The Peter Attia Drive - #232 ‒ Shoulder, elbow, wrist, and hand： diagnosis, treatment, and surgery of the upper extremities ｜ Alton Barron, M.D.

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:41.760 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay,

00:00:47.780 here's today's episode. My guest this week is Alton Barron. Alton is a board certified fellowship

00:00:54.580 trained shoulder, elbow, and hand surgeon with clinical practices in both Austin and New York

00:00:59.780 City. He specializes in both routine and complex problems of the upper limb. Alton is also my

00:01:05.480 surgeon. Some of you may recall I had shoulder surgery in March of 2022, and I've kind of documented

00:01:12.360 that recovery process along the way and promised to do kind of a deep dive on the upper extremity.

00:01:19.120 In this episode, we focus our entire conversation on the upper limb, going from the elbow, the

00:01:24.660 shoulder, to the hand and the wrist, as well as the nerves located throughout that track. Now,

00:01:29.700 for each of these, Alton goes through the structure, the anatomy, the various things that may cause pain

00:01:34.440 and injury, and how and when to think about surgical interventions. In addition to our conversation

00:01:39.940 in the podcast, Alton runs through what a typical physical exam looks like for each patient. And this is

00:01:45.360 really important. In the field of orthopedics, certainly surgeons rely on imaging studies,

00:01:51.660 you know, the MRI of the elbow, the shoulder, whatever. But any good orthopedist I know has

00:01:57.520 always said the same thing, which is the exam and the symptoms matter usually more than what the image

00:02:03.400 shows. So in that sense, it's very important to understand those things. It's also something that

00:02:08.420 you can even do on yourself to kind of help understand if something you're feeling is indeed

00:02:13.420 problematic or maybe it's just going to get better over time. Due to the type of, you know, discussion

00:02:17.800 that we've had here and the exams that he does, this is probably going to be the one episode that

00:02:22.500 if you're not used to watching on video, you do watch on video. Also, given the length of the podcast,

00:02:28.720 I think it's like over four hours or in that ballpark. And to make it more digestible, we've broken it out

00:02:34.140 into some very specific videos, including and isolating the sections of the shoulder, the elbow,

00:02:39.520 hand wrist, and the innervation, as well as isolating the videos of just the various exams

00:02:44.560 that Alton does to demonstrate on me. Now, you can find all of these videos on the show notes page

00:02:50.040 or on our YouTube page. Now, lastly, one other thing that comes up in this interview, and it's

00:02:54.600 something that Alton is very passionate about, is a foundation that he started called the Musician

00:02:59.480 Treatment Foundation. This is a nonprofit that provides direct orthopedic shoulder surgery,

00:03:04.680 hand interventions, along with non-surgical care to uninsured and underinsured musicians.

00:03:09.760 This is something Alton is incredibly passionate about, as he is also a musician. You'll hear him

00:03:14.840 talk about the amazing work that he's done so far, where they want to go next, and basically how

00:03:19.520 they're putting funds to use. Specifically, the foundation has their big annual event in Austin

00:03:23.500 coming up on December 2nd. So if you're local to Austin, please check it out. And if you're not

00:03:28.260 local to Austin, which many of you probably aren't, please head over to their website, www.mtfusa.org,

00:03:37.140 where you can learn more about it and get involved if it's of interest to you.

00:03:40.520 So without further delay, please enjoy my conversation with Dr. Alton Barron.

00:03:50.340 Alton, so great to finally be sitting down with you. We talked about this even before you operated on

00:03:55.220 me, which is at the time of this recording, I think we're coming up on seven months. But this is a

00:03:59.440 topic that I can't tell you how many times I get asked about this by my patients. And I don't know,

00:04:04.900 in some ways, medicine is so siloed. You think, well, I did general surgery. Surely I know something

00:04:11.980 about orthopedics. But the reality of it is outside of trauma, and even in the most basic sense, I know

00:04:16.940 very little about orthopedics. And I think that's probably true for a lot of doctors, primary care and

00:04:22.020 otherwise. And then how much more is that true for patients? So it's a pretty broad and specialized

00:04:28.720 field at the same time, huh? Yeah, I think that's a great point. I mean, I always have told people

00:04:33.940 who've asked about medical school, well, don't you know all these things? And we only do a subset of

00:04:38.040 rotations. So I know nothing about urology. I know nothing about brain surgery. It just depends on kind

00:04:44.060 of the luck of the draw on what you get exposed to. And so I wholeheartedly agree. And then we just

00:04:49.800 narrow ourselves down like a funnel in terms of knowledge, because there's been such a knowledge

00:04:54.680 explosion for the last, really the last two decades, in terms of research, in terms of new science,

00:05:00.700 a lot of which you've talked about and do talk about routinely and know a lot more about than me.

00:05:05.140 But as it applies to orthopedics, even there are subsets of orthopedics, and then there are subsets

00:05:11.440 of shoulder surgery that involves just research versus just clinical practice. And all of that is just

00:05:17.840 an explosion of information. And, you know, my well-informed patients often ask me about things,

00:05:24.200 and I know hopefully a lot of it, but I don't know all of it. They sometimes find, because they're very

00:05:29.460 good now at looking at true scientific articles, and they approach it and approach me with new articles.

00:05:34.980 So I'm learning every week from my patients, actually, about shoulder surgery.

00:05:39.560 Now, when you went to med school, did you think you wanted to be an orthopedic surgeon?

00:05:42.300 I didn't know. I barely went to medical school. I just had a very circuitous path. But I was an

00:05:47.000 engineer at UT here in Austin.

00:05:49.800 I'm an engineer as well. I don't think I knew that. What kind of engineer were you?

00:05:52.460 I did mechanical and biomedical. And so I didn't know anything about it. My dad was an engineer,

00:05:57.560 and so I just went that way. At the end, I was a little edgy about going into industry. And so on a

00:06:06.200 last whim, because I had two uncles that were dentists, I went to dental school for a year.

00:06:10.420 And I actually didn't like that at all. But I loved the science, what was going on with the

00:06:16.080 biomaterials. Dentistry has been at the forefront of biomaterials. And so I left after a year,

00:06:21.360 but I was exposed to the entire anatomical body because the anatomy instructor for head and neck 0.71

00:06:28.360 was actually an MD, PhD. And she said, when I confided in her that I was leaving, she said,

00:06:34.040 you know, you ought to try medical school. And so then I went back, came back to Austin,

00:06:37.440 painted houses for a year, then applied to medical school and went. I still didn't know.

00:06:42.300 And so you go there, you don't know what you're going to do, not even if you're going to do surgery

00:06:45.420 or medicine. Right. I liked it all. I loved invasive cardiology, just all the aspects of the

00:06:51.640 physiology and the electricity really going on in our bodies. But then I was exposed to orthopedics,

00:06:57.880 fortunately. And it was like, I knew all this stuff. I didn't know it all, but it felt so natural,

00:07:02.960 putting things together, piecing them back together, the jigsaw puzzles. And it fell all

00:07:07.900 in perfect line with my engineering background. In the time when you went through orthopedics,

00:07:13.600 was it common for people to also do a fellowship after the five years of residency?

00:07:18.180 It was. I think at our time, we had a big, I went to Tulane. At that time, they had eight,

00:07:22.480 this was pre-Katrina. They had eight residents per year. So it was a big program. And at that time,

00:07:27.360 about four, we're going to general practice. So fellowships were not ubiquitous. Now they're almost

00:07:34.140 mandatory just because you need to have a, I wouldn't call it a gimmick, but you need to have

00:07:39.940 a special interest because the groups that you'd be applying to work for or the hospitals

00:07:44.620 kind of want you to have some subspecialty. That's the case in medicine. Even if you did

00:07:50.080 something like general surgery and didn't do a fellowship after like vascular plastics, cardiac,

00:07:55.000 et cetera, you'd be hard pressed to go even into the community and kind of do everything.

00:07:59.920 You'd probably tend to focus on one part of the body. Where did you do your fellowship? Obviously,

00:08:04.780 upper extremity. Yeah. So I did my shoulder fellowship at Columbia in New York. And then

00:08:09.300 I did my hand fellowship in New York at Roosevelt Hospital. Oh, two separate fellowships.

00:08:13.840 Two separate fellowships. Yeah. And most people didn't do that at the time, but I just really liked

00:08:19.380 both very much. It just evolved into that. I dabbled with spine during residency. And I think

00:08:27.820 the reason I evolved into wanting to do upper extremity is because there's nothing cookie

00:08:33.300 cutter about it. I'm not by any means demeaning any part of orthopedics, but for me, there were very

00:08:39.640 few jigs, cutting jigs, very few linear things that you had to just, there's so much variability

00:08:46.300 in the upper limb, both anatomy and also the specific pathology that you just have to be all

00:08:53.460 over the place. And it was more creative for me, frankly. What have been some of the big steps

00:08:58.960 forward? Let's go back to, so what year did you finish your training? I started practice in 96.

00:09:04.620 So at that time, what was the state of the art in terms of what was being done? So what, for example,

00:09:13.440 there was a day when, if you look at the surgery I had, that would have been done with a big open

00:09:17.840 incision. When did minimally invasive orthopedic surgery take over the joint space? It's crazy.

00:09:23.500 It's such a cool question. I'm glad you asked it because I don't get to speak about it very much,

00:09:28.020 but there was, knee arthroscopy was the first big arthroscopic realm to develop. And a fellow that

00:09:34.920 most of my younger residents don't even know now, Dick Kasperi, was hugely innovative in that space.

00:09:40.040 And so shoulder arthroscopy by the time I was in residency was primitive. We had the basic equipment

00:09:48.580 to get into the shoulder, but we couldn't do much. So by the time I graduated, all we were doing

00:09:54.040 arthroscopically, by the time I even finished my shoulder fellowship, we were doing open shoulder

00:10:00.120 arthroplasty. And I was at one of the meccas of shoulder surgery. So everything advanced was being

00:10:05.940 done there at the level that it could be done, but it was open shoulder arthroplasty, which is still

00:10:10.980 open, but smaller incisions. It was open instability repairs, open labral repairs, but we didn't even

00:10:18.000 appreciate what, for instance, the slap tear. We knew they existed, but we didn't know the impact.

00:10:24.380 And what we started seeing there was, and there were certainly no arthroscopic repairs of the labrum,

00:10:31.380 except these early, early devices where you'd kind of get in there, see it, and you just mallet in,

00:10:38.240 drill a little hole and mallet in this big, broad tack that was just now so primitive, and they would

00:10:44.320 fall out. They had a high failure rate, and it was just, that was the state of the art at that time.

00:10:50.180 And was any of this being done in clinical trials, or was it kind of like patients are saying,

00:10:56.620 look, we have the tried and true way that we do this. The downside is you're going to have a big scar,

00:11:01.620 and we're going to have to tear a bunch of muscle, and your recovery is going to be longer. But once

00:11:05.240 we get in there, we know what to do. Versus we've got this minimally invasive way that has all of these

00:11:10.760 advantages, but the drawback is high failure rate. That was exactly a discussion. There was a little

00:11:16.260 bit of FDA going on approval at that time, but not a lot in terms of using these humanitarian devices

00:11:24.600 and so forth where you could go ahead and try it, and the patients had to sign a release,

00:11:28.780 and it was all fine. And they were trusted surgeons that were doing it. So I wouldn't say there were

00:11:33.140 clinical trials. There were a lot of retrospective analyses going on. Oh, yeah, we did this in 107

00:11:39.900 patients, and 47% failed. In my early years of that, we were actually just still doing mostly open,

00:11:49.180 and then kind of waiting for the devices, for the industry to catch up with some better devices.

00:11:56.800 And some of my colleagues, and occasionally me, were adding little bitty innovative aspects of

00:12:02.800 these, whether they're application devices or the style of implants. So we've gone from today,

00:12:08.600 we went from purely metal to now often purely braided polyester as an actual anchor device,

00:12:18.420 which is super cool because there's no metal in your body, and the transition through that was

00:12:22.680 plastic. And that plastic could be either hard plastic, which stays in your body, but it's still

00:12:27.480 benign, or a bioabsorbable tax, which I have my own issues with because it does create an inflammatory

00:12:35.500 response in the body and creates a little cavity in the bone and so forth. So that's kind of the

00:12:40.980 spectrum. So now we are using tiny drills, tiny suture anchors, and you can put many in. And that's

00:12:48.300 what's nice about if you have to do a revision of some failed repair, you've got plenty of real estate

00:12:54.140 to work with. And it's nice. But one other aspect, which I think shows so much how we change, and I was

00:13:01.300 right at that inflection point, not by choice, just by happenstance, was the slap tears were not

00:13:09.400 appreciated as a clinically relevant entity. But a slap tear, which is-

00:13:15.260 Meaning, so we'll have to tell people what the labrum is in a second and what a slap is, meaning

00:13:19.040 they just were viewed as just another type of labral tear?

