So today we're going to start understanding tendon structure and function to improve patient outcome. So let's get ready to rumble. All right, we are ready today and we have our four contenders today. We have Joanne Borgstein from Boston who goes by the name Chop Chop. She is our reigning world champion and the winner from last year. Following up is Brian Krabeck, the name Bone Crusher. He's been training for the last couple weeks, running extra mileage for us to make sure that he's ready, mind and body ready to go. Ken Lights Out Mautner from Atlanta is also here today. He's still getting over the hangover from the Atlanta Braves winning the World Series, but he's been eating raw eggs regularly to get everything ready. And then we've got Pete Boom Boom Moley, my colleague here at the hospital for special surgery. Pete's a New Yorker. He's ready for everything. He's been doing a little bit of extra biking to get ready too. So the way this is going to go today, we're going to present some cases. We're going to do this in 12 minute rounds. We're going to have each one of these people try to give some opinions on what they see, what they would do, how they would handle some of these problems. And then as you can see on the next slide, I am the judge and I am also the jury. So I am the one who decides who wins at the end of this. I will be kind of awarding points, taking away points. I think everybody got points already for those wonderful backgrounds that we have. And I think all the preparation that went into it. Somebody says the audio is not working. Okay. So hopefully some of them you're saying sound is good, which I like. So let's go to the first case. And we're going to see there's a clock in the corner because we're going to keep everybody on time. Round one. We're going to start with our reigning champion Boom Boom. KT is a 20 year old D1 volleyball athlete with four weeks of right anterior knee pain after resting over the summer. Next slide. And here's some imaging studies. You can see some x-rays of the knee. You can see an ultrasound. And let's start off with Boom Boom. Can you tell us what do you see on the x-rays and ultrasound and kind of what kind of questions might you ask this patient in their history and physical exam to kind of put this patient together for us in terms of what's going on? Well, thank you, Dr. Press. As the reigning champ, I am really excited to be the first one to weigh in on these cases. So on my left, we have x-rays of the knee. It does look like there may be a patella alta and also looks like there may be some lateral tilt to the patella on a skyline view. To the right, it looks like a longitudinal view of the patella tendon. We don't see the distal tip, but at the proximal end, it looks like there's thickening and loss of the normal tendon architecture. There may even be some mild areas of intrasubstance tearing and even possibly some calcification or enthesophyte near the attachment to the patella. What we don't have, which would be nice to help us gauge sort of chronicity versus more acuity to this, we don't have any Doppler flow to know if there's any hyperemia or increased signal in the fat pad or in the paratenon. Any specific question or physical exam thing you might see on this patient that would be really helpful also? Well, I think with all things in the anterior knee, we have to sort of take a step back and make sure we know where the pain is actually coming from. Good old, you know, sports and physiatric principles. So certainly in the history, we want to see if this is sensitive to loading, as might be the case with tendinopathy. We want to look for on exam and ask about symptoms in the patella femoral space, whether there be any prior injuries or dislocations. And certainly we're going to take a step back and look more broadly at alignment, strength, femoral angle, control at the hip girdle, control with squatting, controlled lunging, flexibility of quad and hamstring. And also given this is a female athlete, the other thing that I would always be looking for is generalized hypermobility because there certainly may be overlapping with that syndrome as well. Before we were to go on and think about any further treatments, I certainly would need to know what she's tried, what her sport, you know, what her position is, how long she's been playing. It sounds like in the history, she rested over the summer and I kind of query rested from what? Is this a, you know, recurrent injury? Is this a new injury? Any other knee injuries? So I think all of that would go into our initial assessment. Okay. Dr. Monner, again, congratulations on those braves. Tell us about treatment options. Where would you start? How long would you give it? What would be the kind of progression that you would go through in terms of treatments for this, assuming this is a chronic patellar tendon injury here? Yeah, well, thanks for having me. Hopefully I'll get a couple of points for that real serious win since I play such a big role there, but anyway, yeah. So the most important thing that I think is where she is with respect to the season coming up and it sounds like, you know, volleyball being a, usually a fall sport and with her kind of being back at school now, summer's over, you know, we're talking about an in-season athlete more or less. And that's going to kind of change our treatment paradigm for me because she's got pretty classic proximal patellar tendinopathy from imaging findings. And so from a treatment point of view, you know, once again, we don't know what she's tried. We know there's evidence for, you know, eccentric loading for these patellar tendons. We know there's evidence for like heavy, slow resistance, kind of heavier exercises. Hopefully that was done in the off season. When you started to talk about in-season athletes who are kind of loading their tendon regularly, we don't do as much as the eccentrics. There's actually some evidence that, you know, fast isometrics and some isotonic things could actually help with pain control for this area. There's a classic kind of counterbalance braces, soft tissue mobilization to the area, massage, things to bring blood supply to the area. You know, we're not doing ice, we're not doing NSAIDs. We like passive treatments like nitric oxide patches that could potentially be tried as well as an adjunct to the other things. And then, you know, the newest thing on the block that is gaining popularity is shockwave therapy as an in-season treatment. If you have it available, that may be able to allow this athlete to continue to play and perform while still maybe doing things that can help this tendon heal over time. Brian, what do you think about shockwave therapy? Does it have a role? What about injections as another idea? You know, as Ken sort of mentioned, I'd be very hesitant in regards to an in-season individual undergoing potential injections for this. So, I think you're really looking for more supportive type of care. I think shockwave therapy has the potential to allow the individual to go through, compete in the season without disrupting that as much as they can. So, I think those are options. I would be very hesitant though to think about any injection until after the off-season so that we could get the proper rehabilitative program in place after that and to minimize the extent to which he would miss the season. So, tell us about in the off-season, what would you consider? Well, she has this area of hypoecogenicity in