And we're just gonna get started with the Multi-Institutional Fellows Conference. Tonight, we have Michael Freehill from Stanford University. And we'd like to ask everyone, look down and mute your microphones if you're not muted. And there is a comment section for you guys to add any comments as we go along with the talk. Certainly, slap tears is still one of those subjects that can be a very controversial topic. I'm excited to hear this talk. And so this should hopefully stir up lots and lots of discussion. This is one of those things that it's always primed for discussion because there's a lot of camps out there on how they manage these injuries. And as always, this lecture and the others from this week will appear on the ALSSM Learning Management System. And without further ado, Michael Freehill. Thanks a lot for doing this tonight. Yeah, you're welcome. Can you hear me all right? Yes, sir. All right, so a little change of schedule, but this is gonna be exciting. I appreciate Mark, Dr. Safran asking me to be a part of this. It's pretty humbling when you look at all the faculty that's presenting to all the fellows and how much we can learn all the time. So my disclosures, the only one that, there's some instrumentation that I use, but it's not really should affect anything. So I think that it's important that all fellows realize, your fellowship years is outstanding. And what you learn during that year is gonna be just incredible. And the mentors that you have, they'll go on to be your mentors throughout your career and how much they can do for you. And you can get their advice and they push you forward in societies. I was very fortunate to do my sports fellowship here and to have Dr. Safran as my mentor. And I'm just very thankful he's brought me back. I don't know how, but I'm thankful every day for it. So, really take advantage of the mentors that you have. Now, this is, I also say colleagues, cause this is Dr. Will Workman. He's been coming on a lot of these and he's been a great colleague of mine. I would say he's a mentor in different ways as well. And it's too bad I don't have my video. My video is not linking here, unfortunately, because this is a YouTube link. I don't know how many of you have seen it, but it was Mike Trout hitting a golf ball at that same Topgolf. And he hit it all the way out of there. And the point was that Dr. Workman and I did not do that, but I thank him for allowing me to help him with the A's as well. And then international mentors, even though Hiro Sagaia is not on this talk, you know, my work in Japan with him, with baseball research has allowed me to maybe look outside the box and maybe search for some different answers with regards to the overhead athletes and slap tears. So, you know, we talk about slap tears. Most of us are gonna see patients that aren't pro athletes or even collegiate athletes. We're gonna have the weekend warrior type of recreational athletes. But, you know, the point is that you can get slap tears in many aspects of life and recreation and especially sports. But, you know, for the most part, when we talk about slap tears, we like to think about the overhead athlete and it's probably easiest just to talk about baseball players, because the most research has been done in that particular arena, especially USA and in Japan. Maybe we should be adding in Korea now since they're up and running even with empty stadiums. But I gave a talk in December to the Baseball USA Japan Symposium. That's why I have some Japanese words up there, cautioning, should we be fixing them? And how do we fix them? And the answer is, well, you know, you wanna take this on a case by case and patient by patient basis, but, you know, you wanna be really, really careful if you're doing these in throwers and make sure that you have the right diagnosis and you've exhausted conservative management. Mechanics wise, all of you have seen this before, the classic diagram and the figure that Fleissig and Jimmy Andrews did. And the one, you know, the thing to remember is, where do these slap tears occur? Late cocking, early acceleration, and then deceleration. Most of us know that, but it's good to remember. Late cocking, it's interesting that Jills Walsh was the first to describe this in tennis players back in 1992. And although this internal impingement was described as pathologic contact, you know, if you're an overhead thrower, this is a physiologic contact. And as we'll talk more about it, it can turn pathologic, but if you're getting good external rotation, you're probably getting some contact up there. And we have Burkhart, Morgan, and Kibler's, you know, the three-part paper in arthroscopy, it's a classic, and they went deeper into this, this internal impingement and this late cocking and the way that the biceps tendon, when you're coming back into late cocking, is really wringing on itself with repetition is that biceps tendon eventually gonna pull that superior labrum off the top of the glenoid? But we don't wanna forget deceleration. And that's probably the most harmful. The point here is that, although it makes sense that the hyperexternal rotation could cause a slap, it's probably just as easy that the deceleration can. We know that it's the most violent. We don't want your arm to fly off your body. So your posterior cuff is working pretty hard to slow that arm down. So those muscles are in an eccentric mode. Your biceps tendon is going with that arm. So that's, again, that's tugging on that superior labrum. Doesn't matter, late cocking versus deceleration probably doesn't matter, but it's just a matter of knowing that it can happen in either place. The other point to make with the deceleration is your posterior inferior glenohumeral ligament. And I bring that up because that, with time, has the chance to become contracted. All of us know this is glenohumeral internal rotation deficit, right? The important point here from that Grossman paper is that with late cocking in abduction, you're going to have some migration of that humeral head in a posterior superior direction. If you have GERD, internal rotation deficit, that's going to be hyper accentuated. You can see how that's going to move more superior or at least more posterior. And that's going to ride up into that glenoid and that anterior infraspinatus. So why do we care? Well, we know that this has been associated with pain and with injury, including slap tears. So let's change gears a little bit with anatomy. Ed McFarland at Hopkins described these labral variations. Although we usually talk about these as being the Buford complex, that's only one of three of them, and it's the least common. So about 14% of the time, you'll have one of these three. That can be just a regular sublabral foramen, but you still have some labrum in the superior anterior region. The Buford complex is when you have no tissue, and that's what's drawn here, and a cord-like ligament, or you can have just a cord-like ligament with a foramen as well. So all of those are potentially there, and you want to make sure you identify those and don't repair them. So let's go through some of these slap types. Although now we have many types of slap tears, up past 10, let's stick to the original four by Snyder, at least initially. So type one, fraying underneath the biceps anchor. You can see some of my arthroscopic pictures, hopefully can show this a little better as well. And then I show this, I