predict a poor response to physical therapy, positive circumduction test, positive load and shifts at plus three. The D-PIT and modified D-PIT have been very useful on our hands. It's not been validated yet, but we've been working on it. We're trying to get it in publication. Hypermobility is a problem and obviously it's scapular dyskinesis. All those things worry me with physical therapy to get them better. What about imaging red flags? Well, significant bone loss or significant retroversion is an issue I worry about. Posterior subluxation with the head out the back already is a problem. And then glenoid cartilage analogs that look like that as an issue. And you're gonna see this and that's all cartilage and that's what it looks like when you go to try to fix them, all right? And it's a big hole that you're gonna have to fill with bone and do this other procedures. If you ever got that, just call me. We got a way to fix that. Anyway, there's critical findings on MRI compared to your age match control. So these three things are independent variables. So if you get an MRA that shows glenoid dysplasia, posterior humeral head subluxation or increased capillary volume, guess what? Those are all independent radiographic risk factors in patients with labral tears who develop posterior instability. So if they have one of those, you already know you're in trouble. So I call these JC rules on MRIs. That's John Conway up there. This is what John taught me. If you want to operate on a thrower's shoulder, get an MRI. But if you get one, don't treat the MRI. You can't see the pain on the MRI. In fact, there are only four good papers out there, or even some aren't even that good, on where the neurologic, where the nerves are, where the Pycinian corpuscles are, where the raffinis are, and where the free nerve endings are. So there's only probably Bang's Nest article may be the best. And then are the findings the cause of the result of the primary problem? And are the MRI changes, are they beneficial? Are they adaptive? Or are they purposeful changes, which they may be to make them throw? So Bryson Lesniak, who's with us now, did this study and found that 48% of asymptomatic Major League baseball pitchers had a slap tear. And then Tony Mineachi also showed that 80% of asymptomatic mature pitchers had MRI changes, and 45% of them had a labral tear. Well, it's not the problem sometimes, but sometimes it is the problem. But I would say to you this. You don't operate on MRIs. You operate on history, physical, you know what I mean, and then obviously your exam, and then look at the MRI last. Jeff Towers, we looked at this back in 2010. There are some special sequences that really have helped us. We started with MRI A's. Now, we don't do MRIs anymore. We don't inject the joint at all. I'm not a big fan of gadolinium in joints. So we've seen so many, and then we kind of have a better idea. But these ABER views, these abduction external rotation views, where you stick your arm over your head in the scanner, you can predict dynamic PO back, 100% specificity, and positive predictive value of 100% in our study. And you can find these KIM lesions. It's 75% sensitivity, where the specificity is 75, those little lesions where the arrow is. You've got to watch those very hard. What about bone loss? It's uncommon in throwers. I really don't see it. But we really have no clear answer from the biomechanical, our clinical data and literature what the heck to do with it. But you've got to remember that 5.8 millimeters is 20% bone loss, all right? So in our 200 repairs we looked at, Craig Morrow and I, boning width was much more predictive of poor outcomes. Now, this was all of the group that we looked at, OK? We had 200 repairs, and they weren't all throwers. But of that group, boning width, a small glenoid, is a problem, whereas bone loss wasn't as much of a problem. Then Matt Preventer started getting into it with Justin Arner, my new partner. And we all looked at bone stability with glenoid bone loss and the morphology of bone defects, which is different than anterior. So Matt and Justin's conclusions were there's a loss of posterior bony concavity. There's increased slope from anterior posterior. Diversion increases is gradual, but it's increasing from superior to inferior. And it was Matt's idea to do these new CT scans. But what we said at the end was this. This pattern of bone loss is distinct from anterior glenoid bone loss, which is more abrupt with a steep declination. So everybody asked, well, what's the number? Well, I talked to JT. I talked to Matt. We all think, I think it's somewhere around 13, 13.5, something like that. We're not sure, but we're getting closer. And I think you should ask. That's a tough question. What about retroversion? Well, retroversion is extremely common in posterior instability. Once again, the literature doesn't help us one bit from it. And we also did the study on that, Craig Morrow and I. And 200 athletes, increased retroversion did not make one difference at all, whether it was bony or chondralabral, made no difference in their recoveries. So we looked at all of our athletes with this, just not the throwers. Chondralabral at 10.7 and bony at 7.1. Those both groups were statistically significant retroversion and all the people we operated on. But guess who's worse? The pitchers. We looked at the pitchers, they were 11.5. So pitchers are even worse. So you can expect it in your throwers to have version problems. So my buddy, Brett Owens out of the Academy, I