the area. You have the potential to use something like PRP, which has some suggestions and might potentially be helpful for that as well. So, I think I would be open to that area. You have the potential for percutaneous ultrasound guided tenotomy if there's a significant or lack of response to something like PRP itself. We tend not to use stem cells over here though that I can think be a matter of discussion over well, but that's another potential biologic that could be used in that area. And then I think we need to think about the rehabilitative process afterwards because we'll often spend time discussing with the patient that it's not an immediate response and it will take months for that rehabilitative process and load management rehabilitative therapy to help that individual get back in. And so, we need to time that out for the individual to make sure that they're in essence ready for the next season. Dr. Molli, anything you want to add here to the process here, the timing of things, anything you would do different? I think actually Joanne started, her reigning champ came in pretty strong with her assessment. I think looking at laxity, looking above is really important. This case for me was kind of frustrating in that we see these athletes now working year round and if it wasn't for this, you see them for like a stress fracture because the coach has given these incredible workouts. They never get a break. So, you have the metabolically negative. In this case, here it's just an increased load too fast. And it sounds, in this case, looking at someone who's relatively new. So, I wouldn't be thinking of injections at all in season. I think you've got to unload them and then progressively load them back up. So, what Ken's saying about isometrics have been shown to reduce discomfort and you're just kind of balancing the season and what you can do. These can take a long time, but I think you're looking six to eight weeks sometimes to get somebody back from this and sometimes longer. I mean, the data would show a lot of people's careers are ended with patellar tendinopathies. And so, I think I would be, you know, look at the season, look at the kid and really start out by unloading the tendon and building everything else up around it. So, back up at the hip, look at strength stability, look how they move and land, take away all the other variants and then focus on a progressive loading program for this tendon. It tends to be relatively effective, especially if you get them early and in a younger athlete, I think you're going to find most of your non-operative. Great. One of the things I forgot to mention at the very beginning is that we have over 200 people here and if you have questions, you can't all just jump in, but thank you, Zach, for putting the first question here. What about tendon scraping in season? Anybody want to comment? Go ahead, Joanne, then Ken. Oh, got in ahead of you, Ken. I was first on the buzzer. 30 seconds. Yeah. So, I was going to say definitely there would be a role for tendon scraping, especially if there's, we don't know the exact significance, but if there's some neovascularization, especially at that anterior surface of the, I'm sorry, posterior surface of the tendon. The other thing I've been a fan of for many years is using prolotherapy, not in the tendon, but in that high volume area deep to the tendon. And more recent case series from here and abroad have suggested a combination of shockwave and hydro dissection or tendon technique may have added to value, all of which can be done in the off season without downtime. Ken? Yeah. Yeah. The good thing about tendon scraping, I mean, obviously Joanne gets the points because she would beat me to it, but the benefit is, you know, the loading time or the reloading time is pretty quick. And so usually I give them about seven days off and then within another seven days they can kind of be back to full load. So, it can be a very good way to, to kind of get some pain relief and maybe get them through that season. And sometimes you're good and sometimes you need more definitive treatment after the season. The last thing I'll add is that, you know, I mean, unless we're talking about how these things do pretty well, they don't always do very well. I think Pete mentioned this too. And even if you look at the data on proximal patella tendinopathy and PRP, it's the one area, one of the few areas where sometimes it does take a couple of treatments and I'm not a big series of PRP kind of guy, but I have seen this one and the data may support doing two PRPs in this area or a vacuum debridement device, which was mentioned before as well. Don't worry. Can you still get points for sucking up a little bit? That's okay. I like the sucking up. When you do PRP, how, how restrictive do you make them afterwards? What is your protocol on that? And typically if I do, I'm going to, I'm going to put them on a brace, tell her 10 ruptures and PRP. I just worry. I don't use steroids around it, but what's your protocol for that? Yeah. I mean, I have not seen a rupture or, I mean, I've seen a couple of case reports out there, but I've done lots of PRP in this area over the years. I know Joanne has as well. And the rupture rate is extremely low. And so I do not put them in a brace. I'll put them on crutches for a few days if they need it to kind of just unload the area and help them get around. Um, and then usually around two weeks, we kind of start the rehabilitation process and it is three months though, until they're fully loaded, returned to play on average after these. And so it's definitely something that, you know, I get a lot of people who come in after having rested and then the season started and it's too late at that point. So you really got to be talking to the athletes ahead of time about the role of PRP in the off season, if they continue to struggle with it. Yeah. And I'll, I'll actually be a little bit more, um, aggressive with getting a moving in that sense. I will offload them for a little bit, but within that first week, I'm, I'm, I'm getting a moving. Most of these collegiate athletes do fine. If anything, the biggest thing is they do a lot more than I really want them to. I don't find bracing to be very helpful as well, but I do have a really hard to heart discussion about the fact that it does need to take, you know, three months and even at, um, six weeks, right. We're not expecting to see them bouncing around and recovering, but it is a process that we have to go through. There's the horn. There's the horn. Before we go to the last one, I want to get this one question real quick. Yes or no? Is, um, would you consider high volume peritendinous injection in season as well? Yes or no? Two yeses I see. One no, one three yes. Okay. Next case. Very good. Okay. Round two, round two. We're going to throw this one over to Brian. He's been practicing and running a lot lately to get ready for this, his mind and body. And I think he's already, we have a 50 year old recreational competitive marathoner training for Boston. They report a sharp posterior ankle pain four months prior to the event. Next slide. And here are imaging studies and same question. We want to kind of start with, um, you know, what do you think is kind of going on from the history and what do you see here? Um, somebody did ask if we have a pointer. I'm not sure if you guys have pointers available to show anything that we see on the x-rays or not, but go ahead, Brian. Um, yeah, so