So, thanks for everyone who's here live and then thanks to everyone who watches the recording. My name is Ryan Nussbaum, I'm a physician at University of Pittsburgh, Department of Physical Medicine and Rehabilitation, and I'm the Sports Medicine Fellowship Program Director. And today, we're going to be talking about a great topic here as part of the overhead athlete member community for AAPMR. And so, this is going to be Raising the Bar, Identifying Common Injuries in Overhead Weight Lifting Athletes. And we're lucky to have Dr. Sharnay Mead presenting this topic, and she is currently our fellow here at University of Pittsburgh Medical Center for, what is it, two or three weeks, right? So, you're like, you're ready to go practically in attending here. And so, originally, Dr. Mead is from Columbiaville, Michigan, and she did medical school at Michigan State College of Osteopathic Medicine. And for residency, she completed this at Case Western Metro Health in Cleveland, where she was chief resident. And then, she is currently doing her fellowship here at University of Pittsburgh Medical Center. Already, she has active roles in different high-level weightlifting organizations, including USA Weightlifting and the International Masters Weightlifting Association. She has primary clinical interests in diagnostic ultrasound, advanced ultrasound procedures, and caring for the strength athlete. After completing training, she'll be starting a sports and MSK practice at McLaren Northern in Petoskey, Michigan. So, Dr. Mead, thanks for taking the time to present this today. Thank you, Ryan, for the introduction, and thank you, everyone, for joining us online this evening. I'll dive right into our topic this evening. So, thank you for the introduction, Dr. Nussbaum. I don't have any financial disclosures, but as we said, I do have some affiliation with USAW and IMWA, and I was formerly a NPC bodybuilding competitor, so this is where my love for strength sports really blossomed. So, we'll just dive right into things. Our outline for today's talk will begin with a short introduction about strength sports, with diving more into detail about the movements, mechanics, and epidemiology of injuries regarding the big three strength sports, including Olympic weightlifting, powerlifting, and CrossFit. And since these injuries between the three are not mutually exclusive, we'll move more into talking about the common upper extremity injuries found in all three of these sports. With one caveat, I realized after building this topic I could probably write a book just on the upper extremity injuries that are experienced in these sports, so we're limited by time, so we'll talk more about the more common injuries, ones that are seen mostly in weightlifting, including muscular and tendinous tears, distal clavicular osteolysis, UCL tears, a little bit about shoulder and elbow dislocations, then we'll talk about axillary nerve palsies as well, and then at the end we'll talk a little bit about injury prevention and equipment that is used by strength athletes in regards to upper extremities. So as many of you already know, strength sports are often practiced as a means of conditioning for other sports and activities, and they've also gained immense popularity in the past decade, and we've seen a spike in participation in both men and women of all ages in all categories of strength sports. The traditional sports that are considered to be strength-focused are, of course, powerlifting, Olympic weightlifting, bodybuilding, strongman, there's the Highland Games, and the youngest of the group is CrossFit, which has experienced exponential growth in participants since the start of the sport in the early 2000s. Each of them have their own set of governing bodies and often have multiple federations associated with them, so it's hard to have uniformity even within each of these sports. However, Olympic weightlifting has the most uniformity of the group and is currently the only strength sport that you are able to compete at the Olympic level, with the exception of the bench press, which is also included in Paralympic powerlifting. Each of these sports involves different types of lifts and strength specificities, and while many of these sports have overlap and injuries that may be seen, they also have their own unique set of injuries. So today we'll be highlighting just a few of these, including their mechanisms, diagnoses, and treatment, with specific focus on overhead and upper extremity portions of these lifts. So we'll first start out by talking about Olympic weightlifting, which is a strength sport that, like powerlifting, is focused primarily on maximal power and strength in one repetition. The difference here is that with both competition lifts, the athlete must lift the barbell overhead, requiring movement patterns and strength generation from the entire body. There are two competition lifts, first being the snatch and the second, the clean and jerk. These are both very highly technical lifts that require appropriate mobility, strength, power, as well as perfect timing to be able to thrust this barbell overhead. So these exercises may generate the highest power outputs of any human activity, since the barbell must be thrown up quickly from the ground in an overhead position, so this truly is requiring full body strength. Each lifter gets three attempts at each lift, and their heaviest achieved lift will be counted towards their total. So the snatch is the first one we'll talk about, and it's the most technical of the two lifts. It requires the athlete to pull the barbell from the ground in a wide grip, and at the moment of the pull, the athlete gains velocity of the bar by forceful extension of the knees, then the hips, with the hip extension being the primary driver of the power of velocity. This power from the legs will generate a vertical velocity of the barbell, and the athlete must simultaneously squat while the barbell is traveling overhead. This is called the turnover. The athlete then catches the barbell overhead with their latissimus dorsi, traps, and pectoralis muscles engaged to stabilize the bar, and they must be able to stand up from this position without pressing out from their elbows, demonstrating stability in the elbows in that catch position. And so they stand from here, and they hold the weight until the judges signal them to release the weight to complete the lift. So during this lift, it's completed within one minute of being called to the platform. In most cases, there is some exception if you follow yourself on the platform. So I do have one video. I hope it works here, and I hope it's not too loud for everybody. This is a lift from the Arnold Sports Festival this past year. He is lifting a pretty immense amount of weight, and this is him doing the snatch with Arnold sitting right in front of him, so it was pretty exciting for him to be able to make this lift. Pretty impressive. Now we'll talk about the clean and jerk. This requires cleaning the barbell from the floor while squatting in a catch position and catching the barbell in a squat position, a front squat position. This movement must be fluid so that the athlete, their elbows don't touch their knees. So once they're able to catch the barbell in this front rack position, they then stand up, and then from here, they perform the jerk portion of the lift, and the jerk is traditionally done in a split jerk style. So the athlete will dip and extend the hips, generating power, and at the moment of this movement, the athlete then descends into a lunge, catching the barbell overhead. So at the top of this catch, again, the athlete's elbows cannot press out, and the lift does count towards their total, but if they press out, it does not. So here we have a video of Valentina, who is a Romanian weightlifter, who will be competing at the Paris Olympics this year, performing the clean and jerk. So this is the clean portion, where she catches it in that front rack position, and then she's preparing for the split jerk, which is here. She makes this look very fluid and very easy, but it is a very technical lift as well. All right, so now we'll move on to powerlifting. Powerlifting is another major strength sport division, and during a powerlifting competition, there are three lifts that are performed, including the squat, the deadlift, and the bench press. The competitor has three attempts at each of these