00:13:22.140 Yes, but one that was benign, that didn't matter.

00:13:24.780 I see.

00:13:25.080 And people were coming in, a lot of overhead athletes were coming in with secondary problems

00:13:30.460 as a result of that. And the secondary problems were being treated without treating the underlying.

00:13:36.660 And they were having recurrent pain.

00:13:38.880 So this is probably a good pivot for us to back up and make sure people understand the anatomy.

00:13:43.620 Sometimes when I'm explaining to my patients, which exposes my own naivete, I sort of say,

00:13:48.940 look, I don't know a lot about orthopedics. But to understand and appreciate the complexity

00:13:53.320 of the upper extremity, you have to appreciate what we did during evolution. When we stood up,

00:14:00.380 that became an enormous force multiplier. If you think about this through the lens of like warfare,

00:14:06.120 people talk about having night vision as a force multiplier in war. Well, for us to be able to stand

00:14:11.620 and walk with amazing efficiency on two legs was a force multiplier. And then also to have these

00:14:18.060 incredible upper extremities. But you got to pay a price for it.

00:14:22.320 So the price, the way I describe it, and feel free to correct me or make this more nuanced,

00:14:27.020 the price was stability. We paid an enormous price in these joints. Not as strong, not as stable.

00:14:34.560 Would you agree with that? Is that a fair assessment?

00:14:36.320 A hundred percent. And you're spot on on that. And frankly, that shows you do know something about

00:14:40.820 orthopedics. But the fact is that, yeah, when we went from the ball and socket joints or the very

00:14:47.400 stable, simple hinge joints to these cup and saucer type joints, specifically the shoulder,

00:14:54.020 which is intrinsically very unstable. And also our opposable thumb. Our opposable thumb is the basal

00:15:01.040 joint is terribly unstable. We call it a biconcave saddle, but it's barely that. There's really no

00:15:06.480 intrinsic bony stability. And similar to the shoulder, I mean, we use an analogy that's slightly

00:15:12.180 off, but a golf ball on a tee. The tee is a little bigger, a little bigger, but that's what it is. It's

00:15:17.680 very flat and shallow. And so we can talk about the anatomy. So let's do that. In whatever way you

00:15:23.220 think makes the most sense, Alton, let's assume the audience doesn't know the names of any of the

00:15:28.200 bones, let alone what they look like. Doesn't know the vasculature, the musculature, the innervation.

00:15:33.580 What would be a reasonable way? I know you and I spoke, we were going to do this with models. In the end,

00:15:38.260 you thought you could probably do an easier job sketching for folks. Let's have you explain slash

00:15:43.920 sketch through any of these things. That'd be great. And we're prepared for that. We have

00:15:47.860 some diagrams. So I'm going to take it off the visual and draw some quick pictures. And this is

00:15:53.140 what I do, frankly, for all my patients. I don't like the models because they're just models. So I'm

00:15:59.220 not saying I'm a great artist, but if we just look at just the glenoid, that's the socket. That's the

00:16:05.300 golf tee, if you will. And then you add a humeral head to it. And that is the humeral head. This

00:16:13.180 portion to the right of the dotted line is what's covered by cartilage. So that's the nice, smooth

00:16:18.640 Teflon cartilage. And this space- And so just to orient, folks, what you're looking at is head

00:16:23.600 on to a person. If you're looking straight at them, this is the right humeral head. And that little

00:16:29.140 space we're going to talk about. The glenoid fossa is that flat end of part of the scapula,

00:16:35.680 which is a real complex-looking triangular bone with a big ridge on it and collarbone attaches to

00:16:41.060 it and all that crazy stuff. The high-level point here is in the hip, you have the acetabulum,

00:16:47.280 which creates a true socket for a big ball. And here, the heavy lifting really is done by soft tissue,

00:16:56.380 not bones. Right. You've got a joint that's completely contained like that in the hip joint

00:17:01.920 versus a shallow one that just can slip and slide all over the place. So you've pointed out it's the

00:17:08.680 best way to describe the shoulder joint being a delicate balance of mobility and stability. And

00:17:15.980 it's very easy to get out of whack because it is biomechanically so complicated. So I'm going to add a

00:17:22.640 few more things here, but this space that we see between here is not a space. It's the space

00:17:28.900 radiographically that's occupied by the cartilage. So you have a thick, nice layer of cartilage on both

00:17:37.080 sides. I've left a little gap just to be able to see it, but it's the articular cartilage effectively

00:17:41.480 there. So there's a layer of nice, thick cartilage there. And when we have arthritis, of course, that gets

00:17:47.120 worn down, chipped away and begins to fissure and then actually develop full thickness loss to the

00:17:54.460 point where then at some point it's not really functioning very well and it's very painful.

00:17:59.640 So if we have this basic bony cartilage structure here, it would just fall off. If it were just left

00:18:06.760 there, let's say you had a, well, if you had no ligaments, no, what we're going to call the labrum,

00:18:12.840 which are some additional stabilizing structures, or if we had the muscle tendon units that support

00:18:19.020 it. So I'm going to draw in a few more of that, of those. And while you're doing that, we'll just

00:18:24.200 remind people that ligaments and tendons are not the same. Tendons are the connective tissue that

00:18:30.180 connects muscle to bone. Ligaments are connective tissue that connect bone to bone. Is labrum considered

00:18:36.480 a ligament or is it kind of considered its own entity? It's kind of its own entity. It has a

00:18:41.260 transition zone between fibrous tissue to osseous bony tissue. So it's a fiber osseous structure and

00:18:48.480 I liken it to calamari and it's rubbery just like that. And that's the best analogy that people seem

00:18:54.200 to get. So I've drawn on two of the four rotator cuff muscles here. This is the one up above and this

00:19:02.220 is the one in front. And this is the big muscle that allows us to reach behind our back and pull

00:19:09.820 our hand away from our back. And this is also the one that helps us along with the pectoralis in front

00:19:16.940 to pull things together like doing flies and so forth. The supraspinatus is the primary muscle that

00:19:25.140 initiates elevation of the shoulder. So it's very, very important. So what we see here is this zone

00:19:32.180 in from here and about through here is where the muscle transitions into tendon and then it becomes

00:19:40.660 pure tendon. And it just so happens that this tendon, this supraspinatus tendon, which is so commonly

00:19:47.880 torn, is actually, there's some physiologic downsides to its location where it can be wrung out. It doesn't

00:19:57.320 have a great blood supply. The key is it gets, let me put here, where those two arrows are is

00:20:03.620 essentially where the tendon tears most of the time. And that is the part that attaches to the

00:20:10.760 bone. It gets blood supply from that bone. It gets blood supply, it gets nutrients, it gets growth

00:20:16.420 factors. So our goal, and this is jumping ahead a little bit, our goal is to get that reattached to

00:20:23.560 that bone. So it can get all of those growth factors and that new healing back. And it absolutely

00:20:29.380 can heal back, but there are certain limitations to that. There's two other muscles. So we've got

00:20:35.360 the supraspinatus and the subscapularis there. There's two other muscles that make up the rotator

00:20:40.400 cuff. Everyone's heard of the rotator cuff, and yet it's probably not obvious to people that it's

00:20:45.160 really four muscles that are doing this. What are the other two? So the other two are the infraspinatus

00:20:51.440 and the teres minor. And you can kind of superimpose them over the subscapularis, but they're on the

00:20:57.680 backside of the joint. And they are very important. They are the external rotators. They give us our

00:21:03.540 backhand in tennis. They give us a lot of stability for the shoulder itself. And especially whether you're

00:21:09.900 playing golf or lifting weights, they're a dynamic stabilizer. They're very important doing bench

00:21:15.240 press, pushups, all sorts of activities like that. Archery. Archery. Yes. Very important.

00:21:20.500 So when a person, quote unquote, tears their rotator cuff, that can be a very heterogeneous

00:21:26.560 diagnosis. Technically, that diagnosis would apply to a tear in any of those four muscles,

00:21:32.860 which could be in the muscle, could be at the junction between the muscle and the tendon.

00:21:38.040 And could it also be just a complete separation of the tendon from the osseous structure of the bone?

00:21:41.740 Yes. So that's critical to identify what that is. And you can somewhat predict it based on

00:21:48.820 the age of the person and their physiology and the mechanism of the trauma. And we do broadly

00:21:57.040 classify these into degenerative tears and traumatic tears. So younger people, it's rare to see a young

00:22:05.640 person really under the age of 40 to tear their rotator cuff. It's pretty proportionally rare,

00:22:11.760 but it happens. And it happens traumatically. I had a young fellow who worked as a merchant marine

00:22:17.200 years ago. And he was doing something with the anchor and the massive chain and his glove got

00:22:22.980 caught in that. And it basically, it almost ripped his arm off, but it was okay. Except that he had

00:22:28.680 torn traumatically as a young 20, I think he was 26 or so. It ripped off three of his four muscles

00:22:35.180 and they had to be repaired, but he was okay. But it's that rare, dramatic circumstance that leads

00:22:42.280 to traumatic tears in young people. Someone that young, where's the weak link? Does it tear

00:22:48.880 at the muscle itself or does it tear more at the tendon? That's a great question because the younger

00:22:54.960 you are, the stronger that linkage of the tendon to the bone. So you often pull off some bone.

00:23:01.460 And so in the case of a skier's thumb, just a common injury in the hand from skiers,

00:23:08.520 the younger you are, the more likely it is to pull off with a piece of bone. And that's actually

00:23:12.720 great because bone heals to bone itself much better than tendon to bone. If you can get away

00:23:19.440 with that, there are fractures that occur that involve this area. There's, and I'll draw a picture

00:23:25.500 here, draw a squiggly line to represent a fracture and then I'll show it coming off. That's a common

00:23:31.440 fracture. So right here, what I've drawn is this chunk of bone coming off right here. That's the

00:23:38.900 greater tuberosity. It's a prominence of the bone that the biggest portion of the rotator cuff attaches,

00:23:44.380 the supraspinatus and the infraspinatus that you referenced. That pulls off. So I would rather

00:23:51.620 have that. I would rather pull that off and have a good quality repair of that than have my

00:24:00.000 supraspinatus. Two tendons would pop that bump. Tell me the type of athlete or person that presents

00:24:05.180 with the fracture that you've depicted. So these are generally that isolated greater tuberosity is

00:24:11.380 generally a fracture dislocation. So you have a pretty violent injury, you're rock climbing,

00:24:17.420 you fall off, you maybe hit it directly, your arm is wrenched back, or you have, let's say,

00:24:24.060 a football player who has a traumatic dislocation. They're hitting just the right way mechanically,

00:24:29.260 and it shears that off. So it's often, most often associated with the dislocation

00:24:34.860 as well. The dislocation goes back, but the tuberosity is off. Dislocation meaning a subluxation

00:24:39.760 of the shoulder? Yeah. And let's explain to folks what that is, how that happens. I didn't realize that

00:24:45.540 we could use the word dislocation and subluxation interchangeably. Well, technically we don't.

00:24:49.880 Technically a subluxation is an incomplete dislocation. It's the shoulder coming out,

00:24:56.040 but it pops back in easily. Got it. So dislocation is usually, it comes out and it needs to be put

00:25:01.620 back in. Most often, unless it's recurrent. The more dislocations one has, or subluxations,

00:25:08.300 the more stretchy and compliant the tissues become. Sort of like mine. Yes. And so then it can kind of

00:25:14.180 slip and slide back in and out with regularity. Let me draw a different picture. Okay. What I've done

00:25:20.320 here is taken the, the humeral head away. So we're just looking at the socket and we're looking at it

00:25:26.580 on FOS. If you're looking at me, you took my humerus away and now you are looking directly at the socket

00:25:35.320 of this glenohumeral FOS. Yes. And so the central. So the front of the person. Is to the front. That's

00:25:43.100 anterior. If we speak about that. And posterior is to the back. Superior is up above. Inferior is

00:25:49.940 down below. Oh. And so importantly around the outside, that second circle is the outline of

00:25:57.360 the labrum. So from here to here is the labrum and that's a rubbery calamari like structure.

00:26:04.760 I love that. I love that explanation. It's sort of, you get some bad calamari that's really chewy.

00:26:09.280 That's kind of what I haven't chewed on labor myself, but it's what I imagine it would be

00:26:13.660 behave like. And it's very strong. And what it does, it has an amazing, you were talking about

00:26:20.360 the evolution when we became bipeds. It's super cool because it effectively developed as a way to

00:26:27.980 decrease the depth of the socket, not by very much, but it truly works like a suction cup.

00:26:34.060 If you take a non-arthritic cadaver specimen and dissect away all of the muscle, all the

00:26:40.400 ligaments, and you stick it on the humeral head, on the labrum, it'll sit there.

00:26:45.740 So amazing.

00:26:46.400 Yeah. It's crazy. It's fascinating. But just like a thermometer on a window, if you get your

00:26:53.240 finger on it, lift it up, break it, seal it, it falls away. Well, that's what happens here.