here we have a seasoned, I'll use the term seasoned athlete as well. And someone who I'm going to assume qualified for Boston. So they must be a pretty good runner as well with that. And in their training process about four months out, which gives them a little bit of time, but still they're probably into a relatively good program. Don't know much about their overall history, which meant potentially could play a role in regard to what's going on. Uh, in that we, we can dive a little bit more into the history and the training program as well to briefly look at these x-rays. What I see on these x-rays is, um, on the lateral view towards the anterior aspect of the tibia Taylor region, you can see how there's a little bit of narrowing and lipping, which for me would be suggestive of a little bit of arthritis development. And then in the lower ultrasound, we can see a mid-substance non-insertional. So mid-substance thickening of the Achilles tendon with some disorganization above the fiber superficially. Um, maybe if you strain a little bit, you could kind of wonder if the peritonon, um, might, um, have a little bit of a component as well, but it seems to be more of a superficial hyperechoic area. So in this case, I think we have someone who has a mid-substance Achilles tendinopathy going on, and there's about four months out from their, uh, marathon. So get us started on the treatment options for this patient. Where are we going to start? Well, I think, you know, overall, right, we're in the process again of, this is an overload kind of issue. I would take a deeper dive and step back and try to understand where they are in the process of running and what are some of the mechanics that they have, um, looking at, you know, um, um, cadence in regards to running, perhaps how they're, um, they're, they've altered, uh, rest days with running as well. I'd look at things like flexibility and strength, and then that's going to dictate, in essence, it's sort of a mid-season type of thing as well, where we're treating the athlete to try and get them to their marathon. So with that, we're looking at supportive things that we can do, uh, thinking about the, the exercising, eccentric high loading. Again, it was previously mentioned in the patella, we're going to be a little bit, uh, cautious in regards to, um, the extent to which we're loading that tendon. So you're going to strike a balance between allowing them to continue to train. I like to, to use these athletes and providing unloading by using an Ultra G. So we have a treadmill that we can take pressure off of that tendon, yet allow them to maintain some of that cardiovascular training as well. We're definitely looking at proximal and distal to the Achilles tendon to try and, uh, strengthen with the foot intrinsics, think about gait retraining to sort of offload that area and look at hip strength as well to make sure that we have proximal strength as much as distal strength. We could do supportive, uh, treatment with other modalities to the area. There's some research that suggests a combination of exercise and shockwave therapy can play a role in treating this. I would be extremely hesitant to inject this. I mean, even if you look at PRP data, it's kind of mixed results and let alone the fact that if we were to inject this tendon while they were training, the amount of deconditioning that would have to go on would basically disrupt the opportunity for them to compete in the marathon. Pete, any, um, use for any other imaging, would MRI be helpful here or not really? Uh, looking at this x-ray, I don't, I don't think with the ultrasound, you need an MRI in this runner, especially if you're trying to get them back to running. I think the one thing, I think Brian's was good. One thing we've been doing more of recently is actually working on ankle motion. Uh, there's some research supporting that vascular dorsiflexion is associated with Achilles tendinopathy. So when you think about what is, what is it? What is it? It's disorganized tendon with mucoid degeneration within it. And so what does that, what you see that from science, we see that in the hip and other places when we see loss of normal mobility and the tendon is, is taking different loads. So you want to look back, Brian brought this up, whether the training was there a rapid increase in training and you want to de-load them. But if you want to try to get them to keep running, that alter G is a good idea. I, I, so I, we work a lot more than I used to on trying to get back the motion in the ankle. Um, and I think, you know, use pretty extensively eccentrics. I still think Alfredson's work is, is valuable. There is, you know, heavy slow is good. There's other adjuncts you could use, but it's easy to do. You can do it at home. Everyone has a set of stairs and a backpack. And so a lot of times we're adding that to it. And I find, uh, even when they're uncomfortable doing it, I've seen these, if you get them early enough, revert back pretty quickly. And I, so I think it's, uh, I don't, I wouldn't add more imaging on this. If I saw there's more arthritis, there's a little bit of, uh, anterior joint space loss, but there's nothing, I think, uh, further image is going to change in this patient. And any, any injections you would ever do on this patient and anything else you want to add? Uh, yeah, thanks. A couple of things that my colleagues haven't mentioned yet that I'll go into one is, you know, this is actually the area that I think nitric oxide patches that probably, you know, some of the best research and maybe, um, evidence to put on a patch there. You know, we do a 12 hours at night, so they don't get the taxidermyphylaxis and the, uh, they don't get used to it. Uh, then we take it off during the day. Um, and it's a very passive, easy treatment, uh, can help circulate and stem cells get to the area and MSCs come to the area and may help with the healing and, and yeah, you know, proximal patella tendon and mid substance Achilles tendon is where a scraping or a high volume injection seems to have the best evidence for sure. And so, you know, once again, he's training for Boston PRP is really not an option, um, but a scraping procedure in this area, um, especially if there is hyperemia and Doppler flow between that fat pad and the tendon. And if, as you move that and do some, uh, dynamic ultrasound, you see a lot of stickiness and adhesion between the fat pad and the tendon, then I do think a high volume or scraping or some combination would be a really good treatment because they could just, you know, take it easy for a week. You know, I agree with the alter G it's a great option, um, and some cross training and then kind of start to reload the tendon again. Joanne injection and no injection. What are we missing? Um, I don't think you're missing very much other than the fact that, um, I can't remember the last time I actually went into the Achilles tendon with a PRP injection. Um, I altered my practice years ago and really have, have done peritendinous injections in combination with the scraping. I still don't do those in season or in training. If I need to do an injection, I would use a sort of a low inflammatory prolotherapy solution. And then it's really important to add to your treatment, the myofascial structures, especially proximally. Um, we know there's often a lot of, uh, calf and muscle tightness. Um, so whether you address that with just stretching, uh, uh, Braston myofascial techniques, dry