call them the military mafia, because they all get together and they do such great studies, has showed us that the most significant thing pre-op to get posterior instability, its significant risk factor is increased glenoid version. In fact, for every degree over increased glenoid version from normal, you have a 17% risk of subsequent posterior shoulder instability. Now, these weren't throwers, these were the cadets, but you got to watch for, that's something you want to watch ahead of time because it is a risk factor. So this is the paper that we did. Mike McClincy helped out on this too, of these 200 people. And what we found out, there was no significant difference in scores for bony or chondrolabral version. And this is from all comers, right? Just not throwers. It made no difference at all. So the overview of posterior labral tears in throwers, you can get macro trauma from a base diving into a base, which is uncommon. Deceleration, eccentric load was Jimmy's, Jimmy Andrews talked about, started this. And posterior contraction with the Morgan and Burkhardt and Kibler. And then slap extension, Neil Eletroz and Kibler and myself worked on that a little bit. And then Johnny Conway and I were looking at this dynamic posterior instability. And then there's glenoid dysplasia and retroversion, which has been there the whole time. That's how I break it up in my mind. Remember that posterior pathology is rarely isolated. It comes in combinations of partial cuff tears, raggles, posterior glenoid DJD, depending on what you're doing, right? And this is kind of across the board. I just want you to know, be prepared to do something else when you get in there. So I looked at, we have 688 patients in our current prospective study that we, and this is all sports, just not throwers. 35% of the ones I operate on, which is 688 had additional pathology I needed to address. The question is you gotta be prepared for that additional pathology. So here's an NFL linebacker. This is not about contact athletes, but you can see, I knew beforehand, this guy had a huge haggle, reverse haggle, and I knew I was gonna have to fix that rather than the grenoid, but I knew it ahead of time. So look at that MRI, and that's what the guy looked like. And he's a middle linebacker. You need to know that. This is one for baseball get capsular tears, thermals get capsular tears, and football gets capsular tears. So if you're doing posterior instability, you better know how to take care of the capsule. So what do you do with this? The guy has a posterior labral tear. He comes in there. You don't think he has anything wrong with him, you know, or anything else. And this is what you see, right? And the question is, is what do you fix first? Because there's some disparity. Some people say one thing and some people say the other, but you need to think about, am I gonna fix the labrum first, or am I gonna fix the big capsular tear first? My prejudice is I always fix the capsular tear first, and then I tension the labrum. But there's some very smart guys out there that do the opposite. So guess what? Overhand athletes have poorer outcomes in return to sport versus contact athletes. We've known this a long time. So if you look at posterior instability in overhand athletes in the literature before we started, there were small numbers. They weren't very well documented, and most did not do very well at all. I want you to learn this concept of good slap versus bad slap, because I think it's really important. So a good slap, all right? A mobile segment up there, which is beneficial to throwers, it's purposeful, it's beneficial adaptation to allow an increased labral mobility, humeral head elevation, they externally rotate better, their velocity is better, and their performance is better. But when they go bad, that's now a pathologic process causing translational rotational micro instability at the end range of motion, not in the middle at the end range, they have pain and their performance goes down. So good slap, bad slap. So how do I differentiate? I use this thing called StampBR. That's how I remember. So a good slap, a subacromial injection helps. The tissue looks good. When you abduct and externally rotate them, the labrum rolls back. It does not pop and peel back. It has this nice little rolling. The margins look chronic and smooth and compensated of the labrum. And the patterns are typically a slap one or two B. Okay, the biceps tunnel is not tender and there's no rotator cuff there as opposed to the bad slap. The subacromial injection does not help. The tissue looks bad. The ABR view, there's that snapping you get with an unstableness that you see down there on the bottom. They get this little snap, you'll see. The margins are acute and irregular. And the patterns are typically two A's and C's and threes and fours. The biceps tunnel is plus minus tender, but they usually have a rotator cuff involvement at that time. So that's how I kind of split them. So let's talk a little bit about type eight slaps, which is basically a type two that goes into the posterior labrum. That's a type eight. Rich Ryu is the first one to describe this back with just straight MRI findings. No one did until Shane Schroeder did the first one actually. But you got to fix them from the top to the bottom and by God, just fix the labrum. Do not touch that gutter there because if you touch that gutter, you got a problem. So we want to make them look like that or that. And so Shane did this in 2007. This is the first one in the literature with more than two year followup of type eight slaps, the Hoy from 12 o'clock to six o'clock. We only had 13 patients over two years. We did 23 patients. You know, we did pretty well, we thought, you know, a hundred percent return to sport. But look at this, 69% at the same level. And that's going to be a recurring theme through all this. So that's another example of what you see back there. You get this big split the whole way down. You want to fix the labrum only. So then Forsman and Justin and Darmash and I, we looked at four year followup and we had 46 athletes and 27 throwers. And this is what we found, abysmal. 