WEBVTT

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Welcome to the deep dive. Just take a moment

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and picture the incredible raw power, the whip

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-like speed, and the astonishing precision needed

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for overhead sports. Imagine a perfectly thrown

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fastball scorching towards home plate, the sheer

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devastating force unleashed in a professional

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tennis serve, or the relentless fluid, almost

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hypnotic motion of an elite swimmer cutting through

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the water. Yeah, it's amazing to watch. It really

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is, pushing the human body to its absolute limits.

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But that same intensity, that same drive for

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peak performance, places tremendous, almost unbelievable

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stress squarely on two key joints. The shoulder

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and the elbow. That's right. And for anyone involved

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in these activities, whether you're an athlete

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yourself, a coach, a parent, or maybe just someone

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fascinated by the mechanics of the human body

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under extreme load, understanding why and how

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these joints are vulnerable is, well, it's absolutely

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critical. Definitely. In this deep dive, we're

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going to unpack the complex world of injuries

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common in these overhead athletes. Our mission

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today is to act as your guides. We've taken a

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stack of detailed expert sources on this very

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topic, and we're going to try and cut through

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the complexity, extract the most important insights,

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maybe some surprising facts, and the core knowledge

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you need. We're here to provide you with a clearer

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picture of the unique biomechanical challenges

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these athletes face, the specific problems and

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injury patterns that commonly arise, how they're

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diagnosed using various tools, the range of treatment

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options available both non -surgical and surgical,

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and, crucially, the fundamental principles of

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getting these athletes back to their sport through

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rehabilitation. Exactly. We'll be covering the

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full spectrum, drawing directly from the information

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provided in the material we have here. We'll

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start with the fundamental physics and mechanics

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of how an overhead throw or motion even happens,

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delve into the intricate anatomy and stabilizers

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of the shoulder and elbow, and then zoom in on

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specific issues you hear about, like tears in

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the rotator cuff or the elbow's ulnar collateral

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ligament, complex problems with the shoulder

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labrum, like SLAP lesions, issues with how the

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shoulder blade moves scapular dyskinesis, and

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even conditions affecting the bone itself, like

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osteolysis or OCD. Okay, so quite a range. All

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right, let's jump right in and start with the

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shoulder, because the forces it endures during

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an overhead motion are, well, they sound nothing

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short of astronomical. When we talk about overhead

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throwing, we're not just talking about generating

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speed. We're talking about incredibly rapid movements

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that also have to be stopped. Right, the deceleration

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part. Exactly. Think about the moment right after

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the ball is released. The arm is still moving

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at tremendous velocity, and all that kinetic

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energy needs to be dissipated, absorbed by the

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body. Okay. Experts estimate that during the

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deceleration phase of a baseball pitch, the angular

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deceleration at the shoulder can reach an astonishing

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500 ,000 degrees per second squared. Half a million

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degrees per second squared? That number is hard

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to even wrap your head around. What does that

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level of force actually mean for the body? It

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means the structures around the shoulder Joint,

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the muscles, tendons, ligaments, the capsule

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are absorbing immense energy to slow the arm

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down safely and controllably. It really brings

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you back to foundational physics, doesn't it?

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Like Newton's laws of motion. Absolutely. It's

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not just abstract concepts. They're fundamental

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to understanding these injuries in a practical

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sense. Precisely. Take Newton's third law. For

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every action, there is an equal and opposite

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reaction. So when the muscles generate force

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to accelerate the arm, the body experiences reactive

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forces. When the muscles stop the arm, eccentrically

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contract, the body experiences equal and opposite

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deceleration forces. These forces are transmitted

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through the joints and soft tissues. If the body

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isn't equipped to handle them, or if they are

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applied repetitively over and over, well, something

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has to give eventually. So the shoulder isn't

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operating in isolation then. It's part of a bigger

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system, a chain. It's exactly right. This is

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where the concept of the kinetic chain becomes

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absolutely vital. Effective and importantly,

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injury resistant overhead motion starts far away

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from the shoulder itself. It begins with generating

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power from the ground, the legs, the hips, and

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particularly the trunk or the core. Okay. This

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energy is transferred sequentially up through

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the body to the arm. Think of it like cracking

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a whip. The flick starts at the handle and the

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speed builds exponentially towards the tip. So

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if an athlete has weakness or maybe poor coordination

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in their legs or core, that energy transfer is

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inefficient. Does it break down? Exactly. If

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the lower body and core aren't generating and

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transferring enough force, or maybe if the timing

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is off even slightly, the upper body, specifically

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the shoulder and elbow, has to compensate. This

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puts excessive stress on those later links in

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the chain, forcing them to work harder than they

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were designed to, especially during those high

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-force acceleration and, crucially, deceleration

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phases. And the shoulder blade, the scapula,

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plays a unique role here too, I understand? A

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crucial one. The scapula isn't just a static

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bone. It's a dynamic part of the shoulder complex.

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It needs to move in a coordinated way on the

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rib cage protract, retract, rotate upward to

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provide a stable base. Think of it as the launch

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platform for the humerus, the upper arm bone.

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Right, a platform. This stable platform allows

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the humeral head, the ball of the shoulder joint,

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to rotate through the extreme ranges of motion

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required for overhead activities without putting

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undue stress on the static stabilizers like the

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ligaments and capsule. If the scapula's movement

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or stability is compromised, a condition often

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called scapular dyskinesis, the mechanics of

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the main shoulder joint the glenohumeral joint

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are disrupted, significantly increasing the risk

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of injury. It makes sense. Now, experts often

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break down the overhead throwing motion into

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distinct phases to analyze the mechanics. It

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happens incredibly fast, less than two seconds

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total, apparently, but there's a lot going on

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in that short time. There's tremendous complexity

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packed into that brief window, absolutely. The

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phases typically described are the windup, early

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cocking, late cocking, acceleration, deceleration,

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and follow through. The wind -up and early cocking

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are really preparatory, getting the body and

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arm into position. The arm elevates to about

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90 degrees of abduction, maybe a bit more. Muscles

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like the deltoid and the rotator cuff muscles,

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supraspinatus, infraspinatus, teres minor, start

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engaging. Late cocking feels like the point of

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maximum load, almost like stretching a rubber

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band to its limit. It really is. This phase culminates

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in maximal external rotation at the shoulder,

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often reaching 170 to an incredible 180 degrees

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in elite throwers. At the same time, the scapula

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retracts and rotates upwards, helping to stabilize

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the shoulder in this extreme position. Critically

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at this point, the humeral head actually translates

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forward slightly on the glenoid socket. Muscles

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like the supraspinatus, infraspinatus, and teres

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minor are working intensely here, contracting

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isometrically or slightly eccentrically, and

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the subscapularis, a powerful internal rotator

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at the front, starts preparing for the next phase,

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building up elastic energy. Okay, then acceleration

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is the explosive part, the release. You're right.

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It's a very rapid transition from that eccentric

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pre -stretch to powerful concentric muscle activity.

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The shoulder internally rotates at tremendous

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speed. The scapula protracts, moving forward

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around the rib cage, maintaining that stable

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platform as the arm whips forward. Big muscles

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like the pectoralis major, latissimus dorsi,

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and the serratus anterior are driving this explosive

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motion. And then immediately you have to slam

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on the brakes, stop all that momentum. That leads

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into deceleration and follow through. Yes, and

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these are arguably the most demanding phases.

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biomechanically speaking. They rely heavily on

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eccentric muscle contractions. That's muscles

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lengthening while under tension to slow the arm

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down safely and prevent injury. Right. Lengthening

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under load. Experts consistently point to the

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deceleration phase as having the absolute highest

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forces acting on the shoulder joint. This is

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when the rotator cuff, particularly the posterior

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rotator cuff muscles like infraspinatus and teres

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minor, is under maximum stress and most vulnerable

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to injury due to that massive eccentric load.

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So it's not throwing the ball that tears it,

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it's stopping the arm after throwing? Very often,

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yes. Or at least that's where the cumulative

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damage really occurs. Any kinetic energy that

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didn't efficiently transfer to the ball has to

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be absorbed by the athlete's arm and body. And

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if the core and lower body haven't efficiently

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dissipated energy earlier in the kinetic chain...

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Then the shoulder and elbow take the hit? Precisely.

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The forces landing on the shoulder and elbow

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become even greater here. Muscles like the teres

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minor, posterior deltoid, and middle deltoid

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are highly active in deceleration, working eccentrically.

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The teres minor, a key posterior stabilizer,

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actually shows some of the highest activity levels

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of any shoulder muscle during this phase. Interesting.

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This makes the posterior joint structures, the

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back of the rotator cuff, the posterior capsule

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particularly susceptible to injury during deceleration,

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the torque, the twisting force on the humerus

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during deceleration can reach values around 15

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,000 inch pounds. 15 ,000 inch pounds. Can you

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put that in perspective? Well, it's difficult

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to make a perfect analogy, but imagine trying

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to stop a 1 ,250 pound weight that's attached

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to a one foot lever arm connected to your shoulder.

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That's the kind of force those muscles are dealing

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with, albeit very briefly. Wow. OK, that really

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makes those deceleration forces tangible. So

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what are the key structures actually holding

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that joint together and allowing that incredible

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motion under such extreme stress? You have both

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static and dynamic stabilizers working together.

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The static stabilizers are primarily the ligaments,

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the joint capsule, and the labrum, that cartilaginous

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rim around the socket. The interior gliohumeral

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ligament complex, or IGHLC, is absolutely critical

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for stability. The IGHLC, OK. Within this complex,

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the anterior band of the IGHL is considered the

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most important static restraint against anterior

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instability, the shoulder sliding forward, especially

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when the arm is abducted and externally rotated

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to 90 degrees. Which is exactly the position

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of peak stress and late cocking, right? Exactly.

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In that position, the anterior band is tight.

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Conversely, the posterior band of the IGHL is

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tight in abduction and internal rotation, providing

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posterior stability. And the axillary pouch,

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the sort of hammock -like portion at the bottom,

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also contributes to stability, particularly against

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inferior translation. Can these ligaments get

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stretched out or damaged just from repeated throwing?

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Not necessarily a single big traumatic event

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like a dislocation? Yes, absolutely. That's a

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key point experts make. With a recurrent instability,

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even if it's just micro instability or repeated

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subluxations, that repetitive microtrauma and

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cyclic overloading can cause plastic deformation

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in the IGHL. Plastic deformation, meaning it

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stretches and doesn't fully snap back? Precisely.

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The ligament stretches slightly. and doesn't

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fully return to its original length. Now, the

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reported permanent stretch might sound small

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in some studies, maybe less than a millimeter,

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but even these seemingly minor changes in ligament

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length and tension can significantly impact the

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joint stability in kinematics over time. Research

00:11:00.799 --> 00:11:03.899
has actually shown a direct positive linear correlation.

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The longer the anterior band of the IGHL becomes,

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the more external rotation is possible at the

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shoulder, and importantly, the greater the anterior

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translation, or forward sliding, of the humeral

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head on the glenoid. So a little stretch leads

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to a little more wobble, which can add up. What

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about the dynamic stabilizers, the muscles? The

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rotator cuff muscles are your primary dynamic

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stabilizers. They do much more than just move

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the arm. They work synergistically to actively

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center the humeral head on the relatively small

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and shallow glenoid socket. This crucial mechanism

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is called concavity compression. Concavity compression?

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Yes, by compressing the ball, humeral head, into

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the concave socket, glenoid, and maintaining

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a balanced force couple between the anterior

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subscapularis and posterior infraspinatus teres

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minor cuff muscles. The rotator cuff provides

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dynamic stability throughout the entire range

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of motion, preventing excessive translation or

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shearing of the humeral head, especially during

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high velocity movements. And we can't forget

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the scapulothoracic muscles, the ones controlling

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the shoulders. blade. They are absolutely essential

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dynamic stabilizers too. If they are weak or

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not firing correctly, leading to that scapular

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dyskinesis we mentioned. The platform is unstable.

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Exactly. The glenohumeral mechanics are compromised.

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The rotator cuff has to work harder to compensate,

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increasing its own risk of fatigue and injury.

00:12:22.860 --> 00:12:25.320
Given these extreme forces and all this repetitive

00:12:25.320 --> 00:12:28.220
motion, it's no wonder certain specific overuse

00:12:28.220 --> 00:12:30.720
patterns develop, often described under the umbrella

00:12:30.720 --> 00:12:33.500
of impingement. Right. And one key pattern specifically

00:12:33.500 --> 00:12:36.740
seen in overhead athletes is internal impingement.

00:12:37.039 --> 00:12:39.100
This is distinct from the classic subacromial

00:12:39.100 --> 00:12:40.980
impingement you might hear about more often in,

00:12:40.980 --> 00:12:44.200
say, older individuals with bone spurs. Internal

00:12:44.200 --> 00:12:46.379
impingement happens within the joint itself.

00:12:46.580 --> 00:12:49.379
OK. Inside the joint. How? Specifically, it occurs

00:12:49.379 --> 00:12:51.720
when the undersurface, the articular side of

00:12:51.720 --> 00:12:54.200
the posterior rotator cuff tendons, typically

00:12:54.200 --> 00:12:57.100
the supraspinatus and infraspinatus, makes physical

00:12:57.100 --> 00:13:00.480
contact with the posterior rim of the labrum

00:13:00.480 --> 00:13:02.899
and the edge of the glenoid socket. When does

00:13:02.899 --> 00:13:05.500
this contact happen? It happens during that position

00:13:05.500 --> 00:13:08.740
of maximal abduction and external rotation, the

00:13:08.740 --> 00:13:11.200
late cocking phase of throwing. So the rotator

00:13:11.200 --> 00:13:13.200
cuff is literally getting pinched between the

00:13:13.200 --> 00:13:16.039
humeral head and the back. top part of the socket

00:13:16.039 --> 00:13:18.480
rim. Precisely. But it's the underside of the

00:13:18.480 --> 00:13:21.039
cuff hitting the back top of the socket and labrum

00:13:21.039 --> 00:13:24.120
in that extreme end range throwing position.

00:13:25.080 --> 00:13:28.100
This repetitive contact, this microtrauma, can

00:13:28.100 --> 00:13:31.519
lead to irritation, fraying, inflammation, and

00:13:31.519 --> 00:13:33.740
eventually partial thickness tears developing

00:13:33.740 --> 00:13:36.379
on the articular side of the rotator cuff. Oh,

00:13:36.379 --> 00:13:38.500
OK. It can also cause damage to the posterior

00:13:38.500 --> 00:13:41.200
superior labrum itself, often contributing to

00:13:41.200 --> 00:13:43.899
or occurring alongside SLAP lesions, which we'll

00:13:43.899 --> 00:13:46.580
get to. Internal impingement is strongly associated

00:13:46.580 --> 00:13:48.940
with other factors like posterior capsule tightness

00:13:48.940 --> 00:13:51.620
and some degree of anterior laxity, often linking

00:13:51.620 --> 00:13:54.200
back to that GRD phenomenon. And the symptom

00:13:54.200 --> 00:13:56.720
an athlete might feel from this? A classic symptom

00:13:56.720 --> 00:14:00.019
is posterior shoulder pain. Pain felt deep in

00:14:00.019 --> 00:14:02.620
the back of the shoulder, specifically reproduced

00:14:02.620 --> 00:14:04.700
when the athlete's arm is placed in that late

00:14:04.700 --> 00:14:08.259
cocking or early acceleration position. Experts

00:14:08.259 --> 00:14:10.909
also note that muscle fatigue maybe later in

00:14:10.909 --> 00:14:13.570
a game or practice, can lead to slight changes

00:14:13.570 --> 00:14:15.970
in throwing mechanics and potentially increase

00:14:15.970 --> 00:14:18.570
angular velocity, which could exacerbate the

00:14:18.570 --> 00:14:20.690
severity of this impingement. No, there's also

00:14:20.690 --> 00:14:22.889
a specific impingement pattern that happens down

00:14:22.889 --> 00:14:26.590
at the elbow in throwers caused by those same

00:14:26.590 --> 00:14:29.009
valgus forces we mentioned earlier. Yes, that's

00:14:29.009 --> 00:14:32.259
valgus extension overload, or VEO. The repetitive

00:14:32.259 --> 00:14:34.519
valgus stress of throwing that force, pushing

00:14:34.519 --> 00:14:36.740
the forearm outward relative to the upper arm,

00:14:37.279 --> 00:14:39.639
can over time lead to laxity or stretching of

00:14:39.639 --> 00:14:41.620
the ligaments on the inside, the medial side

00:14:41.620 --> 00:14:45.029
of the elbow, primarily the UCL. Now, as the

00:14:45.029 --> 00:14:46.730
elbow straightens out rapidly during the throwing

00:14:46.730 --> 00:14:50.070
motion, this increased valgus laxity allows the

00:14:50.070 --> 00:14:52.549
back part of the ulna bone, the ulacranon process,

00:14:52.950 --> 00:14:55.350
to repeatedly impact against the humerus bone

00:14:55.350 --> 00:14:57.909
in the post remedial aspect of the joint. So

00:14:57.909 --> 00:15:00.330
bone hitting bone in the back inside part of

00:15:00.330 --> 00:15:03.350
the elbow. Exactly. This causes chronic irritation

00:15:03.350 --> 00:15:05.909
and often leads to the formation of bone spurs,

00:15:06.169 --> 00:15:09.940
or osteophytes, on the ulacranon. This post -permedial

00:15:09.940 --> 00:15:12.399
older crannon impingement is noted in the sources

00:15:12.399 --> 00:15:14.860
as being a very common surgical diagnosis in

00:15:14.860 --> 00:15:18.019
baseball players. It causes pain, clicking, and

00:15:18.019 --> 00:15:20.419
sometimes locking in the elbow. Another phenomenon

00:15:20.419 --> 00:15:22.200
that seems strongly linked to all these throwing

00:15:22.200 --> 00:15:26.139
mechanics is GRD, glenohumeral internal rotation

00:15:26.139 --> 00:15:27.960
deficit. You see this talked about a lot with

00:15:27.960 --> 00:15:30.840
throwers. Yes, GRD is almost an expected adaptation

00:15:30.840 --> 00:15:33.120
you could say in many high level overhead athletes,

00:15:33.399 --> 00:15:35.440
but it can definitely become pathological and

00:15:35.440 --> 00:15:37.740
contribute to injury. It's generally defined

00:15:37.740 --> 00:15:40.679
as a loss of internal rotation range of motion

00:15:40.679 --> 00:15:43.259
in the throwing shoulder compared to the non

00:15:43.259 --> 00:15:46.039
-throwing side. The cutoff varies slightly, but

00:15:46.039 --> 00:15:48.000
it's usually considered significant if it's greater

00:15:48.000 --> 00:15:50.529
than say 20 or 25 degrees difference. What's

00:15:50.529 --> 00:15:53.149
the underlying cause? Why does the internal rotation

00:15:53.149 --> 00:15:55.970
decrease? The primary cause experts point to

00:15:55.970 --> 00:15:58.769
is tightness or contracture, developing in the

00:15:58.769 --> 00:16:01.049
posterior capsule of the shoulder joint and potentially

00:16:01.049 --> 00:16:04.649
the posterior band of the IGHL. Basically, the

00:16:04.649 --> 00:16:06.529
tissues at the back of the shoulder get tight

00:16:06.529 --> 00:16:09.190
and shortened from the repetitive stress of deceleration.

00:16:09.509 --> 00:16:11.830
Okay, so the back of the shoulder gets stiff

00:16:11.830 --> 00:16:14.929
or shortened. How does that actually affect the

00:16:14.929 --> 00:16:18.029
movement, the kinematics? This posterior tightness

00:16:18.009 --> 00:16:20.809
acts like a tether, and disrupts the normal mechanics,

00:16:21.470 --> 00:16:23.350
especially during that critical leg cocking phase

00:16:23.350 --> 00:16:25.350
where the arm needs to achieve maximal external

00:16:25.350 --> 00:16:28.750
rotation. Because the back is tight, it restricts

00:16:28.750 --> 00:16:30.889
the normal posterior glide of the humeral head.