needling will do trigger points. And you can certainly do, you can extend your radial shockwave all the way up the calf and more proximally if needed and combine that with an injection, uh, technique agree completely about the nitro patches in this area. It's very superficial. Um, and especially when the pathology is, is close to the skin margin like that. And you want to pick up, we had a couple of great questions from the audience about the scraping procedure. What are you scraping? How do you do it? Can you want to take that? Yeah. Yeah. That's a good point that they brought up and I'll try and do it relatively quickly, but, uh, there are a couple of techniques out there. And so, um, you know, Alfredson started some of this work, uh, with his, um, you know, uh, sclerosin agency was doing 20 years ago. Um, and then he started going behind the tendon with this kind of ultrasound guided, um, uh, approached, um, where he would go. And basically you go right with a fat pad and the tendon, uh, interface, right? Whether that thick infusiform area is, you're going to answer to the tendon and you're just kind of scraping kind of back and forth, trying to free up the tendon from the fat pad below. And these, uh, British researchers, um, fully, and a lot of these folks in the UK, uh, we're doing a very similar procedure in the early 2000s, but they were using just a high volume. They were putting like 50 CCs, um, anterior to the Achilles tendon to kind of separate that fat pad from the tendon. And so there's lots of different ways and the results have been very similar and there's data suggesting that they do a pretty well early on. Um, because you get, you get rid of some of the pain that's associated with the knee of the vessels and the new nerves that are in that area. And then you can load the tendon better and move it better, which can actually lead to potentially healing of the tendon. Um, but sooner, hopefully, rather than later. And nowadays I would say most people in this country who are doing scraping procedures are either using a no core needle, which are what I use, which has a small little scalpel on the end of an 18 gauge needle, or something called a meniscus tone device, which is kind of a V-shaped device that can get in there and help to kind of really separate out the two areas between the fat pad and the tendon. Right. Um, Joanne, you want to describe the, somebody asked, would you elaborate why you changed your practice of injecting the tendon? Sure. And I would never say always to anything there, there are times certainly we'll combine this with a 10 X procedure, but I found that over the years, every time I went into the tendon with the PRP, it was very inflammatory and very painful and a very slow, uh, recovery from that. And then there were some basic science studies that came out and I think the rat or animal literature looking at the penetration of injectate, uh, into the tendon, uh, from peritendinous sources. So it just occurred to me that I could probably get the PRP in the tendon. Um, if I go peritendinous, mostly, uh, below or, um, anterior, but sometimes I'll add some posterior as well. Um, and then when I started doing that patients there, I don't know that there's any direct comparison trial, but we combine that with some tendon scraping and try to eliminate the neo vessels if we think they're relevant in terms of anatomy. Um, so I rarely go into a tendon with PRP anymore and I've used once maybe, and I think Ken has also once there was a substantial hole, if you will, uh, in the tendon. And we did fill that directly in the tendon with fat. Um, there's, you know, there's not a whole lot of science yet behind that. Um, but we both, Ken and I both have cases documented with serial, um, ultrasounds where the tendon actually healed, uh, not back to normal, but with certainly some, uh, tendon, uh, recovery. Uh, so, uh, that's generally what I do, but it's not an absolute. Got it. And I'm going to give Brian the last word in one second here. I got a text from a colleague, wait one sec, one sec from a colleague who did say, uh, Pete alluded to it a little bit about looking at subtalar motion or whatever in the ankle. What about the rest of the kinetic chain? But Brian, you could, you guys haven't touched on that yet. So I'm taking points away from all of you for not at least bringing that up yet. We did. Brian did. He's not listening to us. Yeah. I would just do the quick things. I think these are all great. Uh, a couple of things I wouldn't know with the nitro just, um, right in somebody who's a bit more mature, just make sure to get a good medical history and make sure there's no contraindication for that. Cause there are a fair number of athletes can get headaches. So I think that's important. No. And other than that next round. All right. We give you, we give you credit. I wasn't listening well enough. You did mention that a little bit. So, so you do get that point there. That was all those pushups you were doing paid off in a big way. Let's move on to the next one. So we stay on schedule. Thank you guys for bringing the questions into the chat room too. That's super helpful. Uh, this one's going to our world series champ, uh, round three. Um, RF is a third. They changed the age last time they made them a lot older last time. And I said it couldn't be better, but RF is a 39 year old right-handed professional tennis player preparing for Wimbledon who presents with three months of lateral elbow pain. Next slide. Um, these are again, some of the imaging studies that you can see on this patient and Dr. Mottner. Uh, we know this can't be Roger Federer since he's really 40 years old, not 30 years old. But, um, what do you see on the images? What do you, what do you think's going on here? Give us some background from what you got as little as that was. Um, so, right. So lots of things to kind of unpack here with the tennis player. And interestingly, you know, we probably see this way more in the recreational tennis player than kind of the elite athlete, uh, tennis player. Um, so first to comment on the imaging on the x-ray on the lateral side, you can see some small little calcifications, uh, off of the lateral epicondyle. They're probably associated with some enthesophytes right at the insertion. Um, there may be some very mild, um, cystic changes on the lateral part portion of the capitellum. So maybe there's a little bit of early arthritis in the joint. Um, doesn't look to be that bad though. Um, but I'm assuming, you know, this is a pretty classic kind of exam for a tennis elbow, uh, with positive codes and test pain laterally on the elbow, um, ultrasound wise, um, two things of note here. Number one is there is a little hole and I wish I could, y'all could see where I'm talking to, but you know, right, kind of on the bottom of the initial ski slope there, you can see that small little hole, which is probably the ECRB tendon, um, associated with some, you know, classic stuff you see with tendinopathy. Um, and then down lower where the radial collateral ligament, uh, goes between the, you know, capitellum and the radial head. Um, there are some hyperechoic changes there, although I don't know if that's the main isotropy. I would want to play with that a little bit, do some motion and rotational things, uh, to kind of see if that's real or not, but that does change my treatment algorithm if I think there's RCL involvement or not. So first thing I would do would not be to do PRP or