00:26:57.220 So we get a lot of static stability in our shoulder from this superior, inferior anterior and posterior

00:27:05.560 labrum.

00:27:05.960 And just to be clear, Alton, in a non-pathologic state, when you have that young person who has

00:27:11.460 yet to be experiencing any trauma of the shoulder, is that a contained space of fluid that is between

00:27:17.140 those two cartilaginous surfaces of the glenoid fossa, the humeral head, fully contained? Because

00:27:21.980 usually to have a suction, there has to be a fluid that sort of contains it, or air that's

00:27:25.940 incompressible, which is technically fluid. But I assume there is an aqueous fluid that's

00:27:29.920 normally in there?

00:27:30.400 Absolutely. You have a nice viscous joint fluid in all of our joints like that. That's a great

00:27:34.840 question. And yes, you couldn't have that suction. As soon as you poke a hole in that,

00:27:39.240 you lose that suction.

00:27:39.940 So when a person has a subluxation, it doesn't necessarily tear the labrum, does it?

00:27:45.860 Correct. And that's another huge point that factors into our treatment recommendations and

00:27:52.320 mechanisms of injury. If you are a young woman playing soccer, generally young women have

00:27:59.200 looser joints. Women in general have looser joints, which is part of difference in physiology. And 1.00

00:28:04.660 actually, because of the weird nature of the shoulders, there are men as well who have super

00:28:10.380 loose shoulders, baseline, born that way. But in general, if you think of someone, whether male or

00:28:16.400 female who has super loose joints, then they can sublux out, in and out, without tearing anything. 1.00

00:28:24.880 They just ride up over that because it's just loosey-goosey. So the tighter the shoulder is,

00:28:30.440 the more you have to lose...

00:28:32.240 What happens to the fluid when they sublux?

00:28:34.300 Nothing. Because they have a more capacious... It's the ligaments. The ligaments are stretchy

00:28:38.920 and they are bigger. It's more like a balloon that you keep blowing up repeatedly. But if you have

00:28:44.560 someone who has basically a pretty stable joint, not loosey-goosey, and then they sublux, the only

00:28:50.780 way you can do that is either tearing the ligaments, but usually you also tear the labrum. And what I

00:28:56.040 mean by tearing the labrum is you separate the labrum, the inner arc, from its hard, bony, cartilaginous,

00:29:05.280 perfectly fused attachment. Very strong. It takes a massive force to dislocate the shoulder. It

00:29:12.060 actually does. Or perfect mechanics. And so if you have the classic, you're reaching up to get a

00:29:19.140 rebound and someone grabs your arm and jerks it backwards, that's a leverage, an unnatural leverage

00:29:26.140 that makes the head tend to go out this direction, anteriorly, inferiorly, like this.

00:29:33.580 So the head is going to go down this way.

00:29:35.820 Yeah. It just leverages it out.

00:29:37.660 And that's also a vulnerability based on where the muscles attach, right?

00:29:41.920 Yes. Very much so. And we'll get to that as dynamic stabilizers. But man, this labrum is tough,

00:29:48.220 but it tears off. This is the classic location where you tear the labrum there. And it takes

00:29:55.000 either a small tear that then is repetitively increased in size just from aggressive but repetitive

00:30:03.740 use or it takes a one-time significant dislocation.

00:30:08.700 And again, just to show people, the attachments of the four rotator cuffs are basically behind,

00:30:17.020 above. It's basically like you got a big one there kind of at nine o'clock, right?

00:30:21.080 That's a great question. You ask perfect questions that I forget to cover. So these are kind of the

00:30:26.480 cross sections of the muscles that are just outside. So these encompass and enshroud the joint.

00:30:32.620 And this is the cross-sectional muscle bellies. And this is where they, as you'd come further out

00:30:36.980 toward the head, which is out here, they taper down and form the tendons. And that's so important

00:30:42.520 because no shoulder can be stable alone just by these static stabilizers, the labrum and the

00:30:50.460 ligaments. And the ligaments kind of lie in between the labrum and the rotator cuff in here.

00:30:55.980 When you're referring to a slap tear, you know, obviously slap stands for superior labral

00:30:59.580 anterior posterior.

00:31:00.580 Yes, exactly. And that is up here. That is the superior. And that's an odd injury that we,

00:31:08.760 the first person that really taught this well to us was a fellow named Steve Snyder in Northern

00:31:14.500 California. And he really kind of categorized these and started identifying these as really

00:31:19.800 actually clinically relevant entities, not for everybody, but certainly for younger, very athletic

00:31:25.800 people, overhead athletes, weightlifters, people doing CrossFit, people doing all manner of more

00:31:32.600 aggressive sports. So unlike, if you have a tear here and you're active, you're going to keep

00:31:39.900 re-dislocating, at least subluxating.

00:31:42.000 That was me, correct? I was kind of all the way around, but big anterior inferior.

00:31:46.700 So I don't know what your first injury was.

00:31:49.920 We've talked about this. I believe it was a subluxation in boxing when I was probably 17.

00:31:58.980 So there's two injuries I remember having in high school. I can't remember which one was first.

00:32:02.820 You might have a sense. One was doing absurdly heavy military press. I think that was the second

00:32:08.680 one. Truthfully, I think the first subluxation was boxing and just bad timing. Hard punch thrown,

00:32:15.820 guy gets out of the way, probably smacked my arm on the way and out it came. And I believe that would

00:32:22.040 have been followed up six months later. I'm doing very heavy weight for me overhead. And I just

00:32:28.800 remember, boom, it just popped out and down. And then from that point on, it was a vicious cycle

00:32:34.780 of never ending subluxations with each couple of years having a really bad one. Another really bad

00:32:41.840 one I had was in an open water swim race. We're swimming freestyle, right? So I'm in the reach

00:32:47.200 phase with the right arm in front and the swimmer in front of me kicked down on that arm. I mean,

00:32:52.800 that's a bit of force, but not absurd, but just the down kick of that arm took me out.

00:32:58.620 So it's so funny. You were describing so many great, I'm sorry you had suffered from them all,

00:33:03.780 but so many great and differing types of mechanisms that happen. I agree with you that it

00:33:09.660 probably was the boxing. I've seen a lot of those, the recoil. And especially if you don't hit

00:33:15.380 something, your body is anticipating and it's tightened up and it is ready for contact and it

00:33:21.840 doesn't have the contact. It's no different than there's an extra step in front of you that you don't

00:33:26.080 know about and you step and you go, whoa, and then you feel like it shudders your whole body.

00:33:30.200 It's the same concept. Your body unconsciously knows what it needs to do. So you probably did have

00:33:35.800 a posterior subluxation. I mean, I will say, and you know this, and this is why it was so important

00:33:41.280 for you is you had a tear going all the way from posterior all the way around to there. So you had

00:33:48.820 about a 240 degree tear and that's, you don't get that from one injury. It's almost impossible.

00:33:57.060 So I basically became looser and looser over time. And then it just now had too much laxity. It could

00:34:02.820 basically move in any direction. Exactly. And you were compensating well for most of the time

00:34:07.980 because you're very fit. You're doing all the right upper body, specifically shoulder strengthening

00:34:13.960 exercises. So you are using your dynamic stabilizers to compensate for the loss of the static stabilizers.

00:34:23.520 And that's a critical, critical problem. And it fits too with your weightlifting. You had a tear,

00:34:29.280 weightlifting, you were fine. But what happens is if you're going kind of maxing out and you're doing

00:34:34.700 it repetitively, the dynamic stabilizers fatigue. And I see this, the one of the most common scenarios

00:34:41.480 is the young, more often female than male, but both swimmers. So they're competing. They need the

00:34:49.700 stability, especially if they're doing fly and backstroke. They really need that. And they acquire

00:34:55.340 all this laxity in their shoulder. And they're so strong dynamically, they're fine. And it gives

00:35:00.660 them that extra pull, that extra inch or two. But when they fatigue, they start out fine on a Friday

00:35:06.900 if they have a weekend-long match and they have eight events in three days. The first two days,

00:35:13.220 they're fine. Maybe they have a little pain at the end of the second day. By the third day,

00:35:16.980 they're fatigued. And so then they start subluxing. And then they get all this secondary

00:35:21.540 inflammation and pain. And that's when the damage occurs. And they have to sit out. And then we have

00:35:26.440 to restrengthen, rehab, sometimes even tighten up the capsule when they get so loose.

00:35:32.340 And one of the things we're going to talk about here is, of course, the physical exam on this.

00:35:36.180 Because the other thing we haven't talked about on this diagram is that little pesky biceps head.

00:35:40.740 And that tendon, boy, if anybody who's experienced tendinosis there, that can be incredibly painful.

00:35:48.140 And I think to an average person, it's not entirely clear where that pain is coming from if they feel

00:35:54.140 pain here, right?

00:35:55.100 Right. So yes, the biceps, which is a weird structure, and it's absolutely part of that weird

00:36:00.600 evolution that we have. The biceps is one muscle in our arm, but it's two tendons at the origin,

00:36:07.580 which in the shoulder. One of the tendons-

00:36:10.040 So starts down here, single point of attachment-

00:36:13.840 In the elbow. In the forearm, actually.

00:36:15.760 Crosses the joint as one muscle and then kind of splits into two bellies with two.

00:36:19.720 Exactly. And it has the long head, which is the one that so often gets inflamed. And you're

00:36:25.660 absolutely right. It can be quite painful. And it can just affect everyday life with that. And the

00:36:32.280 second tendon peels off over here and it goes outside the joint and attaches to a bony prominence in

00:36:38.140 that weird scapula that you talked about, which is such a weird-looking bone. And it attaches there.

00:36:43.620 That never tears. It literally never tears. But people often do tear this biceps. And it can be

00:36:49.800 from wear and tear. It can be acute traumatically. But it leads to a classic Popeye muscle. Kind of

00:36:56.000 half their muscle is balled up and looks weird. It's not really that much of a functional consequence.

00:37:02.520 Usually, it stops hurting when it ruptures. And if I'm not mistaken, I mean, this has been

00:37:07.720 in the orthopedic anecdotes for a long time, was the great quarterback from Denver.

00:37:13.660 John Elway.

00:37:14.220 John Elway. He was having shoulder pain and was even thinking about retiring as far as I know.

00:37:18.500 His ruptured pain went away and then he won another Super Bowl.

00:37:21.720 Two Super Bowls after that. So it's a structure that's not necessary. And there's a lot of argument

00:37:27.060 in orthopedics and I don't need to go into it about how important it really is. But the fact is,

00:37:31.500 it is anchored right up here at the superior labrum. So when you tear that superior labrum,

00:37:36.460 that biceps does funky things. It becomes unstable and it gets more inflamed often. And then that you

00:37:43.240 get all that secondary pain. So some people, I'm not one of them. Some people who fix a lot of these

00:37:50.180 will automatically just snip that biceps and reattach it in the front so it's no longer a pain

00:37:55.620 generator.

00:37:56.300 So that's the tendinesis.

00:37:57.220 Yes, that's the tendinesis. But I do that only when I see tearing, splitting, something structurally

00:38:03.320 wrong with the biceps. I know that I can get a good repair, as any good surgeon can, a good repair

00:38:08.440 of the superior labrum. And once that's stable, the biceps is fine again. It's no longer symptomatic.

00:38:12.940 And I knock on wood, but I haven't had to go back and tendies anyone who I had just repaired and left

00:38:18.240 it intact as long as I got a good superior labral repair.

00:38:21.340 Because we've got the beautiful anatomy here, let's go a little deeper into this because

00:38:25.560 I feel like the torn labrum is to the MRI what the disc herniation, there is to the shoulder what

00:38:33.560 the disc herniation is to the back. You know, we tell our patients, I almost wish when I give you

00:38:39.880 an MRI for another reason, I could ask the radiologist not to show me your spine. In other words,

00:38:45.380 you take somebody who's not having no spine issues, and you stick them in the skin. There's

00:38:49.520 nothing that bugs me more than having to sit there and go through all of these asymptomatic 1.00

00:38:54.500 herniations, which mean nothing. And I suspect the shoulder with its labral tear has to be the same.

00:39:00.300 You're absolutely spot on. And it is such a point of frustration. Radiologists are doing their job.

00:39:05.660 They're just reading abnormalities. The problem is that most of us walking around have, especially

00:39:11.300 from my age, have plenty of positive findings, but they're asymptomatic. I mean, I've never had a

00:39:17.200 spine or originated symptom. It's a very double-edged sword to get those MRIs. Same thing in the labrum.