lifts, and their score is the total of the heaviest lift in each category, and each lift has their specifications on what counts towards a successful repetition and what does not, including the squat, needing to have the knees angled, extending at 90 degrees, you have to lock out with the deadlift, but we'll be focusing primarily on the bench press, considering we're talking about upper extremity injuries today. So the traditional bench press is performed with keeping the spine pressed flat against the bench, while the bar is slowly lowered to the level of the chest. From there, it is pressed up to the start position to achieve one successful repetition. In powerlifting, the athlete must lift as much weight as possible and must be able to touch their chest with the bar, then return to the start position to achieve this rep. So in order to do so with maximal weight, they typically employ a back arching technique with the laps more firmly pressed against the bench. This allows them to harness greater power from the latissimus dorsi instead of relying solely on the strength of the deltoid, which is a smaller muscle. This is required of the traditional bench press. So by arching, it decreases the overall load on the deltoid and decreases the distance the bar needs to travel. So most powerlifters use this technique. And we have a picture here, the top one being the traditional flat bench, and then the bottom picture has the arch position. However, this is actually a pretty mild arch. Some lifters will have an even more exaggerated arch than that. So now we'll talk about some CrossFit. This is an emerging physical conditioning program based on constantly varied, high-intensity multi-joint functional movements. The popularity of this sport is ever-growing, with numbers as high as over 15,000 CrossFit gyms worldwide. This training model has demonstrated to improve cardiovascular and cardiorespiratory fitness, stamina, strength, power, balance, flexibility, as well as the overall health is improved through our regular conditioning through CrossFit. So training is scheduled as daily session called workouts of the day, or WODs, which are composed of different exercise modalities, including calisthenics, metabolic conditioning, gymnastics, weightlifting, which includes both Olympic weightlifting and powerlifting movements. So these programs have been suggested to increase risk of injury due to excess volume, early fatigue, risky movement execution, and improper perform. But despite these notions, literature has found that the risk of injury in CrossFit is actually similar in comparison with other weightlifting and non-weightlifting sports. So there was a study done by Rodriguez et al. that was recently published as a systematic review of the epidemiology and risk factors for injuries in CrossFit athletes. This involved 25 studies that were included for review and over 12,000 CrossFit athletes. And they found that the mean prevalence of injury among those included was about 35%, with an incidence rate between 0.2 and 18.9 per 1,000 hours of exposure. The most injured area in the study was the shoulder at 26%, followed by the spine and the knee. And the authors also reported that there was a rate of 8.7% of injuries requiring surgical intervention. So the incidence rate of CrossFit has been found to be comparable to rates in team sports such as soccer that's clocked in to be about 15 injuries per 1,000 hours. And if we compare it to running, they have an injury incidence of about 7.7 to 17.8. So it's around that of running as well. And when compared to other strength sports, it is very comparable to powerlifting and weightlifting as well. The authors did note that the studies included in the review, there were three of them that skewed the incidence rate to be a bit higher. And they speculated this was due to the response bias as these three were survey response studies. So if these studies were excluded from the review, CrossFit would actually have a lower incidence of injury in comparison to other strength sports such as strongman training, which has an incidence of 4.5 to 6.1 injuries per 1,000 hours. So this has demonstrated that this is pretty safe compared to other sports. The vast majority of injuries are actually caused by weightlifting movements, including deadlifts, snatches, clean and jerks, squats, and overhead presses. Risk factors for developing an injury in CrossFit include being of older age, male gender, having a greater BMI, which the authors here, Nicolay et al, cited that this was actually due to the ability of these athletes to be able to lift heavier. And with any sport, the presence of pre-existing injuries also is a risk factor for developing further injuries in CrossFit. These injuries have also been linked with a lack of coaching supervision, especially in amateur athletes with less than six months of experience, and also with more seasoned athletes greater than three years of experience and participation in competitions, which that last part is not very surprising because most sports competition increases the rate of injury versus those cited in training. So when looking at upper extremity injuries specifically, Nicolay et al. found that training over 11 hours per week also increases injury risk. So this is something that we can keep in mind for counseling anyone who is interested in getting involved with CrossFit in the future. So there are many exercises in CrossFit, and we will see an example of some of the more complex movements on the next slide that require upper extremity strength. But when injuries do occur in this sport, they are most commonly due to gymnastics movements and Olympic lifting, and often these occur due to repetitive movements in the setting of fatigue, resulting in muscular imbalances during the movement, leading to injury. So in addition to Olympic weightlifting, CrossFit involves many overhead movements that can predispose athletes to upper extremity injuries. Some movements are heavily gymnastics-dominated, as previously stated, such as the handstand walk that's demonstrated in that image on the left. We also do handstand push-ups in CrossFit, and there are other more specific movements to CrossFit, including the kipping pull-ups or chest-to-bar, which is demonstrated on that top image here. Let me see if I can get my laser pointer. So this is the kipping chest-to-bar, where you stabilize the glenohumeral joint with the lats, and you activate the posterior chain, and then flex at the core to get momentum to get the bar to the chest. Sometimes this is also done in a muscle-up fashion, so they'll kip and then push up from the bar. This is more of a strict muscle-up, where we pull up to the bar and then press and lock out our triceps to get up over the bar. But there's also kettlebell swings and Turkish get-ups that require a lot of upper extremity strength and stability through the glenohumeral joint. So a systematic review by Assata et al. reported that acute injuries and weightlifting accounted for about 60% of the total injuries, whereas chronic accounted for about 30% of them. 20% of all injuries were due to muscle injuries, and 25% were due to overuse injuries of tendons. So of these injuries, we'll move on to discuss more of the common weightlifting injuries found in the upper extremities. And first we'll talk a little bit about the shoulder, as this is the most common area to experience an upper extremity injury in overhead weightlifting, and accounts for 26% of all injuries in CrossFit, and 36% of injuries between all strength sports. So upper extremity resistance training exercises place emphasis on large muscle groups to create strength and hypertrophy. While doing this, if exercise selection within a training program is not optimized, this may neglect smaller muscles responsible for upper extremity joint stabilization. This may create an imbalance between the internal and external cuff rotators, an imbalance between deltoid or rotator cuff force coupling mechanism, and improper emphasis placement on periscapular musculature. So these imbalances have been associated with increased risk of injury. And additionally, with improper repetitive loading of the joint, improper positioning during exercise execution and biased exercise selection, the risk of shoulder injury increases, and the athlete is at risk for developing labral tears, labral capsular joint dysfunction, shoulder instability, and