37 went back at the same level, okay? So to me, I don't really care about much, but return to the same level. Return to sport is nice. Return to sport at the same level and using the Curlin-Jobe rating system or scoring system. Those are the things that I think are really important for me. But look what we did here. The satisfaction was unbelievably good. The throwers had increasing pain, decreasing function, decreased return to sport at 6.6 years. But look, they all had high satisfaction. So at least we were helping them somewhat in what they were doing, but we couldn't get them back to the same level. So guess what? Those were early in my thing. A lot of those guys were really early in our group. So that's when we started thinking about switching to knotless. And there's a reason to switch to knotless and for many reasons, but we'll get to that. So then Neil Evans-Charles came out with a great paper about how you don't get back when you have a slap and a cuff problem in elite throwers. So I said, wait a minute, we're not finding that in our instability patients or truly posterior instability patients. And what we actually find out was as opposed to slaps, pure posterior instability and rotator cuff involvement did not make a difference in our study group. And we published that in 18. So we had a little disparity there. So on our first group of 100 athletes we did, we had 27 throwers. These were all with sutures, right? They were all tied sutures, which is a problem in my mind now. We had three failures because we didn't use suture anchors. We just kind of put the capsule back to this labrum that we thought was good, but it really wasn't. But the problem is Chris Radkowski did this study with us and then 55% were less likely to return to their preoperative level. So already I knew I had a problem. We were trying to figure that out. Then we looked at our next group of 200. After the 100, we were done. We went to 200, but still that was kind of half and half, knotless versus knotted. And still we only had 61% return same level, which is better, but it's still around that 60 range. But what we learned was this. If I anchored them, I had a 70% return to sport rate at same level versus anchorless 22%. So now we're thinking, hey, these labrums, they are not good. We need to augment them with suture anchors and a good biologic response along the rim. Justin and Mike McClincy then said, okay, we need to do a matching. Okay, we need to do a case match comparison of throwers versus non-throwers in our group. And we did that. And they're almost exactly the same of throwers versus non-throwers. And what did we find? The same thing. Throwers didn't come back as well, but 85% return. But look, once again, here we go. 60% same level. Even though the non-throwers came back at 70, that's 10% difference, which is still bothering us. So I said this quote when I talk about this for the entire posterior, when I talk about everybody that has posterior instability, I said, for baseball players or throwers, in the end, when you fix them, a little loose is always better than too tight in the overhand athletes as opposed to the contact athletes. Why do we prefer arthroscopic desabilization? We addressed that in 2012. We felt it was better because you can address the posterior cuff tears if you have to, the slaps, the capsular tears and the haggles. The literature is pretty clear. There's decreased recurrences or revision rates. And the return to sport and return to sport at the same level and patient satisfaction were all better. So if you're gonna do these, please do them arthroscopically. The one thing I don't want you to do is electrothermal. So Donny D'Alessandro, I looked this in 2012. We had 84 patients. We had 100% follow-up in five years because we used a guy to hunt them down. We had a very good guy. Anyway, 40% failure rate, so don't do that. And then once you get there, then you got a problem fixing them because that capsule, once that capsule gets burnt and charred up there, it's a problem. So my indications for surgery are failed rehab greater than six months, a large labral or flap tear on MRAs. No, it's not gonna go away. Posterior labral glenoid. I think it's around, glenoid bone loss is around 13%. I'm really not sure. It's still nebulous. It's that, like Matt Preventer said last night, that tweener, you know, what do you do with that? Any kind of raggle or capsular rinse, I definitely wanna fix. And then if I can't get them back to the same level, I'm gonna fix it. So my technique in throwers with an avulsion of a labrum is to repair the labrum only. And then I'll release that little chem lesion you see on your left. I'll release that and go underneath it. And then I'll just repair the labrum. I never placate the capsule or close the rotator interval. If you have this thing, if you have a large flap tear like this guy right here, you can take that flap