00:16:31.210 --> 00:16:33.909
So to compensate and still achieve the required

00:16:33.909 --> 00:16:36.789
layback or external rotation, the humeral head

00:16:36.789 --> 00:16:40.529
can be forced to shift abnormally, often posteriorly,

00:16:40.690 --> 00:16:42.830
that's backwards and slightly upwards on the

00:16:42.830 --> 00:16:45.059
glenoid socket. Okay, so it shifts into a slightly

00:16:45.059 --> 00:16:47.279
different spot on the socket. Correct. And this

00:16:47.279 --> 00:16:50.059
abnormal shift then puts increased strain and

00:16:50.059 --> 00:16:52.500
stretching forces on the anterior capsule and

00:16:52.500 --> 00:16:54.759
ligaments, particularly the anterior band of

00:16:54.759 --> 00:16:57.779
the IGHL. Ah, so tightness in the back actually

00:16:57.779 --> 00:17:00.200
leads to stretching and potentially laxity in

00:17:00.200 --> 00:17:02.580
the front. That's counterintuitive. It is, but

00:17:02.580 --> 00:17:05.039
that's exactly the mechanism proposed. And this

00:17:05.039 --> 00:17:07.420
postural superior shift also has consequences

00:17:07.420 --> 00:17:10.140
for the superior labrum and the biceps anchor

00:17:10.140 --> 00:17:12.609
attachment right at the top of the socket. How

00:17:12.609 --> 00:17:15.589
so? As the arm moves into maximal external rotation

00:17:15.589 --> 00:17:18.009
with the humeral head shifted backwards and upwards

00:17:18.009 --> 00:17:20.210
due to the posterior tightness, it can cause

00:17:20.210 --> 00:17:22.769
the superior labrum, along with its biceps tendon

00:17:22.769 --> 00:17:26.650
attachment, to literally peel away or lift off

00:17:26.650 --> 00:17:30.009
the underlying glenoid bone. Okay. Experts call

00:17:30.009 --> 00:17:33.360
this the peel back progression mechanism. This

00:17:33.360 --> 00:17:35.660
specific mechanism is strongly implicated in

00:17:35.660 --> 00:17:37.799
the development of those articular -sided rotator

00:17:37.799 --> 00:17:40.039
cuff tears we talked about as the shifted head

00:17:40.039 --> 00:17:43.019
impinges differently and critically in the formation

00:17:43.019 --> 00:17:47.259
of SLAP lesions. Wow. So GRD isn't just a simple

00:17:47.259 --> 00:17:49.660
lack of internal rotation. It actually sets off

00:17:49.660 --> 00:17:52.000
this whole cascade, this chain reaction that

00:17:52.000 --> 00:17:54.200
can damage multiple structures within the shoulder.

00:17:54.640 --> 00:17:57.140
Precisely. It's a really key insight from the

00:17:57.140 --> 00:18:00.490
biomechanics research. An adaptation, the posterior

00:18:00.490 --> 00:18:02.630
tightness that allows for increased external

00:18:02.630 --> 00:18:05.990
rotation needed for throwing, can become a pathological

00:18:05.990 --> 00:18:08.529
mechanism that directly leads to injury, like

00:18:08.529 --> 00:18:11.230
anterior stretching, the peel -back effect causing

00:18:11.230 --> 00:18:14.829
SLAP tears, and altered contact patterns contributing

00:18:14.829 --> 00:18:17.190
to cuff tears. That's fascinating. It's also

00:18:17.190 --> 00:18:19.250
worth noting, as the sources point out, that

00:18:19.250 --> 00:18:22.170
even with decreased internal rotation and the

00:18:22.170 --> 00:18:24.190
commonly seen increased external rotation in

00:18:24.190 --> 00:18:27.259
the dominant arm, the total arc of motion adding

00:18:27.259 --> 00:18:30.200
IR and ER together, might actually remain the

00:18:30.200 --> 00:18:32.839
same as the non -dominant side. So it represents

00:18:32.839 --> 00:18:35.339
a complex adaptation, a shifting of the motion

00:18:35.339 --> 00:18:37.759
arc, rather than just a simple loss of motion.

00:18:38.019 --> 00:18:40.319
That's a great insight into how the body adapts,

00:18:40.339 --> 00:18:42.420
but sometimes that adaptation clearly has negative

00:18:42.420 --> 00:18:45.220
consequences down the line. This whole biomechanical

00:18:45.220 --> 00:18:47.519
understanding really helps explain why certain

00:18:47.519 --> 00:18:49.680
injury patterns are so common in these athletes.

00:18:50.519 --> 00:18:52.960
Let's dive deeper into those specific injuries

00:18:52.960 --> 00:18:55.660
now, starting with the rotator cuff itself. Right.

00:18:55.880 --> 00:18:58.400
Rotator cuff problems in overhead athletes really

00:18:58.400 --> 00:19:02.019
cover a spectrum from simple tendonitis and those

00:19:02.019 --> 00:19:04.480
impingement symptoms we discussed all the way

00:19:04.480 --> 00:19:07.359
to partial thickness and sometimes full thickness

00:19:07.359 --> 00:19:10.200
tears of the tendons. Okay. A key point experts

00:19:10.200 --> 00:19:12.180
make though is that the type of rotator cuff

00:19:12.180 --> 00:19:14.819
tear often seen in throwers is distinct from

00:19:14.819 --> 00:19:17.880
what you might typically see in say older less

00:19:17.880 --> 00:19:20.569
active individuals with degenerative tears. How

00:19:20.569 --> 00:19:23.269
so? Because of the repetitive tensile overload

00:19:23.269 --> 00:19:25.869
during deceleration and that internal impingement

00:19:25.869 --> 00:19:28.049
mechanism we just discussed, the most common

00:19:28.049 --> 00:19:30.230
tears found in throwing athletes are partial

00:19:30.230 --> 00:19:32.829
thickness tears located on the articular side.

00:19:33.009 --> 00:19:35.170
That's the side facing inside the joint, the

00:19:35.170 --> 00:19:37.309
underside of the tendon. Right from that pinching

00:19:37.309 --> 00:19:40.069
during late cocking. Exactly. These are often

00:19:40.069 --> 00:19:42.170
associated with internal impingement symptoms

00:19:42.170 --> 00:19:45.890
and sometimes underlying instability. In contrast,

00:19:46.150 --> 00:19:48.309
degenerative tears in older populations are more

00:19:48.309 --> 00:19:50.910
often full thickness and tend to start on the

00:19:50.910 --> 00:19:53.900
bursal side, the top side of the tendon. Another

00:19:53.900 --> 00:19:55.920
key difference is that rotator cuff tears in

00:19:55.920 --> 00:19:58.759
athletes can sometimes be secondary to underlying

00:19:58.759 --> 00:20:01.319
shoulder instability, which isn't usually the

00:20:01.319 --> 00:20:03.579
case in older degenerative tears. And the symptoms

00:20:03.579 --> 00:20:05.559
an athlete might report if they have a rotator

00:20:05.559 --> 00:20:07.900
cuff issue. Typically, it's diffuse shoulder

00:20:07.900 --> 00:20:11.140
pain, often poorly localized, but particularly

00:20:11.140 --> 00:20:13.759
bothersome during or after their overhead activity.

00:20:14.220 --> 00:20:16.319
They might notice weakness, especially with movements

00:20:16.319 --> 00:20:19.579
involving rotation or lifting the arm. And crucially

00:20:19.579 --> 00:20:22.279
for a thrower, a common complaint is a noticeable

00:20:22.279 --> 00:20:25.000
decrease in throwing velocity, or maybe a loss

00:20:25.000 --> 00:20:27.799
of control or endurance. You mentioned SLAP pairs

00:20:27.799 --> 00:20:30.119
being linked to that peel -back mechanism related

00:20:30.119 --> 00:20:32.880
to GRD. Let's talk a bit more about those specifically.

00:20:33.400 --> 00:20:37.099
Okay, so SLAP stands for Superior Labral -Anterior

00:20:37.099 --> 00:20:40.019
-Posterior. These are tears that occur in the

00:20:40.019 --> 00:20:42.299
top portion of the labrum, that fibrous ring

00:20:42.299 --> 00:20:44.539
around the glenoid socket, that helps deepen

00:20:44.539 --> 00:20:46.900
it and serves as an attachment site for ligaments

00:20:46.900 --> 00:20:49.200
and the biceps tendon. Right, the rim cartilage.

00:20:49.400 --> 00:20:51.960
Exactly. The superior labrum is precisely where

00:20:51.960 --> 00:20:54.059
the long head of the biceps tendon attaches,

00:20:54.519 --> 00:20:56.579
making this area particularly vulnerable to forces

00:20:56.579 --> 00:20:59.000
transmitted through the biceps, especially peeling

00:20:59.000 --> 00:21:01.640
or twisting forces during overhead motions like

00:21:01.640 --> 00:21:05.319
throwing. The incidence figures for SLAT tiers

00:21:05.319 --> 00:21:07.259
reported in the literature vary quite a bit,

00:21:07.500 --> 00:21:10.319
maybe anywhere from 6 % up to 26 % in various

00:21:10.319 --> 00:21:12.440
surgical series looking at shoulder problems.

00:21:12.759 --> 00:21:15.400
Is diagnosing SLIP tear usually straightforward?

00:21:16.000 --> 00:21:18.140
Actually, it can be quite challenging. One reason

00:21:18.140 --> 00:21:20.440
is that the anatomy of the superior labrum and

00:21:20.440 --> 00:21:22.680
exactly how the biceps anchor attaches to it

00:21:22.680 --> 00:21:25.200
is highly variable from person to person. There

00:21:25.200 --> 00:21:27.519
are normal variations like sublaboral recesses

00:21:27.519 --> 00:21:30.180
or holes that can sometimes mimic a tear on imaging.

00:21:30.759 --> 00:21:34.099
Okay, so MRI might be tricky. It can be. This

00:21:34.099 --> 00:21:36.619
anatomical variability can make interpreting

00:21:36.619 --> 00:21:40.259
imaging like MRI or MRA difficult. Sometimes

00:21:40.259 --> 00:21:42.779
what looks like a tear might actually be a normal

00:21:42.779 --> 00:21:45.299
anatomical variant like a sublaboral foramen

00:21:45.299 --> 00:21:48.740
or the Buford complex. This is why arthroscopy

00:21:48.740 --> 00:21:50.940
actually looking inside the joint with a camera

00:21:50.940 --> 00:21:53.819
during surgery is often considered the gold standard

00:21:53.819 --> 00:21:57.180
for definitively diagnosing and classifying SLA

00:21:57.180 --> 00:22:00.480
tears. So you can see it directly. Exactly. During

00:22:00.480 --> 00:22:02.980
arthroscopy the surgeon can visually inspect

00:22:02.980 --> 00:22:05.680
the labrum, and importantly, use a probe to physically

00:22:05.680 --> 00:22:07.819
assess the stability of the labrum and the biceps

00:22:07.819 --> 00:22:10.140
anchor. They can even reproduce that peel -back

00:22:10.140 --> 00:22:12.839
sign by positioning the arm in abduction and

00:22:12.839 --> 00:22:15.339
external rotation to see if the labrum actually

00:22:15.339 --> 00:22:17.599
lifts off the underlying bone, confirming instability.

00:22:17.839 --> 00:22:20.180
So if the labrum peels away during that specific

00:22:20.180 --> 00:22:22.880
test inside the joint, that confirms the instability.

00:22:23.220 --> 00:22:25.539
Yes. Essentially, it verifies that the labrum

00:22:25.539 --> 00:22:28.460
is detached and unstable in that critical throwing

00:22:28.460 --> 00:22:32.029
position. And as we discussed, SLAP tears don't

00:22:32.029 --> 00:22:34.849
usually happen in isolation. They are often associated

00:22:34.849 --> 00:22:36.769
with other issues like internal impingement,

00:22:37.170 --> 00:22:39.690
those partial articular -sided rotator cuff tears,

00:22:40.210 --> 00:22:42.710
sometimes underlying shoulder hyperlaxity, and

00:22:42.710 --> 00:22:44.829
that posterior capsule contracture related to

00:22:44.829 --> 00:22:48.190
GRD, often via that peel -back progression mechanism.

00:22:48.430 --> 00:22:51.420
Okay. Beyond just tears in the labrum or the

00:22:51.420 --> 00:22:53.539
cuffed tendons, overall shoulder instability

00:22:53.539 --> 00:22:55.740
is a major concern, particularly in young athletes,

00:22:55.839 --> 00:22:58.599
isn't it? Absolutely. Shoulder instability exists

00:22:58.599 --> 00:23:02.180
on a spectrum. At one end, you have a frank dislocation

00:23:02.180 --> 00:23:04.559
where the humeral head completely separates from

00:23:04.559 --> 00:23:06.400
the glenoid socket and usually needs to be put

00:23:06.400 --> 00:23:09.019
back in place. Right. Less severe is subluxation,

00:23:09.279 --> 00:23:11.220
which is a symptomatic partial translation of

00:23:11.220 --> 00:23:13.000
the humeral head on the glenoid. Maybe shifts

00:23:13.000 --> 00:23:15.140
part way out, but then pops back in spontaneously.

00:23:15.920 --> 00:23:18.519
Yeah. Athletes might feel a clunk or a a sudden

00:23:18.519 --> 00:23:21.200
sense of their shoulder giving out. Then there's

00:23:21.200 --> 00:23:23.680
apprehension, which is more of a feeling or fear

00:23:23.680 --> 00:23:26.420
of impending dislocation, often triggered when

00:23:26.420 --> 00:23:28.319
the arm is put in the specific position where

00:23:28.319 --> 00:23:31.380
they previously dislocated or subluxed classically.

00:23:31.980 --> 00:23:35.099
that 90 degrees abduction combined with 90 degrees

00:23:35.099 --> 00:23:37.619
external rotation position. The throwing position

00:23:37.619 --> 00:23:40.539
again. Exactly. And finally, clinicians sometimes

00:23:40.539 --> 00:23:43.579
describe the unstable, painful shoulder where

00:23:43.579 --> 00:23:45.880
the main complaint might be pain during certain

00:23:45.880 --> 00:23:48.920
movements, particularly when tested for apprehension,

00:23:49.440 --> 00:23:52.099
but underlying that pain is evidence of instability

00:23:52.099 --> 00:23:55.619
or associated pathology like a labral tear causing

00:23:55.619 --> 00:23:59.089
the symptoms. And instability can be primary,

00:23:59.309 --> 00:24:01.769
the first time it happens, or very commonly in

00:24:01.769 --> 00:24:04.369
athletes, recurrent. Recurrent instability sounds

00:24:04.369 --> 00:24:06.049
like it's just setting the stage for more and

00:24:06.049 --> 00:24:08.549
more problems down the road. It definitely is.

00:24:08.750 --> 00:24:10.690
Recurrent anterior instability, the shoulder

00:24:10.690 --> 00:24:12.950
slipping forward, is particularly common in young

00:24:12.950 --> 00:24:15.450
athletes, especially those involved in contact

00:24:15.450 --> 00:24:18.150
sports like football, rugby, or wrestling. And

00:24:18.150 --> 00:24:20.509
it has a notoriously high rate of happening again

00:24:20.509 --> 00:24:23.049
after the initial event, especially if treated

00:24:23.049 --> 00:24:25.190
non -operatively in that young, high -risk group.

00:24:26.029 --> 00:24:29.410
it happens, it causes more damage. Exactly. Each

00:24:29.410 --> 00:24:31.750
time the shoulder subluxes are fully dislocated,

00:24:32.069 --> 00:24:33.990
it can cause progressive damage to both the bone

00:24:33.990 --> 00:24:36.690
and the soft tissues. This includes bony damage.

00:24:37.309 --> 00:24:39.930
A bankart lesion, which is essentially a fracture

00:24:39.930 --> 00:24:42.410
or wearing away of the bone on the front lower

00:24:42.410 --> 00:24:44.769
part of the glenoid rim where the labrum and

00:24:44.769 --> 00:24:47.529
capsule pull off. Okay. And a hill -sax lesion.

00:24:47.599 --> 00:24:50.019
which is an impaction fracture or dent created

00:24:50.019 --> 00:24:52.819
on the back, outer part of the humeral head caused

00:24:52.819 --> 00:24:54.619
when it impacts against the front edge of the

00:24:54.619 --> 00:24:57.180
glenoid during the dislocation event. How is

00:24:57.180 --> 00:24:59.920
the severity of that bone loss, say, on the glenoid

00:24:59.920 --> 00:25:01.900
measured? Is there a threshold where it becomes

00:25:01.900 --> 00:25:04.640
really problematic? Yes. Experts use imaging

00:25:04.640 --> 00:25:07.220
like specialized X -rays, like the Brnagov view,

00:25:07.680 --> 00:25:10.519
or more accurately CT scans to assess the size

00:25:10.519 --> 00:25:12.859
and morphology of the bain -carte lesion or the

00:25:12.859 --> 00:25:16.019
amount of glenoid bone loss. Significant glenoid

00:25:16.019 --> 00:25:18.119
bone loss is often considered when it's greater

00:25:18.119 --> 00:25:20.599
than about six millimeters wide, or represents

00:25:20.599 --> 00:25:23.579
more than 20 -25 % of the total articular surface

00:25:23.579 --> 00:25:25.680
width of the glenoid, which is typically only

00:25:25.680 --> 00:25:27.960
about 24 millimeters wide to begin with. So losing

00:25:27.960 --> 00:25:30.460
25 % is a big deal. It's a very big deal for

00:25:30.460 --> 00:25:34.339
stability. Visually, during surgery, severe bone

00:25:34.339 --> 00:25:36.579
loss can make the normally oval -shaped glenoid

00:25:36.579 --> 00:25:39.500
look like an inverted pair, with the bottom front

00:25:39.500 --> 00:25:42.250
portion missing. For Hillsac's lesions on the

00:25:42.250 --> 00:25:44.730
humeral head, surgeons assess not just the size

00:25:44.730 --> 00:25:47.369
but critically whether the defect is engaging

00:25:47.369 --> 00:25:50.910
or off track. Engaging, meaning it catches. Yes.

00:25:51.170 --> 00:25:53.309
It means that as the arm rotates externally,

00:25:53.769 --> 00:25:56.450
the Hillsac's defect lines up with and actually

00:25:56.450 --> 00:25:58.750
catches or drops over the front edge of the glenoid,

00:25:59.049 --> 00:26:01.210
which dramatically increases the risk of future

00:26:01.210 --> 00:26:03.569
instability and often necessitates addressing

00:26:03.569 --> 00:26:06.299
the bone defect surgically. And is there a way

00:26:06.299 --> 00:26:08.240
to predict the risk of the instability coming

00:26:08.240 --> 00:26:11.079
back even after surgery, say, after a standard

00:26:11.079 --> 00:26:13.339
bank heart repair? Yes. For anterior instability

00:26:13.339 --> 00:26:15.440
treated with an arthroscopic bank heart repair,

00:26:15.680 --> 00:26:17.779
which primarily fixes the soft tissues back to

00:26:17.779 --> 00:26:20.619
the bones, experts use scoring systems like the

00:26:20.619 --> 00:26:23.220
ISA score. That stands for the Instability Severity

00:26:23.220 --> 00:26:25.700
Index score. ISA score. It's a 10 -point scale

00:26:25.700 --> 00:26:28.059
that incorporates several predictive factors.