rotator cuff pathology. So the glenohumeral joint is a diarthroidal multiaxial joint with the largest range of motion in the human body, which predisposes it to joint instability. So extra physiologic motion predisposes the shoulder to increases in humeral translation within the glenoid, which can be exacerbated if there's a presence of a defect within the supportive structures, like we had previously mentioned. In the presence of glenohumeral instability, if the shoulder is placed in an externally rotated and abducted position under load, such as during the snatch, this can predispose the athlete to anterior glenohumeral dislocation, which is not uncommon to see within the weight lifting competitions and with CrossFit. So we'll see that in this top picture here, the gentleman on the left, he has more of a trunk forward position and not as deep into his squat. So his shoulder is then required to externally rotate more, putting him in a more compromised position than on the image on the right, where he's more, he's deeper in his squat and his barbell is stacked a little bit better over his spine and his shoulder. So there's less external rotation there and that's much safer position for his shoulder. This bottom image appears to be an athlete that is what we call bailing backwards. So her arms are externally rotated and she's holding on to the barbell while it's falling behind her. And this is a position of compromise. And often when we do see anterior joint dislocations, it's due to this or this positioning. So as far as total anterior dislocations found in the sport, we don't know the exact number, but from 2015 to 2019, it was estimated that there are about 89,000 total athletic related shoulder dislocations in the U.S. 87% occurred in male athletes and it's estimated that about 3.3% of these injuries were due to weightlifting based on the ED visits in this timeframe. So many shoulders are actually dislocated and reduced at the platform. So this portion of injuries are likely not included within this total. So it may be skewed lower than what it typically is. So as far as presentation goes, acutely, the patient will often present with their arm and with a prominent acromion. However, if there's a lot of muscle bulk there, it may be difficult to appreciate this. The arm might be in slight abduction, and the elbow will be in flexion. When this occurs, the shoulder should be attempted to be reduced. And there are over 20 different relocation techniques that won't be covered today. However, if you're involved with strength athletes or involved with sideline coverage, it's helpful to know a couple of these to help with reduction techniques at the platform. So on exam and in the clinic, it's important to know if there is generalized hypermobility, as this will allow us to determine if there's likelihood of recurrent instability events. We'll perform that by doing the Buiten scale. And we'll also test for instability, including the apprehension and relocation tests. And then we also need to assess the status of the axillary nerve, as this may be compromised in a dislocation event. So this is just a quick table of all the different anterior shoulder instability tests and multidirectional instability tests that can be utilized in the clinic to get a sense of what kind of instability pattern the patient may be experiencing. The picture at the bottom is just demonstrating our apprehension relocation test. But we'll move on from here. So anterior shoulder dislocations can lead to glenoid fractures, tuberosity fractures, rotator cuff tears, and nerve palsies. And recurrent dislocations can lead to bone loss, chronic instability, chondral damage, and dislocation arthropathy. So it's not only important to relocate the shoulder dislocations acutely to avoid neurovascular compromise, but it is important to thoroughly evaluate our overhead athletes after a dislocation event in order to prevent long-term complications, in addition to allowing them to return back to their sport. So workup after a closed reduction should include an X-ray, including an AP, true AP, axillary, and scapular Y view to demonstrate successful relocation and to evaluate for osseous abnormalities or fractures. MRI is a valuable tool for evaluating for the labrum, the capsule, and the glenohumeral ligament, including cartilage and the rotator cuff. And that should be considered early on in this population too. Bankart lesions are very common after an anterior dislocation, which is a lesion of the anterior inferior glenoid labrum, which then can lead to chronic instability. And another lesion that's important to note, because it's most commonly seen in our weightlifting population as a haggle or a humeral avulsion from the glenoid labrum lesion that is not really common, but like I said, is seen more often in our weightlifting population due to its mechanism, which are often caused by hyperabduction and external rotation, which can occur if the athlete bails with a barbell behind their back and their head. These are often associated with additional injuries, such as heel sac deformities, labral tears, and rotator cuff tears as well. If we are concerned for a potential fracture, then we can consider getting a CT as well to evaluate for bone loss or glenoid rim fracture, because this can affect their long-term outcomes and their treatment plan going forward. So of course, after dislocation and appropriate workup, we need to consider long-term management and rehab in our strength athletes. Choice of treatment is based on patient history, clinical exam, and results from the imaging modalities. The patient's age, gender, expectations, and strength requirements and sporting requirements are also considered when we are coming up with a treatment plan for them. So young age at first instability event has been shown to be a strong prognostic factor for recurrent instability events. Thus, it's often appropriate to consider early referral for surgical evaluation in this group. In weightlifters specifically, we must consider their desire to return back to overhead lifting sports too, because they are at further risk for dislocation events if not surgically corrected. And as we've learned with repeated dislocations, this may lead to glenoid fractures or bone loss, which can change the surgical approach and make rehab and recovery more challenging. So the return to sport literature in weightlifting is lacking. However, generally, after an anterior dislocation event is required surgery to return to sport. And the return to sport is largely dependent on the extent of the injury. And I've seen in literature that anywhere from six months to 15 months is generally reported for return to sport. However, again, this information is lacking within the weightlifting community. As far as non-surgical treatments, this can be considered for high school athletes in non-contact sports or in our weightlifting population, those who do not desire to return to overhead lifting. Rehab after anterior shoulder dislocation consists of a mobilization period of about three to 10 days and early rehabilitation with referral to physical therapy after a period of immobilization to focus on restoring dynamic glenohumeral stabilizers. And once pain-free range of motion and confidence is regained in the shoulder, the athlete may have a trial return to sport typically reported to be about 7 to 21 days after injury in all comers. So axillary nerve palsies are quite rare. But it's been cited to occur more often in our weightlifting population. And as we remember, the axillary nerve arises from the posterior cord of the brachial plexus and contains fibers from C5 and C6 nerve roots. The nerve then travels through the quadrilateral space, which is created by the lateral head of the triceps, the teres minor, teres major, and the medial border of the humerus. And after this, the nerve travels distal to the posterior glenohumeral joint and wraps around the posterior surface of the humerus before branching to innervate the deltoid. The nerve is tethered posteriorly as a result of the overlying muscle, making it susceptible to stretch and compression due to prolonged pressure. And in weightlifting, this can occur due to repetitive overhead lifting, muscular hypertrophy of the posterior shoulder musculature, or a fibrous band formation of the teres minor. These conditions will make the athlete susceptible to quadrilateral space syndrome, which