tear out, like I showed in the bottom. And if that rim is stable, I don't do anything. But if the rim is unstable, then you treat it like a normal labrum and you fix it. And you always close the posterior portal. I'll get to that. So little procedural pearls. You wanna do an appropriately placed posterior portal. It's about one centimeter lateral to the standard portal. Get that good 45 degree angle to the glenoid face. You have to learn five and seven o'clock accessory portals. You have to. 70 degree scope is also extremely helpful. If you've never used it, once you use that, you're not gonna go back. Make sure you abrade and burr the glenoid first. Don't get excited and fix the labrum. Take your time, burr it down. I have a long, skinny osteotome. I actually fist scaled the thing. I placed the anchors and replayed the labrum. I put one anchor at a time. Then I tensioned from inferior to superior. I always close the posterior portal because it's a stress riser. And I used to get these people that would fail coming in from St. Elsewhere. And I'd look and there's this big hole in their posterior capsule. It was right where they did the portal. You can assess the rotator internal, but in a thrower, I would never fix that. I just wouldn't do it. So here's what my arthroscopic techniques looks like kind of at real time. You got to kind of unroof the thing from the front. You want to look from the back and unroof it. It's the perfect angle. Then I use this little meniscal rasp. It works great, the little meniscal rasp. I abrade that pretty well. I really kind of take my time there. I'm showing you the five millimeter portal that I've used in the past, but I want to make sure you guys know you can use this if you get uncomfortable. There's some new anchors out there that are tacks that can make that turn if you want, or you can do it pericutaneously with a knotless. I use a spectrum or real pass or something like that. There's a lot of instruments the company makes out there. Just get comfortable with them. I go back and forth, whatever they give me. I'm a tape guy and the tape has to have polyester in it because the cells love polyester. They're not big fans of polyethylene, but they like polyester. And then when you put it in, you got to leave a little slack. You don't want to strangulate the labrum. You want to put it in at that angle and notice it's on the face. The inferior labrum is four millimeters on the face of the glenoid, not on the side like the top. So anytime you get below the equator, put it on the face right at that margin where I'm putting it right there. I change my anchor size depending on the size of the glenoid. I go from two nines to, excuse me, two fours to two nines to three fives, depending. And then revisions, I typically use a bigger anchor, like a three five. You're going to have to go right and left with these things. So you go, if this is, you know, right shoulder, it's left, left, left a couple of times, then you got to go right. But it looks like this at the end. And then you always close your posterior portal. You take a spectrum or on one side or, you know, in a penetrator and you close that with a little PDS and that thing will heal really well. So that's kind of what it looks like at the end. And you just kind of get the labrum. So I had to make sure I wasn't very trusting of this paper that came out of Curl and Joe, although I was wrong. So I didn't like that 45 degree angle. I liked the 35 degree angle for that seven o'clock portal in the back there. And I wanted to make sure it was away from the axillary nerve. So I went to the lab and sure enough, after a big lab at a major institution, I started dissecting and I put my portal where I wanted it. And you can see where my forceps are. It's three centimeters is where the axillary nerve is. There's where I want to go. It's still three centimeters. So I did it on a lot of different ones and I felt comfortable now that you can do that. I want to tell you this, when in doubt, please use suture anchoring, just use them the right size and don't be afraid to use more than less, okay? Cause I'm going to show you my revision rates and you'll see why. So my failures came, I knew I was in a problem with this because my failures in my first 100 look, four out of five had a capsular placation, three out of three of the overhand had a capsular placation with no anchors. So I knew I had to start using anchors. And then I went knotless. So why did I go knotless? Cause the literature told me to, it's faster. So I saved 10 minutes every time I do it. But the overall group, when they looked at the overall group, it was 20 minutes if you do knotless versus knotted. So I got 10 minutes. So if I do eight cases a day, that's 80 minutes I'm saving just by doing that. And Brian Hanipsiak showed us that they're lower profile. We looked at them in 2012 and 2017. They had higher pullout strength and pull through strength, sometimes up to 39% higher. More consistent tensioning was shown. And then Dave Dine showed us, or Josh Dine showed us that they're better restore the normal meniscoid anatomy of the labor. I tend to use these thing called shaver drills. I like them cause you just clip them in. Many companies make them, you clip them in. You don't have to worry about using a drill. They're faster, they're cheaper, and they're always sterile and they're always sharp. So I tend to use those right in off my shave. If you look at the literature, open versus arthroscopic, it's not even close. Recurrent