any of my biologics that I enjoy doing, but, um, there are lots of things biomechanically on the tennis court we need to look at. We need to look at his racket grip. We need to look at his attention on his strings. Uh, we need to look at, you know, how his strokes are, you know, on the forehand side, if they do a lot of kind of, uh, rotation of spin, they're more prone to get some lateral elbow pain. Obviously the backhand can be involved as well, um, with that lateral elbow and decrease in string tension could be easy. Um, so I would unpack a lot of the kinetic chain, obviously look up at the shoulder, at the scapula area, um, and, and even the core and other things in a high-level tennis player that may be influencing why they're overloading that elbow to all of a sudden get this problem. Um, but he already has significant pathology. And so I'm going to be more aggressive about treating a high-level player if we have the time to. Okay, Brian, what else you think? Well, I also think I just got to say, I'm a Roger Federer fan. So, uh, he's my goat. So I'll just go there and throw it out there. But I, I do, I, I, I would agree with Ken and basically what we kind of see, I again, would work on unpacking the biomechanics. I would even, you know, think about neck motion and movement, um, as, as well. So I'd even just not just the shoulder, but the neck motion as well as we're kind of walking through. And, and one of the things we haven't quite talked about is balance, right? Sometimes I think we focus on strength and flexibility, but I think balance. And so perturbation with the eyes closed and sort of just making sure the system's balanced as well, uh, would be helpful. So I often like to make sure, uh, that, that athletes incorporate that into their rehabilitation, um, so that they, they can, uh, address the proprioceptive component to this, but I would agree. And especially in a high-level athlete, if you're going to start going into injections and someone has a classic that, that that's going to have a huge, huge impact on the season and the season's long, right? It starts with the Australian open in January and, uh, by September with the U S open. So you really have to think about how you're going to incorporate some of these things and how it can impact the possibility of participating and specifically that in the grand slam. What do you think about, uh, this kind of guy? Does he need an MRI? I, I would feel comfortable here with the ultrasound, uh, in regards to, in regards to what we're seeing. So I don't necessarily need to, to move on and get an MRI. If there was something on exam, uh, that perhaps alluded to maybe something interarticular, then maybe you can get an MRR at the Graham and see if there's something floating around in there. But I don't wouldn't necessarily jump to that. Um, although that being said as a high-level athlete, they all seem to kind of get those imagings pretty darn quickly. This is your buddy, Roger Federer, and you're denying him an MRI. Amazing. And trying to think perhaps, uh, to, to think in a cause conscious kind of way, I think for, for most of the athletes that I have, if I feel pretty comfortable with this, I'll just move forward with treating it. But Roger, if Roger's willing to fly me to go wherever he is in the world and hang out, then once an MRI, then we can discuss that. So I think a few things, one is, you know, is this the first time they've had it? You know, one thing I always ask is if you had it before, have you had a steroid injection? Steroid injections are associated with tears, complete tears and associated with instability, instability, you know, Ken Ken's pointing out on the ultrasound. I think John Kirshner, I'll give him credit for this is like one view is no view. So what he's saying, I, I, I look around and, and really examine this, but that any instability decreases the outcomes of your treatments. You have to be aware that the rate of collateral ligament injuries actually can affect this as well as arthritis. And he mentioned the rate of capitella joint. So there's a couple of things I'd want to know. So whenever I see someone has one, two, three steroid injections in the past, I have a lot of concerns about tears, uh, not only of the ECRB, but also of the rate of collateral. I think the, you know, thinking around other things that hurt, you know, we look at this, we're like, Oh, look, that looks bad, but think about a cervical radiculopathy weakness. And I think that, uh, Brian brought up, you know, how, how do you move? What's your balance? Are you, how do you come to the ball? And so mechanics of how they're playing tennis, uh, you know, they're getting older. Um, are they, you know, they, they get down low enough. Do they use the lower body correctly? Are they overusing the elbows? So try to, you know, we do a lot more now, just looking at kind of the whole chain up to elbow. I kind of look at elbow as a downstream provider for the shoulder. So the shoulder mechanics are super important. And so those, those things I think have to be addressed to get them back. I think Ken brought up a point I think is, I agree with is that you don't see these, these aren't overuse injuries or every professional tennis player to have their intermittent use injuries. These are people who work all week and play three sets of tennis Saturday and Sunday. So they rest, they play the rest, they play. And you start to see these types of, uh, degenerative type conditions in them, but a professional potential, but it doesn't usually come in with lateral hook on the lightest. They just isn't something or OSIS. A couple of quick points. People are asking questions about, one is about cortisone. And the question is, would you do a cortisone injection or not? Yes, no. Give me a thumbs up or thumbs down. All knows. Very good. Okay. Next question is percutaneous tenonomy, a viable option in someone who can't afford PRP or whom we don't have authorization for PRP. I think that that depends for the tendonopathy perhaps. Um, there's really, in this case you have, you do have to go into the tendon. It's not like the Achilles where you have a lot of room around the tendon. Um, so this certainly may be a viable option and that's where a lot of these studies started. And I think good evidence to support it. The big qualification which my colleagues all alluded to is what's going on in the elbow and at the radial collateral ligament or the, or the lateral ulnar collateral ligament, because those are something you would not want to, uh, go into with a percutaneous tenonomy, um, uh, procedure. And I would have a pretty low threshold for getting an MRI. There looks like there's some lateral joint space narrowing. And if, if you were getting to the point after all this wonderful rehab that you were considering an injection, I'd want to know what's going on inside the joint and the cartilage surface, um, as well. Is there any adjacent bone marrow or edema? Because all of that might influence how I, how I treated it with any sort of injection therapy, whether it be, you know, percutaneous tenonomies really only for the tendonopathy. And I would just add one other thing that we all know about, but just as a gentle reminder, um, there's a lot of, um, there's a certainly a lot of topspin and a lot of supination that goes along with these movements. So I think we'd always need to just check the soft tissues and the, um, and the posterior interosseous nerve, the deep range of the