can be worsened in a shoulder abduction external rotation position. And as we mentioned, it can be implicated after a shoulder dislocation, which can occur in 5% to 25% of anterior shoulder dislocation events. So surprisingly, many patients with axillary nerve injuries may be asymptomatic, even though they have sustained complete or incomplete lesion to the nerve. Pain is not necessarily a prominent complaint, but there is usually deltoid weakness. But sometimes this is masked by compensation from the surrounding muscle groups. So in the acute setting, the athlete classically presents with weakness and abduction, decreased sensation along the deltoid muscle insertion, and they can develop progressive atrophy of the deltoid muscle and subluxation of the glenohumeral joint if there is a marked atrophy of the muscle. And when the affected athletes exercise, they may fatigue very quickly too. This is especially noted with overhead activity and heavy lifting. Athletes may also notice reduced strength with abduction or inability to raise the arm and numbness of the lateral arm. So the physical exam, again, can note this weakness. And it's important for us to check external range of motion because 45% of our external rotation is from the teres minor, which is innervated by the axillary nerve. So it's important to note the strength in external rotation as well as abduction, as most of this abduction strength is provided by the deltoid. When the patient is seen later in the course, muscular atrophy can be set in, particularly in the deltoid and the teres minor, and can help us identify the location of the lesion. So if the posterior deltoid and teres minor strength are spared, then the lesion is distal to the quadrilateral space. A complete neurovascular examination should be performed to assess sensation over the lateral arm as we discussed. And it's also important to note that a complete deltoid muscle deficit may occur in the presence of a normal sensation in the upper lateral arm and shoulder in 60% of cases. So athletes with quadrilateral space syndrome may also have dull pain to the posterior shoulder, which may be difficult to discern from impingement syndrome. So this can be sometimes a challenging entity to diagnose here. So diagnosis is typically made with EMG. But if it is unclear, we can always try quadrilateral space block with lidocaine for diagnostic purposes. Once it's diagnosed here, then we would want to do an EMG at monthly intervals for signs of neuroreenergization. The nerve should regenerate about three and four months after the injury due to the short course of the nerve. And surgical exploration can be considered with nerve grafting if there is no return of function by about four or six months after the injury. So moving on to a different shoulder pathology that's seen within our weightlifting community is distal clavicular osteolysis, otherwise known as the weightlifter shoulder. This usually results from repetitive excessive load to the AC joint, typically through horizontal adduction, internal rotation, and forward or lateral flexion of the shoulder, such as with bench pressing or overhead lifting. This repetitive loading causes microtrauma to the subchondral bone and distal clavicular head, resulting in subchondral cystic changes, disruption of the articular cartilage, and metaplastic bone formation with increased osteoplastic activity. So exam will demonstrate pain at the AC joint, worsened with shoulder adduction and internal rotation. And diagnosis is often made with a simple plane radiograph, which will demonstrate microsites or loss of subchondral bone detail and osteolysis of the distal clavicle, otherwise known as the moth-eaten appearance, which we can see here at the distal end of the clavicle. This is that fluffy, moth-eaten appearance that's described in textbooks. We can consider also looking at the joint under ultrasound, which will look similar to this image here, with the acromion on the right and the clavicle on the left. We see some interarticular joint bodies, some cortical irregularities that may indicate that this person may have distal clavicular osteolysis. MRI is not generally indicated if this is what you're suspecting in your athlete. But if you're looking for concomitant injuries, then we can consider obtaining an MRI. So treatment involves conservative treatment, with PT focusing on restoring that shoulder range of motion and rotator cuff strengthening. And then strengthening of external rotators of the shoulder, improving scapular control and multidirectional planes, and minimizing thoracic hyphosis or rounded shoulders through stretching and exercises should be included in our PT prescription. And we also need to address load modification with bench pressing. A lot of times, our athletes will be using a wider bench press grip, which can predispose them to distal clavicular osteolysis. So how we help them is by narrowing the barbell hand placement to less than 1.5 times the biacromial width. And then we also want to control the descent phase of the bench press, too, to end about 4 to 6 centimeters over the anterior chest. How we do this is we typically place a towel on their chest to act as a spacer, so then that athlete can learn where to stop with the barbell when they're doing it on their own. As far as the biacromial width, what you would do is you would measure from the outside edges of both acromial processes and take that number and times it by 1.5. And that's the maximal width that the athlete should be grabbing on the bar. Typically, if they grab there or anywhere inside that length, that will decrease their risk of developing this condition. So injection therapies can also be considered, as well, for their non-operative management of this, including corticosteroid injections, which can be for pain relief and for prognosticating success of surgical intervention, if that is what they are considering for long-term relief. And at present moment, orthobiologics have limited evidence supporting their use in distal clavicular osteolysis. Previous studies have demonstrated that 93% success rate of treating distal clavicular osteolysis. But if the patient does not improve with conservative measures, they can go on to have operative management with good outcomes using arthroscopic resection of the distal clavicle, often allowing them to return back to activity about three to six weeks afterwards, which seems to be pretty fast. And there's two different approaches. There's a direct approach and an indirect approach. And the direct approach seems to be about half the time that it takes to recover from, then, the indirect approach. Now, moving on to more of our muscle etiologies, first one we'll talk about is our pectoralis major tears. And the bench press is a very commonly performed strength exercise, not only in powerlifters, but also in weightlifters and crossfitters. One very common injury that can be seen as a result of bench pressing is a pectoralis major tear. In fact, the majority of pec tears are the result of bench pressing, accounting for about 47% to 70% of reported injuries. The tendon tear typically occurs with forced abduction of the humerus, which is during the eccentric portion of this lift. Often, patients will present with a history, noting acute pain at the time of injury with resulting ecchymosis to the area. There may be a palpable defect in the axillary lesion and a fullness noted within the pectoral region, too, as well, due to the retracted muscle belly. And in this photo, we can see that there is a very prominent axillary fold. And here, there is that loss of that fold. And it looks like the axilla is much deeper than it is on this side. And that could be indicating a pec tear. And then there's ecchymosis here on the inside of his arm. And the chest just appears a bit more full. So diagnosing a pectoralis tear is typically clinical. But we can use imaging for confirmation. We can consider using MSK ultrasound or MRI. So MSK ultrasound can be used, as the picture depicts on the top here. This is a normal scan with the structures labeled to the right here of what it typically looks like. And this is the long axis appearance of the pec major tendon as it comes and attaches to the humerus. The bottom left image in 4A demonstrates a pec tendon tear that appears to be thickened and mixed echogenicity within the tendon, as indicated by the white arrow here. Whereas, this