instability, address concomitant pathology, perioperative morbidity, return to spore causes, the gold medal goes to arthroscopic. So please, open is fun. Actually, it's easier than anterior to tell you the truth, but arthroscopic gives better results. These are the questions people usually ask me about this. When do you anchor? Whenever I'm in doubt, which is most of the time. How much do you placate? Depends on the sport. I know we didn't talk about contacts, but I'm very aggressive in football players. I'm not too aggressive in throwers. In fact, rarely do I placate, except they have a capsule or tear. When do I debride? I debride when there's a large flap tear and the rim is stable and there's no chem lesions. I'll just debride the flap and let it go. When to fix the labor and release the capsule? Really hard question. Actually, it's an hour lecture. If I get an internal rotation deficit of 25 or more that's irresponsible to PT, I will fix the labrum just like I showed you. And then the last thing I do is I go to the bottom of the labrum, five millimeters off the face. There's a posterior band that's about a centimeter wide, and I will cut that. And I'll just take my electrocautery and cut that and then open it up a little bit and I leave it alone because it'll heal in and you'll lose that internal rotation deficit. I'd never close the rotator interval on a posterior capsule or labral lesion in a thrower ever. I did it initially, about seven of them. That was a mistake. I only do it in true MDIs. Please, you're only as good as your physical therapist. I see, you see the patients in a snapshot. The physical therapist sees them in a motion picture. Get good therapists and they will tell you what's wrong. So what about revisions? We talked about how to do it. Well, what are the, because no one wants to talk about the revisions. Well, I'm gonna talk to you about revisions. So this is our overall group without throwers, all right? Guess what didn't matter? Age, type of sport, contact versus non-cocked, level of sport, repair type and bone loss made no difference whatsoever in that group. We had 279 athletes. I did 19 revisions and this were the risk factors of the whole group with no throwers. Female, dominant arm, concomitant rotator cuff injury, three or less anchors and glenoid bone width again, which is really statistic, right? My revision rate for the whole group except throwers was 6.4 at nine years, which isn't too bad. If you look at contact athletes, they do better, especially American football players. They do the best in everybody. But I had 186, 11 revisions. None of those things mattered except for a smaller glenoid width, that was it. So that group, I had a revision rate of 5.9% at 12 years, which is 6% at 12 years is pretty good. I mean, I'll take that, it's probably my best group. Then I looked at the throwers and we knew these were gonna be worse. So these are the thrower revision rates. We did 112. The risk factors were female and decreased preoperative scores were the primary risk factors. Our return to sport rate wasn't too bad, 60% during the revisions versus 86%, but still hovering at that 86%. So the risk in throwers, you gotta tell your patients they're not gonna do as well, especially pitchers. So if you said to me, do the hierarchy, Jim, a hierarchy is the worst, pitchers, catchers, wrestlers. Then the best, American football players, contact athletes at the bottom. Those are the ones I like. So 8.2% at almost three years. Jeff DeLong did this, this was a meta-analysis study that he did, I mean, we did it in 15. He won this award for the AJSM. And basically we looked at 10,000 or 1,035 papers, 607 publications, assessed 53, and then we had scope versus overall almost equal. But this is what I wanna tell you out of that whole thing. So you take this message home. Arthroscopic is better than open for satisfaction, stability, recurrence, return to sport, and return to sport at the same level. So please learn how to do arthroscopic. But also know that throwers are less likely to return to sport, the same level, versus contact of the overall population. So the throwers are the worst group you're gonna do. In conclusion, I'm trying to make this black and white, but in reality, it's kind of many shades of gray. As opposed to Boston, which we had to listen to last night, Pittsburgh PA is the real city of champions with six Super Bowls and five Stanley Cups, and Matt Provence, excuse me, and here you go. All right, that's all I get up there and things. So I hope Provence is listening, and thank you all very much. Thanks, Jim, that's awesome. I'm gonna unmute some of the faculty and also have questions from, again, if any of the fellows or anybody has questions. Jeff, I think you're unmuted, right, Jeff? So Jim, can you comment? We're seeing, it seems like maybe more lat, as you're kind of talking about the lat and its role in this, seeing athletes with more lat injuries, pitchers with more lat injuries as well, and I know that's not really about instability, posterior instability, but you talk about it being a part of the risk factors for some of the posterior instability. Can you comment on that? Yeah, those are baseball pitchers, high-level pitchers. Tony Romeo and Mike Ciccotti, they see a lot of them. I don't see a ton of those because my practice is not major league pitchers. I usually see position players and pitchers, but most of the time, if they get, a lot of people treat them non-operatively, but I think they're swinging towards operative intervention