00:26:28.920 --> 00:26:31.960
The athlete's age, being under 20, scores higher

00:26:31.960 --> 00:26:34.779
risk points. whether they participate in competitive

00:26:34.779 --> 00:26:37.740
contact sports or sports involving forced overhead

00:26:37.740 --> 00:26:39.940
movements, if they have signs of generalized

00:26:39.940 --> 00:26:42.759
joint hyperlaxity, if they have a visible hill

00:26:42.759 --> 00:26:45.119
-sax lesion on their pre -op x -rays, and if

00:26:45.119 --> 00:26:47.759
there's evidence of glenoid bone loss or erosion

00:26:47.759 --> 00:26:50.160
of the glenoid contour. And a higher score means

00:26:50.160 --> 00:26:53.259
higher risk of it failing. Exactly. A total score

00:26:53.259 --> 00:26:56.019
greater than 6 points on the ISA scale is associated

00:26:56.019 --> 00:26:58.000
with a significantly higher risk, potentially

00:26:58.000 --> 00:27:01.180
around 70%, according to some studies of recurrent

00:27:01.180 --> 00:27:04.019
instability after an isolated soft tissue bankart

00:27:04.019 --> 00:27:06.859
repair. This score is really valuable because

00:27:06.859 --> 00:27:08.859
it helps surgeons identify patients who might

00:27:08.859 --> 00:27:11.720
benefit from a more robust procedure, perhaps

00:27:11.720 --> 00:27:14.160
one that addresses bone loss up front, rather

00:27:14.160 --> 00:27:16.460
than just a soft tissue repair alone. Makes sense.

00:27:16.619 --> 00:27:18.759
What about instability that's not just in one

00:27:18.759 --> 00:27:20.779
direction, like forward? Sometimes you hear about

00:27:20.779 --> 00:27:22.880
shoulders being loose all over. Right, that's

00:27:22.880 --> 00:27:25.059
generally termed multi -directional instability,

00:27:25.240 --> 00:27:28.440
or MDI. It's often described by patients, quite

00:27:28.440 --> 00:27:32.220
simply, as loose shoulder. It means the shoulder

00:27:32.220 --> 00:27:34.400
is symptomatically unstable, feeling like it

00:27:34.400 --> 00:27:37.420
slips or shifts in more than one direction, commonly

00:27:37.420 --> 00:27:40.660
anteriorly forward, inferiorly downward, and

00:27:40.660 --> 00:27:44.400
sometimes posteriorly backward as well. MDI is

00:27:44.400 --> 00:27:46.559
usually linked to underlying factors like generalized

00:27:46.559 --> 00:27:49.019
capsule or redundancy, meaning the joint capsule

00:27:49.019 --> 00:27:51.579
is naturally looser or more voluminous than average,

00:27:52.000 --> 00:27:54.000
or it could be part of a picture of constitutional

00:27:54.000 --> 00:27:57.119
hyperlaxity throughout the body. Okay. Now, moving

00:27:57.119 --> 00:27:59.119
slightly away from the main ball and socket joint,

00:27:59.279 --> 00:28:01.859
what about problems up at the AC joint where

00:28:01.859 --> 00:28:04.019
the collarbone meets the top of the shoulder

00:28:04.019 --> 00:28:06.759
blade? Yes, the AC or acromioclavicular joint.

00:28:07.000 --> 00:28:09.019
Injuries here are extremely common, particularly

00:28:09.019 --> 00:28:11.740
in contact sports or activities where falls directly

00:28:11.740 --> 00:28:13.460
under the point of the shoulder are frequent

00:28:13.460 --> 00:28:16.920
football tackles, hockey checks, or falling off

00:28:16.920 --> 00:28:19.380
a bike. The usual mechanism is a direct force

00:28:19.380 --> 00:28:21.759
applied to the point of the shoulder, the acroman,

00:28:22.119 --> 00:28:24.319
while the arm is tucked into the side, adducted.

00:28:24.490 --> 00:28:27.470
This drives the acromion downwards and inwards

00:28:27.470 --> 00:28:30.430
relative to the clavicle collarbone, which is

00:28:30.430 --> 00:28:32.990
relatively stabilized by muscles and its connection

00:28:32.990 --> 00:28:36.089
to the sternum. This force causes tearing of

00:28:36.089 --> 00:28:38.349
the ligaments that support the AC joint, leading

00:28:38.349 --> 00:28:40.809
to varying degrees of separation. And separate

00:28:40.809 --> 00:28:43.630
from those traumatic AC joint sprains, there's

00:28:43.630 --> 00:28:46.049
a specific bone issue that can affect the end

00:28:46.049 --> 00:28:48.490
of the clavicle in some athletes, particularly

00:28:48.490 --> 00:28:50.990
weightlifters. Yes, that's distal clavicular

00:28:50.990 --> 00:28:55.329
osteolysis, or DCO. Experts in the sources particularly

00:28:55.329 --> 00:28:58.710
note the atraumatic form, ADCO, meaning it occurs

00:28:58.710 --> 00:29:01.329
gradually from overuse rather than a single traumatic

00:29:01.329 --> 00:29:04.089
event. It's reported as being surprisingly prevalent

00:29:04.089 --> 00:29:06.589
in dedicated weightlifters, with one study cited

00:29:06.589 --> 00:29:09.490
showing a 27 % prevalence in that specific group.

00:29:09.710 --> 00:29:11.569
Wow, over a quarter of them. What's happened

00:29:11.569 --> 00:29:14.170
to the bone? It's characterized by chronic inflammation,

00:29:14.670 --> 00:29:17.089
stress reaction, and eventually degeneration

00:29:17.089 --> 00:29:19.450
or resorption of the bone at the very end of

00:29:19.450 --> 00:29:21.589
the collarbone, right where it articulates with

00:29:21.589 --> 00:29:24.700
the acromion. Imaging often shows changes like

00:29:24.700 --> 00:29:27.599
bone erosion, cystic changes, and inflammation.

00:29:28.440 --> 00:29:30.500
Sometimes there's even a direct communication

00:29:30.500 --> 00:29:33.680
scene between the distal clavicle changes and

00:29:33.680 --> 00:29:37.019
the AC joint itself. Importantly, it frequently

00:29:37.019 --> 00:29:39.539
occurs alongside other shoulder problems like

00:29:39.539 --> 00:29:42.279
instability or impingement, kind of adding insult

00:29:42.279 --> 00:29:44.440
to injury and contributing to overall shoulder

00:29:44.440 --> 00:29:46.779
dysfunction and pain, especially with pressing

00:29:46.779 --> 00:29:49.619
movements. Okay. And finally, one more structure

00:29:49.619 --> 00:29:52.819
around the biceps tendon, the long head specifically,

00:29:52.940 --> 00:29:54.420
which originates near the top of the shoulder

00:29:54.420 --> 00:29:57.259
socket. That can cause issues too. Correct. The

00:29:57.259 --> 00:30:00.099
long head of the biceps tendon, or LHBT, runs

00:30:00.099 --> 00:30:03.019
in a groove. the occipital groove, at the front

00:30:03.019 --> 00:30:05.619
of the humerus bone. Its stability within that

00:30:05.619 --> 00:30:07.980
groove relies on a complex sling -like arrangement

00:30:07.980 --> 00:30:10.359
of ligaments and tendon fibers, often referred

00:30:10.359 --> 00:30:13.059
to collectively as the biceps pulley system.

00:30:13.119 --> 00:30:15.500
The pulley system, okay. This system is primarily

00:30:15.500 --> 00:30:18.279
formed by parts of the superior glenohumeral

00:30:18.279 --> 00:30:22.259
ligament, SGHL, the coracohumeral ligament, CHL,

00:30:22.460 --> 00:30:25.299
and also contributions from fibers of the uppermost

00:30:25.299 --> 00:30:28.180
subscapularis tendon and the anterior edge of

00:30:28.180 --> 00:30:30.940
the supraspinatus tendon. If this pulley system

00:30:30.940 --> 00:30:33.380
is injured, often due to trauma or associated

00:30:33.380 --> 00:30:36.039
with rotator cuff tears, the biceps tendon can

00:30:36.039 --> 00:30:39.039
become unstable. It can sublux, meaning partially

00:30:39.039 --> 00:30:41.480
slip out of the groove, or even fully dislocate

00:30:41.480 --> 00:30:43.799
from the groove. Does the direction the biceps

00:30:43.799 --> 00:30:46.259
tendon moves, like forward or sideways, tell

00:30:46.259 --> 00:30:48.720
you something about which specific parts of that

00:30:48.720 --> 00:30:51.720
pulley system might be damaged? Yes, it can provide

00:30:51.720 --> 00:30:54.420
important diagnostic clues. Experts describe

00:30:54.420 --> 00:30:57.369
different patterns of LHBT instability. It might

00:30:57.369 --> 00:30:59.829
sublux predominantly anteromedially, forward

00:30:59.829 --> 00:31:02.130
and towards the body, or maybe post -trolaterally,

00:31:02.170 --> 00:31:04.309
or even just shift back and forth and or posterior.

00:31:04.690 --> 00:31:06.890
The direction of instability can correlate with

00:31:06.890 --> 00:31:09.109
which specific components of the pulley system,

00:31:09.410 --> 00:31:11.650
or which adjacent rotator cuff tendons, like

00:31:11.650 --> 00:31:13.809
the supraspinatus or subscapularis, are torn.

00:31:13.829 --> 00:31:17.650
For instance, an anteromedial dislocation of

00:31:17.650 --> 00:31:20.630
the biceps tendon is often strongly linked to

00:31:20.630 --> 00:31:22.849
a full thickness tear of the supraspinatus tendon.

00:31:23.000 --> 00:31:25.380
and sometimes what are called hidden lesions

00:31:25.380 --> 00:31:28.299
involving tears of the deep fibers of the corco

00:31:28.299 --> 00:31:31.460
humeral and superior glenohumeral ligaments along

00:31:31.460 --> 00:31:34.200
with the very top part of the subscapularis tendon

00:31:34.200 --> 00:31:37.799
which form that medial wall of the pulley. Understanding

00:31:37.799 --> 00:31:40.200
these specific patterns helps surgeons pinpoint

00:31:40.200 --> 00:31:42.440
the full extent of the damage during diagnosis

00:31:42.440 --> 00:31:44.960
and ensure all injured structures are addressed

00:31:44.960 --> 00:31:47.440
during surgery. Okay, so from the extreme forces

00:31:47.440 --> 00:31:50.039
to the kinetic chain, the interplay of stabilizers,

00:31:50.059 --> 00:31:52.099
and these specific impingement patterns like

00:31:52.099 --> 00:31:55.000
GRD and internal impingement, we can really see

00:31:55.000 --> 00:31:57.279
how the shoulder is uniquely vulnerable in overhead

00:31:57.279 --> 00:32:00.319
athletes. But as you mentioned, the elbow also

00:32:00.319 --> 00:32:03.079
takes a tremendous beating in these sports. Let's

00:32:03.079 --> 00:32:05.299
shift our focus down the arm a bit. What are

00:32:05.299 --> 00:32:08.119
the most common elbow injuries we see highlighted

00:32:08.119 --> 00:32:10.880
in the sources for these athletes? Well, one

00:32:10.880 --> 00:32:12.740
condition that's quite specific to the throwing

00:32:12.740 --> 00:32:14.819
elbow, particularly in younger athletes, adolescents

00:32:14.819 --> 00:32:18.880
maybe, is osteochondritis diskin or OCD of the

00:32:18.880 --> 00:32:21.670
capitolum. OCD of the capitellum. OK, what's

00:32:21.670 --> 00:32:24.049
the capitellum? The capitellum is that rounded

00:32:24.049 --> 00:32:26.549
bony knob at the end of the humerus, the upper

00:32:26.549 --> 00:32:29.329
arm bone, specifically on the outer or lateral

00:32:29.329 --> 00:32:31.990
side of the elbow. It's the part that articulates

00:32:31.990 --> 00:32:34.529
or forms a joint with the head of the radius

00:32:34.529 --> 00:32:37.710
bone in the forearm. Got it. And what causes

00:32:37.710 --> 00:32:41.039
OCD there? Is it trauma? The suspected mechanism

00:32:41.039 --> 00:32:43.740
in throwers isn't usually a single trauma, but

00:32:43.740 --> 00:32:46.759
rather chronic repetitive direct loading or compressive

00:32:46.759 --> 00:32:49.559
forces acting on the capitellum bone and its

00:32:49.559 --> 00:32:52.799
overlying articular cartilage. As the elbow goes

00:32:52.799 --> 00:32:54.759
through the throwing motion, particularly into

00:32:54.759 --> 00:32:57.380
extension and maybe some pronation, the radial

00:32:57.380 --> 00:32:59.599
head bone compresses up against the capitellum.

00:32:59.599 --> 00:33:01.779
Okay. Because this compressive force is applied

00:33:01.779 --> 00:33:04.529
repeatedly, at high velocity, and often with

00:33:04.529 --> 00:33:06.650
some valgus stress as well, specifically in the

00:33:06.650 --> 00:33:08.869
dominant throwing arm, it's thought to disrupt

00:33:08.869 --> 00:33:11.029
the delicate blood supply to the subchondral

00:33:11.029 --> 00:33:13.190
bone, the bone just underneath the cartilage

00:33:13.190 --> 00:33:16.410
surface. This can lead to a segment of bone and

00:33:16.410 --> 00:33:18.509
the overlying cartilage losing its blood supply,

00:33:18.670 --> 00:33:21.390
potentially softening, becoming unstable, and

00:33:21.390 --> 00:33:23.509
in some cases eventually loosening or even breaking

00:33:23.509 --> 00:33:26.230
off as a fragment. And it's mostly just in the

00:33:26.230 --> 00:33:28.269
throwing arm. Exactly. It's telling that this

00:33:28.269 --> 00:33:30.549
condition is reported as being very rare on the

00:33:30.549 --> 00:33:32.789
non -throwing side, strongly implicating those

00:33:32.789 --> 00:33:35.269
repetitive throwing mechanics. What would someone

00:33:35.269 --> 00:33:38.730
actually see on imaging, like an x -ray or MRI

00:33:38.730 --> 00:33:42.730
for OCD? The findings on imaging vary a lot depending

00:33:42.730 --> 00:33:45.670
on the stage of the condition. Early on, it might

00:33:45.670 --> 00:33:48.410
just be a subtle area of decreased bone density

00:33:48.410 --> 00:33:52.089
or a small area of haziness. a translucency seen

00:33:52.089 --> 00:33:54.670
on x -ray. As it progresses, you might see a

00:33:54.670 --> 00:33:57.109
more clearly defined fragment of bone, which

00:33:57.109 --> 00:34:00.109
could still be attached but unstable, non -displaced,

00:34:00.369 --> 00:34:02.589
or it might become completely detached and form

00:34:02.589 --> 00:34:04.450
a loose body floating within the elbow joint.

00:34:05.200 --> 00:34:08.539
Imaging, especially MRI, or sometimes CT orthography,

00:34:09.000 --> 00:34:11.179
is really critical not just for making the diagnosis,

00:34:11.599 --> 00:34:13.659
but also for staging the severity, looking at

00:34:13.659 --> 00:34:16.199
the integrity and health of the overlying articular

00:34:16.199 --> 00:34:18.380
cartilage, assessing whether the bone fragment

00:34:18.380 --> 00:34:21.360
is stable or unstable, and identifying any associated

00:34:21.360 --> 00:34:24.260
loose bodies. This dating is crucial for guiding

00:34:24.260 --> 00:34:27.579
treatment decisions. Okay, now probably the most

00:34:27.739 --> 00:34:31.179
A well -known elbow injury in throwing athletes,

00:34:31.659 --> 00:34:33.340
largely because of the surgery named after the

00:34:33.340 --> 00:34:37.340
baseball player, is the ulnar collateral ligament

00:34:37.340 --> 00:34:40.960
tear, the UCL tear. Absolutely. The medial ulnar

00:34:40.960 --> 00:34:43.880
collateral ligament, or MUCL as it's often abbreviated,

00:34:44.139 --> 00:34:46.519
located on the inner side of the elbow, is the

00:34:46.519 --> 00:34:49.130
primary victim here. As we discussed when talking

00:34:49.130 --> 00:34:51.849
about valgus extension overload, the repetitive

00:34:51.849 --> 00:34:54.349
high -force valgus stress generated during the

00:34:54.349 --> 00:34:57.550
throwing motion puts tremendous tension specifically

00:34:57.550 --> 00:35:00.869
on this ligament complex, particularly its anterior

00:35:00.869 --> 00:35:03.210
bundle. Right, that outward force on the forearm.

00:35:03.550 --> 00:35:06.530
Exactly. Injuries to the UCL can happen acutely,

00:35:06.530 --> 00:35:08.670
maybe from a single, particularly forceful throw

00:35:08.670 --> 00:35:10.630
where the athlete feels a pop in immediate pain,

00:35:11.070 --> 00:35:12.550
indicating a sudden rupture of the ligament.

00:35:12.849 --> 00:35:14.829
But perhaps more often, these injuries occur

00:35:14.829 --> 00:35:17.639
on a background of chronic microtrauma. gradual

00:35:17.639 --> 00:35:20.400
wear and tear again? Sort of. The ligament is

00:35:20.400 --> 00:35:23.000
progressively overloaded with each throw, sustaining

00:35:23.000 --> 00:35:25.460
multiple microscopic injuries over months or

00:35:25.460 --> 00:35:29.059
years. This leads to gradual attenuation, stretching

00:35:29.059 --> 00:35:32.460
and degeneration of the ligament tissue. Eventually

00:35:32.460 --> 00:35:35.000
this chronic damage can culminate in a partial

00:35:35.000 --> 00:35:37.579
or complete tear, sometimes with an acute event,

00:35:37.800 --> 00:35:40.179
like one bad throw, being the final straw that

00:35:40.179 --> 00:35:42.480
causes the already weakened ligament to fail

00:35:42.480 --> 00:35:45.590
completely. What makes the MUCL so important

00:35:45.590 --> 00:35:48.130
biomechanically for the elbow? Why is it so critical

00:35:48.130 --> 00:35:50.969
for throwers? It's the primary static stabilizer

00:35:50.969 --> 00:35:53.329
against valgus stress, particularly when the

00:35:53.329 --> 00:35:55.409
elbow is moving through the range of motion between

00:35:55.409 --> 00:35:58.429
about 30 and 120 degrees of flexion, which is

00:35:58.429 --> 00:36:00.829
exactly the range used during throwing. Without

00:36:00.829 --> 00:36:03.750
an intact and functional MUCL, the elbow joint

00:36:03.750 --> 00:36:06.090
would essentially be unstable and tend to gap

00:36:06.090 --> 00:36:08.630
open on the inside under the immense valgus forces

00:36:08.630 --> 00:36:10.889
of throwing. But it's not the only thing providing

00:36:10.889 --> 00:36:13.320
stability on that side. No, that's a very important

00:36:13.320 --> 00:36:15.800
point. It's not the only thing. The flexor pronator

00:36:15.800 --> 00:36:17.920
muscle group, which originates from the medial

00:36:17.920 --> 00:36:20.300
epicondyle right near the UCL attachment muscles

00:36:20.300 --> 00:36:23.460
like the flexor carpe ulnaris, FCU, and the flexor

00:36:23.460 --> 00:36:26.760
agitorum superficialis, act as critical dynamic

00:36:26.760 --> 00:36:29.539
stabilizers. Dynamic, meaning the muscles help

00:36:29.539 --> 00:36:33.079
actively? Yes. They contract powerfully, especially

00:36:33.079 --> 00:36:34.960
during the late cocking and acceleration phases

00:36:34.960 --> 00:36:37.840
of throwing, helping to actively resist that

00:36:37.840 --> 00:36:40.760
valgus force and thereby protect the passive

00:36:40.760 --> 00:36:43.820
ligamentous structure, the UCL. If these dynamics

00:36:43.820 --> 00:36:46.920
stabilizing muscles to teague or are weak, then

00:36:46.920 --> 00:36:49.039
the static UCL structure has to take on even

00:36:49.039 --> 00:36:51.059
more of that valgus load, increasing its risk

00:36:51.059 --> 00:36:53.610
of injury. OK. Elbow dislocations, I assume,

00:36:53.650 --> 00:36:55.650
are usually more sudden and traumatic events

00:36:55.650 --> 00:36:58.570
compared to overuse UCL tears. Yes. Typically,

00:36:58.690 --> 00:37:00.710
elbow dislocations are the result of a significant

00:37:00.710 --> 00:37:03.050
trauma, most often a fall onto an outstretched

00:37:03.050 --> 00:37:05.949
hand, what we often call a foosh injury. The

00:37:05.949 --> 00:37:08.090
mechanism usually involves some combination of

00:37:08.090 --> 00:37:10.570
axial load coming up the arm, a valgus force

00:37:10.570 --> 00:37:13.110
pushing the elbow inward, and often some degree

00:37:13.110 --> 00:37:16.050
of supination or palm up twisting of the forearm.

