So, good afternoon. You're in the Game of Bones session, so if that's where you want to be, you're in the right place. I have some announcements to start us off with, so welcome everybody. Please remind everybody to turn off their cell phone or put it on focus, turn it off, make it so we can all hear each other. There are evaluation forms, so please rate this session if this is something you find helpful, something that's good as a brain dump on a Friday afternoon, and it's a learning process. Please note that in the session evaluations. And then a reminder, the PM&R Pavilion offers interactive resources and educational opportunities including the AAPM&R Learning Center with complimentary hands-on education throughout this assembly, and the sponsored educational theaters and cadaver lab as well, so check everything out. And again, make sure you check out a lot of these opportunities are free to attendees. So those are my announcements. And before we get off with the heavy debate of our big contestants here, Dr. Ken Mautner is going to give us a nice tribute. How do I advance this slide? This? Yeah, so this is going to be a very fun session, so I didn't, I don't, not really appropriate maybe to start out this way, but I wanted to give a quick tribute to Jerry Malenga who I think many of us knew. As many of you know, Jerry Malenga passed away this spring after a long battle with cancer. It's impossible to put into words how much Jerry meant to me personally, but it's been more important for us to realize how much he meant to our field of PM&R. He was a visionary. He was a leader. He was a mentor to so many. He was a sports physiatrist before there was a field of sports physiatry. When regenerative medicine and orthobiologics started to come into play, Jerry jumped in with two feet. And he did so because he realized that our system was broken. The way we delivered orthopedic care just didn't make a lot of sense rationally. That was Jerry. He was always one who would stand up for what he believed in. Many of the things we do today in our society and in our practices, we owe to him. Over the past few years, he became very interested in collecting outcomes, and he started a company called Data Biologics. He did this because he didn't feel like there was a good way to collect outcomes with any of the current companies that were out there. So he started his own, and he did this not to make money, but he did it to make a difference. Over the next few months, you're going to see opportunities to remember Jerry through the multiple organizations that he was involved with, IOF, Tobii, AAPM&R, among others. I also encourage you that it won't be enough to homage the man that was Jerry, but the best thing we can do is to try to bring forward all the things that he was working on to try to keep moving our field forward and realizing, you know, PM&R, sports medicine, orthobiologics, and the role that we have as leaders in this space. That is no doubt what he would want for us. So let's just take a quick moment of silence for a true legend in our field, my friend Jerry Malenga. Thank you. Great, thank you. Thank you, Ken, for that. So I'm Heidi Prather. I am not Joel Press. Joel Press voluntarily told me to do this. As former president of the AAPMNR, I have no idea what I'm doing. So hopefully this will be somewhat entertaining. So we have these great contestants here today that are heavy competitors. You should have seen the emails prior to this meeting. They started at least several months ago about who's gonna be who to reach out. So from the south, from Emory University, we have Dr. Ken Mountner. From the west coast, we have Dr. Brian Cranback from the University of Washington. And up in the east coast here, we have Dr. Joan Steinberg from a little known organization called Harvard University. And then my colleague in New York, Pete. So, so we're gonna start this off and hopefully you'll find it educational as well as entertaining. Cause that's what we need on a Friday afternoon. And I'm sure Jerry will be smiling upon us and reading us on. So let's see. I guess I have the slides, right? And that was this one. Here we go. All right. Don't forget the mother of dragons. For those of you who know games of, like are we allowed to say? Oh yeah. Yeah, in the microphone. Okay, so let's also thank the mother of dragons over there. For those of you who followed the series. Yeah, great. All right. So our first case is a case of a 15 year old elite swimmer. Doing elite swimmer, particularly in the stroke of butterfly who presents with three months of right-sided shoulder pain. She is mid-season and hoping to make sectional cuts. Dr. Cranback. All right. Tell us what you know. Don't start out until we get this going. All right. Let's get this on here as well. We're going to put this on to get ready. So I'm ready to go with that. So that's the first thing. Thank you very much. All right. Unfair advantage. That's 20 points for costume. Thank you very much. The second thing that, well, the second thing to note is this is hopefully not foreshadowing for people who've watched Game of Thrones because my character died at the end of the first season and was killed by the mother of dragons. So there you go. Okay. So all seriousness aside, this is like in my space and I love this question as well. As we all know, shoulder pain is prevalent, right? The adolescent swimmer can go anywhere from 5,000 to 10,000 yards. In a practice, they swim six days a week. For those of you who are not aware, a sectional cut is basically someone who is advancing out of the club level. So there's like sectionals, there's futures, and then there's national team as well. So this is someone who's making a jump to the next level as well. And they're competing when I look at this in what's called a short axis type of stroke. So long axis is when you go along the body and short axis is kind of the undulation, think breaststroke or butterfly. And shoulder pain is common and the research suggests a lot of adolescents definitely come in with shoulder pain. When I first start out with this athlete, I'm starting to think about like the big picture, kind of how are they training? What's going on in regards to their training? What's it in regards to mileage, frequency of training? Where is the extent of their shoulder pain and where it hurts? What are they doing in the water? Okay, did I mention we're gonna have one minute a piece? Oh, I'm telling you there. Well, we'll get to that, that's okay. You did tell me, but I'm ignoring you already. So that's okay with that. But there is a complexity to this as the kids are moving up that you have to just think about what's the generation of that shoulder pain. And then in regard to how does it fit into the overall function and their training, including nutrition, sleep and such. So when we get someone who's 15 and a shoulder pain, knowing it, it's a little bit more of elite level and then spending our time to take a better history and trying to tease out the source of that pain, whether that's the biceps, the rotator cuff, the labrum or the structures there is where I'm starting out with this. And that's where I spend a fair amount of time. Okay, so you started off with that. And any of our other players, like any comments on what our illustrious Dr. Craibach is pontificating about? Okay, we all know about swimming now. We know nothing about this case. So on a case level, this is a young swimmer, skeletal mature, he got a miserable MRI where he's filled up with contrast, but that's okay. There's clearly a labral tear anteriorly. So this is someone where their strength is their weakness. You don't swim the butterfly without a lot of mobility. So I think when a kid like this comes in, I call Brian, he goes over 30 minutes about the history of swimming. But the reality is that there's a lot of moving parts here. Her strength is her weakness. And so I'm gonna get like this, I wanna look at a bait and scale. I wanna see how lax are they. And then you're looking at what do we do with this to rehab them, they're hurting when they're swimming. So I like to deload them, they swim less. I like to get them into rehab. You don't go after the shoulder to start. Like the baseball pitch, everyone else, you look at the kinetic chain, look at all the other muscles around that. Okay, okay, okay, okay. Dr. Steinbart, can you help us out with like getting to the point here? Gentlemen, contestants, let me just say, take a look at this imaging. Does that look like a normal, that looks like an over spacious capsule to me. So maybe indeed this is an athlete with multidirectional laxity who happens to be also a gifted swimmer. So we need to take a look, as you said, at the overall picture of who this athlete is, what their core strength is, and what their mobility versus stability of the shoulder is. The labral tear may be secondary to all of this and may not necessarily be the cause of pain. Okay, that's great. You got to the point, five points. Five points for Dr. Steinbart. Just a couple of comments. Poison, poison, I say. You know, this isn't really fair considering Brian Kraybach takes care of like swimmers all over the world. I always see him posing in pictures and posting on social media. But number two, I thought I was talking about biologics here, but I guess this is a rehab issue more than anything. The other point to notice with this swimmer particularly is the top left x-ray, the osteochromiality, which you can see sometimes and may be associated with impingement and some increased stress in the rotator cuff. But to the point that they were making