in those lat people. All right, from Jay Wu, Dr. Bradley, thank you for a great talk. Can you comment on how your surgical technique and or rehab changes in cases with excessive glenoid retroversion? And I'll add to that, do you ever think about doing a humeral de-rotational osteotomy like Cheryl Swalsh had talked about in the past about this? So our study was very clear. I'm just gonna talk about the overall group first. It was very, very clear that retroversion didn't make one difference at all. That one patient I showed you there was a tight end from a large school in Ohio, went to the NFL. I did him, he's been still in the NFL. He's never had another problem with it. So retroversion doesn't really bother me much at all. Quite frankly, I just don't even pay attention to it, believe it or not. In my large group of 688, we did no de-rotation osteotomies. We did no glenoid osteotomies. And I just use, I use a lot of anchors, obviously. What I would say is the thing that bothers me are those posterior analogs. Those cartilage analogs are really a problem to deal with. That and bone loss, if you truly have bone loss. Those are the two things that would bother me. Hey, Jim, it's Jeff Dugas. Great talk. We got a question from Alec Brown. Thanks for the great talk, Dr. Bradley. How do you handle Bennett's lesions in pitchers? So great story. Jimmy Andrews taught me how to take care of those. Jimmy said, you know, in the old days, we went in there and we just went back there and went through the capsule and we took care of the Bennett's lesion. We took it out because it's extra capsular. We didn't have anything that's close it. So I just left it alone and they did pretty damn good. So I agree with him. I just go back there, make a little incision in the posterior beam, go back and get that out of there. And I just leave it alone. If the labrum's torn a little bit, I'll fix the labrum. But if the labrum's not torn, I'm not doing anything because I'm not going to touch that guy's internal rotation. I don't want to do that. Hey, Jim, it's Jeff. While we're waiting for some more questions, I was really, I liked the way you put the, you know, in talking to John Conway, the good slap, bad slap thing. I think we all, you know, years ago would fix those things up there only to find out that our, you know, return to play rate with slap repairs wasn't as good. So kind of delineating the good slap from the bad slaps, kind of something that John really led the way on. Compared to the way we used to do it, or thinking back to when we repaired all those things, what percentage of those things would you say you're seeing are good slap versus bad slap in the throwers now? Like everything else we learn. And my take on that is we're seeing, I'm doing less and less of that. Because I understand that you have to have a mobile segment superiorly. I know it gets bad. What I get worried is when that thing splits into the posterior, into the inferior labrum, beneath the glenoid, when it splits that glenoid, and you can see it on the MRI, that's not going to get better because you've lost your tension band, you've lost your concavity compression, and your edge loading is terrible. So two questions, where does the pain come from? I think it's the free nerve endings in the labrum and that capsule. That's where I think it was. And I agree with Neil Elitrage, that edge loading and that ratcheting, where you kind of rattle your ski around the corner, I think that's the problem. And I think once it splits in there and you get those splits in that capsule and along with the labrum, you need to fix it. But if you don't have that, and you just have a type 2B slap, you should rehab the stink out of it, make sure they don't have any hip problems, leg problems. I mean, there are guys that'll have an internal rotation contracture of their landing leg. All you have to do is fix their internal rotation contracture of their hip and their shoulder pain goes away. So it's very, the more I learn, the less I know. So it's kind of, it's a never ending process. It's like the gift that keeps on giving. I totally agree with you. I just think that the internal rotation loss in the hip may be impingement. I wouldn't try to stretch that out like the posterior capsule of the shoulder. No, I'm not arguing with you, but you gotta look at their hips. I'm just telling you, you better look at their hips, especially the landing leg internal rotation. Yeah. Jim, we got another question from Matt Fury. If the history and exam slash rehab is pushing you to address a slap, what is your threshold for touching the biceps tendon in the thrower? There we go. We got it. So I am the, the first thing you gotta say is what does the superior labral capsular complex do? I personally, my bias is I believe that it helps in translational and rotational stability at the end ranges of motion. And I think if you take the biceps, it's fairly clear cut. If you cut that thing and move it, the humeral head's gonna elevate. So my personal preference, and I even do type four slaps. I'll even fix the biceps in type four slaps. I'm a bicep saver at all costs in throwers. That's not other people that I'm talking about throwers only, but I will do anything I can to give them a chance. And you'll be surprised that these guys with type four slaps off the back, it goes right into the biceps. And if you sew that together, you'll be surprised at how they heal. So I'm opposed to other people like Tony Romeo. Tony is a different, has a different idea about