is the contralateral side. It appears much more thin, much more fibular. And this is the normal side. So it's definitely good when you're looking at this tendon to compare side to side to further evaluate. So the location of the tear, the extent, as well as the competitive level of the athlete will drive the treatment of this. So complete tears at the myotendinous junction occur in 20% of cases. And these are typically managed conservatively, as are partial tears at any location or complete tears without weakness. But more commonly is a complete avulsion at the pec tendon at the humerus, for which surgical intervention is often recommended. And if done within three months, there's good likelihood of the tendon re-approximation just with surgery. However, if an athlete presents for surgical referral beyond that three months, oftentimes they need to have a reconstruction technique done. When considering outcomes of operative versus non-operative intervention for complete injuries, Pochitti et al. performed a small but profound prospective study of 20 male patients, comparing two groups. They found that the operative group who had pec tendon tear reconstruction or fixation, they had a 70% excellent results in the operative group versus 20% good and 50% fair in the non-operative group. With an operative group only having a 13.7% decrease in strength versus 53.8% decrease of strength in the non-operative group. So if our athlete wants to return to heavy lifting, then it is advisable for them to undergo more of a surgical technique, if it's indicated here. But if conservative treatment is indicated, then typically we put them in a sling with internal rotation of the shoulder for about three weeks and then allow them to do passive range of motion after that. And about six weeks, they're then allowed to do both passive and active range of motion, followed by gradual increase in strengthening exercises from there. So next, we'll move on to our next rupture, which will be our distal biceps rupture. So the distal biceps brachii attaches at the radial tuberosity and may be injured at the musculotendons junction or at the radial tuberosity, being evolved partially or completely. So these distal injuries account for only about 3% to 10% of all biceps tendon ruptures, but they most commonly occur in competitive weightlifters. And the mechanism for this is that there's a sudden contracture of the biceps against significant load with the elbow at 90 degrees of flexion. And if there's pre existing biceps tendon degeneration, however, this injury has been seen with our powerlifting athletes in a supinated position as well, lifting, such as with a deadlift can cause this injury as well. And weightlifters specifically repetitive eccentric motion during the catch phase of both the snatch and the clean and jerk can also lead to biceps tendinopathy predisposing them to this as well. And another thing we have to consider in this group of athletes too is if they use anabolic steroid also produce, you know, predispose them to digestible biceps tendon ruptures as well as other tendon ruptures. The athlete will often present with a sudden sharp tearing type pain and activity related pain in the antecubital fossa, there may be ecchymosis in the antecubital fossa, as well as the distal ulnar part of the arm. And oftentimes they have a palpable defect of the distal biceps, they have loss of strength of elbow flexion and grip strength, but especially with forearm supination. And these findings may be subtle if there's only a partial tendon avulsion. And it's important to note that more recent studies have found that the sensitivity of the hook test is not as good as we had hoped, it's 88% sensitive, and with a complete tear, and that's because if there's intact to the surface fibrosis we could get a false negative. So this has become a clinical and a radiographic diagnosis. So, when we are working up a distal biceps rupture, we should include an x-ray, which may demonstrate hypertrophic changes at the radial tuberosity due to chronic tendinopathy, but we can also use ultrasound or MRI to help aid in our diagnosis of this, especially with partial partial tendon avulsion. Recent studies have demonstrated that ultrasound is at least as sensitive as MRI in the hands of experienced ultrasonographers in diagnosing both a partial thickness and a full thickness distal biceps rupture. And in active individuals primary repair of the acute tendon avulsion is best. If it's not repaired then they'll oftentimes lose 30% loss of elbow flexion strength and 40% loss of supination strength so in our strength athletes. This may be a profound decrease in strength and so this is something that we want. They should consider getting repaired. Additionally, if they're not referred quickly, as prior studies suggested after eight weeks, they may need to have a graft. The incidence of this rose from 20% needing a graft to 75% needing a graft after eight weeks so again this is something that we should refer sooner rather than later if considering surgical intervention. So now we'll move on to distal triceps rupture, which also commonly occurs mostly in weightlifters and again local and systemic steroid use may be a predisposing factor and avulsion of this tendon from the bone is the most common, though distal musculotendinous units can fail at the muscle belly or the musculotendinous junction as well. Distal triceps ruptures typically have a male to female ratio of about three to two with the median age around 33 years old, and this is usually caused by a deceleration force during an extension or an uncoordinated contraction of the triceps muscle against the flexing elbow, which are the most likely causes of this presentation. And again findings depend on whether or not the avulsion is partial or complete. So, with a full avulsion, they'll have loss of elbow extension strength and ability to extend overhead against gravity, and there may be a tendon defect, whereas incomplete tear may likely only show weakness of elbow extension. So radiographs may reveal small avulsion fracture of the olecranon, also known as the flake sign which is pathognomonic for this on x ray, but ultrasound and MRI are both reliable imaging modalities that can be used to diagnose both partial and full thickness tears of this. So again, primary repair is a treatment of choice and a complete acute ruptures. Well, there's long term recovery of about nearly six months for this outcome is usually favorable complications of the surgery, usually include a mild extension lag of about five degrees or olecranon bursitis. of the athlete, they may require reconstruction as well. So again, any of these tricep or any of these 10 ruptures usually require a pretty quick referral if they want surgical intervention. So partial injury, however, may be treated non operatively with immobilization and about 30 degrees of flexion for about four to six weeks, followed by PT, and this has been shown to have a positive long term results and regular follow up is recommended And MRI is not indicated for follow up but it is useful to use ultrasound as an effective and cost cost effective and reliable means of tracking patient progress with this as well. So, now moving on from content and tears we'll move on more to like ligamentous tears and UCL is the one that comes to mind with weightlifting. It is the primary medial stabilizer of the elbow with the anterior bundle providing the most support. The anterior bundle arises off the medial epicondyle and commonly inserts on the sublime tubercle of the ulna and the anterior band of the UCL is a primary co-restraint against valgus stresses at 60 and 90 degrees, and the primary co-restraint 120 degrees of flexion so as a result, injuries of the anterior band are more common between full extension and 90 degrees of flexion. So when a weightlifter catches a snatch they're doing so with their elbow in near full extension with the weight causing a valgus force along the joint line. So additionally to during a clean and jerk the athletes are often holding the barbell in a flexed position with a valgus position as they prepare to jerk the bar. So if they don't catch the bar with the elbows already locked in extension they're placing significant valgus force through the medial elbow predisposing them to a tear. Often athletes will present with an acute pop in pain over the medial elbow. And on examination