00:39:24.300 The labrum will naturally degenerate just by using it. So will the cartilage. And look, we know there's

00:39:30.940 a genetic predisposition to arthritis. And by arthritis, I mean not just inflammation of the joint,

00:39:36.300 but a true loss of the cartilage integrity. And that's kind of those two terms are used

00:39:42.020 interchangeably by different people in different subspecialties. But for our purposes as an

00:39:47.780 orthopedic surgeon, it's when the joint is degenerating and the cartilage surfaces are no

00:39:53.680 longer pristine, just like you're chipping the pain on your car. And does that occur preferentially

00:39:59.040 on the humeral head or in the glenoid fossa? Or is it basically one of those things where the second

00:40:04.360 you get one chip, it's going to start happening on both sides?

00:40:08.100 We don't have a good natural history of that. We know that, I mean, I've operated on, done total

00:40:14.020 shoulders on people who had no cartilage left on their humeral head. It was perfectly round and smooth.

00:40:20.140 There was no cartilage left. It was just a bony-

00:40:22.020 Just pure soft, I mean, pure hard ivory type bone with no cartilage on it. Whereas the glenoids still had

00:40:30.060 cartilage on it. Now that's a case where, to your point, the loss on the humerus was smooth enough

00:40:37.080 and gradual enough to where it didn't dig in and sort of eat away at the socket. It doesn't matter,

00:40:43.320 you still have to replace the socket. But we do for our younger athletic people who have a humeral head

00:40:51.500 that's been damaged and they have a big chunk, maybe a quarter size, maybe a 50 cent piece size

00:40:56.940 of cartilage, full cartilage loss. That's not great because that, man, that just keeps sloughing

00:41:02.800 off cartilage. They keep getting inflamed. They're on the young side. You don't want to do a shoulder

00:41:06.640 replacement on them. So we will do just a humeral head resurfacing. They get a nice new smooth metal

00:41:14.680 head, but we leave the glenoid intact and they have good cartilage there. So it's metal on natural

00:41:20.900 cartilage.

00:41:21.880 What kind of metal is that, by the way?

00:41:22.840 It's cobalt chromium alloys.

00:41:24.980 So it's just like the hips. 0.89

00:41:26.140 And the nice thing about those is if you can get five years, I have some people that have had those

00:41:30.540 in 10 years and they're fine. They can be much more aggressive with their activities. And if it ever

00:41:35.620 does wear down the glenoid side, then you just go back in and revise it and put a plastic cup for the

00:41:41.620 glenoid.

00:41:42.440 So let's now talk about when you look at the MRI finding and what you're looking for in the MRI and

00:41:51.720 then how you're looking to contrast that with what you see on the physical exam. And in a moment,

00:41:55.220 I'll have you examine me and we'll do this for all of the pathology we talk about so that we can get a

00:42:00.760 sense of this. Because I remember the very first time I saw you after having sent many patients to

00:42:06.660 you, it was probably a year before I had my surgery. I said, look, you know, Alton, I know I've

00:42:11.080 got this labrum. It's been torn to shreds for years. I really don't want to have surgery unless I

00:42:16.180 need to. You examined me and said, yeah, you're not ready yet. So yeah, walk through how you start

00:42:21.740 to test the surrounding structures to elicit sort of feedback on the labrum.

00:42:28.520 So I will preface that by saying, I'm so glad you brought that up because

00:42:31.920 one should never make their clinical, especially surgical decision-making on just an MRI. I've

00:42:39.700 written a couple of book chapters on that included a very complete examination of the shoulder,

00:42:44.940 the basic exam, the provocative maneuvers and so forth. And one of the things I've always stated,

00:42:50.240 I've never done this study. I've always wanted to, but I believe that a good history, and that

00:42:54.780 involves the mechanics of injury and the mechanics of use, whether you're shooting a bow and arrow,

00:43:00.600 whether you're driving a race car, whether you're playing basketball, whether you're just lifting

00:43:04.320 weights, a combination of the mechanism, but also their symptoms when they have them and then

00:43:11.660 their examination. And I think if you do those compulsively and well, you will be 95% accurate

00:43:18.440 without any MRI. I remember one of the things that had changed because for me, remember archery never,

00:43:24.780 the day before I'm having surgery, I'm out there taking a hundred shots. That was never the issue.

00:43:28.540 But in the months leading up to surgery, I couldn't serve a volleyball with my daughter. I couldn't shoot

00:43:34.620 one basket. I could not do that. And then I could pull a 75 pound bow back. Doesn't make sense.

00:43:41.600 It doesn't. And it's just the mechanics of each individual. And that's where the MRI does come in.

00:43:47.440 I use MRIs more to corroborate. Maybe I'm a little more into sort of the concept of making an accurate

00:43:55.400 diagnosis before the MRI. Kind of the old school.

00:43:57.660 Kind of prove a point. But I always use it to corroborate because there are things that can be there.

00:44:02.380 And especially even just the difference between a partial thickness rotator cuff tear and a full

00:44:07.980 thickness or a full thickness small and a full thickness large. And those are variable based

00:44:14.540 again on the patient's activity. We know from good studies done with ultrasound MRI that walking down

00:44:22.060 the street, half the people age 60 have rotator cuff tears. Half the people over 60 have an asymptomatic

00:44:29.040 torn rotator cuff. Yeah. Unbelievable.

00:44:31.160 That may not be big, but it can be. I've seen people- I mean, I don't doubt it just based on what

00:44:34.560 we see of herniations in the C-spine and the L-spine. And that's where, to your point, it comes in. It's

00:44:40.720 so important that we don't want to ignore something that can get much worse and make their treatment or

00:44:47.580 recovery much more difficult. But at the same time, we need to be more circumspect about who we're

00:44:52.840 operating and who we're not operating on. Are there ever situations where- I'm going to ask

00:44:58.120 this question, obviously, on the shoulder, but if a patient came in and had a totally asymptomatic

00:45:02.700 aortic aneurysm of six centimeters, everybody agrees you would operate because the mortality

00:45:08.120 of a rupture is enormous. And frankly, you don't want to wait until somebody's symptomatic. That can be

00:45:13.120 lethal. So there are certainly indications where we operate on asymptomatic things. Are there any such

00:45:18.260 indications in the shoulder? I would say, in general, no, unless you have, obviously, a tumor.

00:45:25.620 Yeah, not including oncology. Just the standard garden variety structural injuries that can occur.

00:45:32.180 There are very few, except if you've had someone who had- well, I'll give you a good example that's

00:45:39.460 very personal to me. My dad, who passed away at 95, we were swimming in Lake Travis when he was

00:45:44.940 94 and a half. He's really vigorous, mentally fit, physically fit, but he did end up having

00:45:52.020 pancreatic cancer and that's what killed him at 95. Great life, no complaints with anybody. But

00:45:56.700 at 86, a guy who could still do pull-ups, who was still swimming in the lake-

00:46:01.700 So this guy's my hero.

00:46:02.920 All his own yard work, everything. And he was running to get out of the way of the sprinkler,

00:46:08.100 did a banana peel, had a dislocation of his shoulder, ripped off two and a half of his four tendons.

00:46:14.280 And remember, one of them never tears. So almost his complete functional rotator cuff.

00:46:18.800 He was planning to come up to New York to visit and we did a little FaceTime and he couldn't lift

00:46:23.580 his arm. It was like this. And he's 86, but healthy, never took a medication, so forth. So

00:46:29.140 I said, dad, you need to come up early. We're going to need to fix this. So we'll get an MRI,

00:46:33.660 come up here. So my partner and I fixed him and regional anesthesia, they didn't even give him

00:46:39.400 much sedation. He was like talking to us during the surgery. Got a good six anchor repair. He had

00:46:45.320 great tissue to the point that you've helped so many of us understand, but got a good solid repair

00:46:52.180 at 95 and 94. You couldn't tell he ever had a tear. He healed it back. He went back to doing

00:46:58.580 everything.

00:46:58.700 And what would have been the natural history? Because I think a lot of doctors might've left

00:47:01.700 him alone. How would he have evolved?

00:47:03.520 That was the point. He would have been miserable for the next nine years of his life because he

00:47:07.920 couldn't lift his arm. It might not even have been that painful, but he wouldn't have been able to do

00:47:12.140 everything he wanted to do that kept him so vital.

00:47:14.940 So in other words, pain is not a, pain shouldn't be the only symptom we look for. We have to look

00:47:18.460 for function.

00:47:19.080 No. And so what I would tell someone who came in, let's say someone had a bad traumatic,

00:47:23.760 a motor vehicle accident and they tore their rotator cuff at a badly. And there were 60, 65.

00:47:29.420 Would I tell them you absolutely have to have it repaired? No. But I would also tell them, look,

00:47:34.580 if you don't repair this, those muscles have lost their muscle tendon connection. So they're going

00:47:40.320 to atrophy. And later, I know you're not painful now, but if you want to still do the things you're

00:47:45.600 doing in the way you do them before this accident, they need to have them repaired.

00:47:49.440 So this is effectively the discussion you had with one of the patients I sent you

00:47:53.160 six months ago who tore a rotator cuff playing tennis many years ago. And basically once this

00:48:01.380 patient stopped playing tennis, they had no more pain. So today they do yoga and Pilates with no

00:48:07.180 pain, but they can never pick up a racket again. I sent the person to you and that's basically what

00:48:11.800 you said was, you don't have to have this fixed, but you will see a continued diminution of your

00:48:18.200 function as you age. Exactly. And the second caveat, which I'll tell them is, you may start

00:48:24.360 having symptoms in six months, even doing those other things. And if you do come back, don't ignore

00:48:29.380 them. If you start having symptoms, when you've been asymptomatic, something has changed anatomically,

00:48:35.300 physiologically, or something, let's reassess. It's a dynamic state over a long period of time. And so

00:48:40.480 you need to be flexible on that. And as a clinician, certainly.

00:48:43.580 When a patient typically comes in, basically they're just saying, doc, my shoulder hurts.

00:48:49.340 Again, on the exam, absent even an MRI, we're going to show people how you can just based on

00:48:55.320 where I'm weak or strong and what hurts, you probably have a pretty good sense of this person

00:48:59.820 has an intact cuff versus they don't. This person has a labral instability versus they don't. This

00:49:05.920 may actually just be bicep tendon injury versus not. What else is on your differential diagnosis in the

00:49:12.040 exam? You don't have the MRI yet. The guy's just says he's got shoulder pain.

00:49:16.380 I'm going to draw another picture. Okay. So I've drawn the shoulder again. I've added on a couple

00:49:22.220 of things. I've added on the clavicle, the collarbone, and I've added on this other structure

00:49:28.260 up here, which is the bony structure. If you tap on the top of your shoulder, that's the bony roof

00:49:32.920 of the shoulder. That's the acromion. Yet another part of that super weird scapula. Okay. So the joint

00:49:40.480 that when you hear about someone separating their shoulder, it's this joint right here,

00:49:44.760 which is the acromioclavicular joint. It only rotates about 20 degrees. It's just the way I

00:49:51.540 liken this, especially being in Texas, you can talk about it because there are a lot of car lovers

00:49:55.440 and you know about it as a major car lover driver is it effectively is a McPherson strut on a car. So

00:50:02.280 it's a stabilizer bar. If you don't have those, and there are people that are born without

00:50:07.420 collarbones, they can bring their shoulders completely together right here in the center, 0.77

00:50:13.500 just like this. It's kind of super cool, but it holds those out. So that's why it's the one most

00:50:19.620 commonly injured in cyclists who wipe out because they fracture here because they land on the outside

00:50:25.040 of their shoulder. But the AC joint, the acromioclavicular joint is what happens when people

00:50:29.980 separate their shoulders, which is also super common. Different from a dislocation, obviously.

00:50:32.960 Different from dislocation. That's usually from a force coming down from the top. So we're pitched

00:50:37.100 forward. We land on the point of our shoulder and it jams it down. And we can talk about that later.

00:50:42.520 It's super interesting. But this acromion again is the bony roof and under that roof is where the

00:50:48.600 rotator cuff glides. And let me draw this. I've just drawn arrows back and forth arrows here. So as the

00:50:55.440 head rotates back and forth around, the rotator cuff is attached here and it goes back and forth here.

00:51:00.580 So it's rubbing or moving underneath this. Any place in our body that there's two structures

00:51:08.560 anatomically in the limbs that move differentially with one another, there's usually a bursa that

00:51:13.920 forms in between. And so that bursa is here. I'll draw it in green. That bursa lives right in there.

00:51:21.020 And so it's just the thin filmy structure that can thicken up and become very inflamed and become

00:51:27.120 bursitis. And that's very painful. So that's a common, common diagnosis.

00:51:31.020 Because otherwise the purpose of that is to allow these things to glide past each other frictionless.

00:51:35.100 Yes. Perfect. Yes, exactly. And then some of us are born with an extra kind of down sloping of that

00:51:43.440 acromion or a bone spur, or we acquire it from repetitive athletic use. There are multiple reasons.

00:51:49.380 If you have a big, though, bird beak coming down and pointing into that, you can imagine if this

00:51:54.240 is running back and forth there, it's irritating the bursa, creating bursitis. And it's also

00:51:59.160 frictionally rubbing against the rotator cuff tendon. And you can get bursal-sided upper part

00:52:06.960 rotator cuff tears from that alone. I know because I had a big spur like that in my shoulder.