00:37:16.250 --> 00:37:18.369
And are there different types? Yes. They can

00:37:18.369 --> 00:37:20.920
be classified as simple. meaning only the ligaments

00:37:20.920 --> 00:37:23.420
around the elbow are injured or complex, which

00:37:23.420 --> 00:37:25.219
means there are associated fractures involved

00:37:25.219 --> 00:37:28.380
as well. Common fractures seen with complex elbow

00:37:28.380 --> 00:37:30.820
dislocations include fractures of the coronoid

00:37:30.820 --> 00:37:33.699
process of the ulna or the radial head. What's

00:37:33.699 --> 00:37:36.159
the most critical thing to assess right after

00:37:36.159 --> 00:37:39.920
an elbow dislocation is put back in place, reduced?

00:37:40.159 --> 00:37:42.420
Assessing the stability of the elbow joint after

00:37:42.420 --> 00:37:45.360
the reduction is absolutely crucial. the clinician

00:37:45.360 --> 00:37:47.139
will carefully move the elbow through a range

00:37:47.139 --> 00:37:50.000
of motion, often under fluoroscopy, live x -ray,

00:37:50.420 --> 00:37:53.179
to check for any signs of instability or resubluxation.

00:37:54.380 --> 00:37:56.059
A key finding, according to the sources, is if

00:37:56.059 --> 00:37:58.920
the elbow remains unstable and tends to sublux

00:37:58.920 --> 00:38:01.000
or even re -dislocate when it's flexed between

00:38:01.000 --> 00:38:03.619
approximately 45 and 60 degrees. Why is that

00:38:03.619 --> 00:38:07.079
45 -60 degree range so important? Because instability

00:38:07.079 --> 00:38:09.599
in that mid -range of flexion typically indicates

00:38:09.599 --> 00:38:12.480
severe ligamentous damage, often involving not

00:38:12.480 --> 00:38:15.360
just the medial side, UCL, but also disruption

00:38:15.360 --> 00:38:18.460
of the lateral collateral ligament complex, UCL,

00:38:18.659 --> 00:38:20.980
on the outside, which is critical for preventing

00:38:20.980 --> 00:38:24.320
post -relateral rotatory instability. This level

00:38:24.320 --> 00:38:27.019
of instability usually requires surgical intervention

00:38:27.019 --> 00:38:29.699
to repair the damaged ligaments and restore stability.

00:38:29.880 --> 00:38:33.139
Without adequate stability, you simply can't

00:38:33.139 --> 00:38:35.500
start the necessary early range of motion exercises

00:38:35.500 --> 00:38:37.960
needed to prevent debilitating long -term stiffness,

00:38:38.559 --> 00:38:40.840
which is a major risk after elbow dislocations.

00:38:41.219 --> 00:38:42.780
Right. Stiffness is a big problem for elbows.

00:38:43.420 --> 00:38:45.639
And just revisiting VEO syndrome quickly, we

00:38:45.639 --> 00:38:47.699
talked about the post remedial impingement aspect,

00:38:47.800 --> 00:38:50.539
the bone spurs, but it's also considered a syndrome

00:38:50.539 --> 00:38:53.320
of overuse itself, separate from an acute UCL

00:38:53.320 --> 00:38:56.309
tear. Right. While the underlying mechanism involves

00:38:56.309 --> 00:38:59.530
those same valgus overload forces, VEO syndrome

00:38:59.530 --> 00:39:01.849
is really conceptualized as the chronic condition

00:39:01.849 --> 00:39:03.730
that develops over time from repetitive throwing.

00:39:03.929 --> 00:39:07.230
It manifests not just as potential medial elbow

00:39:07.230 --> 00:39:09.570
laxity due to stretching or micro -damage of

00:39:09.570 --> 00:39:12.250
the emusial over time, but also, very commonly,

00:39:12.710 --> 00:39:15.170
involves that painful post -romedial impingement.

00:39:15.550 --> 00:39:18.070
That's caused by the repeated forceful contact

00:39:18.070 --> 00:39:20.110
between the oligacranone process of the ulna

00:39:20.110 --> 00:39:22.829
and the humerus during full extension, leading

00:39:22.829 --> 00:39:25.130
to inflammation and eventually the formation

00:39:25.130 --> 00:39:27.570
of those characteristic osteophytes, or bone

00:39:27.570 --> 00:39:30.190
spurs, in the back, inside part of the elbow.

00:39:30.380 --> 00:39:33.360
And as noted earlier, the symptoms from this

00:39:33.360 --> 00:39:35.639
post -trimedial older cranial impingement related

00:39:35.639 --> 00:39:38.280
to VEO are reported as being a very common reason

00:39:38.280 --> 00:39:40.400
for elbow surgery in professional baseball players.

00:39:40.780 --> 00:39:42.719
OK, so we've covered the demanding mechanics

00:39:42.719 --> 00:39:44.960
and the resulting catalog of potential injuries

00:39:44.960 --> 00:39:47.320
in both the shoulder and the elbow. Now, how

00:39:47.320 --> 00:39:49.659
do clinicians actually piece all this together?

00:39:49.780 --> 00:39:51.480
How do they figure out exactly what's wrong with

00:39:51.480 --> 00:39:53.719
a specific athlete presenting with shoulder or

00:39:53.719 --> 00:39:56.619
elbow pain? What tools are in their diagnostic

00:39:56.619 --> 00:39:59.420
toolkit? Well, the absolute foundation. the real

00:39:59.420 --> 00:40:01.960
cornerstone of diagnosis, is always starting

00:40:01.960 --> 00:40:04.699
with a thorough history and a comprehensive physical

00:40:04.699 --> 00:40:07.300
examination. You simply have to talk to the athlete

00:40:07.300 --> 00:40:09.039
and examine them carefully. What kind of things

00:40:09.039 --> 00:40:11.059
in the history are most important? You need to

00:40:11.059 --> 00:40:13.659
understand how the injury occurred. Was there

00:40:13.659 --> 00:40:17.079
a specific event, a pop, a fall, or did it come

00:40:17.079 --> 00:40:19.739
on gradually over time? What position was the

00:40:19.739 --> 00:40:22.440
arm in when it started hurting? Has this happened

00:40:22.440 --> 00:40:25.199
before? And then really drilling down on the

00:40:25.199 --> 00:40:28.480
exact nature and timing of their symptoms? When

00:40:28.480 --> 00:40:31.019
does it hurt? What makes it worse? What makes

00:40:31.019 --> 00:40:34.039
it better? Is the primary symptom pain? Is it

00:40:34.039 --> 00:40:36.019
instability, a feeling of looseness or giving

00:40:36.019 --> 00:40:40.059
way? Is it weakness? Is it stiffness? Where exactly

00:40:40.059 --> 00:40:42.260
is the pain located? Does it hurt during late

00:40:42.260 --> 00:40:45.219
cocking? During acceleration? During follow through?

00:40:45.559 --> 00:40:48.300
After activity? All these details from the athlete's

00:40:48.300 --> 00:40:50.849
story are critical clues. Then comes the physical

00:40:50.849 --> 00:40:53.230
exam, where the clinician systematically looks

00:40:53.230 --> 00:40:55.530
at the shoulder and elbow, comparing it to the

00:40:55.530 --> 00:40:58.349
uninjured side. They'll assess active and passive

00:40:58.349 --> 00:41:01.409
range of motion, measure muscle strength, palpate

00:41:01.409 --> 00:41:03.969
carefully for specific areas of tenderness, and

00:41:03.969 --> 00:41:06.369
then perform a whole battery of specific clinical

00:41:06.369 --> 00:41:09.269
tests designed to stress or evaluate the integrity

00:41:09.269 --> 00:41:11.969
and function of different structures, ligaments,

00:41:12.210 --> 00:41:15.329
tendons, the labrum, joint stability. They'll

00:41:15.329 --> 00:41:17.690
also look for things like muscle atrophy, or

00:41:17.690 --> 00:41:20.630
wasting, or any visible asymmetry. And experts

00:41:20.630 --> 00:41:22.969
also stress the importance of evaluating the

00:41:22.969 --> 00:41:25.230
cervical spine, the neck, early on, especially

00:41:25.230 --> 00:41:27.730
if the pain is radiating, as pain from neck problems

00:41:27.730 --> 00:41:29.510
can sometimes be referred down to the shoulder

00:41:29.510 --> 00:41:32.409
or arm and mimic shoulder pathology. Right, rule

00:41:32.409 --> 00:41:35.230
out the neck first. And there are dozens, maybe

00:41:35.230 --> 00:41:37.809
hundreds, of specific physical exam tests described

00:41:37.809 --> 00:41:39.769
for the shoulder, right? It seems quite complex.

00:41:40.070 --> 00:41:42.760
There are many. and each is designed ideally

00:41:42.760 --> 00:41:45.639
to try and isolate or stress a particular structure

00:41:45.639 --> 00:41:49.039
or test a specific function. For example, the

00:41:49.039 --> 00:41:51.820
scapular pinch test assesses the strength and

00:41:51.820 --> 00:41:53.960
endurance of the scapular tractor muscles that

00:41:53.960 --> 00:41:56.980
control the shoulder blade. The sulcus test checks

00:41:56.980 --> 00:42:00.219
for inferior laxity or downward instability by

00:42:00.219 --> 00:42:02.119
pulling down on the arm and looking for a gap

00:42:02.119 --> 00:42:05.500
below the acromion. The clunk test, often performed

00:42:05.500 --> 00:42:08.179
with the arm overhead and being rotated, is one

00:42:08.179 --> 00:42:10.239
test used to try and detect certain types of

00:42:10.239 --> 00:42:13.059
labral tears or instability. The load and shift

00:42:13.059 --> 00:42:15.079
test is where the examiner manually tries to

00:42:15.079 --> 00:42:17.039
slide the humeral head forward and backward on

00:42:17.039 --> 00:42:19.900
the glenoid socket to assess the amount of anterior

00:42:19.900 --> 00:42:22.219
and posterior laxity or translation. And the

00:42:22.219 --> 00:42:25.159
apprehension test. The apprehension test. where

00:42:25.159 --> 00:42:27.599
the arm is passively moved into that provocative

00:42:27.599 --> 00:42:30.219
90 degrees abduction in external rotation position,

00:42:30.659 --> 00:42:33.239
is key for assessing anterior instability. Does

00:42:33.239 --> 00:42:35.320
it reproduce the patient's feeling of instability

00:42:35.320 --> 00:42:38.380
or fear of dislocation? And the relocation test

00:42:38.380 --> 00:42:40.960
follows that, where the examiner applies a posterior

00:42:40.960 --> 00:42:43.719
force to the humeral head while in the apprehension

00:42:43.719 --> 00:42:46.539
position. If this pressure relieves the apprehension

00:42:46.539 --> 00:42:49.760
or pain, it further supports anterior instability

00:42:49.760 --> 00:42:52.179
as the cause. What about testing the rotator

00:42:52.179 --> 00:42:54.940
cuff? For the rotator cuff, tests like the liftoff

00:42:54.940 --> 00:42:58.139
test or the belly press test specifically assess

00:42:58.139 --> 00:43:01.039
the subscapularis tendon at the front. Resistant

00:43:01.039 --> 00:43:03.260
external rotation tests, the infospinatus and

00:43:03.260 --> 00:43:06.039
teres minor at the back, and tests like the empty

00:43:06.039 --> 00:43:09.079
can or full can test evaluate the supraspinatus

00:43:09.079 --> 00:43:11.440
tendon at the top. Although the specificity of

00:43:11.440 --> 00:43:14.079
some of these tests is debated, manual muscle

00:43:14.079 --> 00:43:16.039
testing quantifies strength in different planes.

00:43:16.219 --> 00:43:18.860
And impingement tests? Impingement tests, like

00:43:18.860 --> 00:43:21.519
the nearest sign, passively forcing the arm into

00:43:21.519 --> 00:43:24.579
forward elevation, and the Hawkins test, passively

00:43:24.579 --> 00:43:26.820
forcing the arm into internal rotation while

00:43:26.820 --> 00:43:29.920
elevated, aim to provoke pain by mechanically

00:43:29.920 --> 00:43:33.260
narrowing the subacromial space. The Yoakum test

00:43:33.260 --> 00:43:35.619
is another variation, and that hyperexternal

00:43:35.619 --> 00:43:38.260
rotation test we mentioned earlier specifically

00:43:38.260 --> 00:43:42.199
helps assess for posterior superior labral issues

00:43:42.199 --> 00:43:45.119
and internal impingement by stressing that extreme

00:43:45.119 --> 00:43:47.340
late cocking position. You mentioned watching

00:43:47.340 --> 00:43:49.300
the scapula move earlier as being important.

00:43:49.440 --> 00:43:52.179
Is that formally part of the physical exam? Oh,

00:43:52.179 --> 00:43:54.760
absolutely. Observational assessment of scapular

00:43:54.760 --> 00:43:56.719
kinematics, how the shoulder blade moves during

00:43:56.719 --> 00:43:59.139
arm elevation and lowering, is considered crucial.

00:43:59.699 --> 00:44:01.880
Clinicians look specifically for signs of scapular

00:44:01.880 --> 00:44:04.659
dyskinesis abnormal movement patterns like excessive

00:44:04.659 --> 00:44:07.019
winging of the medial border or perhaps decreased

00:44:07.019 --> 00:44:09.119
upward rotation or maybe excessive shrugging

00:44:09.119 --> 00:44:11.780
during arm elevation. And can you test if correcting

00:44:11.780 --> 00:44:15.159
the scapular motion helps? Yes, a key diagnostic

00:44:15.159 --> 00:44:17.780
technique mentioned in the sources is using dynamic

00:44:17.780 --> 00:44:20.519
corrective maneuvers. This involves having the

00:44:20.519 --> 00:44:22.719
athlete perform the painful movement, like raising

00:44:22.719 --> 00:44:25.340
their arm, while the examiner manually assists

00:44:25.340 --> 00:44:28.139
in stabilizing or positioning the scapula correctly,

00:44:28.440 --> 00:44:31.079
for example, manually assisting upward rotation

00:44:31.079 --> 00:44:33.119
or preventing winging, like the sternal lift

00:44:33.119 --> 00:44:36.449
technique described. If the athlete's pain or

00:44:36.449 --> 00:44:39.010
symptoms significantly improve with this manual

00:44:39.010 --> 00:44:41.510
correction of the scapular motion, it strongly

00:44:41.510 --> 00:44:43.590
suggests that the abnormal scapular mechanics

00:44:43.590 --> 00:44:46.570
are a major contributing factor to their problem,

00:44:47.050 --> 00:44:49.469
which then directly guides the focus of rehabilitation.

00:44:49.820 --> 00:44:52.340
That makes a lot of sense. And are there specific

00:44:52.340 --> 00:44:54.760
physical tests for the elbow that are highlighted?

00:44:55.039 --> 00:44:58.300
Yes. For the elbow, careful palpation along the

00:44:58.300 --> 00:45:00.880
medial side for tenderness over the UCL attachment

00:45:00.880 --> 00:45:04.099
or over the post remedial ocarina for VEO spurs

00:45:04.099 --> 00:45:06.900
is important. Palpating along the occipital groove

00:45:06.900 --> 00:45:08.480
at the front of the shoulder down towards the

00:45:08.480 --> 00:45:11.340
elbow can sometimes reveal tenderness if there's

00:45:11.340 --> 00:45:14.159
biceps tendon involvement extending down, though

00:45:14.159 --> 00:45:16.150
as mentioned, it's not highly specific. What

00:45:16.150 --> 00:45:19.250
about tests for the biceps or labrum originating

00:45:19.250 --> 00:45:21.429
near the shoulder but causing elbow symptoms?

00:45:21.530 --> 00:45:24.010
Tests like O 'Brien's test, resisted forward

00:45:24.010 --> 00:45:26.730
flexion with the arm internally rotated, Speed's

00:45:26.730 --> 00:45:28.690
test, resisted forward flexion with the palm

00:45:28.690 --> 00:45:31.429
up, and your Gaston's test, resisted supination

00:45:31.429 --> 00:45:33.570
with the elbow flexed, are traditionally used

00:45:33.570 --> 00:45:36.710
to try and identify pathology involving the proximal

00:45:36.710 --> 00:45:40.619
biceps tendon or the superior labrum. SLAP tears.

00:45:41.159 --> 00:45:43.460
However, the sources note that these tests often

00:45:43.460 --> 00:45:46.400
have variable sensitivity and specificity and

00:45:46.400 --> 00:45:48.960
can be difficult to interpret reliably in isolation.

00:45:49.579 --> 00:45:51.659
Some experts suggest that combining tests, like

00:45:51.659 --> 00:45:53.519
performing the speeds test along with an uppercut

00:45:53.519 --> 00:45:55.579
motion, resistant flexion with the fist moving

00:45:55.579 --> 00:45:57.880
towards the chin, might be somewhat better at

00:45:57.880 --> 00:46:00.420
differentiating true biceps pathology from SLAP

00:46:00.420 --> 00:46:02.440
tears, but it remains challenging clinically.

00:46:02.820 --> 00:46:05.559
And testing the UCL, the Tommy John ligament.

00:46:05.840 --> 00:46:08.340
For assessing the integrity of the critical ulnar

00:46:08.340 --> 00:46:11.139
collateral ligament. The primary test is the

00:46:11.139 --> 00:46:14.400
valgus stress test. This is performed with the

00:46:14.400 --> 00:46:16.719
elbow slightly flexed, usually around 20 -30

00:46:16.719 --> 00:46:20.139
degrees, to unlock the bony stability and the

00:46:20.139 --> 00:46:22.619
examiner applies an outward directed valgus force

00:46:22.619 --> 00:46:25.380
to the forearm while stabilizing the upper arm.

00:46:26.280 --> 00:46:28.639
They feel for any excessive gapping or laxity

00:46:28.639 --> 00:46:30.699
on the medial side compared to the uninjured

00:46:30.699 --> 00:46:33.920
elbow. The moving valgus stress test is another

00:46:33.920 --> 00:46:36.260
dynamic test where a valgus stress is applied

00:46:36.260 --> 00:46:38.280
while the examiner moves the elbow through an

00:46:38.280 --> 00:46:40.800
arc of flexion and extension, looking to reproduce

00:46:40.800 --> 00:46:43.300
the athlete's specific pain or sense of instability,

00:46:43.659 --> 00:46:45.519
often felt in a particular part of the range.

00:46:46.119 --> 00:46:49.000
Okay, so beyond the crucial hands -on history

00:46:49.000 --> 00:46:51.500
and exam, imaging is usually the next step, providing

00:46:51.500 --> 00:46:54.360
that visual look inside. But as you hinted, different

00:46:54.360 --> 00:46:56.179
types of aging are best suited for looking at

00:46:56.179 --> 00:46:58.389
different things, right? That's exactly right.

00:46:58.869 --> 00:47:01.150
You usually start with basic radiographs, standard

00:47:01.150 --> 00:47:03.730
x -rays. These are essential as a baseline for

00:47:03.730 --> 00:47:06.469
identifying any obvious bony abnormalities like

00:47:06.469 --> 00:47:09.489
fractures, including subtle bankart rim fractures

00:47:09.489 --> 00:47:12.469
or hill -sax impaction fractures, assessing the

00:47:12.469 --> 00:47:14.570
overall joint alignment, looking for signs of

00:47:14.570 --> 00:47:17.230
arthritis or degenerative changes, evaluating

00:47:17.230 --> 00:47:20.090
the AC joint for separation or arthritis. The

00:47:20.090 --> 00:47:22.210
Zanka view is specifically good for the AC joint.