that, which I respect what he says. But for me, the good Lord put that there for a very good reason. And I'm not taking it unless I have to. So Jim, I agree with you completely on that. What do you think about, is there a difference with that in a softball thrower? You know, a windmill pitcher versus overhead thrower. How about taking it? Two different things. Softball pitchers, I take it and do a tina disas, they do great, but that's a different motion. That's a totally different motion. I don't know what your experience is, but especially female underhand softball pitchers, that thing gets unstable and you can't control it because it gets unstable in the groove. And I'm not smart enough to know where to put the thing to stabilize it. So I just, I take it and I've had pretty good luck with that. What about you? Yeah, same. We think there's a big difference in that. And I think that those people, you know, the softball players, they all have pain, you know, as opposed to shoulder pain. Their pain's all in the groove. And we've had pretty good results with tina disas. I agree with you, though. I'm not a biceps hater in throwers yet, yet. Jim, do you notice a difference, or is there a difference in how you manage the person that has a slap that goes all the way down posteriorly only to about the nine o'clock position versus one that's going down to six or seven o'clock? Do you treat them any differently, either rehab wise or surgically or expectations wise? So let me make one point. I want everybody to hear this. This is what I've learned. If you have a high middle glenohumeral ligament or a buffer complex, and they tell you that they don't have an instability and that kid's still hurting, if you go in there and take their arm out of traction and put them in abduction and external rotation and go like that, that thing is totally unstable. And those are the ones I sometimes see go around the back just and stop at nine o'clock and don't go the whole way down. Volleyball players, swimmers, people like that get those things. So if you ever see an MRI with that complex, high middle glenohumeral ligament, or a buffer complex, I'm telling you, when you go in there, it's gonna be unstable if they become symptomatic. So those are the ones, the two Bs with that high middle glenohumeral ligament I'm a little more aggressive with. Now, if they just have a two B and they fail everything, I'll use three anchors. I never go to the front unless I absolutely have to. I hate going to the front because that's where all the irregularities are. So I will go from 12 o'clock to nine o'clock, three anchors, always three. I very rarely ever use two unless they're really small. And I've been happy with those. I really have. I just, that's kind of what I've been doing. I will say the other thing I've learned is take your time on the glenoid rim. Don't get excitable and immediately wanna fix everything. No, take your time, unroof it, abrade it, take the meniscal wrasse, take the slappers. I don't care what you use, but just upset that bone so you get a good biologic response. Because my failure is when I went in there and I look, there was a group of them that they didn't heal. So maybe I didn't spend enough time on them. You know, it was like sclerotic bone and it was just kind of spot welded. So, I mean, Jeff, do you have anything like that or? Yeah, I agree with you completely. I think more points of fixation, you know, we've gone to using all the all suture, the real small ones. We went away from the absorbable anchors a while back. We had some problems with some postage stamp fractures through those things. So we went to the peak ones and now we've kind of gone to the all suture ones. But I think more points of fixation, exactly the way you do it, don't grab the capsule. It's more of a down shot to the labrum than an around shot to the labrum. And you don't wanna go wrap up, it's not a lasso. You wanna get just the labrum and not the capsule. And I think those pictures that you showed and the way you showed it, it's really important to be meticulous about that. And be consistent as you go down. You wanna take the same bite always. You don't wanna take a giant bite in one spot and a little bite in another. You wanna be kind of consistent. So you're putting the labrum back and not pulling up that capsule. I think that's a hugely important point of that. Dr. Freehill has a question. Mike? Hey, Jim, great presentation. It was a real treat for all of us to see all your studies and all your experience with this. I had a quick question going back. I go back and forth all the time with this humeral retroversion and going to GERD and going back to the original K-jock descriptions of the anterior capsular laxity. And my question's just getting to that humeral retroversion. We know that Yamamoto had that publication in 2006 talking about the failure to derotate at the humeral physis. So basically, if you're not throwing at a young age, you're gonna independently assort out and you're never going to be in that group that can effectively throw, more or less. So once your physes have closed, so it's always interesting to think about, you're not gonna get more humeral retroversion. So what leans you to think more about that when somebody's gotten to an elite level of throwing versus soft tissue being the main issue? So first thing is, I'm a big fan of soft tissue getting thrixotropy. I think it does. I think it doesn't gel well. I think it gets worse with time. And then you look at the muscles especially, and