00:52:13.220 So to be clear, the spur occurred because you were genetically predisposed to it based on the shape

00:52:20.100 of the bursa? Yes. That's really great that you said that. You should have been an orthopedic

00:52:25.120 surgeon. You can have a type 1, a type 2, or a type 3 acromion. Type 1 is totally flat. That's the

00:52:32.660 majority of people. Type 2, the second most common. And type 3 is about, I don't remember the exact

00:52:37.360 numbers, but certainly it's not rare, like 30% of people. And that's the one that really predisposed you.

00:52:42.800 But only if you're an overhead athlete or lifting weights overhead or doing all sorts of

00:52:47.200 aggressive things. If you're a sedentary actuary who doesn't exercise, then you'll never have a

00:52:55.480 problem because you're just not repetitively loading it enough to wear down or cause a tear.

00:53:01.420 So interesting because you'll often hear people talk about, well, I can do so and so, and I've never

00:53:07.240 had an issue, therefore it's okay. If you have the top acromion there, you can probably get away with

00:53:12.680 a lot more overhead activity. And you might look at somebody who's in category 3, who every time

00:53:18.900 they do excessive overhead activity gets injured. And you might be saying, well, there's something

00:53:22.500 wrong with you. The reality of it is, it would be interesting if we sort of knew these things in

00:53:26.000 advance and we could maybe modify and temper our activity around our genetics effectively.

00:53:30.760 Absolutely. It's a super cool concept. I've always thought about that stuff, the predisposition.

00:53:35.160 And I'm not talking about the predisposition to arthritis. You're talking about-

00:53:39.780 This is anatomic.

00:53:40.380 The mechanics, the mechanics and anatomy. And you're absolutely right. It's so important.

00:53:44.520 I'll give you another example of it. I know just from having MRIs for other reasons, I have a very

00:53:49.880 congenitally narrow C-spine. So I just don't have any wiggle room. And as a result of that, I take my

00:54:00.100 sort of tech neck protocol very seriously.

00:54:03.180 I also know that I already have two small herniations. Now, luckily they aren't doing

00:54:10.380 anything to me, but I know that nobody's going to go in and remove one without doing the other,

00:54:16.360 which means they'd fuse me out of the gate. I think knowing that is very helpful because what

00:54:21.680 it tells me to do is you're going to do a lot of sort of rehabilitative exercises even before having

00:54:28.380 the injury. And I actually think it's very fortunate that I'm no longer a surgeon because I think a lot

00:54:34.040 of my colleagues from surgery have ended up having neck surgery because you're in this position all

00:54:40.180 the time. So I think this is a very interesting idea. I'd never thought about it in the orthopedic

00:54:45.680 context, in the joint context that is.

00:54:47.660 The other thing I thought of when you said that is this has been studied in the spine a little bit.

00:54:51.920 So if you have a congenitally narrow stenotic spine and you're playing football, you're way

00:54:57.700 more at risk for catastrophic spinal cord injury. So if you've had, that's why when we were, I was

00:55:03.280 team doctor for almost 15 years, a college up in New York, everybody doesn't screen these guys,

00:55:08.800 but if you have your first stinger, then you need to be screened and see if you are. And if you are,

00:55:13.780 then you have a very serious discussion about what you're subjecting your neck to. There are a lot

00:55:18.120 of sports to play and you don't necessarily have to be butting heads at high velocity.

00:55:23.320 So that's exactly true there, but you're right. It hasn't been done in the shoulder. And yeah,

00:55:27.880 it'd be a simple, easy screen and say, Oh, you know, I mean, I don't.

00:55:30.700 Well, especially I think when you talk about kids who have lots of athletic potential and they're 11

00:55:35.160 years old and maybe there is a decision to be made. Are you going to be a pitcher? Are you going

00:55:39.960 to be a tennis player? Are you going to be a basketball player? Are you going to play lacrosse?

00:55:42.500 You're going to swim. If you knew you'd have a longer shelf life in one over the other,

00:55:46.440 would that at least weigh into the decision-making process?

00:55:49.760 That's fascinating. I love the way your mind works because yes, there are plenty of multi-sport

00:55:55.700 athletes who have ability and you could do an assessment. For instance, if you have super loose

00:56:01.460 joints, then you're going to need to pick the ones that you can keep dynamically stabilized,

00:56:06.300 but are not going to be subjected directly to unnecessary forces. Yes. Great concept.

00:56:12.260 So I'm guessing Alton, you drew this to expand our understanding of the anatomy to then appreciate

00:56:18.040 the shoulder pain that somebody shows up with? Yes. So all these things that I've drawn on here

00:56:22.420 can be pain generators. And another one, which is exactly to the point we are talking about is this

00:56:29.720 right here, the AC joint. Almost everybody through wear and tear, middle age and beyond has arthritis

00:56:35.040 in the AC joint. And like we were talking about in the neck, it's almost always asymptomatic,

00:56:39.660 but it can be symptomatic. And sorry, just to be clear, the little red structure you've

00:56:44.100 drawn on there, that ligament that is connecting the clavicle to the acromion, there's no fluid

00:56:49.620 within that space or a tiny amount, any place there's cartilage, there's a tiny amount of fluid,

00:56:54.180 but there's very little, but it can expand. And so if it's arthritic, you can get more fluid. If you

00:57:00.020 have, you know, young weightlifters like you were can, I'll draw it here, can develop in the end of

00:57:07.540 the clavicle from that repetitive butt munt doing heavy bench and other types of activities can 0.96

00:57:13.120 develop distal clavicle osteolysis. That repetitive jamming or bruising of the bone and cartilage

00:57:19.200 causes the cartilage to disintegrate and the bone to lose its integrity. And it starts to kind of get

00:57:25.400 very soft and it gets very inflamed. As soon as you start breaking up cartilage, all the macrophages

00:57:31.080 from the body come in there and then you get a big inflammatory response. You get a lot of extra fluid

00:57:35.420 and a lot of pain. So from a chronic perspective, are you going to see that more in somebody doing

00:57:39.420 bench press or military press or which direction? Both, but you'll also get it. I don't do these.

00:57:45.400 I don't recommend my patients do them, but the people that love to do heavy lat raises, that just

00:57:49.680 jams up. It's just so much leverage on that joint. And if you are to do it, I recall you're sort of

00:57:55.720 more in favor of if you're going to do it, thumbs are up, not down. Yeah. And not directly lateral,

00:58:01.080 more in up. In the natural plane of the scapula. Exactly. That minimizes stresses.

00:58:05.080 The other thing about it is that joint, you can imagine it's like your understanding of

00:58:10.040 the biomechanics, you lie directly on the point of your shoulder and it jams that against. So

00:58:14.800 they have a lot of pain there. That pain comes right down the front, kind of follows the bicep.

00:58:19.800 So you have to differentiate that between the two. Then you look at an x-ray without an MRI or anything,

00:58:24.540 and you see these spurs that are down there. Well, those spurs aren't ever going to tear the

00:58:29.180 rotator cuff because that tendon is out there. It never gets that far, but it rubs. We see it as an

00:58:34.860 indentation in the muscle. So, you know, every time you're working out, you know, you hypertrophy

00:58:39.820 your muscles. So if you have that constantly rubbing there and then you hypertrophy around

00:58:45.520 it, it's a true. So that's an athlete who complains that when they're lifting, it hurts

00:58:50.640 more. Exactly. And that's a crystal clear when they're relaxed, they haven't been exercising,

00:58:55.940 they have rock solid strength. If you get them up into positions or if they've been working out,

00:58:59.660 you test them, they'll actually be weak. Not because they're truly weak, but because their brain is

00:59:03.940 saying, no, I'm not going to give you that. It's going to hurt me. It's going to hurt my body.

00:59:07.780 So I'm not going to give you enough electrical current to give you a full strength there.

00:59:11.440 Wow. You know, this reminds me when I was in medical school, once I decided I was going to

00:59:15.280 go into surgery, I read a book and I wish I could remember the name of it, but it was a book written

00:59:18.980 by a general surgeon who had long since passed away. But the entire book was based on diagnosing

00:59:24.480 appendicitis.

00:59:25.760 Cope's appendicitis.

00:59:26.580 That's right.

00:59:27.020 Early diagnosis of appendicitis.

00:59:28.820 And I thought this was the most fascinating thing in the world because you had this old

00:59:32.960 school, old school general surgeon who said, you know, this is before anyone was using a

00:59:37.080 CT, but he was like, this is 100% a clinical diagnosis. Nobody today training would ever

00:59:44.780 dream you could waste an entire book to diagnose something that, by the way, incredibly prevalent.

00:59:50.600 It's the single most prevalent condition in general surgery when you just shove everybody

00:59:54.200 in the scanner and get the answer today. But the reality of it is, this makes me think

00:59:58.580 of Cope's appendicitis. A, this is more complicated. And two, I don't think there'll ever be a substitute

01:00:03.940 for the nuance of the exam and the history, both the history of the injury and the history

01:00:10.100 of what causes pain.

01:00:11.700 It's fascinating. I love that.

01:00:13.160 We're going to come up with Barron's.

01:00:15.740 Well, the guy that was my Cope was our professor of cardiology at Tulane. He was super old when he

01:00:22.620 was teaching us. He was in his 80s at that time. That's not super old, but back then it was.

01:00:27.040 He had had thyroid cancer, so he spoke in a very hushed tone. His name was C. Thorpe Ray,

01:00:32.780 and he was a cardiologist. He could tell you exactly what was wrong with which valve just

01:00:38.920 by listening to, with his testicope, with his hands. Sometimes he just put his ear up there.

01:00:44.380 And exactly, he could tell by the nature of the subtle variations in the heart murmurs what the

01:00:50.760 dyness would. This is a little off topic, but I do sort of lament the fact that that's a dying art.

01:00:57.660 And look, the reality of it is I'm sure that today with Echo and stuff, we're better. And he was

01:01:02.120 probably such an outlier that most people could never rise to that level, just like most people

01:01:06.200 could have never attained the clinical acumen of Cope. But it is a little bit sad to think that

01:01:13.260 we can't have both. You have to think it would be great to have both. So it's interesting to think

01:01:18.020 that in orthopedics, it might be one of those specialties where this judgment of the exam is

01:01:25.460 still really, really relevant. That's right. Obviously, you get pinpoint diagnoses with the

01:01:30.520 various tests. And in orthopedics, there's plenty of things you find that aren't symptomatic. But still

01:01:36.300 thinking back to, I do lament that as well, about the loss of the clinical acumen that comes with

01:01:43.500 all the advanced imaging. But I think that if you have both, and I don't say this self-servingly in

01:01:49.400 the sense of, I want to keep doing what I do as long as I can, because I love it. But our patients

01:01:54.900 need us to be able to still diagnose, listen to them, hear what they're saying. Because, I mean,

01:02:01.180 I don't know anything about general surgery, but there's got to be things that come up positive that

01:02:05.560 you don't necessarily have to have surgery on. Absolutely.

01:02:07.800 And so you want to still be hearing and perhaps examining, but certainly hearing the patient's

01:02:12.940 story and knowing what's really going on to determine whether they need surgical or non-surgical

01:02:17.860 care or what kind of care they need. I feel like that was something that was,

01:02:21.480 if you were paying attention in residency, I think that was a very important message. I think when you

01:02:26.120 start residency, you're just so preoccupied with mastering the technical side of things. I mean,

01:02:31.400 there's so much to learn. It's like learning to master an instrument and learn a new language at the

01:02:36.020 same time and you've only got five years to do it. But I definitely remember the wisdom that was

01:02:42.480 spoken down to us, which is the single most important thing that you will learn is when to

01:02:48.120 operate and when not to operate. That's true.

01:02:50.380 I don't know how long that takes. My guess is it's well after you finish your residency.

01:02:55.560 I don't want to go down this rabbit hole too much, but unfortunately there's-

01:02:58.500 And there's some people who don't learn that.

01:02:59.680 Some people don't learn it or ignore it. And there are plenty of people who will operate on

01:03:04.620 any MRI, whether it's orthopedics or probably general surgery.

01:03:09.160 We had one surgeon who the joke was, if you rubbed betadine on the wall, he would operate on

01:03:15.240 the wall. Don't let betadine near the wall because he'll start cutting it.

01:03:18.680 That's a perfect way to say it without being too pejorative. And there are economic incentives.