of course we're going to do a full thorough elbow evaluation but notable findings in a UCL tear will demonstrate pain and medial joint space widening with a moving valgus stress test from 70 to 20 degrees as demonstrated here. The examiner is placing an external load on the distal forearm, while stabilizing the elbow here and feeling for gapping between that 70 to 120 degrees of flexion. So UCL tears can be classified into proximal, mid substance or distal tears, and most full thickness tears are mid substance tears followed by distal and then proximal tears in the order of frequency. So usually to begin workup, we start by obtaining an x-ray of the elbow, followed by soft tissue studies, dedicating to evaluating the structures of the ligament. So MRI is an excellent study looking for acute ruptures but it's less sensitive for partial thickness tears. An MR arthrogram is better for partial thickness and chronic injuries, but obtaining this study is often limited due to time it takes to obtain the imaging, as well as discomfort that the athlete may experience by the contract injection. So we can always consider obtaining a dynamic stress ultrasound as well. So dynamic stress ultrasounds can detect UCL tears with joint gapping as little as 0.5 millimeters and can offer diagnostic accuracy at about 96% sensitivity and 81% specificity when there's a relative ulnar-fumaral joint gapping of more than 1.0 millimeters under dynamic stress ultrasound when compared to the contralateral side. So evaluating for suspected full thickness UCL tear, stress ultrasound demonstrating more than 2.5 millimeters relative ulnar-fumaral joint gapping is 95% sensitive and 89% specific, which is comparable to MRI and MR arthrogram. So this can be a very reliable test, especially when we're using it at the platform to diagnose people with partial thickness or full thickness UCL tears. So this is just an ultrasound image of the UCL with the left one demonstrating what the UCL looks like with the elbow and 30 degrees of flexion versus 70 degrees of flexion and we can see that in 70 degrees of flexion we can more reliably see the UCL. So this is typically the joint angle you want to evaluate it under ultrasound. This is what it looks like when we're doing joint gapping and measurements here. So this is a standardized study at 70 degrees of flexion adding the external rotation force here and then this is pre gapping and this is post gapping so we can see that there is a notable change in joint width there. So treatment here is primarily based on categorization of injury. So non surgical management is typically trialed for proximal or low grade partial tears. Typically this involves a dedicated rehab program focusing on strengthening of the flexor pronator mass and addressing the upper extremity kinetic chain. And after this time the athlete can transition to sport specific training after about 12 weeks, with a caveat that most of this literature is done in our baseball athletes or throwing athletes, and there's not very much literature, citing this with our overhead athletes so this has to be taken, you know, by case by case basis. As far as bracing we can consider use of range of motion and elbow bracing in this population. But currently there's no publication indicating that their effectiveness that indicating their effectiveness and effectiveness in this population, and in competition we have to also consider, especially in weightlifting athletes can't compete in a device that So this is not something that they can use on the platform either. As far as conservative other conservative measures we can do we can consider doing PRP to this area during the rehabilitation period as well, especially in proximal partial thickness tears. But surgical intervention is typically recommended for distal injuries and higher grade full thickness injuries, especially if the goal is to return to weightlifting, because the injury. compete with the UCL injury, they then lose the medial elbow stabilize stabilizer. And when the athlete is in that valgus position in the clean and jerk or the snatch we are putting immense pressure through that medial elbow joint, and that puts them at risk for developing a posterior elbow joint dislocation. So of course this is going to require reduction of the platform and certain workup and surgical referral, especially if they want to return to weightlifting. Other injuries of the upper extremity that we can see in weightlifting, especially since Olympic weightlifting bench pressing and CrossFit require a lot of movement through the wrist, and they often require forced hyper extension position. And their exposure to repetitive heavy loads in this position. So this puts them at risk for developing extensor tendon pathologies, especially at the extensor carpi ulnaris. They are at risk for developing scapholumnae and luminae triclical ligament injuries TFCC injuries scaphoid and distal radius distal radial Pisces injuries. So we don't really have time to dive into each one of these conditions but I do want to just bring this to your attention and make you aware that risk injuries are also common in this population and something that we need to keep the back of the mind if they present to our clinic. So now I'd like to move a little bit into our injury prevention considerations in this population. So factors such as grip width, speed of movement barbell positioning and direction of gaze might all increase the risk of injury when their execution is not correct. So in addition with finding a center with experienced coaching and direct supervision, we should be advising our athletes to find a gym that encourages scaling workouts for these athletes, with the aim of establishing gradual increased progress and prevent potential overuse injuries. For strength athletes. When they're bench pressing, they choose a wide grip, as they believe that this produces more power. But this also puts them at risk of injury and movement pattern that we can correct. As we talked about earlier, having that wider grip also leads to greater shoulder abduction and internal rotation putting them at greater risk for shoulder injuries like the ones that we had talked about earlier distal clavicular osteolysis. So to prevent this we can recommend that our athletes adhere to that 1.5 times distance of the biocorreal distance that we measure in clinic. And then we could also discuss talking with them about making sure that they don't go beyond that four to six centimeters beyond the chest descent. Our athletes will be reluctant to choose a decreased grip grip weight, because they think that this may decrease their power output overall, but studies have shown that this not only decreased the risk of injury, but without affecting the recruitment patterns of the muscles involved in the lift, and it only changes the difference of one rep maximum of about 5%. So it doesn't have that big of a decrement within their strength, especially if we're talking about decreasing the injury, especially if they're coming back after an injury. So, as far as equipment goes, we can talk about a little bit of bench shirts. These are very tightly compressive supportive shirts, made of elastic slightly elastic and very strong material, it allows people wearing them to press significantly more via the shirts elastic recoil during the bench press. It also promotes a less vertical path causes less work and less load through the shoulders and may therefore be a strategy to reduce strength on the shoulder, but there's a caveat of there's not been very robust studies looking at this. This is not hard and fast evidence is kind of one of those things that can't hurt, but may not help. So, take it with a grain of salt, a lot of power lifters do wear this equipment though. As far as elbow straps. This is an improvement in overall performance, as this has been suggested to increase their load lifted by about 6%. But this is not something that they wear throughout the duration of their exercise, because it's uncomfortable and can lead to other injuries if they do. These, however, have been suggested to improve proprioception of the elbow much like the, the ASO does for our ankle or ankle braces, and they can help with injury prevention during technical lifts and returning from an injury. Again, not robust studies but there's just some suggestions out there that this may be beneficial for our athletes. As far as wrist