before, I think with swimmers, a lot of time we see that rounded shoulder posture. We see a lot of tightness in their pec minor. We see a lot of scapula dyskinesia. And those are the first things we're gonna address before you can get to the rotator cuff. Good chances are you fix some of those issues, which they've had for years, and you can start to address their underlying biomechanics. So Dr. Kraybach, what are you gonna tell this swimmer about swimming right now? Come see me, not my fellow people on the panel here. No, I think we've hit that. Swimming's unique. I mean, it's one of those sports where if you're out of the pool a fair amount, you can decondition quickly. And so a lot of the emphasis, again, is modifying. Are you swimming at the front of the lane? Are you gonna move to the back? One of the important things I find is thinking not only about their shoulder, but the whole kinetic chain. And to that extent, swimming is one of those unique sports where if you think about the kinetic chain, it's also influenced by buoyancy and breathing and breath control. And so you need to take time to talk to someone because in essence of how someone breathes shifts the buoyancy within the swimming pool, and that can affect whether someone's shoulders are too high or their legs are too low. So I'm gonna spend a lot more time making that whole kinetic chain. I actually put people quadruped in the clinic and have them put arms and legs out, and their parents watch them kind of shift all over the place. And it highlights just their core stability because there's a lot of core that goes into that strength. So I'm gonna help this person, assuming that there's no contraindication to continue to swim. I'm gonna really deep dive, ha-ha, into that sense of trying to explore those different things and really hone in that kinetic chain importance and bring in things of buoyancy and weight structure into that. And I think that's something as physiatrists we can really kind of hone in on, especially as you're learning sport. All right, all right, you get 10 points for buoyancy said three times. Okay, I like the buoyancy word. Any other contestants wanna show their knowledge here to help with this case? I'll give you just a quick thing. With these hyperlaxed patients, when you think about GERD, you think about locked mobility, a couple of pointers. There's a ratio between your glenocumulative scapular motion. In the hypermobile patient, that ratio goes way up. They have too much glenocumulative scapular motion. So look at that. Number two with these patients, they can have some tightness. So horizontal adduction in a supine position. The cuff can get tight. They're like a mini version of GERD in a hypermobile patient. So just be careful. The glenoid design allows for much more AP motion than superior or inferior motion. So they're gonna ride in the front sometimes because they're tight in their cuff, even though they're otherwise lax. So think about muscular tightness in a mobile patient. I think the people are speaking. Dr. Su, who? What? Where does her shoulder hurt? Great question. We don't know right now is the answer. That's a great question with that. I would say historically a lot of them tend to be somewhat posterior. This thought of potential instability and the research suggests that swimmers are weak in the posterior aspects of the shoulder. It's a great way to screen them in the clinic as well. So you get your functional screening. You look at the posterior aspect of that. Obviously some scapular dyskinesis. So if you look at the literature and there's several articles out there that question the full predictability of scapular dyskinesis is the only thing. And what's I think the most important, it's connecting that kinetic chain. And in swimming that involves resistance in the water. Should I use buoyancy again? Please do. More points. Minus five. Minus five. Great. And what I didn't mention, so we've got the chat going. We'll have questions through there. And anybody with questions live in the room, please come to a mic. This is live stream. So I'll also just make a quick comment that for any of these overhead athletes, I think the MRI or any image and modality is kind of the last thing that we really should be treating, right? Because you're gonna see so much asymptomatic or maybe clinically not relevant pathology on these MRIs. And so in the hands of us trained sports physiatrists who really understand hopefully the biomechanics and the rehab and the clinical exam is way more important than what the imaging may show us for a lot of these overhead athletes. I asked some five points for sound advice. Yeah. Yes, from the people. Gerd, what are you referring to? Gastroesophageal reflux? The question's Gerd. What are you referring to? It's glenohumeral internal rotation deficit. Okay. Ken will beat it to death in a minute. But it's a feature of a loss of internal rotation. By definition. to 20 degree loss of inter rotation to the contralateral side, it gets more complex. They tend to have an excessive motion in these patients, but be aware that there can be some features of posterior tightness in them because of weakness. And so that's an important, you know, it's not, while you're maybe a little bit lax, there can be some areas to be addressed and PT is super important. I'd say too, you know, Ken's point is very important. Don't treat these MRIs. All right. Athletes don't do well with surgery and the slap lesion repair does not change the natural history of a shoulder. So just keep that in mind. All right. So yeah, you get 10 points for connecting the stomach to the shoulder. There you go. All right. You know, and I would add, and just echoing this imaging, there's a good study by Scott Rodeo who trained somewhere with some people here, actually trained, actually he's one of the physicians there. You trained under him. Yeah. Yeah. There you go. So they basically did an ultrasound study of the Olympic team and they found that basically about 90 plus percent of individuals have rotator cuff impingement findings, tendinopathy and stuff. So to that point, don't just jump to the image and figure out what it is and say, aha, that's your cause because the reality is they probably already had that issue for a while. Yes. The people. Does the open physis on the AP radiograph contribute to your thought process at all? Does the open physis on the radiograph contribute to your thought process? I mean, it should in some ways, but you do have an MRI that doesn't show a true kind of overhead, like a little bigger shoulder pathology where you would probably see some sclerosis on the x-ray or some more widening or the more kind of edema on the MRI findings. So in terms of this being their etiology of pain, I don't think the open physis is causing their pain based on what I know. Also, we would need to correlate it with physical exam and it may just be a marker of some associated tendency to rotator cuff disease as well. Great. Any other questions from the audience for the contestants? All right. Shall we move on to the next exploratory... It takes out one of the competition. It's already done anyway. It's already done. I know. He's probably going to get continued points for the costume. Anyway. So our next contestant here, um, or case, 71 year old right-handed person with Structural Integration Specialist. What is a Structural Integration Specialist? I get to ask a question. It's a fancy word for rolfing. Ooh. How many points did you get? 35 points for that one. All right. Minus 10. Minus 10. Yeah. Who works... I'm a positive person. We give points. Peter. Who works full-time with shoulder pain for three years, worse over the past nine months after a fall. Go ahead to the next slide, too. Go ahead to the next slide? Yeah. Okay. Sorry about that. And here's the imaging. Dr. Borkstein, can you walk us through this? Sure. Well, my diagnosis is it's a mess, obviously. No, seriously. So we need to look at this individual, again, outside of his imaging, but this particular gentleman's career. He works full-time doing manual therapy, and it's pretty robust therapy. So his career and livelihood depend on his functionality with his shoulder. So first, we would need to look at his overall motion, his rotator cuff strength, and see if there's a correlation between what we may see on the imaging and what he may experience in the eye. Okay. Okay. We feel sorry for the guy. So Ken, what do you take on this? In addition to what Dr. Borkstein has started off with for us. Yeah. I mean, obviously, he's 71, but he's extremely active in his profession. And I'm assuming, which maybe I shouldn't assume, that his exam is consistent with this full-thickness rotator cuff tear we're seeing on the top right-hand side, which doesn't look like it's retracted, but certainly does look full-thickness. And you can see some decrease in acromial-humeral distance on that x-ray on the top left, potentially anything less than six millimeters is considered a closer distance there. And some fluid in the AC's joint. But what I was going to get out is a 71-year-old with this issue, the first answer is never going to be surgery for even a full-thickness rotator cuff tear on someone of this age. You know, if they're under 40 and it's traumatic, it may be a different situation. So certainly, we're going to look at his physical exam, and we're going to look at the things that he's deficient in from a rehab point of view. We're going to try to address those first before we get into any other discussion of biologics or other advanced treatments. Awesome. You get 10 extra points for