01:03:24.020 There are even, and these are a version of economic incentive, but there is even incentives

01:03:28.560 in big institutions where it's an RVU concept where you're going to do more because that's

01:03:34.160 how you get your promotion and so forth. And I have to just suppress that information because

01:03:38.860 it makes me too cynical and sad, but it's actually happens. And I'm sure you did when you were doing

01:03:47.300 surgery. And I certainly do now. I see patients that walk in with their MRI all the time and say,

01:03:51.740 I'm scheduled for this surgery in my shoulder or my elbow. My friend said, I should just come get

01:03:57.660 one more opinion. And I say, look, I'm looking at you. I examine them. I do everything I go through

01:04:02.520 and I say, look, I wasn't there at the time of your examination. So I can't speak for what

01:04:07.320 that person saw and what their statement is. But today, based on your MRI, your history and your

01:04:14.860 physical exam, which I've done, I will not operate on you. If your friend said you should come to me

01:04:19.740 because I have decent operative skills, I'm sorry, but I can't in good conscience operate on you.

01:04:24.860 Maybe someday, but not now. I feel like I've sent you patients that have come from out of the 1.00

01:04:28.740 country and it's been, hey, I know that this surgeon is saying so. I just want Alton to have

01:04:33.700 a second look. I've never met a patient who didn't appreciate that, by the way. I mean,

01:04:37.260 sometimes it creates more confusion. And I say that. I say, look, I'm sorry if this

01:04:40.680 confused you. I'm sorry if this is complicating your trajectory of what you're planning for,

01:04:45.660 but that's just the truth. The thing you always have to remember as a patient,

01:04:48.960 and I think of this myself, is once you commit to doing something, the inertia to do it is huge.

01:04:55.660 And you can always just say, look, there's an asymmetry in this decision. To not have surgery

01:05:01.340 doesn't remove any options. You get to have surgery again later if it was the right thing to do.

01:05:06.800 Yes.

01:05:07.360 Once you have surgery, it's not that you can't have surgery again, but the operative field never

01:05:12.120 looks the same a second time. That's a very good point.

01:05:14.300 And so you want to keep in mind the asymmetry of a pause. All right. So let's go back to our

01:05:19.560 shoulder pain patient. I think one thing we've established so far is a patient that has shoulder

01:05:26.840 pain can have so many things going on. Their AC joint can be the problem. They could have brositis.

01:05:33.080 They could have a rotator cuff injury. They could have a labral injury. They could have bicep tendon

01:05:38.640 inflammation. And let's just leave it at that. They could have arthritis. We've got all

01:05:44.240 of these things that are going. Now arthritis would usually be accompanied by one of these

01:05:47.240 other things that predisposed it. So we're going to go through an exam and you're going to basically

01:05:53.020 run me through, these are the things you do. And this is what you look to see on the MRI

01:05:59.080 to basically correlate your findings and give you a set of confidence as you go into the operating room.

01:06:06.120 You named the bulk of them. I want to add two things to that before we do our exam. One of them,

01:06:12.180 I've drawn just kind of a red arc down there. And what I'm showing there is the capsule. That's the

01:06:20.000 best place to see the capsule when you're looking at an MRI because it's thicker there and it's more

01:06:27.360 distinct. There's not other structures obscuring it. Normally, if you have a super loose joint,

01:06:34.680 you can have a very capacious capsule like that, that allows it to flop down and even sublux or

01:06:39.900 dislocate. When it's very high and tight and thick there, that can be representative of something

01:06:46.600 called adhesive capsulitis. And the reason I say that is because that's so common, one, and two,

01:06:53.360 it can conflate all sorts of diagnoses. And the frozen shoulder, there's the layman term for

01:07:00.880 adhesive capsulitis. We don't know why this happens. It's super common. I see probably two

01:07:07.420 or three new cases every week in my office. It's that common, but it's multifactorial. It's worse

01:07:14.400 like many things are if you have diabetes, but you don't get it with more frequency if you have

01:07:19.140 diabetes. But it is, and it's a full spectrum. And there's a lot of misinformation about it because

01:07:26.720 the original old literature said that, oh, all of these just get better with time. Well,

01:07:33.060 they don't all, we know they don't all. And even a subset of them in my practice, about only one out

01:07:38.220 of five actually ever need surgery. And we never do that at the beginning. And it's just a simple

01:07:43.800 little 30 minute release of the capsule and a reduction in the inflammation. And then they're so

01:07:48.980 happy, but that's the exception. 80% do not need any surgery. They need some way to control the

01:07:55.480 inflammation. They need really good physical therapy and a home program.

01:07:59.860 For mostly mobility?

01:08:01.240 Yes, for mobility. That's why I'm saying that is because you can get a stiff shoulder if you have

01:08:07.100 impingement, if you have a big bone spur, because your brain says, I'm not going to let you move it

01:08:11.620 there. And then it just gradually stiffens up. That's a secondary stiffness or adhesive capsulitis.

01:08:17.540 It's not the weird primary adhesive capsulitis that could happen to you or me just suddenly.

01:08:24.180 And it just happens. It's a spontaneous, intense inflammation in the lining, inner lining. If

01:08:31.000 you take a little camera and stick it in there and just look, you see it's beet red. Normally

01:08:34.960 everything, when you're in arthroscopy, everything's kind of off white. But in the case of it's just

01:08:40.520 beet red. And it's crazy. And people have done all sorts of laboratory tests, biopsies, evaluations

01:08:49.040 have happened over a long period of time. I mentioned to you, there's a colleague of mine

01:08:53.440 in Northern California that wants to talk to you because you're so smart in this about frozen

01:08:58.140 shoulder because that maybe he thinks some of the things you've said might overlap with that

01:09:03.100 biochemically.

01:09:04.860 I was going to say, what are the, I mean, do these respond to NSAIDs or is this a part of the body that

01:09:09.920 doesn't have enough of a vascular supply in the capsule that you don't get enough penetration?

01:09:14.540 It has a rich vascular supply, but I think in this case, I give NSAIDs when people want them and

01:09:20.780 they're afraid of an injection, but because it's that inner lining and it's so robust. I mean,

01:09:25.880 if you look at it microscopically, it's just these angry red fronds. And I think it's just not

01:09:31.520 strong enough. So I like to put a small dose of cortisone into the joint.

01:09:35.860 Where do you inject?

01:09:36.460 One time. I always inject from the back for two reasons. One, this part is more richly supplied by

01:09:42.340 the brachial plexus. So it's more sensitive. And two, people kind of see you coming at them with

01:09:46.700 the needles. So I always go in the back and I never use an ultrasound. That's a whole nother thing

01:09:51.620 that a lot of clinicians use the ultrasound just to see, but you can feel where you're going. You

01:09:56.160 just get it in there. And what's super cool about this is people come in with a lot of stiffness and

01:10:02.320 a lot of pain, and then you inject them and put local anesthetic as well in there.

01:10:07.660 They're free in 10 seconds.

01:10:08.460 Oh my gosh. They walk out. They're saying, oh my gosh, it's amazing. And they still probably need

01:10:13.440 physical therapy. But the fact that they got such dramatic relief with such a simple treatment is

01:10:18.800 so fulfilling.

01:10:19.520 So do you recommend that a patient with frozen shoulder

01:10:21.600 err on the side of earlier intervention with a cortisone shot to then allow them to do more

01:10:28.980 rehab sooner? Or do you say, I don't want to do a cortisone shot until you've done three months of

01:10:33.360 rehab?

01:10:33.620 It's purely based, again, on their exam. Their exam and their history, how long they've had it

01:10:38.480 and how acutely symptomatic it is when I'm examining them. If I can stretch them and they

01:10:44.680 start kind of saying, oh, that hurts a little bit at the end, but they've got decent motion,

01:10:48.260 they're tight.

01:10:48.660 Then go back and do the rehab.

01:10:49.940 Go to PT. Go to a good PT who will really stretch you out. You don't need anything. You don't even need

01:10:54.100 insets. But if I can't get them to move and they're screaming, they're not going to get anywhere in PT

01:11:00.180 because it's going to hurt too much to do it. So I'll inject them, then send them to PT. And I always

01:11:04.720 see them back at about six weeks. Most of them are dramatically better, but not all of them.

01:11:09.040 Very rarely, they need a second shot. And then some of them are just recalcitrant and they just

01:11:13.820 stay stiff. And then I'll do the little procedure on them.

01:11:17.640 So there was one other thing you wanted to mention.

01:11:19.440 Oh, yes. A big source of neck pain, which you and I have discussed multiple times is referred

01:11:26.120 pain from the spine, from the neck. And so we'll include that in our exam because it's so important

01:11:31.700 because-

01:11:32.460 You at least have to rule that out.

01:11:33.640 Well, especially because someone comes in with shoulder pain and I see that I take care of a lot

01:11:37.540 of professional musicians. Their necks are doing all sorts of crazy things from all the violinists

01:11:41.820 and the philharmonic or et cetera, just all types of musical instruments that lead to having to

01:11:47.740 maintain these certain postures that sometimes are very counterproductive to their overall

01:11:52.040 musculoskeletal health. But they'll come in with shoulder pain going down their arm,

01:11:57.640 maybe even down to their hand. And they'll have already gotten a shoulder MRI and they're 55 and

01:12:04.280 they have four findings on their MRI, but it's not coming from their shoulder. It's coming from their

01:12:09.200 neck. And so we have to make sure and differentiate that. And because the worst thing I could do to them

01:12:15.980 is have them take time off from music to fix what does need to be fixed in their shoulder.

01:12:20.900 And then they have them return.

01:12:22.000 And they still have the pain.

01:12:23.240 And in that situation, is there something you see on exam that makes you think,

01:12:27.720 we better go look at your neck first with the MRI because the symptoms fit as something I'm

01:12:32.500 expecting to see. And then you look and you see, well, I do see that. So now that's-

01:12:36.600 Yes, exactly. So intrinsic shoulder pathology, whether it's a rotator cuff, whether it's impingement,

01:12:43.160 whether it's arthritis, almost never does the pain radiate down below the elbow. Whereas neck

01:12:50.920 origin, whether it's pinched nerves at the lower cervical spine, where it's more common to have

01:12:56.820 pathology, almost always goes down below the elbow and into the hand.

01:13:02.440 One odd ball is C7. And I learned this not that long ago from some really great cervical spine

01:13:08.580 surgeons is that if you have a deep posterior pain under your scapula, that can be C7. And that's

01:13:16.780 right where it goes. And so I've had two musicians whom you know recently, both with that diagnosis.

01:13:23.660 Yeah, it's funny. The only time I've ever had a complaint of a neck issue, what turned out to be a

01:13:29.220 neck issue was not, didn't present as neck pain. And this was several years ago. Now, again, in the back

01:13:34.320 of my mind, I've always known I'm susceptible, I'm susceptible, I'm susceptible. And I woke up

01:13:39.700 one morning and my left trap felt like it was in spasm. And I kind of ignored it. I was like,

01:13:47.580 oh, I slept wrong, you know, whatever. This is super uncomfortable. You know, the next day it was

01:13:53.700 still in spasm. I just sort of ignored it. I might've taken some NSAIDs. This went on for like

01:14:01.020 two weeks, maybe not two weeks, it might've gone on a week at that point. And at this point,

01:14:04.700 I'm thinking, I've never had a muscle that's this tense for this long. And at about that time,

01:14:11.280 very abruptly, I started to notice a loss of tricep strength.

01:14:15.680 Wow. Yes.

01:14:16.640 You know, I noticed it in the gym because, and it was subtle at first because I was doing,

01:14:20.960 you know, skull crushers where you have two dumbbells. So now the right arm can't compensate

01:14:25.820 for the left because you're using two dumbbells. And all of a sudden, I couldn't move the weight

01:14:29.400 with this arm. That's weird. I can move it this way. And then it progressed so rapidly

01:14:33.440 that within about two days, I couldn't pull my bow back because this arm couldn't support here.

01:14:40.100 So at that point, I was kind of freaking out. I'm now down to, you know, only being able to do a

01:14:43.840 couple pounds. So I know, hey, once you have those motor symptoms, but here's the thing,

01:14:47.340 zero pain, not a lick of pain, no numbness, tingling, no paresthesias anywhere. My neck doesn't

01:14:53.620 feel a thing. I just have this trap on fire. Make a long story short, I see a person who says,

01:15:01.640 look, we could operate on you. But unfortunately, this is a surgeon who shares your ethos. And she 0.82

01:15:06.200 said, look, let's rehab the heck out of this. I think if you want, we could do an injection. 0.76

01:15:11.060 I wasn't excited about it because it was an anterior injection. And I said, no way, I'd rather do

01:15:15.200 prednisone and traction. And so we did prednisone traction. And sure enough, within three months,

01:15:21.480 the strength was back. It's never returned. But that was a real wake-up call to me that I had a

01:15:27.980 cervical symptom that didn't present with any neck pain. That's a great story. It's so instructive

01:15:33.380 and you're absolutely spot on. When I see, especially the musicians, as long as you don't

01:15:38.440 have, now you did have some, so you were absolutely right getting more deeply studied to make sure

01:15:43.140 because you had triceps. But if you have no weakness, maybe you do have a little tingling or

01:15:47.520 something, but I just know it's coming from the neck, I won't lurch in and get MRIs of the neck,

01:15:52.680 x-rays and MRIs of the neck. I'll often just give them one very low dose of prednisone. And it usually

01:15:58.040 goes away. They don't have to worry about it. And they don't have to go down the rabbit hole of worry

01:16:02.720 and anxiety about that. At this point in the conversation, Alton demonstrates on me what he'll

01:16:08.320 do for a typical physical exam of the shoulder. This includes what he looks for, as well as what might

01:16:14.400 be the root cause of any pain or issues. As this lends itself much more to video, we decided not

01:16:19.640 to include this in the audio version of the interview. If you'd like to see what this exam

01:16:23.340 looks like, you can head over to the show notes page or to our YouTube page, where we have the

01:16:28.100 full exam videos very clearly broken out and available. Now, back to my conversation with Alton.