don't know how many of you have looked at those shoulder dock images, which are outstanding. And this is the guy that's behind that, Leonard Funk in the UK, who's a tremendous shoulder surgeon, does all the high-level rugby players, and that's Uma Srikumaran and myself on our traveling fellowship for shoulder elbow there last fall. But the cool part about Len Funk's house is he's got this separate garage and he's into all these American muscle cars. So they're just lined up, probably six or seven of them with all of his Americana souvenirs to go with them. So if you ever have the chance, he would love to show this off to you. We'll skip type two for now, but let's go to type three bucket handle, but the biceps anchor is stable. So you can see the bucket handle type of tear coming in. Generally speaking, if you're to treat these, this is debridement with regards to a type one or a type three. Then you get the type four, it's a bucket handle again, but now you have this extending up into the biceps anchor. This is interesting because I think historically, they would say biceps tenodesis for this. I think you have to weigh in the patient's age and what you're trying to get them back to. You can repair this. It depends on the tear quality, et cetera, but I wouldn't just automatically jump to a tenodesis, especially in a younger patient. So now let's get back into our type two here. So all of you are sports surgeons on this call. You have to understand it's not a type two tear. It's a type two A, type two B, or type two C. They're different. Type two A, under the anchor and just anterior. Type two B, under the anchor and just posterior. Type two C, under the anchor, extending both anterior and posterior. And that's gonna change things as you treat these. How about imaging? Really controversial. In this day and age, a lot of people will say, you can get what you need out of a regular MRI. And maybe in some places that's true. I think when you're talking about labral pathology, that the contrast medium can really help you as it will outline what's going on under that superior labrum a little bit better. I know that we've had people present to us and we all have mentors that have been doing it a long time. And we start talking about the professional athletes. Yes, that's a little different if you have a player that not necessarily can't compete, but you just wanna make sure nothing's going on. Putting dye in there does knock him out for a while, for probably up to a week. But if you have a player or an athlete who's unable to perform, I think that helping yourself with the contrast is gonna be more beneficial. Well, we know that determining whether or not it's a tear or not is very difficult. This is a JP Warner publication where he had these 22 vignettes, 15 second snips and 73 members and a shoulder elbow AOSSM. And you can see that there was difficulty distinguishing different types of lesions, but the most difficult, interestingly, was normal shoulders versus type two tears. And there's probably some faculty members on this call that were maybe part of this study. So this is an expert hand, so we know it's difficult. Are there some hints that we have? Yes, there are. You look at a tear, a full thickness slap up top versus what I would call more of a normal variant cleft. Here you have some hemorrhagic type of tissue, some granulation tissue in there. You have a full space. Even if it's small, it's a full space. Here, you don't really see that. You do see a back of that labrum. The way that your probe pulls up, this is more of a tent. It's more of a sharp angle versus more of this smooth arch. And then the presence of cartilage. Here you can see it's a little rough up there. It's a little hemorrhagic there. We're here, and you guys will see this a lot. You'll pull up the labrum, but there'll be smooth cartilage on there. That has to make you think, is that a true tear or not? So is this a tear or is it not? Well, it's probably a type one tear, but it looks like it's not full thickness. There is some cartilage on the top of the glenoid. So you have to ask yourself, what are you gonna do with this if this is your patient? What are you gonna do with this if this person's symptomatic and you've moved on to surgery? Are you gonna repair that? These are good questions. As far as physical examination, different people have different ways to attack this. What I would tell you is have at least three different examination maneuvers. You're gonna learn different examination maneuvers from your faculty at your different fellowships and different things that work for you. I'll do the O'Briens every time, and I'll just have them put their hands together. That's how I make sure that they're doing what you want. The important part with this is that when you flip their thumb up, that the pain improves. If it does not, I usually call that equivocal and start looking somewhere else. Mayo shear, this kind of a Kim-type test derivative, but the mayo shear is basically bringing that arm up and trying to reproduce almost the throwing motion. You're trying to catch that superior labrum with a tear, and I call this a Savoie. Buddy Savoie doesn't like me to call it that. He says it's not his test, but nonetheless, this is just resisting in about 45 degrees with the arm in 90 degrees of abduction. When he resists, when that patient resists, if they have a full thickness superior labral tear, that humeral head should translate superior and cause some discomfort. Always, always take the shirt off and look at the scapula. You have to assess the scapula. Many, many times, regardless of what the MR says or the reason for the visit to you, their scapula is going to be having some difficulty. Now, that doesn't necessarily mean that they have everything going on, but more times than not, you can address that and help them. Also, they're going to have internal rotation deficits. I talked about that a little before. You can see the dark lines here. That's going to be the throwing arm. External rotation is increased. Internal rotation is decreased, but the total arc of motion or range of motion is the same. When you start to lose this, and we can say 19, 20 degrees is what's been shown to probably be relevant and be concerned about, a lot of your players are going to come in, or athletes are going to have a slap tear. You're going to see it, but they're going to have scapular dyskinesia. They're going to have internal rotation deficit, and you can address that non-operatively and they'll get better. Here's a professional thrower. Same thing, shut them down for six weeks. That's what you want to do for sure. Anti-inflammatories, we'll get into some different injection types, get them into plyo, rebuild their core, and then move forward. How about biologics? A lot of great talks in these seminars about biologics, and you have to remember there's different preparations. We've gone through all that. We're not going to beat this too much. People are injecting different types of cells and PRP around the superior labrum. To my knowledge, nothing's been published that would support this. There is some expert opinion that says it helps. I think at this point in time, is it a stem cell or a biologic that's helping the healing, or is it the fact that maybe they finally shut down because they had a procedure or intervention performed? It's very interesting when we talk about treatment. This is