talking fast, even though you're from the South. So... I'm going to try. Isn't that good? I'm getting there. I like that. He's quick. Dr. Moley, could you really drive us home on the difference between a traumatic tear and an idiopathic rotator cuff tear in this age group? Like why did he make that comment? I mean, I think two things. Number one, I think this is globally more arthritis than anything else. And I think because of that, I think this is more of a traumatic tear. The fall, I think, is a thing. And I think it's a bit... Joanne was saying, you've got to do a good exam. I will say, at 71, you should also look at their neck. Just make sure you're looking above. This guy fell. This could be a problem. It could be a radiculopathy. You could be noticing it there at the first point. So always do the full exam, look at mobility. Back to my ratio thing. Now we're looking at a decreased ratio to glenocumulative. So they're using a lot of scapula. This is a weight-bearing job. And I look at his shoulders taking a lot of load. And you've got to be careful with his shoulder. Because if you did operate on it, if you wanted to operate on a 70-year-old, he's out of work for four to six months. So you have to really look at it and look everywhere around it and try to make this shoulder function a little bit better. There's already a little subscap tendinosis you can see in the front there. That subscap is going to be super important. You'll be going down the line looking at something like a replacement if it worsens over time. So look at it, take care of it, be careful with injections, and really get a good history and figure out what you can do to optimize this guy's shoulder because it's how it works. Okay, okay, okay. So we're kind of going down this path of this could go in a bad direction towards OA and joint replacement. Can anyone on the panel kind of educate us on why rotator cuff intact versus not intact? What the decision-making tree is for people with osteoarthritis of the shoulder. Well, I can say that one. Huh? Well, I mean, the reality is... All right. He's taking over already because I'm dead. I'm taking over. I spent my day next to a shorter surgeon. So we're going to get some negative points going. And the reality is that the rotator cuff is important as far as what kind of replacement we're going to do. So you're looking at it where the... And Ken's point that you're seeing a hemo head elevation, you only do it between an anatomic versus a reverse total shoulder. And so if you have an intact rotator cuff, you can get an anatomic shoulder. They tend to function a lot better, though the reverse total shoulder is working better. So if you have a hemo head elevation, rotator cuff tear that's chronic, you're going to get a reverse total shoulder. So it makes a difference in what they're going to... If they go on to further arthritis, how they're going to be treated. Okay. Does anybody have any comments on... Okay, we've taken them all the way to arthroplasty. So let's go back into the present moment. What are you going to do? What's the first thing we're going to do here? Let me say, I'm not that impressed with his arthritis. I mean, he's got a little bit of arthritis on there, but... Ten more points. Certainly, I'm not going to have an arthroplasty discussion with this patient on day one. And just to get back to basics, the supraspinatus is responsible for depressing the humeral head. And so that's why an insufficient supraspinatus can lead to humeral head elevation, which can lead to rotator cuff arthropathy over time. The question is, is there enough ability with strengthening and rehab to get this patient functional enough that we don't have to talk about any other surgery or advanced procedures? Certainly, if you have failed physical therapy, I'm not convinced steroid injection will be that indicated for a patient like this without a lot of fluid in different areas. I would have a biologic conversation about potentially PRP or adipose or bone marrow. Okay. Okay. But before we start going with the needle, what did they fail? We say fail physical therapy. What did they fail? This particular patient was seen by the head of physical therapy at one of the HAVA teaching hospitals. Plus, he's part of a interdisciplinary center at one of our hospitals for musculoskeletal care. Plus, he gets very often manual therapy himself. So his strength and mobility and soft tissue extensibility and all were really excellent. And he had nothing neurologic going on at the time. So I considered him having had outstanding non-operative care for which he was very compliant. Great. And is there anything in their history that makes you think going to injection, other than they failed physical therapy, like other characteristics like something they can't do at night that they're supposed to be able to do? That would be a hint. Oh, I thought it was the specific case. Yeah. I mean, yeah. I mean, if people, one of the big rotator cuffs, thank you, Heidi, for dating the, of course, for you, Heidi, on that one. But it's a very good point. I know we're kind of jumping the gun because we're very limited on our time here. But obviously, taking a thorough history is part of it. And one of the questions I always ask my rotator cuff patients is whether or not this interrupts their sleep at night. And people who get interruption of sleep, number one, they tend to be more likely to have rotator cuff pain. And number two, they tend to be more likely to have pain. And number three, they tend to be more likely to have pain. And number four, they tend to be more likely to have pain. And number five, they tend to be more likely to have pain. And number six, they tend to be more likely to have pain. And number seven, they tend to be more likely to have pain. And number eight, they tend to be more likely to have pain. And number nine, they tend to be more likely to have pain. And number 10, they tend to be more likely to have pain. And number 11, they tend to be more likely to have pain. And number 12, they tend to be more likely to have pain. And number 13, they tend to be more likely to have pain. And number 14, they tend to be more likely to have pain. And number 15, they tend to be more likely to have pain. And number 16, they tend to be more likely to have pain. And number 17, they tend to be more likely to have pain. And number 18, they tend to be more likely to have pain. And number 19, they tend to be more likely to have pain. And number 20, they tend to be more likely to have pain. And number 21, they tend to be more likely to have pain. And number 22, they tend to be more likely to have pain. And number 23, they tend to be more likely to have pain. And number 24, they tend to be more likely to have pain. And number 25, they tend to be more likely to have pain. And number 26, they tend to be more likely to have pain. And number 27, they tend to be more likely to have pain. And number 28, they tend to be more likely to have pain. And number 29, they tend to be more likely to have pain. And number 30, they tend to be more likely to have pain. And number 31, they tend to be more likely to have pain. And number 32, they tend to be more likely to have pain. And number 33, they tend to be more likely to have pain. And number 34, they tend to be more likely to have pain. And number 35, they tend to be more likely to have pain. And number 36, they tend to be more likely to have pain. And number 37, they tend to be more likely to have pain. And number 38, they tend to be more likely to have pain. And number 39, they tend to be more likely to have pain. And number 40, they tend to be more likely to have pain. And number 41, they tend to be more likely to have pain. And number 42, they tend to be more likely to have pain. And even with a good repair, it will go back to the same length it is today. You might have some tendon there, but the tissue you put back there will stretch back to that same length. So surgery isn't a great option, and I think you're looking at, what are you going to do? I think biologics, even steroids, I wouldn't throw them out, and the guy can't sleep at night. You have to deal with the inflammation at this point for sleep, and then you're looking at function. Right. Dr. Molli, what if I, oh, I'm sorry, I'm taking it all. Go for it. Whoa. I'm so sorry. I think she's sucking up to me. Well, you've got to be aggressive with this matter here. So, Dr. Molli, what if I told you we had two surgical consultations from prominent Boston surgeons, one of whom said rotator cuff repair, and the other said reverse total shoulder? Tell him to come to New York. So two points to make. One point is that we went over this a little bit with the last case, but the amount of even full thickness rotator cuff tears in asymptomatic individuals is not small on MRI imaging. And so in the study a few years ago where they were MRI contralateral shoulder, the people who had symptomatic rotator cuff tears and found almost identical findings on their contralateral asymptomatic side. So just because he has that cuff tear and it is pretty significant doesn't necessarily mean that that's the cause of his pain as well. I mean, the shoulder is a much more complex joint than that that we have to examine all possibilities. The second point, and this is to Peter's point, I'm not arguing there's some arthritis there. In my clinic, when I have a patient like this and I'm trying to determine my next steps, I will often consider a differential kind of numbing agent injection. Now, it's a little tricky with him because if you have a full thickness cuff tear, the numbing agent