over time, you will get deficits due to that. On the other hand, I don't think, we're gonna change our mind about humeral torsion or you say increased retrotorsion. It's not increased retrotorsion. It isn't because the arms initially when they're younger like that, they're in retrotorsion and then they derotate. So they have torsion. This non-dominant arm goes like this and the dominant arm stays back, right? You agree with that? And I totally agree with you. If you're a young man and you're not throwing a lot, this one's gonna keep going like that. Is where do we work? We work in internal rotation all the time. We don't work like this. We work in here. So I think what I wanna get my point across is this, please start thinking about torsion because I think some of the problems we're seeing is they're stretching the posterior capsule when they should be stretching the anterior capsule. That's my point and I'm getting that. Does that make sense to you? Yeah, it's something to definitely to think about. It's outside of the kind of the norm of what, we've been thinking recently, but I think that in certain players or athletes, certainly that's correct. I was just having a conversation with Mark Shickendance and Sal Frenjen more about some of these throwers at risk when you evaluate them and their external rotation's at about 90. Oh yeah. So I have to wonder, are those the guys that are a setup for to generate what they need to, to throw effectively? Is that when your lat's pulling a lot harder? Is that when your internal rotators, they have to make up the deficit and that's why we're seeing the rise in that injury. It's almost like the more we're learning, the more tougher it's getting. I told you, it's the gift that keeps on giving. If you start studying this, the more you ask questions, the more you're gonna not know the answer to that and you're gonna have to have all much more questions. This is where I'm at right now. And I've got fairly good data with the way we've been doing it for returning. I mean, 8.2% revision rate at three years is not great, but it's better than what I had before. So I think myself personally, I'm gonna be much more cognizant of relative humeral torsion versus the normal, versus their non-dominant arm in the way I rehab them. And I think probably one of the best slides I actually gave to everybody is all that sequence on how you look top to bottom and you go right down the list and just check them off. And what I worry about is their parents come in here and they want them operated on, I'm going, wait a minute. He doesn't need operated on, he needs physical therapy. Hey, JB, it's Albert. Nice to see you. I always enjoy this talk. So, and I always get something different. Hey, I wanted to ask you, sometimes I get these, I'll get patients with a lot of attritional cartilage. They'll have some cartilage loss or cartilage wear right in the back. Throwers, are they throwers? Usually they're non-throwers. I think they're non-throwers, right. They're usually non-throwers. But I wonder, you've had so much experience with this. Do you see this in throwers? And when you see that, what do you tell them and what do you do and how do you address that? Well, I typically see that in NFL linebackers, to tell you the truth, that's type five. Jeff Towers described that, we had a paper on it. I will tell you what I typically do in non-throwers is I take the labrum and I put it right up on top of that. And I basically decrease the size of the glenoid, but I'm getting a soft tissue on top of that arthritic circular segment. Luckily, in my practice, I don't take care of the 40-year-old throwers that have gone through the NFL or gone through the major league. And I don't see that much arthritis. I honestly don't. I do see those cartilage analogs, which is really hard to take care of. So Albert, to answer your question, if I had one along the rim, I'd probably just move the labrum up a little bit, but I definitely agree with what Jeff said. Yeah. He said, you don't make a lasso, you go kind of in the middle to the posterior two-thirds and you move it forward a little bit. And once again, one other point I wanna make is this, the inferior labrum from here to here around the bottom is four millimeters on the face of the glenoid. So you can move that up in the face of the glenoid. The top in the back is three millimeters off and the front, God knows where that can be anywhere. Hey, Jim, we got another question from JMB. Could you expand on when to do a double row label repair versus standard repair? So I use double row label repairs only anteriorly and that's when I have bone loss. And I think I can get the piece back that way, going underneath it and on top of it. In the back, I have never done it. I don't wanna do, well, and throwers, I'll never do it, but I have never had to do it. I've just never done it. In the front, I have. Yeah, I would say the same. We're using it for bone stuff. So listen, we're gonna say thank you to Jim Bradley, our current president and leader of the AOSSM and thanks for your leadership. Thanks for taking the time to do this. Great talk as always. And we thank all of you for listening and we'll be back tomorrow night. And thanks again to Mark Safran. So we're gonna wrap it up. Thank you. Enjoyed it, guys. Thanks, Jim. Thanks, Jim. See you. Thanks, Jim.

posterior instability

shoulder

throwing athletes

sports medicine

shoulder dysfunction

clinical tests

labral tears

knotless sutures

physical therapy

rehabilitation process