not so much specific for the athletes, but just for the everyday person that comes in, and this was back in 2012, and they looked at the individuals taking the type two candidates or the second step for the boards, and they were concerned at that time that the number of candidates were reporting doing all these slap tears three times what the published incidence was. So there was some concern there, and they were also concerned that maybe they were doing it in individuals older than should be having this procedure. Nick Verma and the Rush Group came back last year, not necessarily the same exact step two candidates, but looking at a big private payer database, and it did seem that people were still addressing slap tears, but more so with biceps tenodesis, especially in older patients, and again, we'll get into that with regards to support from the literature. So going back to the overhead athletes, specifically the baseball players and the outcomes and why this is a bigger deal than you think, getting somebody that is a very effective thrower at whatever age that might be and doing a slap intervention or slap repair could be very detrimental, regardless of how good you think that surgery went. We won't go into too much depth, and maybe some of the Jefferson guys are on this call, Steve Cohen or Michael Ciccotti, and I still talk about this study with patients if this is even being discussed, that we may need to move forward with surgery, and I think that you're not doing your patient or their families justice not to say that in overhead athletes, this is maybe a little bit better now, but 63% coming back to what they once were, that's not so good, so you wanna move into this with ease. There's one of my mentors from my previous life, Lou Yocum, who's passed away since, but I think that this was a very telling story with regards to this manuscript. He took care of a lot of pro athletes for a long time. It was Andrews, Yocum, and Joe probably seeing them all, and so he's an experienced guy in the bottom line here, pro and college pitchers return 57%. Interesting, if they just had a slap and the cuff was okay, 80%, that's pretty good, but a lot of them have partial thickness tears, none of them even 50%, just the breeding mats and doing the slap repair, 12.5% return, not so good, right? So we need to be very thoughtful before moving in and doing this. Let's talk a little bit about techniques and thoughts, and I put the American flag there because I think that what we're gonna lead into with some different philosophies, it's important to discuss at least some of the dogma that I've learned. So type 2B thrower, type 2B slap tear, I think that you have to make sure if you're gonna go posterior, which that's what we've been taught, don't go anterior to the biceps anchor, stay posterior, you can go through the rotator cuff, we'll get that on the next slide, it's not really the rotator cuff, it's actually the musculotendinous junction of the rotator cuff using knotless anchors, but go through that trans tendon portal to get those anchors where you need them to be. So again, I think it's a little bit of a misnomer, it is going through the rotator cuff, but we're going through that musculotendinous junction, you're going medial to the arch there, the cascade to make sure you're not going through the tendon. HSS studies show they followed them for pretty long time, almost four years, and there was no rotator cuff pathology later, so this is safe, and you can do this. Here's an example of it, you can see the movie running there, coming through, it's a port of Wilmington, you can make that anywhere you want, really off the acromion, the tighter you are to the acromion with your spinal needle, the better you're going to be for your alignment, but you can see how that's going to line up anywhere on that superior and posterior glenoid. The point though, is be medial, be medial to the tendon itself, and you can see there, maybe I could even be a little more medial, but that's where you want to be. With that said, okay, so here, there's some tricks that I told you, but are we still missing the mark going back to 63%? And that's where some of these thoughts, I think are interesting to share that I've learned from Hiro Sagaia, and I'm not saying that he's right, and we're wrong, or we're right, and he's wrong, I'm just saying that at this point in time, we don't have enough answers and enough success that we should just close the door on this and not be thinking about it. So that's with Hiro in the Tokyo Dome there. And his point was, well, he thinks that the baseball players weren't doing so well with regards to slap repair, because, and this is interesting, because a lot of these knotless anchors came out, but they're very, very rigid. We put different heavy number two nonabsorbable suture, now we're putting tape, you pound those in, there's not a lot of control. Are you over-tightening that superior labrum to the point where they cannot get back, they cannot get that the glenohumeral translation posteriorly that they need to be an effective thrower. Totally switching gears, you know, if you look at throwers a lot and the pathology that goes on, you know, for a lot of us on this call, we kind of were ushered in with the Kibler, Morgan, Burkhardt, the Gerd, maybe Ben Kibler, scapular dyskinesia, but you go back to the some of the original work at Curl and Jobe, who were looking into this before anybody for the most part, you really think about the anterior capsule and the ligamentous structures up there and what was going on, and this is what kind of led to the thermocapsulography and everything else, but we know that this starts to stretch out. 18 degrees increase in external rotation, the capsule elasticity really increases. Well, most of these guys do get hyper external rotation. Are you overstretching that anterior capsule? You're actually sliding forward, sliding back. If you're sliding forward, are you pulling down? Again, it's something to think about and it's leading into Hero's thought process. Terry Mahada, we all know of SCR fame, also showed that the anterior inferior glenohumeral ligament is elongating with that excessive external rotation. So this anterior superior corner that Hero's talking about, well here we go. There's a nice diagram or nice drawing here of a slap tear. This would be that type eight that Ben Kibler talks about a lot now, and this is coming down. We don't want to miss that. Ben gets excited because he likes that type eight. Now the point would be in America for the most part, we would repair posterior ligaments. Hero's point is that's fine, but don't forget to just now, again, if it's a sublateral foramen, you got to be careful. But if it's just SGHL, if it looks like some capsule that's stretched out, putting that down might help with the normal mechanics of a thrower, even if you left a little bit of a tear back there or you didn't repair it with such rigidity. Again, we'll get into some more constructs as we move forward. It's certainly food for thought. So right now, slap repair, well what do we know? Well as far as technique goes knots, I think that all of us would say knotless up there is probably better now, so you don't get some chondral damage and you're not getting irritation rolling onto those knots. Suture material wise, well that's probably what's used mostly. I think that I've kind of gone back to the way it once