you put in the joint might escape into the subacromial area. But numbing areas up and then kind of seeing clinically how they respond can certainly help me decide if I'm going to do a biologics where I might aim for. Awesome. Awesome. Does anybody else have any opinions on the injection piece? Yes. Well, I just have a question because it was kind of touched on on that MRI and I know the exam is critical, but since that was kind of skipped in the presentation, there's a significant amount of edema in that AC joint. So why isn't that kind of being more addressed and targeted? It's like, yeah, this guy's an older guy. They may just have an asymptomatic rotator cuff tear and there's just a lot of screaming edema in that joint. Why not just address the joint and see where you go from there? I think that's an excellent thought. If you're planning a biologic injection of any sort, they're... Honestly, they're paying for as much as... In my opinion, as much as you can give and you can address at one time. So if on clinical exam you think the AC joint is part of it, by all means address it. If you think the shoulder joint is part of it, address it and the rotator cuff, same deal. So I would say yes to that, but in the setting of this kind of situation, you may need to be a little more comprehensive in your approach. And if you're uncertain, you can do diagnostic injections. And if you're still uncertain, you could treat multiple pain generators or components at the same time. I do think... Why is it... Why does it look like that? And the reason is back to this increased amount of scapulothoracic mobility and decreased clinical mobility. So you're overloading that joint. So you can inject it, but they will come back. I mean, that's my... So you got to correct that difference somehow and I think really the correction is in the joint not... The glenohumeral joint, not the AC joint. I got it. We got it. We got it. We have another important question from the crowd and I think Dr. Borgstein gets a few points for sucking up to the question in the crowd. Okay. Yes. This patient insurance is not covering for biologics and the patient cannot afford it. What do we do? So the question is, what do we do if can't afford regenerative injection? You can inject him with steroid. Yeah. I mean, the shoulder is very tolerant. It's not generally weight-bearing. Be careful on this guy though because he does use his shoulder a little bit more like weight-bearing, but the shoulder is much more tolerant than say the hip or other weight-bearing joints to injections. It also tolerates a tremendous amount of carbs loss and can function very well. So if it can't, I mean, I don't do as many biologics, but I do think it's don't... An initial steroid injection isn't a bad idea. Visco supplementation, generally not approved, but there's a good... Ted Blaine put out a pretty good article when he was at Columbia showing pretty good efficacy of using visco supplementation. So yeah, those are our options. Yeah. Okay. Three extra points. He actually quoted literature. Yes. There you go. I can give points for that. I can give points for that. Well, I think too you're getting into the shared decision-making process, right? And anything we do is going to have risks and benefits in that. And you have to think about the extent of how this is affecting this person, the financial component for their job. And then you might just say, all right, I understand I'm not going to put hosts of steroids in there all the time, but if I can figure out the pain generator and perhaps provide some relief. And for me, that might just then translate to progressing the physical therapy or getting them into a better place than in a shared decision-making process that we've helped this patient along. Perfect. Yeah. I think that's a challenge because of cost. I think Dr. Craback's coming back. He said, you know, shared decision-making and better place all in one sentence. He's coming back. Yes. A question from the people. What, where, why biologics would you pursue in this case? All right. I know what happened to this patient, so I will tell you. We started with platelet-rich plasma because there's the most evidence for that. It's least expensive and the least invasive. And it worked beautifully. He was able to sleep again and go back to his job everywhere. The glenohumeral joint, the AC joint, and around the rotator cuff. Poor boy, poor, okay, completely poor, I mean, Lucas, I'm sorry. Lucas is not poor, you play the poor, like somebody's poor right now. Somebody's poor right now. Dr. Molli, don't confuse the other contestant, Dr. Molli, okay. Now, the PS to that is it kind of wore off, if you will, his pain recurred in just under a year and we had informed decision making about this all and we went to adipose micronized fat and it's now maybe about six years later. of his case. I think... Oh, the adipose was applied to all three locations. So she gets 80 points for six year follow-up. She should lose a point. Yes. That's it man. Right there. I didn't submit like an easy one. There you go. Let me give points for kissing up to Joanne, because the really only two case reports or case series looking at adipose for shoulder disorders, one with Joanne did and one with Jerry Malinga and them did, total of about 50 patients. Case series, it was a mixed bag, much like this, of people with rotator cuff, some arthritis, some AC joint stuff, and they injected all of them. And it's, I mean, once again, it's case series, but they did really well overall. So I support that. Here we go. Here we go. All right. Yeah, but let's go like the counter. right, like you're injecting everywhere and something happened, like I get it, like that's part of that, but like we gotta call out that fact that we're just kind of throwing stuff in there and this was one of those that did well and I respect Joanna and Ken as well, but I mean we have that, we gotta kind of really need to do a little bit of pause and the beauty of this panel is that these are experts who do pause, but I wanna just caution people, right, like just don't be like, well I heard Director Berkstein said, yeah, yeah, you should go out there and just throw everything everywhere and they'd have great outcomes, because I've had patients show up who can, and people are savvy, and they quote, they're like, do you know about the five cases in Germany that got better, and I have $30,000, I had one patient tell me, I have so much money in the world, I can do whatever I want, and I'm like, well, you're not gonna get it here, because it's not indicated, and so I think we just have to take it all with a grain of salt, although I appreciate the work that's being done. All right, another question from the people. So, the question is, in general, is this an OA picture going forward? Is there a component, there's capsular thickness, can you comment on capsular thickness and the setting of rotator cuff tear, I think is the question. I think this is an interesting case because this represents, I think, best case scenario of somebody maintaining their shoulder with both manual therapies and their own sort of exercise program on their own. So, his range of motion was excellent. There was no limitation. I would imagine in other folks, there might be significant limitations. All right. We're going on because I think Borgstein won with this one because six-year follow-up alone. And Dr. Moley is trying to keep the mic away from Dr. Craback, so we've got issues. All right. All right. So, our next case. Thank you. It's a 42-year-old right-handed father who wants to play ball with his kids. He's referred by a colleague with progressive right shoulder pain and restricted motion. Mmm. And the imaging is? All right. All right. Spin that this way. All right. So, this is my life right here. So, my older patient. You're not 42. Come on. He should lose points for that. That was mean. Oh, I thought it was good. I was going to give points for that. So, I'm going to donate to a charity. I'm going to donate to a charity. at pretty you know you're gonna AP of the shoulder looks okay you've got an articular side rotator cuff tear there well represented on ultrasound and you can see it in a again a contrast enhanced MRI so holy this guy's coming in he's got pain he's trying to throw the first thing I'd say is just look at this he's got an articular side when you're looking at the rotator cuff there's a difference between this the bursal side articular side so articular side tears do significantly better than bursal side tears so they can be much more likely to be what so I'm gonna look at this guy's it's gonna watch pain you gotta look at what's the pain is the pain because of the tears not because the tear is there other factors involved in this I don't see a lot of bursitis or other changes so I'm not thinking that but pain in a rotator cuff of the tear may not be a bad thing so we have to look at the role of inflammation in recovery too so this is something I'm not gonna inject early I'm gonna watch them the other thing I think when you're when you're seeing these patients is you want to look at the Yamaguchi article it's a great article they surely watched rotator cuff tears and when you had a tear and your rehab you felt better typically as long as you stayed better you were fine if they had an increase in pain it often meant increasing the tear so that's a good way to kind of like monitor someone when you're treating them but I'm looking this guy and I'm gonna you're gonna look at all the basics of your shoulder the scapular rhythm I'm gonna look at how they move I look at their