00:47:22.769 --> 00:47:24.869
Looking for loose bodies. bone chips floating

00:47:24.869 --> 00:47:27.389
in the joint, identifying osteophytes or bone

00:47:27.389 --> 00:47:30.130
spurs, like in VEO, and helping to stage OCD

00:47:30.130 --> 00:47:32.730
lesions in the capitalum based on bony changes.

00:47:33.530 --> 00:47:35.250
X -rays are also crucial, of course, for confirming

00:47:35.250 --> 00:47:37.969
that an elbow dislocation has been properly reduced.

00:47:38.210 --> 00:47:40.050
What if you need more detail on the bone, say,

00:47:40.309 --> 00:47:42.730
to measure the exact amount of glenoid bone loss

00:47:42.730 --> 00:47:45.110
after dislocations or to get a better look at

00:47:45.110 --> 00:47:48.420
a complex fracture? That's where CT scans, computed

00:47:48.420 --> 00:47:51.059
tomography, particularly with 3D reconstructions,

00:47:51.300 --> 00:47:54.360
become invaluable. CT provides the most detailed

00:47:54.360 --> 00:47:56.480
assessment of bony anatomy and is considered

00:47:56.480 --> 00:47:58.480
the gold standard for accurately quantifying

00:47:58.480 --> 00:48:01.280
the extent and morphology of glenoid bone loss

00:48:01.280 --> 00:48:04.480
and hill sacs lesions. This information is critical

00:48:04.480 --> 00:48:06.739
for surgical planning, especially when considering

00:48:06.739 --> 00:48:09.659
bone augmentation procedures like the Littarjet.

00:48:10.219 --> 00:48:12.960
CT is also excellent for visualizing AC joint

00:48:12.960 --> 00:48:15.719
displacement in multiple planes and for assessing

00:48:15.719 --> 00:48:18.599
the changes seen in distal clavicular osteolysis.

00:48:19.079 --> 00:48:21.980
And 3DCT reconstructions are very helpful for

00:48:21.980 --> 00:48:24.900
planning surgery for complex OCD lesions, allowing

00:48:24.900 --> 00:48:26.519
the surgeon to really understand the shape and

00:48:26.519 --> 00:48:29.340
extent of the defect. Okay, so CT for bone detail.

00:48:29.539 --> 00:48:31.780
What about the soft tissues, the ligaments, tendons,

00:48:31.940 --> 00:48:34.199
the labrum, the cartilage? What's the best imaging

00:48:34.199 --> 00:48:37.309
modality for those? For soft tissues, MRI magnetic

00:48:37.309 --> 00:48:40.050
resonance imaging is generally the go -to modality.

00:48:40.429 --> 00:48:42.409
It provides excellent visualization of the rotator

00:48:42.409 --> 00:48:44.630
cuff tendons, showing tendinosis, partial tears,

00:48:44.710 --> 00:48:47.349
full tears, the labrum around the glenoid, the

00:48:47.349 --> 00:48:49.590
glenohumeral ligaments within the capsule, the

00:48:49.590 --> 00:48:51.969
joint capsule itself, and the articular cartilage

00:48:51.969 --> 00:48:55.210
covering the bone surfaces. Is standard MRI always

00:48:55.210 --> 00:48:57.969
enough, or are there variations? For detecting

00:48:57.969 --> 00:49:01.050
more subtle tears, especially the labrum or the

00:49:01.050 --> 00:49:03.750
ligaments, or small partial tears of the rotator

00:49:03.750 --> 00:49:07.030
cuff, MRA magnetic resonance orthography is often

00:49:07.030 --> 00:49:10.190
preferred. This involves injecting gadolinium

00:49:10.190 --> 00:49:12.690
contrast dye directly into the joint before the

00:49:12.690 --> 00:49:15.630
MRI scan. The contrast fluid fills the joint

00:49:15.630 --> 00:49:18.510
space and, importantly, seeps into any tears

00:49:18.510 --> 00:49:20.929
or defects in the labrum, ligaments, or cuff

00:49:20.929 --> 00:49:24.300
tendons, making them much easier to see. The

00:49:24.300 --> 00:49:27.199
dye highlights the tears. Exactly. Experts and

00:49:27.199 --> 00:49:29.780
the sources often recommend direct MRA, injecting

00:49:29.780 --> 00:49:32.219
into the joint, as the diagnostic tool of choice

00:49:32.219 --> 00:49:34.099
for evaluating the rotator cuff and particularly

00:49:34.099 --> 00:49:36.719
the labrum in young athletic populations, as

00:49:36.719 --> 00:49:39.199
it significantly increases the sensitivity and

00:49:39.199 --> 00:49:41.719
diagnostic accuracy for these often subtle injuries

00:49:41.719 --> 00:49:44.920
compared to non -contrasted MRI. MRA is also

00:49:44.920 --> 00:49:46.900
very useful for assessing the integrity of the

00:49:46.900 --> 00:49:49.500
UCL in the elbow and for visualizing the status

00:49:49.500 --> 00:49:51.820
of the cartilage and detecting loose bodies in

00:49:51.820 --> 00:49:54.239
cases of OCD of the capitalum. But even with

00:49:54.239 --> 00:49:57.099
MRA, you mentioned earlier that diagnosing SLAP

00:49:57.099 --> 00:49:59.179
specifically can still be tricky because of those

00:49:59.179 --> 00:50:02.380
normal anatomical variations. Yes, that's a known

00:50:02.380 --> 00:50:05.300
limitation and a common challenge. Even with

00:50:05.300 --> 00:50:08.139
state -of -the -art MRI or MRA, it can sometimes

00:50:08.139 --> 00:50:10.280
be difficult for radiologists to definitively

00:50:10.280 --> 00:50:12.380
differentiate certain normal variations in the

00:50:12.380 --> 00:50:14.440
superior labrum and biceps anchor attachment,

00:50:14.860 --> 00:50:17.019
like a sublaboral foramen or Buford complex,

00:50:17.619 --> 00:50:21.139
from a true pathological SLAP tear. This inherent

00:50:21.139 --> 00:50:23.260
ambiguity on imaging is one of the main reasons

00:50:23.260 --> 00:50:26.079
why arthroscopy, the minimally invasive surgical

00:50:26.079 --> 00:50:28.260
procedure where a small camera is inserted directly

00:50:28.260 --> 00:50:30.280
into the joint, is often still considered the

00:50:30.280 --> 00:50:32.739
gold standard for definitively diagnosing and

00:50:32.739 --> 00:50:35.119
classifying certain lesions, particularly SLA

00:50:35.119 --> 00:50:37.460
tears, and also for evaluating the cartilage

00:50:37.460 --> 00:50:40.559
surface and OCD of the capital. So seeing is

00:50:40.559 --> 00:50:43.889
believing, essentially. Pretty much. Arthroscopy

00:50:43.889 --> 00:50:46.210
allows the surgeon to directly visualize the

00:50:46.210 --> 00:50:48.889
structures in question, magnify them, and use

00:50:48.889 --> 00:50:51.750
a small probe to physically palpate them, assessing

00:50:51.750 --> 00:50:54.969
their stability and tissue quality. They can

00:50:54.969 --> 00:50:57.530
perform dynamic testing, like reproducing the

00:50:57.530 --> 00:51:00.210
peel -back sign for acessilabed hair, and directly

00:51:00.210 --> 00:51:02.070
assess the condition of the articular cartilage.

00:51:02.400 --> 00:51:05.679
It removes much of the ambiguity that can sometimes

00:51:05.679 --> 00:51:08.159
exist with imaging alone, although care must

00:51:08.159 --> 00:51:10.420
still be taken by the surgeon to distinguish

00:51:10.420 --> 00:51:13.340
true pathology from normal variants even during

00:51:13.340 --> 00:51:16.599
arthroscopy. Are there any other imaging techniques

00:51:16.599 --> 00:51:19.599
commonly used? Ultrasound is also mentioned as

00:51:19.599 --> 00:51:21.519
being used, particularly for certain applications.

00:51:22.059 --> 00:51:24.159
It has advantages like being relatively inexpensive,

00:51:24.719 --> 00:51:27.119
portable, can be done in the clinic, non -invasive,

00:51:27.280 --> 00:51:29.539
no radiation, and generally well tolerated by

00:51:29.539 --> 00:51:32.809
patients. Musculoskeletal ultrasound is particularly

00:51:32.809 --> 00:51:35.590
useful for evaluating rotator cuff tendon pathology,

00:51:35.949 --> 00:51:38.389
looking for tendonitis, calcifications, partial

00:51:38.389 --> 00:51:40.769
tears, or full tears. It's also very good for

00:51:40.769 --> 00:51:43.010
assessing fluid collections, like in the subacromial

00:51:43.010 --> 00:51:45.750
bursa. Can it be used for treatment, too? Yes,

00:51:45.929 --> 00:51:47.889
it's excellent for guiding injections accurately

00:51:47.889 --> 00:51:50.230
into specific locations like the subacromial

00:51:50.230 --> 00:51:53.449
space, the biceps tendon sheath, or the AC joint.

00:51:53.659 --> 00:51:55.820
It's also used by some clinicians to monitor

00:51:55.820 --> 00:51:58.420
the healing of rotator cuff repairs after surgery

00:51:58.420 --> 00:52:01.179
by visualizing the tendon integrity over time.

00:52:02.119 --> 00:52:03.860
And the source has also mentioned it can be helpful

00:52:03.860 --> 00:52:06.840
in assessing the superficial aspects of OCD lesions,

00:52:07.199 --> 00:52:09.119
although MRI is generally better for overall

00:52:09.119 --> 00:52:11.360
staging. And you mentioned earlier incorporating

00:52:11.360 --> 00:52:13.300
the athlete's own perspective in the assessment

00:52:13.300 --> 00:52:16.420
process. How is that done? Absolutely. Using

00:52:16.420 --> 00:52:18.840
patient -reported outcome measures, or PROMs,

00:52:19.119 --> 00:52:21.719
is increasingly recognized as being very important.

00:52:22.280 --> 00:52:24.260
The source has mentioned tools like the Senane

00:52:24.260 --> 00:52:26.099
score, that's the single -assessment numeric

00:52:26.099 --> 00:52:28.519
evaluation. It's very simple. The patient is

00:52:28.519 --> 00:52:30.460
just asked to rate their affected shoulder or

00:52:30.460 --> 00:52:33.460
elbow function on a scale from 0%, worst possible,

00:52:33.519 --> 00:52:36.579
cannot use the limb, to 100%, completely normal,

00:52:36.780 --> 00:52:39.059
pre -injury level. OK, just one number. Just

00:52:39.059 --> 00:52:41.659
one number. Giving a global sense of their perceived

00:52:41.659 --> 00:52:44.699
function. Another tool mentioned is the PSFS,

00:52:45.019 --> 00:52:48.119
the patient -specific functional scale. This

00:52:48.119 --> 00:52:51.119
one is more individualized. The athlete identifies

00:52:51.119 --> 00:52:53.400
up to three specific activities that are most

00:52:53.400 --> 00:52:55.559
important to them but are currently difficult

00:52:55.559 --> 00:52:58.500
due to their injury. Maybe it's throwing a baseball

00:52:58.500 --> 00:53:01.019
at full speed, swimming a specific stroke without

00:53:01.019 --> 00:53:03.820
pain, or lifting a certain amount of weight overhead.

00:53:03.980 --> 00:53:06.460
Right, things relevant to them. Exactly. Then

00:53:06.460 --> 00:53:08.679
they rate their current ability to perform each

00:53:08.679 --> 00:53:11.400
of those specific activities on a scale of zero.

00:53:11.719 --> 00:53:14.559
unable to perform the activity at all, to 10,

00:53:15.199 --> 00:53:17.000
able to perform the activity at their pre -injury

00:53:17.000 --> 00:53:19.980
level without any difficulty. These tools are

00:53:19.980 --> 00:53:22.219
valuable because they directly capture the patient's

00:53:22.219 --> 00:53:24.539
subjective experience and their perceived functional

00:53:24.539 --> 00:53:27.079
limitations, which are vital pieces of the puzzle,

00:53:27.500 --> 00:53:29.920
especially early in the diagnostic process and

00:53:29.920 --> 00:53:32.469
for tracking progress over time. Okay, so putting

00:53:32.469 --> 00:53:34.949
it all together, the detailed history, the thorough

00:53:34.949 --> 00:53:37.070
physical exam with all those specific tests,

00:53:37.550 --> 00:53:41.170
the targeted imaging like x -ray, CT, MRI, or

00:53:41.170 --> 00:53:44.050
MRA, maybe ultrasound, and getting the athlete's

00:53:44.050 --> 00:53:46.110
own functional rating clinicians can usually

00:53:46.110 --> 00:53:49.309
arrive at a pretty accurate diagnosis. What are

00:53:49.309 --> 00:53:52.630
the next steps then? Treatment. When is trying

00:53:52.630 --> 00:53:55.349
non -operative management without surgery, the

00:53:55.349 --> 00:53:57.630
right path to start on. Non -operative treatment

00:53:57.630 --> 00:53:59.650
is typically the first line of management attempted

00:53:59.650 --> 00:54:02.889
for many, if not most, shoulder and elbow conditions

00:54:02.889 --> 00:54:04.949
in athletes, especially those that seem to be

00:54:04.949 --> 00:54:07.670
related to chronic overuse or involve less severe

00:54:07.670 --> 00:54:09.989
structural damage that doesn't necessarily require

00:54:09.989 --> 00:54:13.250
surgical repair to heal or become stable. This

00:54:13.250 --> 00:54:15.690
would include conditions like rotator cuff tendonitis,

00:54:16.170 --> 00:54:18.429
milder forms of shoulder impingement, both subacromial

00:54:18.429 --> 00:54:21.650
and internal, chronic distal clavicular osteolysis,

00:54:21.929 --> 00:54:25.190
DCO, lateral epicompylitis, tennis elbow in the

00:54:25.190 --> 00:54:27.590
elbow, and critically, as we mentioned, most

00:54:27.590 --> 00:54:29.789
initial cases of multi -directional instability,

00:54:29.969 --> 00:54:32.349
MDI, or general shoulder looseness. What does

00:54:32.349 --> 00:54:34.449
that conservative non -operative treatment usually

00:54:34.449 --> 00:54:36.849
involve? The core components generally include

00:54:36.849 --> 00:54:39.989
a period of relative rest and significant activity

00:54:39.989 --> 00:54:43.079
modification. This means substantially reducing

00:54:43.079 --> 00:54:45.780
or temporarily stopping the specific activity

00:54:45.780 --> 00:54:48.300
or movements that provoke the pain, like throwing,

00:54:48.639 --> 00:54:51.239
swimming, or heavy lifting. Okay, stop irritating

00:54:51.239 --> 00:54:55.599
it. Exactly. NSAID's nonsteroidal anti -inflammatory

00:54:55.599 --> 00:54:58.679
drugs like ibuprofen or naproxen are often used

00:54:58.679 --> 00:55:00.900
for a short course to help manage pain and reduce

00:55:00.900 --> 00:55:03.059
inflammation, although their long -term use is

00:55:03.059 --> 00:55:05.599
generally discouraged. Injections can sometimes

00:55:05.599 --> 00:55:08.239
play a role in providing temporary relief and

00:55:08.239 --> 00:55:10.880
aiding rehabilitation. Corticosteroid combined

00:55:10.880 --> 00:55:13.099
with local anesthetic injections can be targeted

00:55:13.099 --> 00:55:15.500
to specific areas like the subacromial space

00:55:15.500 --> 00:55:18.800
for impingement, the AC joint, or around inflamed

00:55:18.800 --> 00:55:21.039
tendons to calm down inflammation and break the

00:55:21.039 --> 00:55:23.199
pain cycle. What about other types of injections

00:55:23.199 --> 00:55:26.099
like PRP? The sources mention other types of

00:55:26.099 --> 00:55:29.099
injections like hyaluronic acid, fisco supplementation,

00:55:29.599 --> 00:55:32.519
or platelet -rich plasma PRP, but they also note

00:55:32.519 --> 00:55:34.280
that the evidence supporting their effectiveness,

00:55:34.599 --> 00:55:36.900
particularly for many shoulder and elbow conditions,

00:55:37.420 --> 00:55:39.940
is still somewhat debated or evolving, and they

00:55:39.940 --> 00:55:42.099
aren't universally recommended as first -line

00:55:42.099 --> 00:55:45.219
treatments based on the material presented. For

00:55:45.219 --> 00:55:48.000
certain elbow issues, like MUCL sprains or during

00:55:48.000 --> 00:55:51.079
recovery from VEO, bracing might be used for

00:55:51.079 --> 00:55:53.599
instance. A hinged elbow brace that limits full

00:55:53.599 --> 00:55:56.039
extension might be employed to provide support

00:55:56.039 --> 00:55:58.260
and protect the healing tissues during activities.

00:55:58.960 --> 00:56:00.539
And physical therapy, I assume, is absolutely

00:56:00.539 --> 00:56:03.539
central to any non -operative approach. Absolutely.

00:56:03.820 --> 00:56:06.380
Physical therapy or physiotherapy is paramount.

00:56:06.519 --> 00:56:09.179
It's really the cornerstone of effective non

00:56:09.179 --> 00:56:12.099
-operative management. The specific goals are

00:56:12.099 --> 00:56:14.219
always tailored to the individual athlete and

00:56:14.219 --> 00:56:16.699
their specific injury. But broadly speaking,

00:56:16.900 --> 00:56:20.460
PT focuses on several key areas. Restoring normal,

00:56:20.599 --> 00:56:22.840
pain -free range of motion is often a primary

00:56:22.840 --> 00:56:26.449
goal. Improving flexibility is crucial. especially

00:56:26.449 --> 00:56:28.670
addressing any specific tightness identified,

00:56:29.130 --> 00:56:31.510
like that posterior capsule contracture contributing

00:56:31.510 --> 00:56:34.809
to GRD enthrowers, strengthening the key muscle

00:56:34.809 --> 00:56:36.769
groups responsible for stability and controlled

00:56:36.769 --> 00:56:39.659
motion is vital. This includes the rotator cuff

00:56:39.659 --> 00:56:42.199
muscles, the scapular stabilizing muscles like

00:56:42.199 --> 00:56:44.619
the serratus anterior, rhomboids, trapezius,

00:56:44.820 --> 00:56:46.980
and importantly, strengthening the core and lower

00:56:46.980 --> 00:56:49.099
body musculature to improve the efficiency of

00:56:49.099 --> 00:56:51.500
that entire kinetic chain. Right, fix the chain.