was. I like using zero PDS. It's going to dissolve in four months. I think that it's got a little bit of elasticity, so it allows the superior labrum to heal. Probably more anatomic to the way it should be than over constraining it. I think anchor material wise is dealer's choice and your comfort level and the position. Again, you know, it probably depends on your patient and what they're doing and what you're getting them back to. But, you know, maybe we should be doing a little more anteriorly. So paper that Will Workman really drove and came up with this thought process, which I thought was great. If a faculty member is reviewing this for arthroscopy right now, please give it good marks. But the bottom line here was, what's out there about the reported technical aspects, the reported constructs? Is there anything that we can take from that? And not surprisingly, surgical technique, if reported, is extremely varied. And the detail of how they're reporting that is varied as well. And the bottom line here, although you see some trends here and there, we're really unable to define the best, most effective treatment or technique at this point. But I think it's important to know that. Not just to say slap repair doesn't work, because there's so many different repair types. And I've showed you some potential thoughts of maybe of what we can do to make that better. So it's important to know that we don't have enough technically to know if we're doing what's best to even allow this to be repaired correctly. So this is my old technique. We'll go through this a little. You can see there I switched. I put a smaller cannula on my low anterior, an eight millimeter cannula high anterior, so I could instrument through that. So this is one where I wasn't going trans rotator cuff, right? I am going to go all through the rotator interval. And there's pluses and minuses to this. This isn't a throwing athlete, but the labrum looks pretty good overall. Probably don't need to be too crazy here. But they were symptomatic and I added some rapivacaine into their contrast dye to help rule in, make sure that this was where this discomfort was coming for. Technique-wise though, need to concentrate on this. So heavy, actually I did, I did go through my tendon there. Okay, so here we go. This allows us to get posterior to that anchor. Make sure you don't incarcerate the biceps. That's important. A smooth silver cannulas, that's just the trocar. You don't even need, or the cannula, you don't even need to put a, you don't want to put a real cannula with threads through the musculotendinous junction. You can. I think it's probably easier to do this. This was peak. And just put this one anchor in. But you can see this is a pretty robust repair. Three anchors. I put a little one up front because this was, was more of a weekend warrior type of athlete. But that's pretty robust, right? If that was a thrower, would that be too tight? Maybe. This is my current repair. And you know, Javier Duralde showed me this trick. And I think it's great. It's, it's doing a luggage tag using the zero PDS. But the thing that's nice about this is when this gets tapped in, that luggage tag will pull it. So your, your labrum is rolling in. Your labrum is rolling back to where it needs to be. Versus if you go the other direction, it's going to pull it away. And I think that this is a little bit better. Like I said, you have a little bit of elasticity there. Those sutures will resorb. And I think they'll do okay. We had a great talk by Dr. Bradley, the president of AOSSM right now, about posterior labral repairs. And he had some great recommendations, advice, and experience with the throwers. Remember that if I, if you're doing a football player, some kind of collision athlete, you're going to do it on there. Take some, take a pinch of capsule and then go under the labrum. You need to do the capsuloraphy. That's very important. But remember what Dr. Bradley said. If it's a thrower, you're not going to take that capsuloraphy pinch bite. You're just going to repair the labrum. So again, you got to customize. You can't do the same thing every single time. Somewhat, but you have to have slight differences and changes. This is something that to my knowledge hasn't been supported in the literature, but I do this with slap repairs as well as posterior labral repairs. And I think that with this external rotation brace, you know, just past neutral, that that allows that slap to heal, not in this position. If they're here, look, you need to get them back to here. I think it's just, I think it's better and it's easier to get them to where they need to go by putting this type of brace on them. Bottom line, they're going to get back to some kind of sport in probably this nine month timeline. But to be effective, especially with a baseball thrower, you're probably looking out over a year. So does this work? I think in certain athletes it does. I put these videos on because both of these guys, I mean, men's gymnasts at that level are freak athletes to begin with. They'll make all of us look good. But both of these guys had that slap repair with that technique I showed. And you could probably say that they're putting a lot of force and a lot of tension across that. And these guys seem to do pretty well. So I do think that, you know, there are ways that we can be successful and maybe we need to look more into this. But like I said, it'll be great to get faculty members advice at the end of this talk that have done a heck of a lot more slap repairs than I have. What about biceps tenodesis? Mark Safran told me I needed to spend a significant amount of time on this because it's his favorite procedure. So I think that all of us would say if you, if someone fails a slap repair, it is a legitimate option. Mitchell? I'm just muting you there, Freehill. You know, because we don't want to hear about the... Wow. All right. Are we back? Yeah, you're back. All right. Age 35, 36. Again, we'll get into some of the literature. And I think most of us would support doing a biceps tenodesis even as an index procedure there. But a big question becomes, what about the younger patients? Can we use this as an index procedure? And going back through what I went through with rigidity of these heavy number two knotless fixation anchors, the loss of the physiologic motion if you tighten them down too much. We know that it's a very highly innervated region at that proximal portion of the labrum where the long head inserts into. And we know the rates of return in the throwers aren't so great. So would this be a legitimate option? Going back to the age. So in 2013, this is a classic paper by Matt Preventer looking at the military population and looking at where was the break point or what was the greater association where you saw that break point of where failure seemed to be present and revision rates seemed to go up. And it was 36 years of age. A year later, this was from the Harvard Shoulder Group. It was very interesting looking back at J.P. Warners and he just looked at who'd had a biceps tenodesis, who'd had a slap, kind of looking back. And it was pretty fascinating that the excellent results did demonstrate a demarcation at the age of 35. So very similar to what Matt Preventer published. So I personally use that 35, 36 unless there's a reason to keep it or it looks really pristine. If you're going to do address a slap tear, tenodesis might