neck because he's older okay okay okay but what about his pitching arms going down here as range of motions down how do we assess that what do we think about that in this scenario yeah so this is huge pet peeve of mine is that these folks I think their capsule is the issue 90 some points for pets so when my residents come out of the room my fellows I always ask them what about his motion what about his motion and so we know in this age group on MRI alone you'll see at least 40% of folks love asymptomatic rotator cuff tears ultrasound that number it's gonna even go up because it's more sensitive for picking up cuff tears and so if they have restricted motion in this age group 40 to 60 year old population we know women are more likely than men to have adhesive capsulitis but men or women I'm always checking their motion holding the scapula down comparing the side to side but if you don't correct their motion no matter what you try on them whether steroids or biologics or anything else they're not gonna they're not gonna do well so so the motion and the possible adhesive capsulitis is probably the biggest thing here for me well isn't there some other things that can restrict motion in this case dr. board I mean you're definitely gonna always kind of think that what's going on in regards to the other structures there you're gonna think about the referral is there something going on with the neck and such because maybe you know there's overlapping causes to that kind of pain I do think you get caught up in the defect which is often where people try to put injections and such so I think you need to really kind of focus on that I'd probably talk to the person like if they're kind of middle-aged as well and trying to throw baseballs around like you could use this as an opportunity to talk about lifestyle stuff as well and like how they're trying to train to throw their kids and moving along so you can actually expand it a little bit more and just I agree focusing on the shoulder but I would definitely rule out anything that that could refer to that area as well and then the bigger picture of not just the therapies but is helping them understand as we all move through life that there are just certain changes that happen in regards to flexibility and strength and we need to it's a good opportunity to think about lifestyle and how we can help this person as they continue to age okay so of course he said the word lifestyle so another ten points for me so yes anybody else have any recommendations on what to do next so I'll bring this up and then Frank Carrasco did the study for the articular bursal side that's two quotes I didn't get any points points there so I think when you're looking at patients be aware what the patient wants to do and then determine whether it makes sense so do you think this so I agree with Ken rarely but occasionally says I look old that you have to restore the motion I see all these people go in the cuff strengthening everything else and they don't have their motion back get their emotion back whatever the cause is get their motion back dig into that work your therapists have good therapists stabilize the scapula and see how much motion have a look at side-to-side differences but you also have to look at everything else that goes into throwing so when you're working with therapist or with a patient make sure you're all on the same page you know the patient wants to throw a couple balls you may want to talk about lifestyle but you want them maybe to do that you think they can based on your exam and everything else make sure the therapists also agree so everyone should be an alignment of what you're trying to do so that's maybe bringing the kinetic chain you're gonna bring the lower limbs so I have to ask this of you Pete is there another body part that's really important in the throwing mechanism it's like to bring up yes the kinetic chain so but you have to look at all that in the thrower so this is not an elite level thrower but it's a thrower and so look at how they move and you have a lot of time while it's aching to work on other things around the shoulder so I think it's very important to hit mobility look at the kinetic chain and match your goals up he's not gonna throw a 95 mile fastball he didn't do it early enough to learn how to do that so but he wants to throw a ball look at the rest of the chain especially the hip and I think it makes a big difference there's plenty of time in PT but make sure you're all in alignment looking for the same outcomes all right any other contestants want to add to this to try to get more points I'm not trying to get more points I'm not looking to brown nose the teacher but since I happen to know this patient this patient had one of the best again PT's in our sports medicine system and one of my best colleagues downtown who had done three injections for adhesive capsulitis over the course of a couple of years to which he responded beautifully pain went away but it was back again in a few months so with that situation does that change anything you'd want to offer him what's it most in like now it's restricted as restricted internal rotation mostly and a little bit of restriction and range flexion oh we're stumping I would say capsulitis to me is a loss of external rotation impingement loss of internal rotation so I don't see a loss of extra rotation I'm not going to treat it as a capsulitis that MRI it's not very helpful but a good MRI you can see the inflammation of the capsule minus points he doesn't like the MRI but I would say that the the tall mark of arthritis and capsulitis is a loss of extra rotation the loss of internal rotation to me is more impingement so I'm thinking in this case more impingee until he loses external rotation anybody run debate that thought well I mean you can get you can get isolated posterior capsulitis which we'll get to probably our next case with our baseball players so there are different forms of capsulitis that can reach different areas I will agree though the best way to test capsulitis in the office a true adhesive capsulitis is just armor their side you compare external rotation side to side or the same thing at 90 degrees of abduction and I'll go back to what I said on the last case which is if you really thought that you needed to treat that super spadatus defect and do some kind of biologic or prolotherapy into the area I would consider putting a little bit of numbing medicine in there just to see if their pain went away or dynamically with ultrasound looking at and see if there is any true impingement going on we got to realize once we get above about a hundred hundred ten degrees of motion we call things impingement but they're really just a capsule that's getting tight above there so I think that's really important to see is there a really true truly an impingement from this cuff issue causing pain all right so the patient does well and then what are you cautioning or educating them on what they need to do in the future since this is a repeat offender are there do you have goals in mind that you really want the patient adhere to I think once we get this patient back to some level of function throwing a ball in the backyard with his kids he needs to be more consistent or most consistent on his exercise program at home I think this is a situation where he'd feel better for a few months and then kind of fall by the wayside and don't forget you you know you have kids to do chores they take out the trash like next time maybe one of the kids can throw the ball a little bit better so they don't have to so that's a lifestyle change but I would I might talk to them a little bit about that as well no all kidding aside I think you know as again as we talked to we all go through certain changes over time and maintaining physical activity and function is important and we need to make sure that that's a key message throughout all this awesome I think we have a question what is the article dr. moly mentioned two articles there's Frank Kodasko has an article and I can I can put it up and something on a link if you want just looking at the difference between particular side and versatile side tears and outcomes and the outcomes are significantly better for particular side tears than personal side tears that other article is Yamaguchi and he's got a tremendous number of I thought I'd get points for that one and so he's got a lot of work looking at ultrasound and following tears where tears start but I think the really that that that article I've been I think it's 2007 or so it's a while back that's a good article because it looked at and follow them when they had a progression of tear they had pain it's worth reading I yeah so I'm gonna get points so anything Yamaguchi gallops or Keener they were a trio that what wrote on the natural history of rotator cuff disorders so any of those names look it up it's it's there yeah it's it's well done yes question yeah looking at the global health of the shoulder I wonder if any of you do trigger point injections to the lat and pec minor if this gentleman's a sitter and he can't she gets points because she's talking about something outside the caps which I was trying to lead the witnesses up here to talk about can you talk to us about that absolutely yes yes yeah so what what does the trigger point do other than hopefully reduce pain and then what else what is the product what are you trying to get out of it really for me things are often in balance so things are often in balance so you might have tight pecs even deltoid or upper trapezius in compensation for some of the limited motion in the