00:56:52.039 --> 00:56:54.360
Exactly. And enhancing neuromuscular control

00:56:54.360 --> 00:56:56.920
and coordination, essentially retraining the

00:56:56.920 --> 00:56:58.980
brain and muscles to work together smoothly and

00:56:58.980 --> 00:57:02.510
efficiently, is also a major focus. Specific

00:57:02.510 --> 00:57:04.250
stretching techniques mentioned in the sources

00:57:04.250 --> 00:57:06.710
include the cross -body stretch, the sleeper

00:57:06.710 --> 00:57:09.250
stretch, lying on the side and internally rotating

00:57:09.250 --> 00:57:12.050
the arm, and other internal rotation or horizontal

00:57:12.050 --> 00:57:14.429
adduction stretches, all designed to target that

00:57:14.429 --> 00:57:16.610
posterior shoulder tightness associated with

00:57:16.610 --> 00:57:20.349
GRD. For elbow conditions like lateral epicondylitis,

00:57:20.570 --> 00:57:23.469
kinase elbow, eccentric training protocols, which

00:57:23.469 --> 00:57:25.630
focus specifically on the muscle's ability to

00:57:25.630 --> 00:57:27.949
lengthen under load, have demonstrated particularly

00:57:27.949 --> 00:57:30.599
good results in research. Can you get a sense

00:57:30.599 --> 00:57:32.760
during that initial assessment phase if someone

00:57:32.760 --> 00:57:35.860
is likely to respond well to just physical therapy

00:57:35.860 --> 00:57:37.539
and conservative care or if they're probably

00:57:37.539 --> 00:57:39.639
heading towards surgery eventually? For certain

00:57:39.639 --> 00:57:41.539
conditions, yes, there might be some predictive

00:57:41.539 --> 00:57:44.460
factors. For instance, experts note that for

00:57:44.460 --> 00:57:46.980
internal impingement of the shoulder, certain

00:57:46.980 --> 00:57:49.360
findings during the physical examination can

00:57:49.360 --> 00:57:51.659
help predict the likelihood of success with non

00:57:51.659 --> 00:57:54.269
-operative management. These might include the

00:57:54.269 --> 00:57:56.849
specific pattern of pain reproduction with resisted

00:57:56.849 --> 00:57:59.909
arm movements like abduction or forward flexion,

00:58:00.269 --> 00:58:02.530
the athlete's baseline scapular position and

00:58:02.530 --> 00:58:04.530
their ability to control it during arm motion,

00:58:04.949 --> 00:58:07.050
and perhaps their ability to sustain rotator

00:58:07.050 --> 00:58:09.849
cuff strength, particularly at 90 degrees of

00:58:09.849 --> 00:58:12.750
abduction. If these factors look favorable, the

00:58:12.750 --> 00:58:15.050
prognosis with rehab might be better. And for

00:58:15.050 --> 00:58:17.710
MDI, that generalized loose shoulder. You mentioned

00:58:17.710 --> 00:58:19.570
earlier that therapy is strongly recommended

00:58:19.570 --> 00:58:22.000
as the primary approach there. Yes, absolutely.

00:58:22.539 --> 00:58:24.780
For multidirectional instability, the sources

00:58:24.780 --> 00:58:27.539
emphasize that non -operative treatment, focusing

00:58:27.539 --> 00:58:30.119
intensely on strengthening the dynamic stabilizers,

00:58:30.559 --> 00:58:33.079
the rotator cuff and the scapular muscles, and

00:58:33.079 --> 00:58:35.340
improving neuromuscular control and proprioception

00:58:35.340 --> 00:58:37.840
is strongly recommended as the primary treatment

00:58:37.840 --> 00:58:40.699
strategy. The goal is to improve the muscular

00:58:40.699 --> 00:58:43.460
control and stability around the joint to compensate

00:58:43.460 --> 00:58:47.280
for the underlying capsular laxity. Experts explicitly

00:58:47.280 --> 00:58:49.519
state in the material that thermal capsulorophy,

00:58:49.960 --> 00:58:52.280
an older surgical technique that used radio frequency

00:58:52.280 --> 00:58:55.019
heat to try and shrink the redundant joint capsule,

00:58:55.480 --> 00:58:58.360
is not recommended for MDI due to unacceptably

00:58:58.360 --> 00:59:00.719
high rates of failure, recurrence of instability,

00:59:01.239 --> 00:59:03.099
and potential complications like nerve injury

00:59:03.099 --> 00:59:06.219
or cartilage damage. So PT is really the mainstay

00:59:06.219 --> 00:59:08.880
for MDI. So non -operative treatment is often

00:59:08.880 --> 00:59:11.019
the starting point, especially for overuse issues

00:59:11.019 --> 00:59:14.039
or less severe injuries. When does surgery become

00:59:14.039 --> 00:59:16.639
the necessary or recommended option? Surgery

00:59:16.639 --> 00:59:18.480
is typically considered when a well -structured

00:59:18.480 --> 00:59:20.860
and compliant non -operative treatment program

00:59:20.860 --> 00:59:23.800
fails to adequately relieve the athlete's symptoms

00:59:23.800 --> 00:59:27.139
and restore their desired level of function after

00:59:27.139 --> 00:59:29.260
a reasonable period, usually at least three to

00:59:29.260 --> 00:59:32.619
six months. or surgery might be indicated more

00:59:32.619 --> 00:59:35.320
acutely if the injury involves significant structural

00:59:35.320 --> 00:59:38.059
damage that is unlikely to heal on its own and

00:59:38.059 --> 00:59:40.719
poses a clear risk of ongoing instability, progressive

00:59:40.719 --> 00:59:44.079
damage, or functional limitation. This would

00:59:44.079 --> 00:59:46.559
include things like symptomatic large partial

00:59:46.559 --> 00:59:50.039
thickness, greater than 50 % thickness, or full

00:59:50.039 --> 00:59:52.519
thickness tears of the rotator cuff tendons,

00:59:52.820 --> 00:59:55.679
especially in younger active individuals. It

00:59:55.679 --> 00:59:58.860
includes significant shoulder instability, particularly

00:59:58.860 --> 01:00:01.900
traumatic interior dislocations in young, high

01:00:01.900 --> 01:00:04.619
-risk athletes that keep recurring despite attempts

01:00:04.619 --> 01:00:08.059
at rehabilitation. Symptomatic bony lesions that

01:00:08.059 --> 01:00:10.800
cause mechanical problems, like large, engaging

01:00:10.800 --> 01:00:13.840
hillsacks defects or significant glenoid bone

01:00:13.840 --> 01:00:17.500
loss, often require surgical correction. Unstable

01:00:17.500 --> 01:00:19.599
OCD lesions in the elbow with loose fragments

01:00:19.599 --> 01:00:22.739
usually need surgery. And complete tears of critical

01:00:22.739 --> 01:00:25.980
ligaments, like the elbow, UCL, that result in

01:00:25.980 --> 01:00:27.900
functional instability and don't respond adequately

01:00:27.900 --> 01:00:30.320
to conservative care are also common surgical

01:00:30.320 --> 01:00:32.460
indications in athletes. Let's go through some

01:00:32.460 --> 01:00:34.500
of the specific surgical procedures mentioned

01:00:34.500 --> 01:00:36.400
for the shoulder, starting again with the rotator

01:00:36.400 --> 01:00:38.380
cuff tears in athletes. What are the typical

01:00:38.380 --> 01:00:40.659
options there? The surgical options really depend

01:00:40.659 --> 01:00:42.500
on the specific characteristics of the tear,

01:00:42.780 --> 01:00:45.440
its size, thickness, location, and the quality

01:00:45.440 --> 01:00:48.769
of the tendon tissue. For smaller partial thickness

01:00:48.769 --> 01:00:51.989
tears, say less than 50 % of the tendon's thickness,

01:00:52.429 --> 01:00:54.969
particularly if they're causing impingement symptoms,

01:00:55.530 --> 01:00:57.510
an arthroscopic debridement might be performed.

01:00:58.150 --> 01:01:00.289
This essentially involves shaving or cleaning

01:01:00.289 --> 01:01:02.690
up the frayed edges of the tear without actually

01:01:02.690 --> 01:01:05.329
repairing it. Okay. For larger partial thickness

01:01:05.329 --> 01:01:08.090
tears, generally considered more than 50 % thickness,

01:01:08.670 --> 01:01:10.690
or for full thickness tears where the tendon

01:01:10.690 --> 01:01:13.489
is completely torn through, surgical repair is

01:01:13.489 --> 01:01:15.869
usually indicated, especially in active individuals.

01:01:16.139 --> 01:01:18.719
This typically involves reattaching the torn

01:01:18.719 --> 01:01:21.500
tendon back down to its bony insertion site on

01:01:21.500 --> 01:01:24.320
the humerus, the greater tuberosity. This can

01:01:24.320 --> 01:01:26.920
usually be done arthroscopically using suture

01:01:26.920 --> 01:01:29.900
anchors placed into the bone. Occasionally, for

01:01:29.900 --> 01:01:32.699
very large or complex tears, a mini -open technique

01:01:32.699 --> 01:01:35.050
might be used. Is anything else done at the same

01:01:35.050 --> 01:01:36.989
time, like addressing impingement? Sometimes

01:01:36.989 --> 01:01:39.389
an acromioplasty, which involves shaving down

01:01:39.389 --> 01:01:41.349
some bone from the underside of the acromion,

01:01:41.710 --> 01:01:43.969
the bone forming the roof of the shoulder, might

01:01:43.969 --> 01:01:46.650
be performed concurrently, particularly if there

01:01:46.650 --> 01:01:49.210
are clear signs of subacromial impingement, like

01:01:49.210 --> 01:01:52.510
a bone spur or associated changes in the corco

01:01:52.510 --> 01:01:54.469
-chromial ligament contributing to the problem.

01:01:55.210 --> 01:01:57.780
However, The routine use of a chromioplasty,

01:01:57.960 --> 01:02:00.239
especially in the context of tears primarily

01:02:00.239 --> 01:02:02.719
caused by internal impingement or instability

01:02:02.719 --> 01:02:05.500
in athletes, is somewhat debated among surgeons.

01:02:05.920 --> 01:02:07.780
Are there specific repair techniques mentioned

01:02:07.780 --> 01:02:11.480
for larger tears? Yes. Experts mentioned advanced

01:02:11.480 --> 01:02:14.219
arthroscopic techniques like the MPTOE repair,

01:02:14.639 --> 01:02:17.199
which stands for medial portal, transoceous equivalent.

01:02:17.739 --> 01:02:19.760
This is often used for full thickness tears that

01:02:19.760 --> 01:02:21.760
are larger than about 10 millimeters in size.

01:02:21.980 --> 01:02:24.519
The goal of this technique is to create a stronger

01:02:24.519 --> 01:02:27.900
and more anatomical hair interface by using suture

01:02:27.900 --> 01:02:30.699
anchors placed both medially closer to the joint

01:02:30.699 --> 01:02:33.159
surface and laterally on the bone footprint,

01:02:33.280 --> 01:02:35.900
creating a broader area of tendon to bone compression

01:02:35.900 --> 01:02:38.460
that better mimics the natural tendon insertion

01:02:38.460 --> 01:02:40.780
and potentially improves biomechanical load sharing.

01:02:41.239 --> 01:02:43.500
Sounds complex, are there downsides? Like any

01:02:43.500 --> 01:02:46.369
technique, it has potential pitfalls. The source

01:02:46.369 --> 01:02:48.570
has mentioned concerns like potential failure

01:02:48.570 --> 01:02:50.909
of the medial row anchors, if not placed securely,

01:02:51.409 --> 01:02:54.150
or a possible purse string effect where overtightening

01:02:54.150 --> 01:02:56.090
the sutures could constrict blood flow to the

01:02:56.090 --> 01:02:59.449
tendon edge. But regardless of the specific repair

01:02:59.449 --> 01:03:01.949
technique used, a critical point that experts

01:03:01.949 --> 01:03:05.389
emphasize repeatedly is that athlete noncompliance

01:03:05.389 --> 01:03:08.630
with the lengthy and strict post -operative rehabilitation

01:03:08.630 --> 01:03:11.630
protocol is a major risk factor for surgical

01:03:11.630 --> 01:03:14.469
failure and re -tear. even if the initial repair

01:03:14.469 --> 01:03:17.329
was technically perfect. Rehab is key. Now what

01:03:17.329 --> 01:03:19.929
about surgery for those tricky SLA peers we discussed?

01:03:20.070 --> 01:03:22.909
When is that done and how? Surgery for SLAP tears

01:03:22.909 --> 01:03:25.170
is generally considered for symptomatic unstable

01:03:25.170 --> 01:03:27.809
tears, typically those classified as type 2,

01:03:28.030 --> 01:03:30.110
where the superior labrum and biceps anchor are

01:03:30.110 --> 01:03:32.590
detached from the glenoid rim, or more complex

01:03:32.590 --> 01:03:34.730
types, especially in athletes who haven't improved

01:03:34.730 --> 01:03:36.389
sufficiently with a course of physical therapy

01:03:36.389 --> 01:03:38.690
focused on addressing associated issues like

01:03:38.690 --> 01:03:41.789
GRRD or scapular dyskinesis. And what does the

01:03:41.789 --> 01:03:44.349
surgery involve? The standard procedure involves

01:03:44.349 --> 01:03:46.909
arthroscopically repairing the torn labrum back

01:03:46.909 --> 01:03:49.949
to the bone. The surgeon will first abride, or

01:03:49.949 --> 01:03:52.429
clean up, the frayed edges of the torn labrum

01:03:52.429 --> 01:03:54.710
and then prepare the bony surface of the glenoid

01:03:54.710 --> 01:03:56.730
rim underneath it to create a bleeding surface

01:03:56.730 --> 01:04:00.269
that promotes healing. Then, small suture anchors

01:04:00.269 --> 01:04:02.690
loaded with strong sutures are placed into the

01:04:02.690 --> 01:04:05.690
bone along the glenoid rim. These sutures are

01:04:05.690 --> 01:04:07.590
then passed through the torn labrum and the base

01:04:07.590 --> 01:04:10.050
of the biceps anchor and tied down securely,

01:04:10.550 --> 01:04:12.369
compressing the labrum back onto the prepared

01:04:12.369 --> 01:04:15.530
bone bed. Are there any nuances in how the repair

01:04:15.530 --> 01:04:19.210
is done? Yes, surgeons often prefer using multiple

01:04:19.210 --> 01:04:21.530
smaller anchors rather than fewer larger ones

01:04:21.530 --> 01:04:24.570
to create a broader area of fixation. They are

01:04:24.570 --> 01:04:26.510
also typically careful about anchor placement,

01:04:27.010 --> 01:04:29.070
particularly avoiding placing anchors too far

01:04:29.070 --> 01:04:32.110
anteriorly and superiorly as this could potentially

01:04:32.110 --> 01:04:34.650
over -constrained the biceps tendon or alter

01:04:34.650 --> 01:04:37.269
its normal excursion, leading to post -operative

01:04:37.269 --> 01:04:39.940
stiffness or pain. And critically, if there are

01:04:39.940 --> 01:04:41.900
any other associated injuries found during the

01:04:41.900 --> 01:04:43.940
arthroscopy, like other labelled tears elsewhere

01:04:43.940 --> 01:04:46.179
around the rim or concurrent rotator cuff tears,

01:04:46.639 --> 01:04:48.619
those are usually repaired during the same surgical

01:04:48.619 --> 01:04:52.059
procedure. Is repair always the answer for SLAP

01:04:52.059 --> 01:04:54.780
tears? What about that biceps tenodesis you mentioned?

01:04:55.019 --> 01:04:57.800
biceps tenodesis, which involves detaching the

01:04:57.800 --> 01:04:59.980
long head of the biceps tendon from its origin

01:04:59.980 --> 01:05:03.019
on the superior labrum and reattaching it surgically

01:05:03.019 --> 01:05:05.659
to the humerus bone lower down, outside the joint

01:05:05.659 --> 01:05:08.099
is presented as a viable alternative option in

01:05:08.099 --> 01:05:10.440
certain situations. It might be considered for

01:05:10.440 --> 01:05:13.480
failed SLAP repairs, for SLAP tears that extend

01:05:13.480 --> 01:05:15.699
significantly into the biceps tendon itself,

01:05:16.119 --> 01:05:18.639
classified as type 40 tears, or often in older

01:05:18.639 --> 01:05:21.380
athletes, say over 40, where the SLAP tear might

01:05:21.380 --> 01:05:23.800
be more degenerative in nature and the primary

01:05:23.800 --> 01:05:26.019
pain generator might be the biceps tendon itself

01:05:26.019 --> 01:05:28.019
rather than just the labral instability. Okay.

01:05:28.260 --> 01:05:30.199
And for contact athletes with both instability

01:05:30.199 --> 01:05:33.260
and a SLAP tear. For contact athletes presenting

01:05:33.260 --> 01:05:35.480
specifically with anterior shoulder instability

01:05:35.480 --> 01:05:39.019
and a concomitant SLAP tear, some experts mentioned

01:05:39.019 --> 01:05:41.260
in the sources advocate for earlier arthroscopic

01:05:41.260 --> 01:05:44.039
intervention to repair both the anterior labrum,

01:05:44.300 --> 01:05:47.400
bank cart lesion, and the SLAP lesion simultaneously,

01:05:47.980 --> 01:05:49.940
along with addressing any other associated injuries

01:05:49.940 --> 01:05:52.579
found, aiming for a quicker and more stable return

01:05:52.579 --> 01:05:55.519
to their high -demand sport. Makes sense. Now,

01:05:55.519 --> 01:05:57.699
how about the surgical approaches for shoulder

01:05:57.699 --> 01:06:00.269
instability itself? Especially when there's that

01:06:00.269 --> 01:06:03.030
significant bone loss we talked about. A simple

01:06:03.030 --> 01:06:05.510
bankart repair isn't always enough, then. That's

01:06:05.510 --> 01:06:08.130
correct. For anterior shoulder instability, that

01:06:08.130 --> 01:06:11.090
is primarily due to soft tissue damage, a tear

01:06:11.090 --> 01:06:13.130
of the anterior labrum and stretching of the

01:06:13.130 --> 01:06:15.989
capsule, a bankart lesion, and where there is

01:06:15.989 --> 01:06:18.429
minimal or no significant glenoid bone loss,

01:06:18.650 --> 01:06:21.690
generally considered less than 20 -25%. A standard

01:06:21.690 --> 01:06:23.869
arthroscopic bank heart repair is often the procedure

01:06:23.869 --> 01:06:26.449
of choice. This involves using suture anchors,

01:06:26.570 --> 01:06:29.630
similar to SLAP repair, to reattach the torn

01:06:29.630 --> 01:06:31.590
labrum and tighten the stretched anterior capsule

01:06:31.590 --> 01:06:34.389
back to the front rim of the glenoid. But when

01:06:34.389 --> 01:06:36.429
there is significant bone loss? When there is

01:06:36.429 --> 01:06:40.389
significant glenoid bone loss, more than 20 -25%.

01:06:40.389 --> 01:06:42.789
Or a large, engaging hill sacs lesion on the

01:06:42.789 --> 01:06:45.489
humeral head, performing just a soft tissue percent.

01:06:46.119 --> 01:06:48.860
Bancart repair alone has been shown to have a

01:06:48.860 --> 01:06:51.860
very high failure rate, with recurrent dislocations

01:06:51.860 --> 01:06:54.679
being common, particularly in young active athletes

01:06:54.679 --> 01:06:57.659
playing contact or collision sports. In these

01:06:57.659 --> 01:07:00.239
situations, osseous reconstruction procedures,

01:07:00.900 --> 01:07:02.639
surgeries that address the bone deficiency are

01:07:02.639 --> 01:07:05.059
often necessary to restore stability. What kind

01:07:05.059 --> 01:07:07.460
of procedures? The latarjet procedure is perhaps

01:07:07.460 --> 01:07:09.559
the most well -known and commonly performed for

01:07:09.559 --> 01:07:12.599
significant anterior glenoid bone loss. It involves

01:07:12.599 --> 01:07:14.599
surgically transferring the coracoid process,

01:07:14.820 --> 01:07:17.000
which is a bony projection from the front of

01:07:17.000 --> 01:07:18.800
the scapula that has strong muscles attached

01:07:18.800 --> 01:07:21.460
to it and fixing it onto the deficient anterior

01:07:21.460 --> 01:07:24.570
glenoid rim. This does two things. It creates

01:07:24.570 --> 01:07:26.750
a bony buttress that physically blocks the humeral

01:07:26.750 --> 01:07:29.190
head from dislocating forward. And the transferred

01:07:29.190 --> 01:07:31.789
muscles also provide a dynamic sling effect when

01:07:31.789 --> 01:07:34.329
the arm is abducted and externally rotated, further

01:07:34.329 --> 01:07:37.110
enhancing stability. Okay, the Letarjet for glenoid

01:07:37.110 --> 01:07:39.389
bone loss. What about the Hill -Sachs lesion

01:07:39.389 --> 01:07:42.139
on the humeral head? For large hill -sax lesions

01:07:42.139 --> 01:07:44.179
that are deemed to be engaging but maybe occur

01:07:44.179 --> 01:07:46.380
in the setting of less severe glenoid bone loss,

01:07:46.880 --> 01:07:49.420
a procedure called Rimpel -Sage might be performed,

01:07:49.739 --> 01:07:52.039
often in conjunction with an arthroscopic bankart

01:07:52.039 --> 01:07:55.199
repair. Rimpel -Sage involves arthroscopically

01:07:55.199 --> 01:07:58.079
suturing the posterior rotator cuff tendon, infus

01:07:58.079 --> 01:08:00.840
minatus, and the posterior capsule into the hill

01:08:00.840 --> 01:08:02.840
-sax dinafect on the back of the humeral head.