radial nerve area to see if there's any, uh, radiating pain, any soft tissue tightness that could be, um, uh, causing a tunnel syndrome that can be compounding the pain. So, um, long-winded answer is yes, it's an, it's an option, but it really has to be carefully thought out in relationship to the rest of the structure and function of the elbow. So you're saying that you would get an MR before doing any type of injection therapy around the elbow? If my clinical suspicion were not that it would just, this is simply tendonopathy, I would probably go ahead and get the MRI before doing an orthobiologic. There are things deeper to the elbow that certainly if there was an effusion that we don't see, anything that would suggest that I don't want to miss something intra-articular, I would definitely get an MRI before, uh, before spending someone's money and time and energy and to make sure I'm more focused with the orthobiologic if we get that far. This is kind of a generalized question, but we have two minutes. I want to get everybody's gets about 30 seconds on this consensus or status of PRP for joint arthritis. Go ahead, Brian, you start, and I'm going to move right down. 30 seconds. Sure. I think, uh, I think there's some suggestion that PRP can be somewhat helpful for arthritis. We think we talked about that last time. If, if I had tried some other areas, I mean, we have a lot of things to unpack here, but, but that may be a viable option, but I would focus on some of the other biomechanics first before I get to PRP. I think Luke said core or ACP for joint arthritis is equivalent to viscous supplementation, which in and of itself, we're not looking at like super high rates of success, but I think that there is a role for it and we are studying it. We are definitely trying to look at it. I wouldn't say the elbow, but we're looking at the knee and the hip right now. So I think there's something there. Um, we got to pick winners, like what does well, what doesn't do well. Ken. Yeah. So I'll use my 30 seconds to kind of talk a little bit differently. So I, I, I would do a PRP into the tendon issue. I would also do it into that RCL. Um, I've had pretty good success with PRP for these kinds of radial collateral ligaments that are a little bit afraid and kind of partially torn. Um, certainly that's one indication where surgery could be indicated if the RCL really was unstable. We know the results of surgery, uh, for just lateral epicondylopathy is not very good. Um, lastly, if they have RCL involvement, that's an instance where I don't want to do 10 X or vacuum debridement device, obviously. So even though I would like to do for those calcifications and the tendinopathy, I probably would stay away from it and do the athlete if I thought that RCL was real. Awesome, Joanne, you get the last 25 seconds. I agree with everything that Ken said. He said it beautifully. Just to address Zach's question, I think Ken answered it, but absolutely you could use an orthobiologic into the ligaments, into the joint. I was just saying you don't wanna use 10X into those areas. You wanna save that for the tendon. We're all in agreement on that. Perfect, and you all get points for sucking up to each other. All right, here we go, spinning out of the pen. We're coming down to the last one. Let's go to round four. This is a very close one. You guys are killing it today. I mean, everybody is just giving great answers and we're getting great feedback from the audience. Round four, Dr. Moley, this one's gonna be to you to start. GM is a 58-year-old golfer. I know you like to golf. With several years of right lateral hip pain, worse with activity. They note stiffness involving the hip. Not like the most history you're gonna get, but you can comment on other things you might've wanted from the history too. And let's show the next picture, please. So we can at least look at the imaging if you can describe this for us a little bit and then kind of put the picture together for us and get us started. Yeah, thank you. So I think we're gonna switch this to a left hip for some other purposes also that we have left hip up here. So just looking at imaging, I think imaging, even with tendon issues, it's very important to look at the joint. Here we have, looks like mild dysplasia with a non-congruent joint, which is concerning. If you look kind of closely, you could see small osteophytes superior and inferiorly. So there is some concern looking at this joint, the health of the joint. Outside of that, laterally, I don't see that much. We have an ultrasound, so it's a short axis, a long axis view of what appears to be a very thickened gluteus medius tendon that's attached to the great trochanter. There's partial tears and possibly some calcifications within the tendon. You know, I think this is a common case. You see a lot of them. And I think if I'm looking at outside, this is a tendon conference that I'd worry about the hip a bit. When you see a hip like this, I think Joanne's point is very good. You have to, periarticular tendinosis in the face of arthritis is very common. You can do all the injections you want around that. It's not going to get better. The joint itself is not healthy. So I'm going to say that, you know, this is, I'd have a low index to image this hip and look at the cartilage. We do non-contrast here in cartilage sense, which I think is important. But for the sake of this talk, I'm going to say that the hip is good. The one thing to look at in the physical exam, motion's very important. And the stiffness would be a concern for me. So look at arcs of motion. How, I would say a moderately under-constrained hip should have a fairly large arc of motion. So you see a restricted motion. So normal in 70 degrees, you know, look at the right hip and they've got 70, they get 80, 90 degrees. Left hip has 50 degrees. You have a reduction in motion. If it's loss of internal rotation, I'm more concerned about it being more arthritis. If it's loss of external rotation in the face of a lot of gluteus medius tendinosis, you can get a trochanteric pelvic impingement and you can get pain from that. I've seen people lose a little bit of motion, but I think your physical exam is very important. Always look up top. We get a little bit of the spine there. Underlying L5 radiculopathies could affect weakness. Check their strength. It's particularly in the posterior aspect of the gluteus medius. If you look at the gluteus medius is really divided into three sections, anterior, middle, and posterior. The posterior is the one portion you need during stance. And so if you tear your posterior aspect, you cannot walk without trying to elevate gait. So look at that. When I'm examining them, I really look back at the posterior, a lot of the pains there, but the typical injection done blindly is done to the anterior aspect. That's why you see a lot of tears there. So again, I'm going to ask how many injections have you had? A lot of people have had. Finally, this is a golfer. So the sport's really important. Making it a left hip makes it a little bit easier. They're loading, they're doing high eccentric loads into this each time. And I think that that's something we're going to look at in the rehab is say I clear the joint, it's not arthritic, and we're looking at the gluteus medius tendinosis. We're really going to spend a lot of time working on that kind of core above stability, limb mechanics, abductor strengthening, both passively and then dynamically, and