be the right thing to do. 2014, some interesting papers came out. This one came out of Rush and they were looking at the abducted externally rotated position. Looking at that late cocking position and had some different types of constructs but this biceps tenodesis and a slap repair. So tack the slap down. It was very interesting that they had near complete restoration of the biomechanics of that joint doing the biceps tenodesis and the slap repair. Anterior instability was still a little bit of an issue when you had a type 2a or a 2c. Makes you think a little bit about that Hiro Sagaia philosophy. But nonetheless, the point was, hey, if you have a slap tear and they're a certain age or knowing our slap repairs don't do so well, is this an option? That same year, the Rochester group with Voloshin and Michael Maloney looked at cadaveric specimens and they left some bicep stump. They did a tenotomy not leaving any stump. They did a full detachment of the superior labrum and then they repaired that full detachment. Very fascinating that when they did have a tenotomy but then repaired the labrum, that statistically the stability was no different than baseline. So at this point, about 2015, I thought to myself, could this be the future? Could this be the breakthrough that we are waiting for? Biceps tenodesis, perform a slap. You might not have to do as much of a slap, just fixate that tendon or the labrum down enough so it's acting normal. And I did do this, not in any baseball throwers, but did do it in some crossfitter type of people and they seemed to do okay. Well, since then, it's interesting because the initial report from Tony Romeo was that this might be going okay doing a tenodesis in more elite throwers, but then we know in 2018 he came back and published maybe not as good as we thought with regards to return to play. And you can see biceps tenodesis alone, return to play for at least 20 games, and I think that's important when you look at baseball literature to realize what is the return to play criteria? Is it one game or are we looking at things in more detail? And here's your biceps tenodesis and slap repair, only a quarter of them got back. So I think that that let us know probably need to take caution and that that's not the best answer either. Well, how about when we do do the tenodesis? I think that it's very important to understand these three zones, A, B, and C. Understand what Moon has shown us that about 22 percent of lesions, whatever you want to call lesions, that might be interstitial tearing, tenosynovitis, whatever, is getting down there into zone C. If you do a subpectoral tenodesis, you are ticking that off the board. If you do not, there is a chance that you could have some residual symptoms or pain. This is a big deal with those who are anti- subpec and this was a veil study and no doubt this is a risk factor. You are going into the hardest bone in the humerus in the bicipital groove, but you got to be careful and make sure that you're perfectly perpendicular with that groove. If you're not and you have an eccentric hole, you can reduce the the humeral torque strength significantly and that could cause you to get into some trouble. Now remember they did this study with eight millimeter interference grooves by the way. This was a very important study to me because I like using as small of a hole as possible and I think that this showed us that at least for biceps tenodesis, though you can't apply this to other places in the body, that you don't need to dunk the tendon. You just need it on on a roughened periosteum or a roughened cortical surface. That's where your your calcification and your healing that that new bone formation is going to take place. So you don't need to be messing around where do I make this hole? How far do I whip stitch the biceps? It's all irrelevant because you just need to get put the hole where it needs to go and get this down and I'll show you some tricks that I have for this. I made these models a while back for some courses and I think it's interesting to see what an eight millimeter interference screw looks like and how much real estate that thing's taking up. When I came out of fellowship, this was this is what I was doing. The second fellowship, Dr. Safran, I don't want you to think you were making me kill all these biceps, but I was using these two millimeter peak anchors, very small pitch on those threads and I think that what this you know fake biceps tendon is doing is what would happen sometimes with real biceps tendon. This is just not biting well enough and that's why I went to the smallest pilot hole I could. It's about 1.9 millimeters, double loaded, send that that suture button out, expand it in the intramedullary canal. It's got incredible strength. So this is my technique now, just finding a crease already there. The bottom line, this is a safe entry. If you find the inferior aspect of that pec tendon, know where your conjoint is, sharp homin up over lateral cortex. Don't pull medial. I use a blunt homin and I don't pull very hard. I'm just reflecting. Saw my long head, roughing up the bicipital groove right there. There it is. Very small incision. Here's the point, make sure you're perpendicular, gestural unicortical. Here comes that button, hit the back cortex, pull the guide up. So now I can deploy this into the intramedullary canal. And you notice I have not gone into the joint yet. So all those questions about how do you tension this, we don't have to worry about that in theory. So what I'm going to do now is take a right angle clamp and just get that biceps where my anchor is and pass one of the sutures. Okay, that's a post. By definition that suture, that post should be where the biceps wants to lay. Pop into the joint really quick. Very, very quickly go up to the biceps and cut it. Now I've done my tenotomy. Some people say I don't want to do that extra step. This takes legitimately five minutes. Then you pop it out. You've done all your preparation work. You don't have a boggy shoulder if the cuff was big and it took you a long time. I've changed this a little bit now. I don't go through the tendon to perform these lasso loops. I just go around. That was Di Giacomo from Italy with our Issacash shoulder group that said, hey this is a great technique, but just go around it and do the same thing without going through the tendon with the non-post. And he's right. It's outstanding. You only go through the tendon two times. Know which one's your post. Pull those posts. That's going to suck that long head right onto the bone. Tie this down. Cut away your tendon. It's pretty quick. It's reproducible. Two 2-0 vicorals to re-approximate. 