shoulder and a lot of that can be confused with intrinsic shoulder pain so it's really low-hanging fruit and these days a fair number of our physical therapists who work with do dry needling so I find myself doing a little bit less because the physical therapists can incorporate that into their into their treatment awesome great great question all right we're on to our next case it's a tight it's a tight race here so our next case has lots of words so dr. Mockner already gets a few points down because there's a lot of words here but an 18 year old d1 freshman baseball pitcher has two months of increasing shoulder pain and tightness continue to pitch without seeing the athletic trainer the team doctor so withholding information no history of significant shoulder elbow pain in high school or before so he's a first-timer to this this issue the fall ball season is ending soon in late October he's lost seven degrees a fast ball velocity between 90 down to 83 miles per hour and his control is diminished as well and here's the MR arthrogram all right so start us off I will start impressive lots of information here and you know if you're taking care of pitchers and overhead athletes you need to learn kind of all the right questions to be asking which is some of that information there is you want to know you know what their offseason schedule is like you want to know when they're throwing how much they're throwing you want to know their velocity you want to know if their velocity has gone down if their control has gone down and and obviously as force medicine physician the timing of the season and where they're at is super important to to what protocol or what decision we might make in terms of that shared decision-making and treatment goal so you know in baseball players specifically we talked about GERD a little bit and that's in conjunction a lot of time with something called a six scapula so we need to examine the patient so a six scapula if you don't know so someone's gonna ask us online is what is it's a scapula not feeling well yeah nothing to do with GERD stomach GERD so the scapula like a scapula malpositioning they get inferior medial prominence of the scapula they get coracoid pain and they get scapula dyskinesia that's SICK and then with it oftentimes they'll get tightness in their pec minors so this is one thing that can cause people to get some loss of internal rotation compared to external rotation so real quick though on that people who pitch from a young age they tend to get humoral retroversion that they throw a lot of fastball so their humorous naturally gets rotated backwards when that happens they naturally get increased external rotation and they'll usually lose the same amount of internal rotation but the total arc of motion will stay the same so when you talk about someone who has an internal rotation deficit we're saying that that total arc of motion has gone down even though the proportions may be very out of whack compared to the other side but like Peter said before greater than 20 degrees side to side different the total arc of motion is consistent with GERD and honestly that's the thing you want to address first and foremost before you even talk about the fact that he has a you know slap tear on his MRI sleeper stretch most people know it dry needling working on lower trapezius strengthening scapular stabilization those are gonna be a first-line treatment for someone like this to try to get them feeling better anybody have anything to add to that you know Ken takes care of baseball players now congratulations the Braves no used to I think Ken brought up actually decent points and I give him credit for that but one thing you said it into some of the catchers are like trom so total range of motion so you're looking at that and then I think the other thing pitchers aren't born they're made so you have to throw pitches to get the retroversers aren't born they're made that's a good one yes or no so there's two schools of thoughts on this so that total arc of motion is important and so if you look at it there's the Gilles Walsh thought which is the retroversion of the humorous and then there's the Burkhart Burkhart was the beginning of all this kinetic chain lower limb and he talked about the thickening of the poster capsule I think nowadays you would say the capsule and combined do it so the only treatable thing in a picture who's losing motion isn't the retroversion they've already created that it's the stretching out the posterior capsule and the cuff and so I think when you're looking at this a treatable stuff you can do on the whole slap lesions don't do well surgically so these and then and if you look at the pitching world they've gone away from surgery to a lot of rehab better rehab a lot of hip rehab a lot of kinetic chain with these guys so keep that in mind when you're looking at this type of so dr. Molly's walk us through what you would look at in the hip or the trunk on a patient like this especially in this d1 pitch yeah I mean I what would you do for me I'm gonna I'm gonna look at like a functional exam I'm gonna have to do a step down I'm gonna look at them squat and how they move I'm gonna lay them on the table I'm gonna stabilize their pelvis I'm gonna look at internal exploitation I'll look for their ability you know they impinge or not I'm gonna sideline them to look at strength and then I'm gonna look at just like basic core measures I you need you know I can't tell me pictures I see after they've had their elbow done and and you go down below and they can't even stand on one leg very well so I want to see that they can control and move through there because they're generating force and the weight rate limiting step the weakness is going to be your shoulder and your and your elbow it's the end if your hip isn't working not landing correctly you're gonna get yourself into trouble so we see a lot of them yes question Okay, so the question I'm repeating for those online is that the question is all around arthrogram. Do we need one? When do we do it? When do we absolutely need one? When do we not need one? I think some of it's going to be about where your MRI is being taken. So can we have some comments from the players here? I think that depends on a lot of factors. Mostly the answer is you probably don't need one. The caveat to that is it depends on the skill of the skeletal radiologist and the strength of the magnet and the way they sequence their protocols. So ours get their special sequence with a 3T magnet and they all go to skeletal radiology teams. So most of the surgeons are fine with that. We're certainly fine with that. Yeah, and I agree. I think that the panel, I think, is probably on the same exact page of that, which is it's and it's not just like I got a 1.5 to a 3. There has to be a specific protocol that's coordinated with your radiologist. So if you send someone outside your system, you need to be aware about what they're doing in regards to what they're looking for. So we, too, have gravitated away from what really is sort of a traumatic nature, especially for a kid to need to get an arthrogram. Okay, he gets points for trying to unify the panel. Yes, another question. What do you do if they can't go in a closed MRI? What is your recommendations when the player wouldn't be able to go into a closed MRI? What is an open MRI? Add a van. You know, add a van. An open MRI, you just throw them all away, the old plates. You know, the new MRIs today, the short bore MRIs are much wider. We're having less problems with people managing them. We put all the football players and stuff into them. So it's not as bad as it used to be. You put on glasses, look backwards, and you get a little bit of volume, but don't get an MRI. MRIs aren't all equal. We don't use contrast. It distorts the joint. You can see a lot. A lot of it's physical exam anyway. I don't know if there's inflammation or changes. All I could see is all this fluid in there. So I don't think you need it. I think it was Job came with the first Abra position and that became like the thing. Oh boy, he's starting to suck it up with the whole thing. I gave him positive reinforcement and now it's going in a different way. The bad MRI is not worth it. Get a good MRI or just look at an x-ray and treat them systematically. I trained 20 plus years ago with Dr. Andrews, who's one of the most famous orthopedic surgeons and operated on baseball players for a living. One of his famous quotes that he used back then is, if you want a reason to operate on a baseball player, just get an MRI. They will all have changes on their shoulder by the time they're in college if they've been pitching for a long time. To Peter's point, you don't need the MRI unless you're looking for a reason to do surgery and you're looking to find things. You're going to see these sort of things. We haven't really talked about it, but typically in this type of athlete, they tend to get a type two slap tear because with that humoral retroversion and with that late cock and early acceleration, they get kind of anti-glide or they're humorous, which puts a little more stress. They talk about that peel back mechanism where that biceps tendon attaches to the front of their labrum. Once again, that's almost a consequence of being a pitcher is you're going to get these findings on your MRIs. As someone who does take care of professional baseball players on this panel and has a world series ring at home, I would... Yeah, yeah. I'll remind you that I was a physician with the Baltimore Orioles. We sucked, but that's okay. I would have worn it if I knew that you were wearing