then loading it into this like eccentric. So, you know, if you are a golfer and you're PT, you should be standing, rotating, doing different activities that you would do in golf. So PT should match your sport a little bit better. I think there's a lot of times a lack of alignment between what the physician wants, what the patient wants, which is most important, and what the therapist is doing to achieve that. So that all would go into this as far as basic workup, but I would start, you know, assuming that hip is healthy with a physical therapy program, working on progressive loading and strengthening of the gluteus medius, but you have to strengthen everything around it. You can't have a strong gluteus medius without a good core. Ryan, anything else specific to the rehab program that you would consider or think about? You know, I think Pete kind of hit everything as well. Again, I'm sort of torn to this balance component of that. I think if you have an opportunity and have a therapy place with force plates, you could look at that weight distribution as they're going through the golf swing to see just how that's changing. I think that can give us a good sense in regards to how that person's, not necessarily only loading the muscles, but the joint itself in multidirectional pain plane. And I like to utilize that with some video to look at the mechanics to try and see if we can help, help correct those issues in regards to loading. Ken, the patient now coming back a month later and they've really done this great rehab program that Pete's had them working on, they're not getting better. Where are we going to go now? Yeah, you know, Pete mentioned this too, but lumbopelvic pain is sometimes difficult to unpack and try to really find these pain generators in there and looking at the spine and the SI joints and the pelvic motion and everything else. You know, you get an MRI with or without contrast, you're going to see a labral tear, you're going to see some arthritis and you got to be careful about those findings and not trying to, you know, jump all over them or have the patient jump all over them. I do in this area, especially a lot of times, if I'm unsure of the pain generator between the hip and the tendon, I will do some kind of injection of anesthetic, usually with a pivot cane. Usually I'll do it in the joint because it's a very confined space, try to reproduce their pain and kind of make sure they were dealing with the right structures. So let's assume that's all been done. Let's assume we're talking about the glute medius tendon being the problem. I think at this point, the evidence is pretty clear that, you know, Jane Fitzpatrick has done great work at glute medius tendinopathy PRP compared to corticosteroid injection. To your follow-up, the PRP group is going to do significantly better. I don't like doing steroids in this area. It's not an absolute no for me, like it is for like the elbow where I never do steroids anymore, but in an active person, I'm more likely to, you know, either do a needle tenotomy of that area, PRP of that area, or now I've even gotten some more 10X in vacuum debridement devices for these glute tendons if they do not have too much adipose tissue. Joanne, what do you think? Wow, it's hard to top these excellent contributions. I just add a couple of little things that I've learned over the years. Number one, when it comes to the lateral hip, assuming you've looked at the spine and all that, if you come just a little bit cephalad, you will come to the lateral hip capsule. It's where there, you know, there's an attachment to the reflected head of the rectus. And I do find a lot of people are tender. And then if you look at them deeply with ultrasound, you can see some enthesophytes and tendinosis there as well. And there's been quite a few times where people have been recalcitrant to other injections, and they really need to have treatment at their lateral hip capsule. And then the other side, just that we've all learned to check over the years is posteriorly. So certainly problems in the ischiofemoral space can overlap and sort of compete for our attention in that posterior to posterolateral hip girdle region. So just a couple of little additive pearls that I've picked up. One of the points I wanted to make here that Brian had answered to a question, and the thing about don't forgetting about the thoracic spine rotation, because this is a rotational sport, which has obviously its own specific issues. So the rotational component, very important. Another question that came up is, could you discuss the program of eccentric strengthening of the hip abductors? Pete, I'll let you start with that. That's from our president, Stu Weinstein. That's a good question, because I think it's low-hanging fruit. We're doing the hamstring with eccentrics, but the hip abductor is much harder. I'll say one thing leading into this, and Ken kind of brought it up a little bit. The gluteus medius PRP, which I think is relatively effective, we use it a lot, and we see a lot of this disease, is only effective if the patient can provide force. So if you cannot have four, four plus, five on a five strength, the PRP was ineffective when we looked back at kind of our studies and who didn't do well. So making them strong enough to do it is super important. I think I rarely ever use steroids around the gluteus medius, but occasionally if someone is so uncomfortable, we'll do it to progress their rehab, realizing most are going to come back. I think the fist factory stuff is really good. I think that at this point, PRP is really the way to go. So I think when you're looking at eccentrics of the gluteus medius, we work with our physical therapists on loading, rotational loading of these golfers once they've achieved enough strength and they're pain-free. So we're doing with our band work, we'll do it in kind of a sideline position with them providing force and pushing down on it, kind of a slow load against gravity with the therapist adding more load to it as the patient can handle those loads. And I think it's helpful. It's not as easy to do as like RDLs, but I think it can be done. And I think it's important, particularly when someone is going to load that way. So we'll start out kind of isometrics to concentrics to eccentrics based on the patient's tolerance. Okay, one question here. I just want to make sure I'm trying to get to everybody. We have the last two minutes. A question about proper squat technique. I've been seeing many people have been plantar flexing by placing weight under heels and having knees over their toes. Any comments on that? Anybody? Proper squat technique. So quickly, I'm talking a lot here, but basically a lot of people load in the anterior chain. So there's a lot of TFL anterior portion. You want to just try to get them back to load. Sometimes we'll have them take a rope or something on a doorknob or TRX and load back posteriorly. And I think that's the key is get that, those glutes and all those glute max and glute meet together is important. You see how equally important to get the glute max to function correctly. All right, sorry. And I think the other thing is too, right? There's these concepts of how we do things, but you need to individualize it. I love that Pete was about like, let's work with our therapists. Let's think about the individual and their movement pattern and flow pattern, as opposed to just saying your knees need to be over your toes or whatever, right? I