wraps. These are often more by power lifters and weight lifters for injury prevention to the wrist. Unfortunately, there's no publication thoroughly evaluating their effectiveness and injury prevention, but their role is to keep the wrist in a more neutral position while lifting heavy to prevent excessive wrist extension and chronic compressive forces on the TFCC, the ECU and the radiocarpal joint. And finally, talking about wrist straps. And these can be considered for less requiring more grip strength. And they're typically used for like deadlifts rows, even some overhead movement and CrossFit such as the kip swing, although the grips are a little bit different than these ones shown here to improve performance because it requires less grip strength to perform And it may help with chronic tendinopathies of the arm such as, you know, our distal biceps that can help with deadlifts there or it can help with our medial lateral epicondylitis by decreasing the amount of grip strength that's required, but they can't be used in a lot of competitions such as with power lifting. So these are all, you know, equipment and movement patterns that we can consider when talking about talking to our strength athletes. So just some key points I would like to leave you with from this lecture strength sports are a safe way to promote overall health and longevity and our elite athletes to our everyday patients, looking for a new health promoting means of exercise, and it's something that we should all be encouraging shoulder pathology is the most common upper extremity injury that we see on our overhead athletes, due to its increased mobility and comparison. Mobility in comparison with the rest of the body. Other injuries more unique to lifting includes pectorals major injuries distal clavicular osteolysis distal biceps and triceps tendon ruptures and axillary nerve palsy or quadrilateral space syndrome. UCL tears are also very common in our Olympic weightlifting CrossFit athletes, and if not properly addressed can lead to more serious injuries such as posterior elbow dislocations due to the nature of the lifts. So this is something that we should be aware of and be more proactive about diagnosing and treating in these patients. And there are means of primary and secondary injury prevention within our overhead lifting athletes that we should be aware of, so we can counsel our patients appropriately on how to appropriately select gyms after when they're trying to get involved in gyms or coming back from injury, how to properly modify their exercise selection and to counsel on equipment use to enable participation within this sport. I do want to thank you for your time this evening, and want to entertain any questions or comments you may have. Hey, thanks. Thanks, Dr. Mead, for this great content and information. And so I was curious, you, I know you're going to be covering the U.S. Essentially, the USA national is it is the term, it's nationals week is the appropriate description, right? Yes. So have you covered this before? I have not. It's gonna be my first time. Okay, well, I guess, you know, you've been in your this has been a part of your identity. This is something you're now contributing back to the sports you're passionate about. I was sort of surprised at looking on this roster. I see that there's U-11, U-13 events. Any comment on that? Any comment on just age and in how early people should be getting into this type of event, this type of lifting or competitions? Well, it's just like any other sport. Athletes are getting involved really early. We just have to worry. We just have to be mindful of the load. But lifting inherently is not dangerous to our younger athletes. It's just going to be about, again, load modification and making sure that they execute the lifts properly. A lot of times, you know, and I say a lot of times, I've only done a few of the events with the with our youth athletes. But the few injuries that we do see are typically due to technicalities. They're not gripping appropriately or they're dropping the barbell on themselves. We don't typically see the big acute injuries that I listed here just simply because they can't lift that weight. But it's more like dropping the barbell on themselves. They may have acute injury that way, like fractures or any other, you know, injuries such as that. I don't know what the literature says about like apophysitis or, you know, fractures with it, with the incidences in that population. But the few that I did see, it was due to technical technical issues. OK. I think the other question I had was with regards to overhead sports. I think that there's always a different culture or expectation in each sport with regards to monitoring workload. I think baseball gets a lot of attention for it and they counsel participants to take three months off from throwing. Is there any sort of cultural recommendation or weightlifting recommendation about taking time off in a year? Or is it I know swimming they really never take time off. They may just do a decrease. They just fluctuate how much they how much load they go through during the year. Is there any sort of, I guess, cultural norm in this weightlifting? So I have not heard of one. And just by my lit review, I haven't come across a recommendation. The best one that I came across was that that CrossFit article by Nikolai et al. Demonstrating that risk of injury increases after 11 hours of CrossFit per week. So if any indication can come from that, maybe we should be recommending less than 11 hours per week. But there's not a cultural norm that I'm aware of. But I did kind of skim over that bodybuilding has some of the least amount of injuries. It's like zero point two to one injury per thousand hours. So and that's the the community I'm most involved with. So I think that maybe that's why we don't have that. I haven't heard of that cultural norm because our rate of injury is actually pretty low, especially compared with most sports and even our other strength sports. OK. Yeah, I think probably had a couple more minutes. I'm always interested in learning more about this. I mean, are you are you part of a CrossFit gym or have you ever been? I just joined a CrossFit gym and I've just been dabbling in overhead, you know, our Olympic weightlifting. But I'm certainly not seasoned. I've covered more events than I've been practicing myself, I should say. OK, so you you probably know more than the average person joining a gym like that. Given their orientation or given your experience in this gym, have you how many times have you gone? I've been there for a month and a half now. OK, so that's a that's a fair amount of sessions. I'm kind of curious, what was your experience with them checking for like your your technique, screening you with functional movements was was what was the experience like? So there was an onboarding class for me and I took a six week progressive Olympic weightlifting like intro course before starting. So my onboarding didn't take too long, but they did have a required one to one with a coach. And these coaches are USA weightlifting certified coaches to assess your techniques first before they allow you into class. And I really like that because then they can catch any functional abnormalities at that point to try to correct them before releasing them into a class. And some CrossFit gyms are very large. The amount of athletes that go to them. And I would caution anyone who's new to go to a gym that big just because then you can't have quite as much one to one with a coach. A lot of our classes they have, I think the maximum I've been in is seven people. But I think that they take a maximum of 14, which I think is a reasonable size. Some of these gyms will do many, many more than that. They'll just pack the gym full of them. So if you're new to CrossFit or if you're your patients are asking you about it or asking about gyms, I would say go to one that has smaller class sizes. They have a one to one onboarding with them. And they allow for appropriate scaling, too. So with our classes, they'll go through the workout that's prescribed or the RX workout. And then they'll describe like how they can properly scale it or modify the movement as they need for their orthopedic issues or just kind of getting used to the movements. So just to make sure I'm on the same page. So when I go to a CrossFit website, I notice that they there's like 13 gyms around