your outfit here. Yeah. I mean, we don't get an MRI of one of our players without seeing these sort of things and they rarely go for shoulder surgery because the outcomes are not good. Less than three quarters get back to return to the same level of play. Awesome. Great. Any other pearls? Yeah. Where do we start with him? I'm always like, what do you do that visit about playing and where you are right now? That's a hard conversation. Kevin Wilk, Jimmy Andrews. There's a lot of data out there and I think you look at a number of things. GERD's gone away as being a singular focus, so look at the TROM, GERD, amount of flexion, and then supine horizontal adduction should be about 40 degrees. Piece them all together with your patients when you're thinking about it. That's not one finding and try to really look at that and then understand the rest of the history. But these are, this is our wheelhouse. This is non-operative stuff, you know, throwing athletes. So you're seeing, they have ugly looking shoulders. You can't throw a fastball like that without having some humeral retroversion, some acetate, some, I'm sorry, some glenoid humeral. Your shoulder. He doesn't know what Johnny's talking about. So some glenoid retroversion. So they're going to look bad. They have ugly looking shoulders and they'll sign them for $100 million and they'll throw fastballs all day long. So treat the patient and look at the deficits around them. There's a lot to do. Okay. Mottner's still winning because he's got the World Series ring. He does have a ring. I'd like to see it later. Thank you. You know, I would, I think this was mentioned before, but don't forget that proprioceptive balance aspect of this rehab. I think sometimes we get caught up on whether they have GERD and the scapula is moving, but it is about that time and space and how you feel. So often in clinic, I'll make sure to not only do functional things, but have them close their eyes and open their eyes so that they can see that there's sort of a difference. And two, a lot of times we talk about the kinetic chain and it's about how the foot interacts. But if you think of that principle of proximal to distal kind of load, the kinetic chain actually starts with the brain. And we need to start thinking about that, especially in someone who's like younger and that how they activate and control those muscles as well. So I, you know, and here's a kid, maybe he's into college. It's a new scenario, right? There's maybe a mental health component to something you might explore. Again, it gets to this bigger picture of who this person is. And I think we can all work on trying to figure out how to go through this, but we need to think of a little bit more broader in that sense. Okay. Points for fuzzy wuzzy. Connecting the brain to the shoulder. We're good. We have a question over here. I'm going to interrupt you for a minute. It's kind of a two part question. I don't want to go off the rails a little bit, but it sounds like on the inertial scenario, there's this concept of the dead arm syndrome where he's losing velocity with a lot of pain. And I have orthopedic colleagues who say this absolutely needs to be repaired or it's never going to get better. And then you mentioned, well, the outcomes for these slap tear repairs really aren't that good in this patient. So a, is this kind of a precursor to that dead arm syndrome? Cause I'm a little fuzzy on what that really is in totality. And two, how do you navigate that conversation with your orthopedic colleagues? And then the patient who's like, well, I see the tear. I need to go get it fixed. So I'll say this. I mean, dance around this. No, it's a great question. You're right. And I think it's very dependent on where you practice and who are your orthopedic colleagues. But you know, I have the advantage of saying, well, I can tell you that if this were one of my greatest players and he would not have surgery done, right? I mean, our, our, our shoulder surgeons who take care of professional athletes would not operate on this unless he has failed multiple attempts at, at conservative care and it was the off season and we felt like it had to be addressed cause it was a, you know, cause they weren't getting better. So I'm not saying we never do these things, but it's very rare that we do these in high level players. And I've had a lot of my athletes over the years who have gone to get second opinions and that exact scenario happened where a surgeon operated on them cause they saw the slap tear and you know, you can tell them the data. And if you look at an article on this, you don't look at return to play, right? Return to play just mean they got back to one game at any level of competition. You want to look to return to the same level of competition play, which is a whole different statistic that a lot of these articles don't even talk about. So just a point in there. So that's a great point. These, these survey articles looking at who came back, the incentivization for a pitcher to come back is very high in the professional athletes. So they all come back. Do they throw the same velocity? Generally not. It's kind of true to the thoracic outlet syndrome too. But when you're talking to someone and preparing that slap is one variable whether you're gonna do well. Number two, doesn't change the natural history of the shoulder. So it's not going to, it's not preserving of the shoulder. So it's not like if they're telling him, oh, you don't do it, you're gonna get arthritis. That's not true. We have no data to support that. So the slap tear is best left alone and talking, Ken has more experience than I do, but talking to high level people who do a lot of these shoulders, they're rehab, rehab, rehab, don't, don't get in there. You're going to get yourself into trouble. All right. We have a question. Okay. So we heard it here first that physiatrists are the best people to be physicians in major league baseball. If anyone's looking to hire, we're all here. Okay. So let's get practical, right? You have this high level, maybe really, you know, an adolescent baseball pitcher that's looking to get into college baseball or a freshman or sophomore that wants to try and get in the draft. And them and their parents are sitting in your office and you have a two hour consult trying to debate, am I going to get this person a steroid injection? Am I going to, am I going to give them steroid or not? And so I was hoping that the panel could talk to us about how you counsel patients when they come in looking for a steroid and if you're not going to give them that, are you giving them oral steroids? Are you going to orthobiologics? How do you handle that discussion? Two and a half hours. You just added another half hour to the consultation. I just try to walk them through the pros and cons of steroid injection and the lack of long term benefit, perhaps maybe even some negative effects down the line. So we just have that conversation back and forth and there are some times where you just need to get an athlete through the end of the season and then they'll be able to work at or work through it in the off season. So I would not say never, but I really try to talk them off of that and most people are very happy, not happy, but understand the risk, benefit, pros and cons thereof and are usually willing to go with you. Now by the same token, you may need to do something else that we've spoken about in terms of managing the pain or the soft tissue component, the neuropathic component, the sleep issue, whatever component that you can address with other types of treatment. Well, I will say this. My orthopedic colleagues who take care of the high level team will do steroid injections for these folks quite a bit. And so a couple of things I would say. For a 17, 18 year old kid, obviously you're going to be a little bit more conservative on that front than for a professional athlete. I purposely put in this case the timing of it because he's just finishing his fall season. So he has three months right now, so this is really an ideal time to not put a cortisone shot in, but to really focus on the rehab, all the biomechanical things that we talked about. So from a practical point of view, I would usually walk them through their all season program and tell them, you know, six weeks, you're not throwing a ball at all. You're working on your range of motion, you're working on your core, you're working on your hip abductors, you're working on your scapular kinetics with the trainers or a PT. For a pitcher, you really need two full months to complete an interval throwing program, right? The first month is flat ground throwing, second month you get off the mound. That program's been around for 20 plus years. There's some iteration, some shorter programs I'll use sometimes for folks who have kind of shorter kind of stents where they're not pitching, but if they're taking six weeks off and this is a significant issue, I'm going to want them to go through that interval throwing program kind of step by step to make sure that they can handle the load before they increase loads to more. So those are the conversations. And then I will tell that athlete though, if we get towards the season, especially if a college athlete or above, if you get towards the season and you're still having some pain and you've worked on the range of motion, I think doing one ultrasound guided cortisone injection, in this case probably into the joint, would be a reasonable thing to do. One thing about this case and these college athletes is this may be the end of their career. You don't know where they're going to