3-0 monocryl to run this and Dermabond glue. These are very cosmetic. You've made it in a crease that's already there. Females who like to wear the spaghetti straps are very appreciative. That's my technique for that. So in conclusion with regards to slap tears, I think that still with an overhead thrower of any sport, you need to exhaust conservative management. Usually you can get them back doing fixating on their core, getting their scapula retrained, and just balancing them. Make sure that the internal rotation deficit and thrower is taken care of as well. In these recreational athletes, it's a little bit different, but you want to make sure that it is the slap that's causing the trouble. I think that the slap repair is still the gold standard, especially in the younger people, but questions remain. Are we missing the mark a bit? Should we be thinking outside the box? Should we be considering maybe putting some of that anterior tissue down just to help with the dynamics of the joint? The technique I think is critical. Utilize that trans musculotendinous rotator cuff portal, and you can do it without doing much damage. Use the smooth silver cannula. Place those anchors where you need to. Do not over constrain. I think that you can do this with techniques using zero PDS, using knotless technology, and then I think tenodesis and throwers and overhead athletes is reasonable. However, I think that it's it should be done with caution in revision settings or in certain age settings, but at this point in time, I don't think it should be utilized as an index procedure. Thank you. Excellent. That was great talk. Except for the part about the biceps tenodesis. If anyone out there has any questions, feel free to add that into the chat, and while we're waiting on some questions to filter in. Michael, you're an athlete with the paralabral cyst with a slap tear with or without involvement of their suprascapular nerve. What's your approach to that athlete, and how do you manage those? Well, where is the cyst? Is it staying more superior, or is it getting down into that more posterior? That's part of the question I would have, and then how involved is it down the down the posterior labrum? So in posterior labral tears, I think that that one you can decompress even through the tear, and then go ahead and repair that. The slap, it's a little bit trickier. I think that you have to take into account all of the above, but generally speaking, if I thought that that cyst was causing trouble, I would decompress it through the tear, and that would be just getting the, liberating what was left, getting the shaver up to the edge. I don't want to dive down there, but just trying to milk it however I can. It's a little easier on the posterior ones, but letting that shaver run. Usually you can get most of that out, but then I would go ahead and repair that and I would use the zero PDS in an atlas. Still waiting on some questions here. Also, so you spoke about the dismal sort of return to play in athletes with, you know, undersurface sort of posterior cuff tears. What do you, in the setting of slap tear also, what's your conversation with those athletes, you know, before surgery, after they fail conservative management, just in terms of, you know, besides just telling them the numbers, because certainly athletes hear numbers, but they really don't hear numbers. You know, what's your conversation with that overhead throwing athlete? Yeah, I mean, those are tough conversations because we know that it's hard to return, at least to the level that you want to be at. So I think that to me, and it will be interesting to get Steve and Will and Dr. Saffron's ideas on this, but I think that that's a horizon that we're still going to get to and there's going to be an answer that I think that when you have to repair this, so everything else being equal, they can't get back. So you have to do something, right? But I think if you do a slap repair, however you do it, that's been successful in your hands, but with regards to the undersurface cuff and the results of just debriding it in that setting, I think that there's going to be options. I don't know what that is yet. I think I got all the recycling stuff. That might be able to help you. Now I just debrided, I wouldn't repair that. Yeah, is there ever, and again, I have not ever seen a situation where, you know, I've gone on to repair one of those undersurface tears. Is there any situation where you see that and you say, well, I think we're going to try to repair this if it's high grade, high grade lesion, or is that always just a debridement and, you know, address the slap and get out of dodge? For me, it's a debridement and get out because I don't think they're going to come back from a cuff repair. Anyone else want to call? It'd be interesting to get Steve's, Will's, Mark's thoughts on that. Steve, when you want to start. Sorry, just, I was with you and then I got distracted by one of my kids. So Steve, I'll just repeat the question. So any situation where you look at a, you know, athlete, overhead athlete, throwing athlete, type two slap tear, unstable biceps anchor, and they have an undersurface tear involving a rotator cuff. You know, I think most of us are looking at debridement of those lesions. Is there ever a lesion in the rotator cuff that you look at that's not full thickness? So whether it be very high grade in a thrower that you consider repair or some other treatment, you know, for that? Yeah, I think it's a good question because I, you know, oftentimes it's very difficult to discern, you know, and I think Mike and Will will probably, you know, anybody who takes care of throwers will agree with this. You know, ultimately, what are their symptoms coming from? Is it the cuff or is it the slap? You know, the good slap, bad slap as, you know, as kind of the new term that John Conway and Jim Bradley have been starting to use. You know, I think certainly some slaps are adaptive, other ones are not. I think the majority of time you're thinking you're gonna debride, if at all possible, a cuff tear because we know the results of any type of cuff repair in an elite overhead athlete are just, they're worse than the slap results. So I think when in doubt, you really wanna try to debride it. If you really have a sense that it is the cuff and it's very thin or, you know, they're imminently gonna develop a full thickness tear, then I think the results of an in-situ postural repair are gonna be way better than if you try to take down the cuff and reattach it. So I think, you know, I think Mike's point of, you know, and the athletes know this, the very last resort for a professional athlete, a pitcher, is a shoulder surgery. They'll easily acquiesce to an elbow surgery, but will not to a shoulder, that they know better than a shoulder surgery. All right, so I also have a question from Jake Kelsey. Thank you. Is there a role for suprapectoral bicep tenodesis in your eyes? Yeah, there is, but in this population, I don't think there is, but yeah, I mean, there's certain people I will do suprapec on, you know, certain types of subscap tears, I'll tie that in, body habitus, certain age, diabetics that aren't as well controlled. So I'll use the biceps tendon as an augment to massive tear. So there's certainly, you know, things I do with the biceps that's not, but all things being equal, I think I, subpec is my workhorse. Excellent, and then a question from Joseph Donahue. Excellent, and then a question from Joseph Donahue. So what about biceps tenotomy versus tenodesis? When do you do those? I think you sort of talked a little bit about that, but is there a situation where you're gonna tenotomize a biceps and overhead throwing athlete? Quarterback. If I can paraphrase that question, I guess, yeah. Quarterback? Yeah, you know, I mean, I think that Dr. Safran's talking about the quarterback because Elway and Favre had those, but you know, this is like the independent assortment of two of the greatest of all time. So I, and I don't know. I don't know if I would do a tenotomy on a thrower or even a quarterback, but you can't, I guess you can't argue with it. I'd be a little worried, but