01:08:03.519 --> 01:08:05.519
This effectively fills the defect and prevents

01:08:05.519 --> 01:08:07.900
it from catching or engaging on the front edge

01:08:07.900 --> 01:08:10.590
of the glenoid during external rotation. For

01:08:10.590 --> 01:08:12.949
cases with severe bone loss on both the glenoid

01:08:12.949 --> 01:08:15.510
and humeral head, more complex bone grafting

01:08:15.510 --> 01:08:18.149
procedures using bone taken from the patient's

01:08:18.149 --> 01:08:20.689
iliac crest, hip bone, or allograft donor bone

01:08:20.689 --> 01:08:23.470
might be required. These osseous reconstructions

01:08:23.470 --> 01:08:26.109
generally require a different, often more cautious

01:08:26.109 --> 01:08:28.430
rehabilitation approach compared to simple soft

01:08:28.430 --> 01:08:30.789
tissue repairs. Okay. And quickly, what about

01:08:30.789 --> 01:08:33.630
surgery for severe GRD or DCO if conservative

01:08:33.630 --> 01:08:36.489
treatment fails? Yes. For significant GRD that

01:08:36.489 --> 01:08:39.189
remain symptomatic and restrictive despite dedicated

01:08:39.189 --> 01:08:42.390
stretching and physical therapy, a surgical posterior

01:08:42.390 --> 01:08:44.909
capsular release can be performed arthroscopically.

01:08:45.729 --> 01:08:47.550
This involves carefully cutting or releasing

01:08:47.550 --> 01:08:50.270
the thickened posterior capsule to restore more

01:08:50.270 --> 01:08:53.689
normal internal rotation range of motion. Studies

01:08:53.689 --> 01:08:56.189
cited have recorded significant increases in

01:08:56.189 --> 01:08:58.430
internal rotation gained after this procedure.

01:08:59.130 --> 01:09:02.439
And for distal clavicular osteolysis, at DCO,

01:09:02.739 --> 01:09:04.680
that continues to be painful and limit function

01:09:04.680 --> 01:09:07.159
despite rest, activity modification, and other

01:09:07.159 --> 01:09:09.479
conservative measures, surgical resection of

01:09:09.479 --> 01:09:11.779
the very distal end of the clavicle, usually

01:09:11.779 --> 01:09:14.899
the outer 5 -10mm, is performed to remove the

01:09:14.899 --> 01:09:17.340
damaged inflamed bone and decompress the AC joint.

01:09:18.060 --> 01:09:19.979
An arthroscopic approach, often done through

01:09:19.979 --> 01:09:22.340
the subacromial space, is frequently pursued

01:09:22.340 --> 01:09:24.920
by surgeons for this, allowing for quicker recovery

01:09:24.920 --> 01:09:27.310
compared to an open approach. Alright, now shifting

01:09:27.310 --> 01:09:29.590
down to elbow surgery. What are the surgical

01:09:29.590 --> 01:09:32.130
options outlined for OCD of the capitellum, that

01:09:32.130 --> 01:09:34.390
bone and cartilage issue? Surgical treatment

01:09:34.390 --> 01:09:37.390
for OCD of the capitellum is really dependent

01:09:37.390 --> 01:09:40.329
on the stage of the lesion, particularly its

01:09:40.329 --> 01:09:42.609
stability and the condition of the overlying

01:09:42.609 --> 01:09:46.470
cartilage. For very early, stable lesions where

01:09:46.470 --> 01:09:49.390
the cartilage is intact, continued non -operative

01:09:49.390 --> 01:09:51.970
management might still be attempted, sometimes

01:09:51.970 --> 01:09:54.760
with adjuncts like lipis. low -intensity pulsed

01:09:54.760 --> 01:09:56.819
ultrasound, which some research mentioned in

01:09:56.819 --> 01:09:59.340
the sources suggests might potentially help shorten

01:09:59.340 --> 01:10:02.000
the natural healing or repair period, although

01:10:02.000 --> 01:10:04.159
evidence is limited. But if it's unstable or

01:10:04.159 --> 01:10:07.500
loose? For unstable lesions, or those with detached

01:10:07.500 --> 01:10:09.800
or loose fragments, or lesions that have failed

01:10:09.800 --> 01:10:12.380
to heal with non -operative care, surgery is

01:10:12.380 --> 01:10:15.899
usually necessary. Several options exist. Arthroscopic

01:10:15.899 --> 01:10:18.180
drilling or microfracture involves creating small

01:10:18.180 --> 01:10:20.340
holes in the underlying bone within the defect

01:10:20.340 --> 01:10:22.659
to stimulate bleeding and hopefully promote some

01:10:22.659 --> 01:10:24.640
fiber cartilage healing. However, the sources

01:10:24.640 --> 01:10:27.140
suggest this has limited indications, maybe only

01:10:27.140 --> 01:10:29.899
for very small, contained, early -stage lesions.

01:10:30.119 --> 01:10:32.279
What about filling the defect? Bone peg graphs

01:10:32.279 --> 01:10:35.100
are a technique described where small cylindrical

01:10:35.100 --> 01:10:38.229
plugs of bone often harvested arthroscopically

01:10:38.229 --> 01:10:40.550
or through a small incision from the patient's

01:10:40.550 --> 01:10:42.949
own olochranon process, the bony point at the

01:10:42.949 --> 01:10:45.489
back of the elbow, are used to fill the bony

01:10:45.489 --> 01:10:48.590
defect beneath the unstable cartilage lesion,

01:10:48.729 --> 01:10:51.250
providing structural support. The harvest site

01:10:51.250 --> 01:10:53.510
in the olochranon typically regenerates bone

01:10:53.510 --> 01:10:56.689
over time. Osteochondral mosaicplasty is another

01:10:56.689 --> 01:10:58.810
option, particularly for slightly larger defects,

01:10:59.229 --> 01:11:01.090
where plugs of healthy bone and its overlying

01:11:01.090 --> 01:11:03.470
cartilage are harvested from a less critical

01:11:03.470 --> 01:11:05.250
non -weight -bearing part of the patient's knee.

01:11:05.390 --> 01:11:07.949
or sometimes the elbow itself, and transplanted

01:11:07.949 --> 01:11:09.869
into the capitolar defect, like laying mosaic

01:11:09.869 --> 01:11:12.649
tiles. What if the lesion is really large? For

01:11:12.649 --> 01:11:15.829
large, extensive OCD lesions, especially if there's

01:11:15.829 --> 01:11:18.630
significant cartilage damage or perhaps early

01:11:18.630 --> 01:11:21.550
secondary osteoarthritis developing, more complex

01:11:21.550 --> 01:11:24.409
reconstructive procedures like costal osteochondral

01:11:24.409 --> 01:11:27.050
grafts might be considered. This involves harvesting

01:11:27.050 --> 01:11:29.770
a larger piece of cartilage and underlying bone

01:11:29.770 --> 01:11:31.970
from one of the patient's ribs and shaping it

01:11:31.970 --> 01:11:34.439
to fit the defect. The sources mention a case

01:11:34.439 --> 01:11:36.800
example where delayed treatment of a large OCD

01:11:36.800 --> 01:11:39.939
lesion led to significant osteoarthritis, highlighting

01:11:39.939 --> 01:11:41.859
the importance of timely intervention for better

01:11:41.859 --> 01:11:45.340
outcomes. Okay. And the famous Tommy John surgery

01:11:45.340 --> 01:11:47.680
for the UCL tear in the elbow, what does that

01:11:47.680 --> 01:11:50.199
involve? Right. Ulnar collateral ligament reconstruction,

01:11:50.420 --> 01:11:52.420
often called Tommy John surgery, is performed

01:11:52.420 --> 01:11:55.039
for athletes, most famously baseball pitchers,

01:11:55.239 --> 01:11:57.279
who have significant medial elbow instability

01:11:57.279 --> 01:11:59.979
due to a complete or high grade partial tear

01:11:59.979 --> 01:12:03.020
of the MUCL that has not responded adequately

01:12:03.020 --> 01:12:05.039
to non -operative management and prevents them

01:12:05.039 --> 01:12:07.399
from throwing effectively. The indication is

01:12:07.399 --> 01:12:10.199
usually based on clinical exam findings. laxity

01:12:10.199 --> 01:12:12.720
with valgus stress, especially between 45 -60

01:12:12.720 --> 01:12:16.020
degrees, and confirmed by imaging like MRA. How

01:12:16.020 --> 01:12:18.560
is the ligament reconstructed? The goal is to

01:12:18.560 --> 01:12:21.020
reconstruct the torn ligament using a tendon

01:12:21.020 --> 01:12:24.359
graft to replace it. The most commonly used graft

01:12:24.359 --> 01:12:27.720
source is the palmaris lungus tendon, a small

01:12:27.720 --> 01:12:30.119
tendon in the patient's own forearm, which is

01:12:30.119 --> 01:12:33.159
functionally redundant for most people. If that's

01:12:33.159 --> 01:12:35.699
not available or suitable, Other options include

01:12:35.699 --> 01:12:38.100
using a portion of a hamstring tendon from the

01:12:38.100 --> 01:12:40.960
leg, or sometimes using an allograft tendon from

01:12:40.960 --> 01:12:44.260
a cadaver donor, like the Achilles tendon. Various

01:12:44.260 --> 01:12:46.460
surgical techniques exist to secure the graft

01:12:46.460 --> 01:12:49.140
tendon across the medial elbow joint, drilling

01:12:49.140 --> 01:12:51.340
tunnels in the humerus and ulna bones in the

01:12:51.340 --> 01:12:53.699
location of the original UCL attachment points.

01:12:54.399 --> 01:12:56.180
Common techniques mentioned include the original

01:12:56.180 --> 01:12:58.449
job technique, often using a figure of eight

01:12:58.449 --> 01:13:01.130
graft passage, or newer techniques like the Dane

01:13:01.130 --> 01:13:03.489
TJ which use interference screws for fixation

01:13:03.489 --> 01:13:05.510
in the bone tunnels. What about the ulnar nerve

01:13:05.510 --> 01:13:07.550
which runs right near there? That's a critical

01:13:07.550 --> 01:13:10.329
consideration. The ulnar nerve runs in a groove

01:13:10.329 --> 01:13:12.949
just behind the medial epicondyle, very close

01:13:12.949 --> 01:13:16.609
to the UCL. Historically, the ulnar nerve was

01:13:16.609 --> 01:13:19.329
often routinely transposed. surgically moved

01:13:19.329 --> 01:13:22.210
to a different position, usually more anteriorly

01:13:22.210 --> 01:13:24.630
during Tommy John surgery, to prevent potential

01:13:24.630 --> 01:13:27.010
irritation or scarring around the nerve from

01:13:27.010 --> 01:13:30.329
the surgery itself. However, experts in the sources

01:13:30.329 --> 01:13:33.010
now generally recommend selective ulnar nerve

01:13:33.010 --> 01:13:35.970
transposition. This means the nerve is only moved

01:13:35.970 --> 01:13:38.069
if it was already symptomatic before surgery,

01:13:38.430 --> 01:13:40.949
if it shows signs of instability, subluxing out

01:13:40.949 --> 01:13:43.510
of its groove, or if it seems clearly at risk

01:13:43.510 --> 01:13:46.600
during the ligament reconstruction. This selective

01:13:46.600 --> 01:13:48.960
approach aims to avoid the potential complications

01:13:48.960 --> 01:13:51.880
associated with nerve transposition itself, such

01:13:51.880 --> 01:13:54.520
as neuropraxia, nerve bruising or temporary dysfunction,

01:13:54.960 --> 01:13:57.319
or persistent nerve symptoms. Okay. And for those

01:13:57.319 --> 01:13:59.359
unstable elbow dislocations after they've been

01:13:59.359 --> 01:14:01.600
reduced, what's the surgical approach? If the

01:14:01.600 --> 01:14:04.180
elbow remains significantly unstable, particularly

01:14:04.180 --> 01:14:07.640
in that 45 -60 degree flexion range, after closed

01:14:07.640 --> 01:14:10.140
reduction, surgical repair of the disrupted ligaments

01:14:10.140 --> 01:14:13.210
is usually indicated. In the common posterolateral

01:14:13.210 --> 01:14:15.710
dislocation pattern, the lateral -collateral

01:14:15.710 --> 01:14:18.649
ligament, LCL complex, is often the primary structure

01:14:18.649 --> 01:14:21.250
injured and requires repair back to its attachment

01:14:21.250 --> 01:14:23.390
on the humerus to restore stability against gravity

01:14:23.390 --> 01:14:26.130
and prevent recurrent sublixation. The medial

01:14:26.130 --> 01:14:28.770
-collateral ligament, MUCL, may also be injured

01:14:28.770 --> 01:14:31.289
and require repair, especially if there is significant

01:14:31.289 --> 01:14:34.210
valgus instability as well. The goal of surgical

01:14:34.210 --> 01:14:36.149
repair is to restore enough static stability

01:14:36.149 --> 01:14:38.569
to allow for early controlled range of motion

01:14:38.569 --> 01:14:41.239
exercises to begin shortly after surgery. Why

01:14:41.239 --> 01:14:43.720
is early motion so important? Because the elbow

01:14:43.720 --> 01:14:46.239
joint is notoriously prone to developing severe

01:14:46.239 --> 01:14:48.739
stiffness and contracture if it's immobilized

01:14:48.739 --> 01:14:51.439
for too long after an injury or surgery. Achieving

01:14:51.439 --> 01:14:53.979
stability that permits early motion is absolutely

01:14:53.979 --> 01:14:56.479
critical for preventing long -term functional

01:14:56.479 --> 01:14:59.380
deficits. In rare cases of severe instability

01:14:59.380 --> 01:15:01.880
where even ligament repair doesn't provide adequate

01:15:01.880 --> 01:15:04.739
stability, temporary external fixation using

01:15:04.739 --> 01:15:07.399
a frame outside the arm connected by pins drilled

01:15:07.399 --> 01:15:09.779
into the humerus and ulna might be used for a

01:15:09.779 --> 01:15:12.020
few weeks to hold the joint in a reduced position

01:15:12.020 --> 01:15:14.300
while the soft tissues begin to heal, allowing

01:15:14.300 --> 01:15:16.319
for some controlled motion through the fixator

01:15:16.319 --> 01:15:19.319
hinge if possible. And finally, surgery for VEO

01:15:19.319 --> 01:15:21.600
syndrome, those bone spurs causing impingement.

01:15:21.899 --> 01:15:24.039
Surgical treatment for symptomatic valgus extension

01:15:24.039 --> 01:15:26.539
overload syndrome typically involves arthroscopic

01:15:26.539 --> 01:15:29.609
debridement. The surgeon uses minimally invasive

01:15:29.609 --> 01:15:31.689
techniques to go into the back of the elbow joint

01:15:31.689 --> 01:15:34.489
and remove the problematic osteophytes, bone

01:15:34.489 --> 01:15:37.489
spurs, from the post remedial aspect of the olacranon

01:15:37.489 --> 01:15:40.170
process and also remove any loose bodies within

01:15:40.170 --> 01:15:42.130
the joint that might be causing mechanical symptoms

01:15:42.130 --> 01:15:44.850
like clicking or locking. The goal is to relieve

01:15:44.850 --> 01:15:47.970
the impingement. Importantly, if the chronic

01:15:47.970 --> 01:15:50.609
valgus stress that led to the VEO has also resulted

01:15:50.609 --> 01:15:53.550
in a significant symptomatic tear or insufficiency

01:15:53.550 --> 01:15:56.590
of the MUCL, then UCL reconstruction is often

01:15:56.590 --> 01:15:58.850
performed at the same time as the spur removal

01:15:58.850 --> 01:16:01.189
to address the underlying instability component

01:16:01.189 --> 01:16:03.930
as well. Okay, so that covers the main surgical

01:16:03.930 --> 01:16:06.210
options. Now, whether an athlete has had surgery

01:16:06.210 --> 01:16:08.630
or has been managed non -operatively, the recovery

01:16:08.630 --> 01:16:10.609
process, the rehabilitation phase seems like

01:16:10.609 --> 01:16:12.710
it's absolutely crucial for getting back to sport.

01:16:13.050 --> 01:16:15.600
It cannot be stressed enough. Rehabilitation

01:16:15.600 --> 01:16:17.760
is not just some passive part of the treatment.

01:16:18.300 --> 01:16:20.739
It is arguably the most critical phase for determining

01:16:20.739 --> 01:16:23.859
the ultimate success of the intervention. Experts

01:16:23.859 --> 01:16:26.699
in the sources consistently highlight that athlete

01:16:26.699 --> 01:16:29.220
noncompliance with the prescribed rehab program

01:16:29.220 --> 01:16:32.479
or trying to rush the process is a major risk

01:16:32.479 --> 01:16:35.640
factor for failure, re -injury, or a suboptimal

01:16:35.640 --> 01:16:38.079
outcome, regardless of whether the initial treatment

01:16:38.079 --> 01:16:40.960
was surgical or non -surgical. What are the general

01:16:40.960 --> 01:16:43.979
principles guiding that rehab process? It must

01:16:43.979 --> 01:16:47.020
be carefully structured. Yes. Rehabilitation

01:16:47.020 --> 01:16:49.640
almost always follows a structured, phased approach,

01:16:50.060 --> 01:16:52.460
with progression based on meeting specific criteria

01:16:52.460 --> 01:16:55.300
related to healing time, pain levels, range of

01:16:55.300 --> 01:16:57.880
motion, strength, and functionability, rather

01:16:57.880 --> 01:16:59.760
than just following a strict calendar timeline.

01:17:00.079 --> 01:17:02.340
Typically, it's divided into phases like the

01:17:02.340 --> 01:17:05.119
acute early protection phase, the intermediate

01:17:05.119 --> 01:17:06.979
strengthening and neuromuscular control phase,

01:17:07.260 --> 01:17:09.659
and the advanced or return to play phase. What

01:17:09.659 --> 01:17:12.300
happens in that early acute phase? The primary

01:17:12.300 --> 01:17:14.760
goals in the acute phase are to protect the injured

01:17:14.760 --> 01:17:17.399
or surgically repaired structures, control pain

01:17:17.399 --> 01:17:19.840
and swelling using things like ice compression

01:17:19.840 --> 01:17:22.960
elevation, and initiate gentle controlled range

01:17:22.960 --> 01:17:25.659
of motion exercises to prevent stiffness and

01:17:25.659 --> 01:17:28.529
maintain joint health. Early range of motion

01:17:28.529 --> 01:17:30.569
is particularly critical for the elbow after

01:17:30.569 --> 01:17:33.170
dislocation or surgery to try and prevent the

01:17:33.170 --> 01:17:35.909
development of debilitating stiffness. Slings

01:17:35.909 --> 01:17:37.729
are commonly used for support and protection

01:17:37.729 --> 01:17:40.289
after shoulder injuries or surgery. Sometimes

01:17:40.289 --> 01:17:42.670
specific types like external rotation slings

01:17:42.670 --> 01:17:45.050
are used after certain rotator cuff or instability

01:17:45.050 --> 01:17:48.600
repairs to offload the repaired tissues. Hinged

01:17:48.600 --> 01:17:50.659
elbow braces are frequently used after elbow

01:17:50.659 --> 01:17:53.840
surgery, like UCL reconstruction, or complex

01:17:53.840 --> 01:17:55.939
dislocations to allow controlled motion within

01:17:55.939 --> 01:17:58.340
a safe range while protecting the healing ligaments.