01:16:34.240 So now we have a sense of how complicated and nuanced the exam is. So now let's assume we have

01:16:40.040 the diagnosis. So let's walk through some of the surgical treatments here. Again, let's start

01:16:44.220 with the operation I have. So a labral repair, is the approach significantly different, whether

01:16:49.400 it's a slap versus a complete tear like mine? I assume it's just the number of ports or how does

01:16:54.040 it? It's just a little more technically to do and you need a few more little. And we do most of these

01:16:59.980 now, as I was talking about the technology earlier, that we can do these percutaneously. So we don't

01:17:04.660 need five big, I mean, these are only a centimeter and a half. The biggest ones are only about a centimeter,

01:17:09.860 a centimeter and a half. But the others, they can be percutaneous tiny little holes that we

01:17:14.060 use a little cannulas through and then put the drill through and so forth. So that's right. It's

01:17:18.280 more just adding a little time. You know, it takes 10 minutes to do each anchor sort of thing. And so

01:17:23.360 you just add on and you needed a bunch. It seems like the first thing, if I recall,

01:17:27.380 that exam under anesthesia is crucial, right? Oh, I'm glad you mentioned that. Yes. So

01:17:31.880 even with a good exam, remember that a dynamic exam, your brain has been dealing with this problem

01:17:38.480 for a long time. You're naturally, well, not naturally, you work, but have good muscle tone. So if I'm

01:17:43.060 examining you, I probably can't sublux your shoulder. I have to kind of jump up on top of

01:17:47.480 it to do it. The rare case is somebody who's had such longstanding instability that their body's no

01:17:53.100 longer responding to it. And usually I can get one or two subluxations, but then they tense up,

01:17:59.320 but I can usually get one or two. So that's one subset. So great thing about an exam under anesthesia

01:18:05.280 is once you're in your position where you're going to have the surgery, you've got a regional block

01:18:09.980 where your arm is super numb and you're sedated so that you're relaxed and you can't control

01:18:14.500 anything. And then I can just, it's as if your muscles aren't really there. I mean, they have a

01:18:19.560 little effect on it, but mainly I'm testing the static stabilizers. In your case, I could take it

01:18:25.180 pretty far out back and weigh, I could completely dislocate your shoulder out front. It still hurts

01:18:30.600 for me to watch that video. It's interesting. It's super cool. And so then, you know, then that tells me,

01:18:36.740 okay, I need to be careful when I'm looking on the inside, I need to assess not just the labrum,

01:18:42.720 which I know is torn. I need to, in the case of the anterior, you've been like the balloon you're

01:18:48.900 blowing up repeatedly. You've been also stretching out your capsule. You're still compensating

01:18:53.840 well, less well and less well with the muscles, but you are compensating. So if that is stretched

01:19:00.180 down the front, I need to know that in addition to just repairing the labrum itself, I need to gather

01:19:05.180 up some of this capsule, which has become too capacious and do what we call a capsulography,

01:19:11.300 which is to gather and tighten that up too. And that's kind of a judgment call. When you've done

01:19:15.980 a lot of them, you kind of know how much to gather. You don't want to gather too much because then it

01:19:19.960 tightens them up too much to that point. And this is a caveat about, well, yeah, unnecessary surgery.

01:19:26.460 Had a lovely violinist, professional violinist who I'd treated her whole family. They're all violinists.

01:19:31.780 And she had been up in Vermont, farther enough away to where when she had a frozen shoulder or

01:19:39.720 shoulder pain, she got an MRI, saw a sports doctor who saw, and again, she's 60 at that time, 62,

01:19:47.540 63, and had some degenerative labral tearing. Well, he said she needed to have a repair of that. 0.81

01:19:55.020 And she presented with what pain?

01:19:56.700 Just pain, a little stiffness. Okay. So just read the MRI. It said labral tearing. Didn't really

01:20:04.000 have anything else. So said, you need a repair of your labrum. Did a repair of the labrum. She came 0.96

01:20:09.340 to me about six months later in tears, had not been playing for six months, had the stiffest shoulder

01:20:15.980 I think I've ever seen. Basically didn't move.

01:20:18.220 So he tightened the hell out of the capsule?

01:20:19.780 And did a labral repair that in a 62-year-old who's not an athlete would never be necessary. Sort of

01:20:26.780 universally true. So I had to go in and scope her. It was really hard because it was so tight.

01:20:32.840 Had to just bit by bit release everything that had been done and release the capsule that was all

01:20:38.920 crunched up and tightened up. Even had to take some of the sutures out to free up her shoulder. 1.00

01:20:44.580 Do you have a sense of what her initial injury was even caused by? I mean, do you think it was

01:20:48.900 just capsular?

01:20:49.780 I think she just had the classic frozen shoulder. 0.99

01:20:52.620 So someone that should have had PT plus or minus at most a single injection to reduce the

01:20:58.540 inflammation has the exact opposite. They get a complete tightening of the capsule. And there's

01:21:03.280 a school of thought in orthopedics that says, we just don't like repairing labrums and doing capsule

01:21:08.340 repairs in older people because that's the outcome you get. 0.55

01:21:11.900 Yes. And that's completely valid.

01:21:13.380 I remember some people that I spoke with who said, wow, at your age, Peter, you're basically

01:21:18.460 50. You're having a labral repair. Are you crazy? Now, of course, in my case, I think I haven't

01:21:23.840 lost any mobility, which is kind of remarkable.

01:21:26.360 No. And in fact, you and I discussed that some.

01:21:28.540 That was one of my biggest fears.

01:21:29.800 So one has to pay extra attention to that. For me, if we want to be specific about your

01:21:35.420 case as just a case example, I don't think we had a choice because your subluxation, you're

01:21:40.780 so active, you're subluxation with all the different activities. You already had some

01:21:45.760 arthritis. You're already wearing down some cartilage. It's either that or the inevitability

01:21:50.660 of having a shoulder replacement in another 10 years.

01:21:53.180 I think when I saw the little bit of arthritis there, I kind of wished I'd done it sooner.

01:21:59.120 Knowing what I know today, I almost wish I had more pain sooner. I really had a ton of pain 10 or

01:22:06.300 15 years ago. But with a lot of good tissue work and a lot of training, I kind of got out of it.

01:22:13.900 And I made some modifications. Like there were certain things I just decided I couldn't do.

01:22:17.420 But another component of that is, especially now, people are so much younger, mainly because

01:22:22.660 they're all rucking now. No. People are so much younger physiologically, in better condition.

01:22:27.500 And we know that from whether it's cancer treatments and everything else and the advancements of

01:22:32.180 science, that a 50-year-old now that would have applied to that data that we have 20 years ago is

01:22:39.880 misleading. So I base it on, you were kind of an outlier.

01:22:44.260 Yeah. You base it on biological age, not cardiological age.

01:22:47.380 And even, look, there are some people that have, I'll scope them. I'll say, look,

01:22:52.180 I don't have any other way than looking and seeing what's there. And in some cases,

01:22:55.900 they have better cartilage than what the MRI is indicating. And then I can go ahead and do a

01:23:00.560 repair. And some of them are, I've done a couple, maybe I shouldn't say this on air,

01:23:06.160 I've done a couple of like 58-year-olds, 60-year-olds, but their joint was pristine. I mean,

01:23:11.320 it looked as good as a 25-year-old. They just had a discreet labral tear.

01:23:16.340 This is to me an extension of what I think of as precision medicine, which is we use evidence-based

01:23:21.760 medicine, which is incredibly heterogeneous to make population-based assertions and general broad

01:23:29.320 recommendations. But ultimately, the only patient that really matters for most doctors is the one

01:23:35.500 right in front of them. And therefore, you have to be able to make evidence-informed decisions

01:23:40.640 based on the appropriate physiology that you see.

01:23:43.880 And it's also a conversation. It's a conversation with that patient, not a unilateral decision. It's,

01:23:49.100 okay, what do you want to do? What do you know about this? Here's what I know about this. Here's

01:23:53.840 what I'm seeing with you. And we need to say, here are the possibilities and what do you want to do?

01:23:59.300 So how often when you go in for, I guess, just explain to people. So the biggest port puts the

01:24:05.840 camera and then you have like a few working ports, obviously.

01:24:09.400 Yeah. So typically, since more of the pathology is superior and anterior, although you had some

01:24:15.300 in the back, if you're working in the superior in the front, you go in through the back with the

01:24:20.320 camera. So you just have a good panoramic view of everything. We have two different kinds of angled

01:24:24.860 lenses. So we can see around corners if we need to. Usually you don't need them for most things.

01:24:28.380 But then I can see the superior labrum. I can see the biceps.

01:24:32.960 In general surgery, we insufflate with carbon dioxide, right? So you're shooting carbon dioxide

01:24:37.000 to blow everything up. I assume you're using saline to do the same thing. So you're making

01:24:40.780 that capsule bigger.

01:24:41.780 And that's a good point. So I don't use, I mean, I've done a lot of these. I don't use high pressure.

01:24:47.200 Some people use around 50 millimeters of mercury pressure. I use 35.

01:24:51.360 And that means less post-operative pain, presumably.

01:24:53.580 It's less going, yes.

01:24:55.100 Less distension.

01:24:56.040 Distension of the whole shoulder and so forth.

01:24:57.960 So that's what I do. And you can still put in little retractors, kind of pull tissue out

01:25:02.680 of the way and so forth. So that's just a technique. That's more of an extension of what

01:25:05.720 I do in the elbow because there's a lot more peril because of the nerves being so close.

01:25:11.540 So then usually you need two working portals in the front, which are just cannulas that are

01:25:16.120 just basically canals to get in with instruments that are long enough to fit through and do the

01:25:21.540 work.

01:25:21.780 And then in the case of, for instance, a superior labrum, we use a percutaneous right through the

01:25:27.540 top, just underneath the kind of right here, actually, right through here where that red

01:25:33.300 arrow is going. And that just gets you to the superior labrum. So that's a little percutaneous.

01:25:36.920 You make a tiny little hole in the rotator cuff, kind of muscle tendon junction. It just spreads

01:25:42.120 the fibers apart. So it doesn't do any damage to that. And then you've got a perfect bird's eye

01:25:47.040 direction for the drilling and putting in those few anchors in the top. And then that's really it.

01:25:52.960 And explain how that works. So you drill a little hole in the glenoid fossa. What's the diameter of

01:25:58.380 that hole?

01:25:59.320 It depends on what kind of anchor you're doing. Usually roughly not more than three millimeters.

01:26:05.100 And now we're down to 1.8.

01:26:07.280 Okay. Even three seems big.

01:26:09.040 Three seems big, but that's what you fit the plastic or the absorbable anchor in that you just

01:26:15.080 kind of tap in with the mallet. All of them you tap in with the mallet. And you're drilling

01:26:18.700 into the bone. You're drilling around here, kind of this angle here. And you have to get the angle

01:26:26.660 right. It's a very three-dimensional, but you put them in so that you're drilling into hard bone.

01:26:31.720 And then the anchor inserts through that.

01:26:34.360 So they're not circumferential.

01:26:35.940 No.

01:26:36.420 They're just straight in.

01:26:37.300 If we did them open, we used to do them even with-

01:26:40.240 Like a suture, basically.

01:26:40.620 Drill holes and a suture going through circumferential.

01:26:42.980 And so what holds the anchor in? Is it just the pressure? You're putting an anchor in that is

01:26:47.280 bigger than the hole. And so it's sort of like a nail.

01:26:50.320 Yes, exactly. Or a tent.

01:26:52.360 Not a screw.

01:26:53.360 Not a screw.

01:26:54.360 There were historically some that we screw in, but not anymore. And now the ones that are purely

01:26:59.320 basically braided polyester, those go in, the suture goes in. And then as you carefully pull it

01:27:06.200 back out, the way they're designed, they ball up and it creates a, I mean, they're super strong.

01:27:10.660 You can lift the shoulder off the table. So it's super cool to use those.

01:27:14.460 Wow. That's so interesting. So you have a lot of confidence in the integrity of that repair.

01:27:19.440 Yes. I know that if I tug on it multiple times, it's not going to come out. I mean,

01:27:24.400 it would take a fully traumatic force to do that.