end up. You're going to try to get them back and I think this story might have enough of a negative effect that they don't get back that it's not really worth it. It may affect the naturalness of their shoulder anyway. I think one start injection in healthy college is perfectly fine, but keep in mind, he may just be failing. It's just the guy who dropped off. Remember that major league baseball is a pyramid. All these kids threw balls and now you've got the very top who didn't fail. So I kind of keep that in the back of my mind when I'm talking about it. I always ask them, do you love baseball and do you want to get back? The first question I had, do you like what you do? And then we go through this two hour consultation, but keep in mind, this may be the end of this guy's throwing career and you're going to have to work on that side of it later and not send it to Brian. All right. Question from the people. Oh, well, so we're a little off topic of this, but the question is about if this pitcher had signs, I think we're going into nerve entrapment, which may be with that dead arm. What do you do if there's a neurogenic source or component of this? So first you have to, yeah, what is TOS? He gets extra points because he gets in a curve ball here. Yeah. Well, I think the question of what's causing their thoracic outlet syndrome, right? And so the most common thing by far we see as cause is biomechanical kinetic issues where they have, especially in these baseball players and swimmers too, where they really tighten their pec minors or in their, uh, you know, scalene muscles. And so, you know, from my point of view, obviously you're, you're stretching out the areas need to be stretched out. You're doing, you know, soft tissue work and dry needling on their pec minor. You're working out there, any scalene entrapment issues they may have to try to clear all that those issues. And then you're working a lot on, you know, scapular thoracic strengthening, you know, lower trapezius, serratus anterior strengthening, because I think most people know that, but you know, you get those areas stronger, they're going to keep your shoulder blade back, your shoulder blade goes forward, your acromion more likely to pinch on your rotator cuff, your pec minor is more likely to get tight and more likely to get entrapment of the, of the nerves coming out there. If you truly have a true neurogenic or vascular cause of TOS, sometimes these methods may fail, although they still may work. And that's when we start getting into some of the surgical discussion, which is a whole nother, you know, tricky situation where it's still a lot of level of, they're doing a first rib intersection as a detreatment for thoracic outlet syndrome. You know, in Emory, we have a surgeon doing a lot of pec minor releases and much less invasive surgeries, which probably are better outcome wise, but, you know, 90 plus percent of these, probably 99% of these just need the right kind of rehab done. Great, great, great answer to the curve ball. Yes. I mean, they just, Ken's talking about scapula, scapula, scapula, but the surgery has not been particularly successful. It was, it went through a phase of Matt Harvey, everyone was getting it done and they never came back to throw at the same level. So there's a lot of ins and outs, but I, I don't know what the panel thinks, but I'm not seeing that referral anymore. They're rehabbing it. They're doing, that's fine, I did it to you before. They're rehabbing it. You can have scapula back. We can have some good points, but scapula, get it back, look at posture, open things up. But the surgery I think is going out of favor. I don't, I don't know what you guys are seeing around here, but we're not. We have a whole center run by a thoracic surgeon just for this. And I have, I mean, I love him, he's a great guy, but I have yet to see a patient come back and be better. And the other, the other, no, no, I mean, obviously it's a skewed view. And then the other thing that I'm plus minus about are the diagnostic Botox injections, which can be done with a lot of units of Botox, sometimes a hundred or more units of Botox. And then people feel better for a little while, but they're often young, they're often female and then they end up weak and worse off in the long run. So I think the answer lies probably in us laying hands and scalpel off for the most part and treating the underlying etiology. Great. Great. Another question? So the questions about outreach programs to Little League players or is anyone on the panel involved in any of that? Yeah, I mean, yeah, we do some of that You know most of I do work with my kids that they grew up playing Little League baseball and a lot of that kind of stuff but we do partner with the Braves and Have had some clinics to put it on and you're right It's it's it is a lot of education at a young age But as Peter said earlier these kids need to be thrown and the answer is not to throw But they need a proper rest period every year. They need to not throw through pain They need to play multiple sports and they need to not you know Like some of the organization now have pitch rules about pitching multiple games in a day or pitch counts And you know, we don't have time to get into that. That's a whole nother conversation but Yes There's a lot to be done and there are organizations out there pitch smart and these other ones that are kind of working with some organizations to try to help out And you know if anyone wants to reach out to me, I'm happy to give more information We have one last question here So the more of a comment just to bring the outside of the box like we did with trigger point injections something else that you Can offer patients instead of a corticosteroid injection is osteopathic manipulation for those who are trained in it addressing all of the kinetic chain Decompensation in the cervical thoracic lumbar and pelvic spine Treat I treat a ton of patients with this all the time and it's something that they leave the office feeling better So just something to keep in mind if you don't do it refer to a colleague points for promotion Go osteopaths. All right. All right, so aren't my esteemed panels. We're nearing the time here. Can you give us two seconds on? What we should remember about shoulder. What's one of the pearls you want to get you get a you get a chance to give a pearl And they weren't prepared for this I Steal from everyone on this one You got to look at the get get rid of all this imaging and look at that patient moves Look at the scapular motion kind of get that ratio understand your your hyper mobile and hypo mobile How good these affect somebody but really look at them and and look at the whole chain Definitely get the hips involved hips hips hips hips, but but that's that's longing for we should be that's what we're good at And so don't the images can throw you off most of these people did not need surgery, even though you could find a slap and a partial tear so Fix that and get a great group of therapists you work with who understand throwing. It's super important to say Understand the biomechanics of the sport because the foundation on what you decide to do and how you help them is built off of that Foundation, I probably say efficacy instead of economics and don't forget the brain Oh Profound I Have to agree with my two colleagues over there that I would just add there are a lot of moving parts and articulations Within the shoulder girdle complex even sparing the neck for a moment So it's sometimes it's really hard, but you need to be mindful of the scapula thoracic articulation and other You know aspects of pain generators that are outside just the cuff in the labrum So I'll send you on with the practical point that you know for your everyday practice You'll see a lot of you know obviously not what we're talking about here or not the first and last case of more that 40 to 60 year old kind of rotator cuff related pain And a good buy-in for patients to kind of prove all this to them Which we haven't mentioned yet today at the scapular assistance test And so if you can hold their scapula in place while they raise your arm And you can reduce or eliminate their impingement signs on exam. You can kind of prove to them that it's not really the shoulder We got to work on all this other stuff And so that's been a good way for patients to kind of buy-in and the fact that you know they might not need surgery They need to kind of rehab that area Great pearls, okay, so I'm asking for audience participation and thanking our players today So a round of applause and your appreciation for this Dr.. Kravac Dr.. Mottner All right And I get to name a winner At least that's what Joel said I got to do and he's on a bike in Italy somewhere So I'll get to do what I want to do so we had great discussions, and you know dr. Mautner was out there leading with The big diamonds and the and he does take care of professional athletes, and thank you for doing that and and dr. Borg Stein your your care of looking at the scapula and Thinking about the muscle and how that impedes, and then you know dr. Moly you actually quoted some great literature, and you got people thinking but Got to give it to dr. Kravac He put he took luggage space to wear this outfit today He used the word proprioception and buoyancy our winner dr. Kravac Thank you Thanks for joining us and thank you guys for putting this together

panel discussion

physicians

shoulder injuries

athletes

kinetic chain

scapular motion

rehabilitation exercises

soft tissue issues

surgical interventions

corticosteroid injections

injury prevention