01:17:58.670 --> 01:18:00.829
What kind of exercises are typically involved

01:18:00.829 --> 01:18:03.050
in these different phases? In the acute phase,

01:18:03.489 --> 01:18:05.689
basic exercises might include simple passive

01:18:05.689 --> 01:18:08.329
pendulum swings for the shoulder to encourage

01:18:08.329 --> 01:18:10.390
joint fluid movement without muscle activation,

01:18:11.270 --> 01:18:13.529
gentle passive or active assisted range of motion

01:18:13.529 --> 01:18:16.369
exercises within protected limits, and maybe

01:18:16.369 --> 01:18:18.869
isometric exercises, muscle contractions without

01:18:18.869 --> 01:18:21.380
joint movement. Specific stretching techniques

01:18:21.380 --> 01:18:24.319
might be introduced early on to regain lost motion

01:18:24.319 --> 01:18:27.180
or address identified tightness, like those sleeper

01:18:27.180 --> 01:18:29.180
stretches or internal rotation stretches for

01:18:29.180 --> 01:18:31.039
posterior capsule tightness in the shoulder.

01:18:31.119 --> 01:18:33.380
And as they progress. As the athlete progresses

01:18:33.380 --> 01:18:36.180
to the intermediate phase, the focus shifts towards

01:18:36.180 --> 01:18:38.979
gradually restoring full range of motion and

01:18:38.979 --> 01:18:41.789
initiating strengthening exercises. This usually

01:18:41.789 --> 01:18:44.529
starts with low resistance using elastic bands

01:18:44.529 --> 01:18:46.770
or light pulleys, targeting the rotator cuff

01:18:46.770 --> 01:18:50.350
muscles, internal external rotation, abduction,

01:18:50.770 --> 01:18:54.109
the deltoid, and critically, the scapular stabilizing

01:18:54.109 --> 01:18:57.189
muscles, exercises like rows, protraction, retraction.

01:18:57.500 --> 01:19:00.079
More advanced strengthening in the later intermediate

01:19:00.079 --> 01:19:02.500
and advanced phases involves progressively increasing

01:19:02.500 --> 01:19:05.520
resistance and complexity, incorporating exercises

01:19:05.520 --> 01:19:09.020
like seated cable rows, various push -up progressions,

01:19:09.220 --> 01:19:11.739
starting against a wall, then incline, then floor,

01:19:12.119 --> 01:19:14.500
dumbbell exercises like flies or presses carefully

01:19:14.500 --> 01:19:17.020
introduced, and more challenging tubing or cable

01:19:17.020 --> 01:19:19.119
exercises targeting different muscle groups and

01:19:19.119 --> 01:19:20.979
movement patterns. What about the rest of the

01:19:20.979 --> 01:19:24.560
body? Crucially, Throughout all phases, rehabilitation

01:19:24.560 --> 01:19:26.760
should incorporate core strengthening exercises

01:19:26.760 --> 01:19:30.199
and lower body exercises like squats, lunges,

01:19:30.520 --> 01:19:33.220
and gluteus activation exercises. Remembering

01:19:33.220 --> 01:19:35.520
that kinetic chain concepts, a strong and stable

01:19:35.520 --> 01:19:37.699
core and lower body are essential for efficient

01:19:37.699 --> 01:19:40.140
energy transfer and reducing stress on the throwing

01:19:40.140 --> 01:19:43.699
arm. Addressing specific muscle imbalances identified

01:19:43.699 --> 01:19:45.779
during the assessment, like tightness in the

01:19:45.779 --> 01:19:47.800
pectoralis minor muscle, which can pull the scapula

01:19:47.800 --> 01:19:49.439
forward and contribute to altered mechanics,

01:19:49.939 --> 01:19:52.220
is also an important part of comprehensive rehab.

01:19:52.659 --> 01:19:54.600
And specifically for the throwing athlete who

01:19:54.600 --> 01:19:56.420
wants to get back on the mound or the tennis

01:19:56.420 --> 01:19:59.300
court or into the pool, the rehab must become

01:19:59.300 --> 01:20:02.140
very sport -specific towards the end. Absolutely.

01:20:02.380 --> 01:20:05.340
The final phases of rehabilitation must become

01:20:05.340 --> 01:20:08.180
progressively more sports specific to prepare

01:20:08.180 --> 01:20:11.079
the athlete for the unique demands of their activity.

01:20:11.920 --> 01:20:14.079
Key principles reiterated by the experts for

01:20:14.079 --> 01:20:16.739
throwing athletes include maintaining the necessary

01:20:16.739 --> 01:20:18.880
functional range of motion, which might even

01:20:18.880 --> 01:20:21.819
include preserving some of that adapted GRD pattern,

01:20:22.260 --> 01:20:24.859
increased ER, decreased IR, seen in their dominant

01:20:24.859 --> 01:20:27.619
arm, as long as the total arc of motion is symmetrical

01:20:27.619 --> 01:20:29.800
to the non -dominant side and they have good

01:20:29.800 --> 01:20:32.869
control. ensuring excellent muscle balance, strength

01:20:32.869 --> 01:20:34.729
and endurance throughout the entire kinetic chain

01:20:34.729 --> 01:20:37.569
is paramount. At achieving high levels of neuromuscular

01:20:37.569 --> 01:20:40.329
control and proprioception, the joint sense of

01:20:40.329 --> 01:20:42.750
position is critical for coordinated efficient

01:20:42.750 --> 01:20:44.909
movement. What does that look like in terms of

01:20:44.909 --> 01:20:47.670
exercises? The intermediate phase often involves

01:20:47.670 --> 01:20:50.149
building strength and power through both open

01:20:50.149 --> 01:20:53.670
chain hand -foot free and closed chain hand -foot

01:20:53.670 --> 01:20:56.329
fixed exercises and starting to introduce basic

01:20:56.329 --> 01:20:59.149
plyometric exercises like medicine ball throws,

01:20:59.430 --> 01:21:02.369
rebounder work, to retrain explosive power and

01:21:02.369 --> 01:21:05.159
reactive muscle firing. The advanced phase is

01:21:05.159 --> 01:21:07.119
where the athlete truly prepares for a return

01:21:07.119 --> 01:21:09.479
to their sport. This involves progressing from

01:21:09.479 --> 01:21:11.760
light activity to increasingly intense sport

01:21:11.760 --> 01:21:14.659
-specific drills, like initiating an interval

01:21:14.659 --> 01:21:17.300
throwing program for baseball players or specific

01:21:17.300 --> 01:21:19.560
stroke drills for swimmers. And scapula control

01:21:19.560 --> 01:21:22.739
remains important throughout. Yes. Experts emphasize

01:21:22.739 --> 01:21:25.380
that optimizing scapular control and ensuring

01:21:25.380 --> 01:21:27.920
proper scapulohumeral rhythm, the coordinated

01:21:27.920 --> 01:21:30.279
movement of the scapula and humerus, should be

01:21:30.279 --> 01:21:32.260
a key determinant for deciding when an athlete

01:21:32.260 --> 01:21:35.000
is ready and safe to begin a return to play throwing

01:21:35.000 --> 01:21:38.399
or overhead activity program. The goals for clearing

01:21:38.399 --> 01:21:40.680
an athlete to return to sport typically include

01:21:40.680 --> 01:21:44.000
achieving full pain -free range of motion, demonstrating

01:21:44.000 --> 01:21:45.819
strength and endurance that's close to their

01:21:45.819 --> 01:21:48.939
baseline, or the uninjured side. often measured

01:21:48.939 --> 01:21:52.000
ithokinetically, having static stability on clinical

01:21:52.000 --> 01:21:54.739
testing, and exhibiting smooth, well -controlled

01:21:54.739 --> 01:21:56.640
movement patterns during functional activities

01:21:56.640 --> 01:22:00.020
and sport -specific movements. OK. So after going

01:22:00.020 --> 01:22:02.520
through potentially months of this entire process

01:22:02.520 --> 01:22:04.779
diagnosis, maybe surgery, definitely lengthy

01:22:04.779 --> 01:22:07.149
rehab, The ultimate question for the athlete

01:22:07.149 --> 01:22:09.409
is, when can I actually get back to competing?

01:22:09.590 --> 01:22:11.689
And maybe more importantly, what are the chances

01:22:11.689 --> 01:22:13.890
of me returning to the same level I was at before

01:22:13.890 --> 01:22:16.050
the injury? Yeah, that's a million dollar question

01:22:16.050 --> 01:22:18.390
for every injured athlete. And the answer is

01:22:18.390 --> 01:22:20.909
that return to play timelines vary significantly

01:22:20.909 --> 01:22:23.630
based on a lot of factors. The specific injury,

01:22:24.090 --> 01:22:26.170
the type of treatment they had, surgical versus

01:22:26.170 --> 01:22:28.909
non -surgical and which specific procedure, the

01:22:28.909 --> 01:22:30.970
demands of their particular sport, their level

01:22:30.970 --> 01:22:33.270
of competition, professional versus recreational,

01:22:33.930 --> 01:22:36.779
and individual factors like age, adherence to

01:22:36.779 --> 01:22:40.039
rehab, and biological healing response. It's

01:22:40.039 --> 01:22:42.720
rarely a quick process, particularly after major

01:22:42.720 --> 01:22:44.720
surgery for significant structural injuries.

01:22:45.279 --> 01:22:47.319
Are there some typical timelines mentioned in

01:22:47.319 --> 01:22:49.340
the sources for common procedures that give us

01:22:49.340 --> 01:22:52.260
a ballpark idea? Yes, they do provide some examples,

01:22:52.260 --> 01:22:54.239
but these should be seen as general guidelines.

01:22:54.939 --> 01:22:58.140
For instance, after a SLAP repair surgery, return

01:22:58.140 --> 01:23:00.340
to contact sports might be possible around the

01:23:00.340 --> 01:23:02.760
three month mark. But for repetitive overhead

01:23:02.760 --> 01:23:04.880
athletes like pitchers or swimmers, returning

01:23:04.880 --> 01:23:07.199
to full sport activity typically takes much longer,

01:23:07.399 --> 01:23:10.239
often cited as being over six months. And the

01:23:10.239 --> 01:23:12.159
sources note that patient satisfaction rates

01:23:12.159 --> 01:23:15.340
after SLAP repair can sometimes be lower for

01:23:15.340 --> 01:23:17.939
chronic tears compared to acute traumatic tears.

01:23:18.180 --> 01:23:20.420
What about rotator cuff repairs? For rotator

01:23:20.420 --> 01:23:23.260
cuff repairs, especially in elite athletes like

01:23:23.260 --> 01:23:25.739
professional baseball pitchers, the outlook can

01:23:25.739 --> 01:23:28.899
be more guarded. Experts point out that reported

01:23:28.899 --> 01:23:31.060
return to play rates back to their pre -injury

01:23:31.060 --> 01:23:33.260
elite performance level have historically been

01:23:33.260 --> 01:23:35.699
somewhat poor, although surgical techniques and

01:23:35.699 --> 01:23:39.220
rehab protocols are continually improving. Osseous

01:23:39.220 --> 01:23:41.619
shoulder reconstructions, like the latarget for

01:23:41.619 --> 01:23:44.220
bone loss, might allow a return to some activities

01:23:44.220 --> 01:23:47.159
around 2 -3 months, but returning fully to contact

01:23:47.159 --> 01:23:49.500
sports likely takes longer. maybe six months

01:23:49.500 --> 01:23:52.460
or more. Similarly, posterior shoulder instability

01:23:52.460 --> 01:23:54.659
repair aiming for return -to -contact sports

01:23:54.659 --> 01:23:56.960
is often targeted around the six -month mark.

01:23:58.680 --> 01:24:00.979
Limited surgical resection for distal clavicular

01:24:00.979 --> 01:24:04.000
osteolysis is one of the procedures with a potentially

01:24:04.000 --> 01:24:06.699
faster return, with athletes possibly resuming

01:24:06.699 --> 01:24:08.920
training within just one to two weeks if symptoms

01:24:08.920 --> 01:24:12.659
allow. UCL reconstruction, the Tommy John surgery,

01:24:12.739 --> 01:24:14.739
generally reports high rates of return to play

01:24:14.739 --> 01:24:18.039
overall, but the time frame is notoriously lengthy,

01:24:18.380 --> 01:24:20.539
often taking 12 months or even longer for pitchers

01:24:20.539 --> 01:24:23.300
to get back to competitive pitching. Arthroscopic

01:24:23.300 --> 01:24:25.579
treatment of VEO syndrome, removing those bone

01:24:25.579 --> 01:24:28.479
spurs, also shows generally satisfactory results

01:24:28.479 --> 01:24:30.279
in high return rates mentioned in the sources,

01:24:30.500 --> 01:24:33.439
perhaps around 4 -6 months on average. Are there

01:24:33.439 --> 01:24:35.420
factors that help predict who will do better

01:24:35.420 --> 01:24:37.800
or worse in terms of returning to play? Yes.

01:24:38.029 --> 01:24:41.609
Some prognostic factors are mentioned. For SLIP

01:24:41.609 --> 01:24:44.430
tears, having other simultaneous injuries identified

01:24:44.430 --> 01:24:47.170
during surgery, like a concurrent rotator cuff

01:24:47.170 --> 01:24:50.270
tear or additional labral damage elsewhere, are

01:24:50.270 --> 01:24:52.829
generally considered negative prognostic factors

01:24:52.829 --> 01:24:55.430
associated with potentially less successful outcomes

01:24:55.430 --> 01:24:58.399
or a more difficult return. For anterior shoulder

01:24:58.399 --> 01:25:00.760
instability treated with a standard bankart repair,

01:25:01.380 --> 01:25:03.600
that ISA score we discussed earlier is a valuable

01:25:03.600 --> 01:25:05.779
tool for predicting the risk of redislocation,

01:25:06.000 --> 01:25:07.920
which obviously impacts the ability to return

01:25:07.920 --> 01:25:11.279
safely to high -risk activities. A higher ISA

01:25:11.279 --> 01:25:13.380
score predicts a higher chance of failure and

01:25:13.380 --> 01:25:15.579
may influence the initial surgical choice or

01:25:15.579 --> 01:25:18.300
counseling about return to sport. It sounds like

01:25:18.300 --> 01:25:20.020
while the science on the surgical techniques

01:25:20.020 --> 01:25:22.239
and the rehab protocols are incredibly advanced,

01:25:22.699 --> 01:25:25.000
the road back to peak elite performance can still

01:25:25.000 --> 01:25:27.140
be a really significant challenge for some athletes,

01:25:27.500 --> 01:25:29.079
depending on the specific injury and the demands

01:25:29.079 --> 01:25:32.239
of their sport. It absolutely can be. Managing

01:25:32.239 --> 01:25:34.659
the cumulative effects of chronic microtrauma

01:25:34.659 --> 01:25:37.380
versus a single acute injury, dealing with the

01:25:37.380 --> 01:25:39.279
complexities of certain surgical procedures,

01:25:39.859 --> 01:25:42.319
and avoiding potential complications like...

01:25:42.029 --> 01:25:44.449
nerve issues after some elbow surgeries, or stiffness,

01:25:44.989 --> 01:25:46.869
or hardware problems after certain shoulder bone

01:25:46.869 --> 01:25:50.010
procedures, and simply regaining the highly fine

01:25:50.010 --> 01:25:53.069
-tuned neuromuscular control, confidence, and

01:25:53.069 --> 01:25:56.149
power required at the elite level after a major

01:25:56.149 --> 01:25:59.029
structural injury are all ongoing challenges

01:25:59.029 --> 01:26:01.729
in sports medicine. It's not always straightforward.

01:26:02.140 --> 01:26:04.760
This deep dive has really highlighted the incredible,

01:26:04.880 --> 01:26:06.760
almost violent demands placed on the shoulder

01:26:06.760 --> 01:26:09.260
and elbow in overhead sports, showing us exactly

01:26:09.260 --> 01:26:11.939
why these specific and often complex injury patterns

01:26:11.939 --> 01:26:14.279
occur. We've navigated through the diverse ways

01:26:14.279 --> 01:26:16.819
these injuries are diagnosed, explored the wide

01:26:16.819 --> 01:26:18.779
range of non -operative and surgical treatment

01:26:18.779 --> 01:26:21.340
strategies available, and underscored the absolutely

01:26:21.340 --> 01:26:24.020
non -negotiable importance of a dedicated, structured,

01:26:24.579 --> 01:26:27.140
and highly tailored rehabilitation program to

01:26:27.140 --> 01:26:28.859
even have a chance at successfully getting back

01:26:28.859 --> 01:26:31.420
on the field. court or in the pool. It really

01:26:31.420 --> 01:26:34.359
gives you a profound appreciation for the remarkable

01:26:34.359 --> 01:26:37.520
engineering of the human body, capable of generating

01:26:37.520 --> 01:26:40.560
such forces and velocities, but also its inherent

01:26:40.560 --> 01:26:43.840
limitations when pushed consistently to its absolute

01:26:43.840 --> 01:26:46.779
physical edges. And it highlights the constant

01:26:46.779 --> 01:26:48.619
evolution of the science and medicine dedicated

01:26:48.619 --> 01:26:50.960
to understanding these limits, helping athletes

01:26:50.960 --> 01:26:54.119
recover, and hopefully finding better ways to

01:26:54.119 --> 01:26:55.539
prevent these injuries from happening in the

01:26:55.539 --> 01:26:58.109
first place. And thinking about the sheer magnitude

01:26:58.109 --> 01:27:00.949
of those forces, the way chronic microtrauma

01:27:00.949 --> 01:27:03.710
seems to inevitably build up over time in many

01:27:03.710 --> 01:27:06.369
athletes, the way the body sometimes adapts in

01:27:06.369 --> 01:27:09.170
ways that seem helpful but actually become harmful,

01:27:09.670 --> 01:27:12.789
like GRD leading to peelback, and the fact that

01:27:12.789 --> 01:27:14.970
even with the very best treatment available today,

01:27:15.130 --> 01:27:17.270
returning to that pre -injury elite performance

01:27:17.270 --> 01:27:20.069
level isn't always a guarantee. It definitely

01:27:20.069 --> 01:27:21.909
leaves you with a provocative thought, doesn't

01:27:21.909 --> 01:27:24.699
it? It certainly makes you wonder. in this relentless

01:27:24.699 --> 01:27:28.079
pursuit of maximizing athletic performance pushing

01:27:28.079 --> 01:27:31.630
boundaries harder, faster, stronger. Are these

01:27:31.630 --> 01:27:34.029
kinds of debilitating joint injuries simply an

01:27:34.029 --> 01:27:36.989
inevitable trade -off, the unfortunate but accepted

01:27:36.989 --> 01:27:39.189
cost of competing at the highest levels in these

01:27:39.189 --> 01:27:41.789
overhead sports? Or is it possible that a truly

01:27:41.789 --> 01:27:44.569
perfected understanding of individual biomechanics,

01:27:44.729 --> 01:27:47.310
maybe combined with predictive analytics, personalized

01:27:47.310 --> 01:27:49.710
prevention strategies, and even more advanced

01:27:49.710 --> 01:27:52.270
biological treatments in the future could one

01:27:52.270 --> 01:27:54.949
day fundamentally shift that balance? Could we

01:27:54.949 --> 01:27:56.630
reach a point where athletes can achieve these

01:27:56.630 --> 01:27:58.989
incredible feats of power and precision without

01:27:58.989 --> 01:28:01.949
necessarily paying such a long -term physical

01:28:01.949 --> 01:28:04.909
toll on their shoulders and elbows. It's a fascinating

01:28:04.909 --> 01:28:06.869
and critical question for the future of sports

01:28:06.869 --> 01:28:08.829
and the long -term health of these dedicated

01:28:08.829 --> 01:28:09.310
athletes.