think that's important. It becomes important for movement in specific sports and movement and rehabilitation. And often I'll get patients who are like, just give me a piece of paper that shows me the exercise. And that's not the way to go. That's not what's going to help them. If they're committed to rehabilitating this, let's work as a multidisciplinary team, as we do to really individualize that program. So it's hard to generalize. Let's make it specific. Go ahead. Who's going to comment there? No, I just said that was well said. My only comment I think someone put in the chat too, is especially with these hips, sometimes to externally rotate your feet a little bit, especially if I'm reducing the stress on the joint point of view, can kind of help with the squat technique as well. So. I think Ken's point's important. Look at the version. Are they anteverted, retroverted? You got a retroverted femur, don't have them put their feet straight. You're just creating impingement. I think a lot of times that's a problem. Good point. Well, well, well, that does wrap things up. I want to give, we actually stayed like really on time and it looks to me like we still have about seven minutes left. I do want to give everybody maybe another minute or so to kind of wrap up kind of any concluding thoughts of the day of what they thought and kind of main points that they want to make to people. This has been an incredibly great educational session for me, I can tell you. We're going to start with the defending champion. Boom Boom, you got any final comments for us? No, I'd just like to acknowledge my fantastic colleagues as well as Dr. Press. But I think the points that we're hearing today, we all know in sports medicine, the needle is the last step. The injections are very much a small part of this. And we all value and look to the biomechanics and the strength and the flexibility and how our athletes do their sports. And then and only then do we consider doing an injection therapy. And what we choose really depends on a lot of factors that you've heard about in season, out of season, chronic versus more acute aspects to tendinopathy. Is this something that needs to be unloaded, et cetera. And then always the last sort of frontier that we haven't done well with is putting some science behind our rehabilitation protocols. And making sure we're always incorporating the muscle as well as the tendon in our rehabilitation processes. Great, Bone Crusher, Craig Beck, you got anything to end with? Yeah, I agree. Thanks everyone. And it's been an honor to be on this with the group. Overall, treat the patient, not the image, right? Tendons don't always look well when we image them, but it's about the patient, the function and put it in the perspective of their goal. And I think if we do that and we keep people functional and moving, we've done our job. Boom Boom Moley, I'm glad nobody asked any questions about clams on this one. So do you have any comments? Never do clams, they do not work. But no, I would like to say it's last time and this time I learned a lot being on this panel. These guys really are thoughtful in their approach. Joanne's point is, I mean, and I think the research is, the science is super important and we have to study right now just trying to categorize like, and let's get the science of it. The rehab works well, I put a lot of time into it. And I think that individualizing it for each patient, working in outreach, you know, think about when you're a rehab resident and you sat down at the table and talked about with OT and PT you know, try to do that in a manner. It's the best thing, especially you see it at a high level of sports teams. I'm sure, you know, that where everyone's together yet you leave it for your patients, go out and see this person. Here's a list of PTs. Try to meet the people, try to know who they are and share ideas. And I think outcomes are a lot better, particularly with something like tendinopathy because it's so much about the mechanics around it. And then the last thing is, do you add something, an adjunct at the end? And I think that that's working. And I think we should all be working on trying to advance this as best we can. But patient outcomes are based on good history, good physical exam, a good relationship and team working together, you'll have better outcomes. Lights out, Monner. You got the last word here before we pick a winner. We, I get to pick the winner. Thanks, Joel. You did an excellent job, I will say. And for the second year in a row, this is probably gonna be my favorite lecture panel I'll be a part of. I mean, it's lots of fun. I'll keep doing this if y'all like it and people want it. But my comment is, you know, we get up here and we talk about PRP and I talk a lot about PRP, but we need to be very thoughtful in our conversations with our patients about what we know, what we don't know. And, you know, we can easily say, oh yeah, let's do PRP for this. We all know that not everyone's gonna get better from PRP. And, you know, I think a lot of the field of biologics is getting a bad reputation because of folks who are just out there putting needles in people and charging money for it, sometimes really large sums of money. And so, you know, having thoughtful conversation with our patients and really discussing the pros and cons of the different treatment options is what I think we need to move forward with. And, you know, we can tell you what the evidence says, but like everyone else has said, individualize it and just, you know, make sure that the expectations of the patients align with what you think that you may get out of it. Okay, I wanna thank you guys. The four of you have been amazing. You are all great clinicians. You are all great friends. And I can tell you in my 32 years in this academy, this has kind of been the most fun and probably the most educational one I've had. This one in the last year. And so I think we're gonna just have to do this every year. As I think I go through this, you have to pick a winner. It's like, you know, which one is your favorite child? It's not the easiest thing to do. And I think I can say that, you know, Brian, you brought it this year. I mean, you definitely had the... Don't put the champion up yet. You had all that workout made a big difference. Pete, you always amaze me with your knowledge and talent and skill. Joanne, great reigning champion. But I do have to say that, you know, this is kind of the year of Atlanta. I mean, you got the Braves, they won. You got the Georgia Bulldogs, they're number one. So what the heck? We got to make our champion, the man from the South who's got the World Series ring and the hat and everything. Dr. Motner, you're our champ. All right, well-deserved. Well-deserved. Well done, Ken. You got a role. And last, I want to thank everybody for... You get the last word after I just thank everybody for participating. We had over 250 people most of the time. And champ, you get the last word. Well, you know, this is just the beginning. I'm going to train harder for next year and come back bigger and better than ever. So be ready because, you know, I'm going to try and defend my title since Joanne couldn't. All right. Repeat. Thank you guys all. This was fantastic. And thank you all for your participation. Thank you.

tendon injuries

treatment options

individualized treatment plans

biomechanical issues

injection therapy

PRP

rehabilitation

targeted exercises

multidisciplinary approach