you know, I guess if you laid the crepe that, I mean, I would imagine that they're gonna end up with a Popeye with the number of times they're gonna throw. I mean, I would think that that's just gonna fall down. If they're okay with that, they know that there's a, you know, 10, 12%, 15% chance of cramping, maybe even more. I haven't done a tenotomy on many active athletes. I don't know what others have. Yeah, same here. You know, I don't do a whole lot of subpectinodesis, but that's the group that I think I will do subpectinodesis in without a doubt. And I think you don't have to worry about disease in the bicep tendon, because pretty much you're at that muscular tendinous junction. And so, you know, I can make an argument in some of my older patients to do super pectoral versus subpec, you know, based on what the biceps looks like. But as you sort of mentioned that, you know, I like the idea of subpec for that reason in the young athlete. Question here. Latul, real quick, just along those lines, and I think Mike made the really good point that, you know, the initial hardware were these eight millimeter holes, seven millimeter screws. You know, you can, there's any number of ways to do a subpectinodesis, either with small anchors, with small drill holes, with a biceps button, you know, that you're drilling, you know, three millimeter holes, four millimeter holes, even if you use, if you size it based on the biceps, you know, the old way of putting an interference screw, but you size it appropriately, you can put a less than a five millimeter screw in there, and you don't have the size. So I don't think that the risks are nearly as high for that fracture of the proximal humerus when you're doing it with probably more modern techniques and appropriate hardware. Yeah, very good point. So next question, what are your thoughts about the function of the biceps on overhead throwers, specifically pitchers? And then the second part, it seems to me that most non-overhead throwers do great with the tenodesis, while pitchers are completely different animals. Yeah, yeah, that's kind of interesting, right? I, you know, this will probably get some argument, especially from Dr. Safran, but the reality is, to my knowledge, it's very limited what's out there about the true function of the long head of the biceps tendon. Yes, God put it there for a reason, but what are the studies that, there's very limited literature, a couple of EMG studies, a couple of plain film studies that show that it's a humeral head depressor. And those studies, you know, and they're not even uniform in what they're showing. So yes, I think it does have an aspect of helping to contain that humeral head in that hyperabducted position. And maybe if you don't have that, you know, maybe it's kind of like having that ger, you know, maybe you have a little too much play. And when you're talking about an elite thrower, maybe it's just not compatible with being able to do what you need to do, even though you can throw adequately. A guy throwing across the diamond from short or from the outfield or even catcher is different than somebody that, you know, millimeters of change at their release point here is gonna be a drastic difference of where the ball crosses the plate. I wanted to ask Will Workman though, cause it's very interesting. He's taken care of the A's for 10 years now. And, you know, we always talk about the baseball players and certainly we see most of these patients in the clinic and they're high school kids and college kids because they come in and they have wear and tear, their mechanics are poor, they're all imbalanced, their scapula is all over the place and they've gotten an MRI and it showed a potential slap. But the reality is even the guys at the highest level, almost all of them have a slap. And my question for Will, and we can go around with the different guys who take care of the pro teams, how many slap repairs have been done over a decade? Yeah, that, you know, I was thinking about this whole thing and it, you know, when we're talking about the elite overhead, well, essentially major league baseball player, right? Major league baseball pitcher, you know, it's the one area where we can't just repair, restore the anatomy and expect them to do well. In fact, we've learned from the giants of our specialty from Andrews and Jobe who, you know, early on repaired rotator cuffs and repair slaps that it just doesn't work. So it's not as easy as just making the anatomy go back where it was. It's obviously much more complicated. You know, it's their capsular attenuation that's causing instability on top of the slap. And I mean, it's easy on MRI to see cuff pathology and labral pathology, but, you know, findings is not truly pathology. We've done, I think roughly zero slap repairs in the decade that I've been with the A's, you know, on pitchers. We see some sort of labral pathology in almost every pitcher at that level. I think as far as managing these guys, I mean, I would echo what Steve said. You, surgery is sort of a last result, which is not very reassuring. It becomes sort of a hail Mary. We have baseline MRIs now on most of the guys, which I think is helpful because if we can truly see a change in the cuff, that's, you know, going way downhill or a change in the labrum that's going way downhill, that may be a reason to address it surgically. I wanted to bring up something about the cyst, paralabral cyst. I think that gives you a good excuse to operate a lot of times, but those can also sometimes be managed by aspiration, particularly mid-season. You know, if they're getting some pain from that, I mean, an ultrasound guided aspiration of a paralabral cyst can help. My feeling about the biceps is that, you know, it is put there for a reason and an isolated biceps tenodesis in a young thrower, I'd be very careful about. I think it makes sense possibly in a revision, but again, it's a salvage procedure. So, you know, I don't really have much experience doing that because I would do a slap repair first and, you know, my failures, I don't know, maybe I just don't see them back. So I haven't done a tenodesis in those guys. And the final thing is, Freehill, I thought our story was that we also hit the ball out of the park like drought was. I don't know what you're talking about there. Yeah, I'm so upset that I didn't show that video. I might even escape this to see if I can get it to run for those that haven't seen it. How about this for a question? I'm, well, what do you think, Steve, Atul, Jodani, what do you guys think about Hiro Sagaia's thoughts? Well, I guess I'm not really fixating it with like significant tension. Is that what you're? And putting a little, he'll repair the SGHL. He'll just take a little bite and just tack that anterior down just a touch. And his whole thought is that, look, that anterior capsule has taken a beating. It's stretched out a little on these elite throwers. So instead of messing around so much with the slap in the back, you might not even have to repair the slap. Just tack down that front tissue to just help, instead of having that sloppy motion of the humeral head, maybe if you just tighten up that front part, they can still get back. It's not really what we do, but. Well, again, I think it's a good theory. And I think there is a component of capsular attenuation laxity anterior with these guys, but it's a nice idea, but getting something