my house. And then I noticed there's trainers that there are people that are CrossFit certified L1 to L4. It sounds like you're describing a different certification. Is that through USA? USA Weightlifting. There are CrossFit certifications, too, that you're reading into. I think most of my coaches are L3 or L4 so that you're competing on that higher levels. But I was the most technical lifts with, you know, I haven't worked my way up to like muscle ups or keeping chest to bar or anything like that quite yet. But I've heard even the coaches say the snatch is the most technically difficult lift that they can do in CrossFit as well as with Olympic weightlifting. So if you're going to do those lifts, I would say go to a gym that has USA Weightlifting certified coaches so that you can properly do those lifts. And I just looked on their website. It looks like there's a way you can find these clubs, too. Yeah. Which I did not know that. I didn't know that USA Weightlifting had this. That's pretty cool. Any other thoughts from anybody? Hi, Dr. Mead. This is Jake Sellin, Mayo Clinic. Great talk. You know, you talked a lot about acute injuries. And I'm just wondering, I have patients that are involved with CrossFit or strength sports ask me about the risk of osteoarthritis. And I was curious if you came across anything with regard to the risk of shoulder, elbow, wrist osteoarthritis with, I guess, with, you know, years of heavy lifting. Yeah, so I'll be honest. The literature is really lacking in strength sports. But what I can glean is, you know, if we have these chronic issues or chronic injuries that our athletes aren't reporting with, such as, like, chronic medial elbow pain and they have an underlying UCL tear, that can put them at risk for developing, like, posterior medial impingement of the elbow or elbow arthritis, things like that. But as far as, like, incidents in comparison to other sports, I'm not very, I'm not sure what the literature says about that. But I would caution people just like I would with running, too, because I know that there's a stigma about running can cause arthritis or X, Y, and Z sport can cause arthritis. But we know that, you know, motion is the lotion for the joint. So I wouldn't want to, I wouldn't want to deter someone from weightlifting or doing any kind of other sport by fear of arthritis. So I would just, you know, talk to our patients about like, yes, there's a risk of injury with doing any sport. But we know our health benefits far outweigh the risks of developing something like that long term. So we should be encouraging them to do so and we'll help them along all the way with modification if need be, if they do develop something like that. But it's hard to say that if they did do X, Y, and Z workout, if they would develop arthritis versus if they did not, you know, so I don't really have a very good answer for that. But that's just my thought process on it. I don't know if that answered your question or not. Yeah, no, I mean, it's been a few years since I looked at the literature on it. But that's that's kind of I was pretty disappointed last time I reviewed things and it seems like it, you know, it's something that's right for study if you look at it, you know, athletes that are, you know, whatever 1020 years out from competitive careers or even just, you know, recreational lifters and compared to, you know, control population. Yeah, absolutely. And it's kind of cool. And the CrossFit literature that is getting way more robust now, because people that started the sport early in 2000s, they did not, you know, a lot of them that love CrossFit didn't like hearing the stigma of CrossFit being bad for you. So now they're doing more way more studies. So it is up and coming, at least in the CrossFit literature. I just hope that our other, you know, our other strength counterparts increase their contribution to literature too. Well, that's great. Thanks, Dr. Mead for all of this content. And thanks for everyone jumping on today. If anyone is interested in discussing topics about overhead athletes in the future, feel free to put a message either in our community chat, or you can just email me directly as well. We're looking to stimulate more topics and conversation. And thanks again, Dr. Mead for all this information. Could I ask one other question? I apologize. Yeah. Yeah. My name is Jeff Garrett. I'm with Rotherham Orthopedics in Philadelphia. It's interesting. You know, a couple years ago, I feel like we were seeing more injuries secondary to CrossFit, as you mentioned. In the last year or so, I've actually been seeing more patients with injuries due to pickleball. And I was wondering if you had any suggestions as far as advice to patients to help with prevention of injuries? Because a lot of them, I think, are not necessarily athletes, and they get into this, and it's an enjoyable sport for them. And then it gets competitive, and they're not always doing maybe a concurrent sort of exercise program focused around, you know, pickleball itself or other types of overhead activities. Yeah, that's a good question. I'm not as involved with racquet sports. My advice to all my patients is always doing strength sports or doing kind of like some sort of strength training. Because we know if we can increase our strength, we decrease injury. We improve our, you know, overall mortality, we decrease injuries. And that same goes with like runners and, you know, other endurance athletes too. So I would assume that it would be about the same for racquet sports. But as far as injury prevention measures for pickleball itself, I'm not sure. Dr. Nussbaum, do you have any comment on that? Yeah, so I love that sport. I love pickleball. And I think the challenge with it is people get into it, and before they know it, they're playing two or three hours in one day. And then they try to do that five days a week. And this is probably more in retirement communities, but I think it's very easy to increase your load very quickly. And before you know it, your acute workload is way higher than your chronic workload. So it's almost giving some recommendations of, hey, you know, you got to go slow here with building up. And I think the other thing is, a lot of people get into pickleball with no racquet background, including myself. And I think more and more you're seeing these, I guess they call them pickleball club pros, which, you know, it's kind of comical, but people that take it very seriously and will go over like appropriate technique. Those are the things that come to mind. But I mean, I bet in Rothman in that area, I don't know, what do you think? I mean, I bet you're seeing, like you're saying you see a lot of this. What are your thoughts? Well, yeah, again, it's just interesting. Like I said, you know, it used to be more the CrossFit injuries. I'm not seeing as much, and it's definitely older patients. I think that's a good thought, too, is that, you know, overuse type of injury secondary to running up or revving up the hours that they're playing so abruptly without doing any other types of activities. And I think also to the point of establishing a baseline exercise program, you know, especially for shoulder strengthening, knee strengthening, you know, those types of cutting type exercise programs as well. But yeah, the injuries have been shoulder, you know, obviously I deal mostly with spine, so back and neck types of things, but definitely a lot of shoulders. And maybe that's a future topic. Yeah, absolutely. It's getting popular. I mean, as you mentioned, like our gym that I go to, I mean, guys were upset because they lost a basketball court. It's became a pickleball court. Yeah. Yep, seeing that, definitely seeing that. Yeah. Well, hey, thanks again for everyone contributing. And thanks again, Dr. Mead. We will have some more content in the future. Don't hesitate to message if you feel passionate about a particular topic. If you want any content from my slides, feel free to contact Christy or Dr. Nussbaum. I'd be happy to provide them to anybody. And then if you're interested, all my references are here too. If you want to slide through later and look at them. Yep, and this will be recorded and put on the APMR content website as well. Cool. Thanks, everybody.

overhead weightlifting

athletes

shoulder injuries

nerve palsy

osteolysis

diagnosis

treatment

prevention strategies

technique

load management

strength sports