reproducible like that in throwers, again, I think we're doing a Harold and Mary when we fix these guys sometimes. If that thing truly looks pathologic, like Mike, you were pointing out, if it truly looks like it's torn away and not a sub label for Raymond, yeah, maybe. And I do think you have a better chance of getting them back if they have more like that type A, where you can fix it all the way back. But other than that, it's very speculative. I think that kind of brings in, there was a question from Jonathan Hughes about putting an anterior anchor in, on a slap that comes to the front. I think the whole concept of, and I've got partners and a very well respected partner that says, oh, you should never put an anchor in anterior to the biceps. And I have, and we argue about it and I'm perfectly fine admitting that we argue about it, but I think that Neil gave a talk on, like an MLB talk last night about slaps. And there is a role for fixing the labrum at the anterior superior quadrant. It shouldn't be all the time, but there is a role for it. And I think to say that we should never fix or never put an anchor anteriorly is kind of the concept that you're talking about, Mike, about, well, do you do anything to the SGHL? I personally think that when I put an anchor in that anterior superior quadrant, I don't wanna see a, not even a millimeter of capsule that goes into my bite because I do not wanna restrict their external rotation at all, whether it's an abduction or at any position. And I think that that's a very, that's a slippery slope that if you start fixing the superior glenohumeral ligament and you take somebody who could throw 94 miles an hour, now he's throwing 84 and he's out of the game. So I think that, you know, Will's point of, you know, well, we really don't fix many of these. I think that the big league guys, somehow they have that adaptive mechanism that they have a slap, but they're able to get through it. Whereas the minor league guys have slaps, they have symptoms, they can't work through it. And then they ultimately have surgery because they have no other option because they're either gonna retire or they're gonna try to have surgery. So, you know, I think that there is a role for fixing some labrum anterior superior ligament, but it has to be on the right setting. Yeah, and I just, I might add, I'm kind of curious to see what you guys think about this. You know, I agree with Steve. I think a lot of times we see these labral changes in the big leaguers because it is adaptive. They've survived. They've managed to get through to that level. I'm almost feel more aggressive about fixing slap tears in say high school, college age that present with that pain that failed physical therapy. Because I think that they would probably benefit, you know, they're not gonna, they're obviously not surviving, not adapting, and they probably would benefit more from having that repair. I'm just gonna say, you know, I mean, the real key for me for putting an anchor anteriorly is, you know, is there really clear pathology there? Was it a sub labral foramen? And if it was clearly attached there before and beat up, I think some, I just sometimes bite the bullet and do it. But I do, you know, as Steve said, you wanna be very careful about not catching capsule. You don't wanna really capture the whole biceps anchor because I do think they get a little bit stiffer and it's a problem and you have to work hard on trying to get that mobility back. Otherwise you have a problem. So I think if I have to, I do put it there, but generally I try to stay just behind the biceps and posterior to that. That's generally my approach. Well, I think the capsule attenuation, I think it depends on what region you're talking about. I agree. If you capture capsule higher up there, you know, anterior to superior, I think that's more of a problem with external rotation. If, you know, if you could, and it's theoretical, but, you know, do it more sort of down in the Bankart region to get that tightened up, that might be more where they're stretching out because that's really where they're pushing on it in, you know, extremes of external rotation abduction. Yeah, for anteriorly. But when you have like the type eights, you know, Kimbler's type eight, you definitely don't wanna capture any capsule back in the back with your, if you have the extension posteriorly, cause that's almost like giving them a, giving him a GERD. Hydrogenic GERD, yeah. Yeah, so. Hey Mark, I think on another note, when we start talking about those techniques, I'm not so sure that when you look at all the literature and why they do so bad, that the point you just made is not what's happening. Cause we think so much about doing the capsulography, you know, posterior and anterior, doing our bank card capsulography in these collision athletes. But if you get that, you know, layer five, that undersurface capsule of the cuff, which is easy to do sometimes, when you get under the labrum, I think that's when the trouble starts. I think you're right. I'm not so sure that that didn't happen a lot in those early publications. Well, it was very interesting, you know, because Ben Kibler and I talked about this literally around 2004, 2005. My results of slap lesion seemed to have been, you know, out of the ordinarily good. And, you know, Ben and I talked a lot about it. And his feeling was, at that time, everybody was really capturing the biceps. You know, sometimes they were putting the, you know, the anchors right under the biceps and capturing the entire biceps and putting anchors in the front and in the back, in which, you know, now people have gotten away from putting in those anterior anchors and capturing the whole anchor itself. And I think that that does make a difference in their ability to wind and unwind, you know, to get into that late cocking position. And so I do think, you know, technique has changed. You talk to those, the older guys, about how they repair the biceps for slap lesions, and they were capturing the biceps. They were, you know, you look at the diagrams and the papers from back then, anchors are going on either side of the biceps and out from there. And now people are putting in less anchors and less tight. And I think, I don't know that I believe, you know, I don't know that the PDS keeps the strength for as long as I would want necessarily, but I do like that idea that, you know, you're using a suture or something that's a little bit more forgiving that allows for some of that mobility there and not making it too stiff, because, you know, it's all about getting some of that flexibility to be able to get back into the throwing and make cocky position so you have a greater arc over which to accelerate and throw the ball hard or hit the tennis ball. Cool. So I don't think you can kill the biceps. So that was awesome. So great discussion. You know, thanks Will, Steve, Mike, Mark for all your comments. Thanks everyone for tuning in. I think it was a fantastic discussion. You know, as again, this will be posted and I look forward to seeing everyone next week and everyone have a wonderful weekend. Thanks Atul. Thanks everybody. Thanks Mike. Thanks for last minute pitching in. Great job Mike. Thanks everybody. Awesome.

slap tears

management

overhead throwing athletes

conservative management

surgical intervention

knotless anchors

zero PDS sutures

biceps tenodesis

treatment options

research