01:27:27.720 So before you do this, I assume you do an exam of the cuff while you're in there?

01:27:33.660 Absolutely. So you go through and do a survey of the joint. You look at the cartilage surfaces from

01:27:38.120 the nooks and crannies cartilage surface. You look at the rotator cuff inserting on the bone

01:27:42.760 from inside out. And you can see that being smooth. If it's frayed, if it's notably frayed,

01:27:48.900 you can probe it and you can see, oh, that, you know, actually has a also, and I occasionally see

01:27:53.520 that because they're athletes, a small, almost full thickness tear. Then I may put a stitch or two in

01:27:59.120 that to fix that. You look at the biceps, you can pull the kind of the biceps into the joint and see

01:28:04.460 a pretty good segment of it and see if it's inflamed, torn, something abnormal there.

01:28:10.040 And you can see the tendon of the bicep really well.

01:28:12.840 Oh, yes.

01:28:13.260 To see, obviously, is it frayed?

01:28:15.060 Yes.

01:28:15.680 So how much damage do you need to see to do the tendonesis?

01:28:19.460 Not a lot. If I see a combination of a modest amount of fraying and a lot of inflammation around it,

01:28:25.680 and when I pull it in the joint, that extends further out, then I'll tend to ease it.

01:28:30.000 It's interesting. I think for people to understand how much your eyes are helpful here,

01:28:33.820 right? As you said, when you look at these images, and we'll link to some images in the

01:28:37.460 show notes of what these pictures look like. In fact, we can include my pictures and just

01:28:40.680 other pictures we'll find online. It is just a very plain, banal, sort of gray, white, normal thing.

01:28:47.680 And to think that inflammation just shows up is like, wow, that's really red.

01:28:52.160 Exactly. And for me, some people don't like to waste the time,

01:28:55.360 but I get a little electrocautery wand, and I paint the internal and get rid of all that pink 1.00

01:29:00.580 because it's inflammatory. It hurts. And that's part of one of the big pain generators. So I just

01:29:05.100 do that automatically. Now, theoretically, if you fix everything, that's going to go away anyway,

01:29:09.000 but it helps them, I think, early post-op. A recent patient I had, I did a pretty significant

01:29:14.180 repair on, and he, after five days, said, I haven't had any pain. What's going on? Do you do

01:29:18.780 anything to my shoulder? So I said, yeah, I did repair it. But I think part of it is just getting

01:29:23.280 rid of that inflammation and so forth. So now contrast that with the pure rotator cuff repair.

01:29:29.860 Let's do two examples. Let's talk about a patient. What is the most common athlete's tear? Which one

01:29:35.400 is it going? Did we say it's going to be subscapularis or supraspinatus? It depends on-

01:29:40.840 If they're an overhead athlete. If they're an overhead athlete, then it's going to be supraspinatus

01:29:44.660 almost always. And sometimes it can be the infraspinatus. Right. So if a guy just has a straight

01:29:50.340 up supraspinatus tear, you don't even need to enter the capsule necessarily, depending

01:29:54.560 on how close it is.

01:29:55.820 No, you do. Because you want to, first of all, you want to make sure that you're not missing

01:30:00.140 anything, which is common in the athletes. There's a couple of interesting various. I'm

01:30:04.680 going to draw some pictures. Okay. So here I've drawn three sequential axillary views, which

01:30:12.520 are a bird's eye view looking straight down on the top of your shoulder. If I were sitting

01:30:16.000 on top, looking straight down. So we've got the glenoid, the socket here.

01:30:20.340 Toward the head. And we've got the ball out here toward the outside where the deltoid

01:30:26.020 lives. This is the supraspinatus I've drawn in here on the top. In the back, as we talked

01:30:32.140 about before, that's the infraspinatus. And then in the front is the subscapularis.

01:30:36.680 Those are the three. The teres minor, which is the fourth muscle of the rotator cuff, it's

01:30:41.000 not really a relevant player in the pathology.

01:30:43.700 Very true. It almost never tears.

01:30:45.660 This is actually really a cool way to look at it. It's not normal that we usually look at them

01:30:49.980 from front and back, but the bird's eye view is what allows you to see how the subscapularis

01:30:55.860 and the infraspinatus are stabilizing the front and the back while the supraspinatus is coming

01:31:00.140 in over the top. Is the supraspinatus that wide, relatively speaking?

01:31:04.020 Yeah, it's pretty wide.

01:31:05.000 Wow. That's so interesting.

01:31:06.000 More about here. Here it is. I drew it a little wide there.

01:31:09.260 Okay. But that's interesting. Again, in anatomic diagrams, because you're looking at it from

01:31:13.100 the front, it looks like a tiny little muscle.

01:31:15.300 Yes, but it's broad. It has three-dimensionality in it. That's about three, roughly three and a

01:31:19.340 half centimeters of width going front to back. And so there's three different views. The most common

01:31:24.860 one is the middle one because that's anterior. The biceps is here. That's an anterior superior tear.

01:31:31.400 That's the one that the overhead athletes get a lot, non-throwing athletes, but tennis players,

01:31:37.500 volleyball players, and weightlifters. And that is one of the critical zones where it can get

01:31:44.080 wrung out and not have good blood supply. And that's where they tear. That's where I had my

01:31:47.340 little tears on both shoulders, but that's the garden variety one. That's also the one that can

01:31:51.700 be caused by the spur pushing down on it. And I've drawn a little arc because that's kind of

01:31:56.900 they'll tear off and then they'll form a little arc of smooth tissue. And you freshen that up,

01:32:01.820 freshen up the bone, and then put the sutures in that leading edge of the tendon and put it

01:32:06.880 back just like you'd put a tarp with a tent stake back in. And that's how you repair it.

01:32:11.540 You get it back to the good bony bed and you get that good biologic healing. And that's a small tear

01:32:16.360 that I've drawn there. And they can be bigger and bigger, if you can imagine, and more chronic.

01:32:20.360 Now, the one down below shows the subscapularis in the front. And that is the one that can tear

01:32:25.960 in young people or older people based on mechanism. So if you have a linebacker who has, he's going

01:32:36.860 forward at full velocity and then somebody is knocked into him and shoots him across, he's got

01:32:42.660 his arms out there ready to go. And he gets eccentrically loaded into external rotation like

01:32:48.820 that. That's how you can tear the subscapularis. The other way is people falling downstairs and

01:32:53.820 grabbing the banister and wrenching back that way. That's the common, it's commonly torn with

01:32:59.000 eccentric load. Abnormal, weird stretch where they're contracting and then it's just torqued

01:33:04.840 on it. Now, this upper one is very interesting because we were talking about throwing athletes.

01:33:09.980 So the throwing athletes, baseball players and football players, they externally rotate dramatically.

01:33:16.820 That's how they get their extra angular velocity to really get that zip on the ball. So they acquire

01:33:23.000 external rotation starting at a young age. Their arms are very asymmetric, their shoulders. One side

01:33:29.740 will externally rotate to 90. The other one will go back another 45 degrees. And that's how they get

01:33:34.940 that whip. One of the consequences of that in a subset of them is that as this rotates and follows this

01:33:42.660 area around, that area of the rotator cuff, which is at the junction of the infraspinatus and the

01:33:48.080 supraspinatus abuts up against the hard bony rim of the glenoid. And they get an internal

01:33:55.740 impingement, ultimately get small partial thickness or even full thickness tears there. So we have to

01:34:02.920 be super cautious with those. We have to repair those, but you have to be really careful because

01:34:07.480 if they lose 10 or 15 degrees of external rotation, they lose.

01:34:11.820 So where does the Tommy John fit into this?

01:34:13.640 Yeah. So that's the elbow, but it does. No, it's maybe that was just intuitive because since you are

01:34:17.780 a good orthopedic surgeon is actually it fits in because a lot of people add torque on their elbow

01:34:24.840 because they have shoulder pathology. If they have a little weakness or something going on in their

01:34:29.400 shoulder, they will overthrow with their forearm and their flexor pronator mass. They'll overthrow with

01:34:34.920 the torque and then they'll tear their medial collateral ligament of their elbow. It's crazy,

01:34:38.840 but true. And vice versa, if they have a weak, if they have a partially torn medial collateral ligament

01:34:45.900 that hasn't yet been identified, they can overthrow with their shoulder to compensate,

01:34:50.960 to get more angular velocity on that because they can't muster it through the elbow.

01:34:55.280 How many years ago would it have been the case that a torn rotator cuff was the end of a pitcher's

01:35:00.880 career or a quarterback's career at the professional level?

01:35:03.780 I would say easily not more than 20 years ago, probably even not 15 years ago, probably 15.

01:35:11.020 And today that's not the case?

01:35:12.820 No, no.

01:35:13.960 What has been the advance that has changed? Because I can't think of anything that could

01:35:18.880 be possibly more stressful. I mean, to me, throwing a baseball seems even more stressful

01:35:22.780 than throwing a football because you do it more times in a game.

01:35:25.840 Absolutely, right.

01:35:26.000 So what has changed that has made that?

01:35:28.460 What's changed is earlier diagnosis. Now, certainly at the Division I collegiate level

01:35:33.720 and the professional level, there's any pain is evaluated, kind of over-evaluated. And that can

01:35:40.500 be good for them. I mean, it's used a lot of resources, but it identifies these very early.

01:35:45.520 So that's one way. So you get to them earlier.

01:35:47.960 So in other words, quarterback pitcher says, you know what? It's starting to hurt a little bit.

01:35:53.620 You see a very small tear in the cuff. You're saying it's better to go in and repair that than

01:35:59.120 let it become a bigger tear?

01:36:00.840 Yes and no. It depends. You'd certainly watch it carefully and you correlate the symptoms with,

01:36:06.560 sometimes it's not the tear. It's just some inflammation that's related to it. If you can

01:36:11.020 cool that down, the tear is not biomechanically significant yet. I've said this to many people.

01:36:16.820 I have full thickness tears in people that are minimally symptomatic and partial thickness

01:36:23.480 tears that are very symptomatic. It kind of depends on what you-

01:36:25.980 And I think one thing that's kind of missing from this picture in the subscapularis and the

01:36:29.900 infraspinatus is how long they are. So we're looking at the top, but these muscles cover the scapula.

01:36:37.020 Totally.

01:36:37.780 So when you say a full thickness tear, I want to make sure people understand the size of the tear.

01:36:45.100 Yes. So when I say full thickness, I mean like when we were looking on that other view,

01:36:51.040 draw that again. Oh, actually I can just go back to the previous one that I drew.

01:36:56.640 So when I've drawn the supraspinatus tendon, that perpendicular distance through there is the

01:37:03.260 thickness, the full thickness. It varies depending on the size of the patient.

01:37:07.600 But it could be across the entire four centimeters. It could be a whole four centimeters by

01:37:12.660 half a centimeter. Yes. So you could have, when we speak typically about full thickness,

01:37:18.940 we mean the depth of it this way so that you can have a partial thickness tear that's maybe half

01:37:24.840 the tendon there or full thickness. Now, if you have half the tendon torn, you've lost enough

01:37:29.840 biomechanics that if you're a high level throwing athlete, no way.

01:37:32.980 Whereas a partial thickness tear off the tendon could easily be ignored.

01:37:39.000 Correct.

01:37:40.280 So then when we talk about this, yes, those muscle bellies are huge. Now, the reason you 1.00

01:37:45.920 jogged my thinking about that is you can have, especially if you have, these guys are so strong,

01:37:53.240 like the football players and so forth. Sometimes they have that wrenching injury. They don't rip the

01:37:58.560 tendon off the bone, but they interstitially tear at the musculotinnitus junction. And they have a

01:38:04.620 tremendous amount of edema, weakness, pain, but that will heal. That will heal without any intervention,

01:38:10.700 just some tincture of time and some anti-inflammatory and just time to heal.

01:38:15.320 What role do stem cells or PRP play in any of this? Certainly anecdotally, there are a lot of people

01:38:21.720 saying, look, stem cells aren't going to replace a labrum. They're not going to work there. But

01:38:25.820 you have a tear in the muscle, stem cells can be valuable. Now, I'm not really aware of RCTs that

01:38:34.240 have looked at this, but I also haven't scoured the literature on the rotator cuff. Are there people

01:38:38.860 running clinical trials on stem cells in that indication? I think so. I don't know that literature

01:38:44.640 as well as maybe I should. I tend to go to all the meetings and I stay fairly abreast. There is

01:38:52.200 obviously a lot of activity going on, but there's a lot of terribly designed studies all around that

01:38:58.860 are being used to justify using whether PRP or stem cells. So one has to be careful to extrapolate it to

01:39:06.880 your individual practice. And there's a lot of money involved in it too. I mean, I have patients

01:39:11.760 routinely that fly to various places, including Germany, including, and I'm not pillaring by any

01:39:18.140 means because they exist everywhere. I just happen to know a couple that just got back and they pay a

01:39:22.220 lot of money to get stem cells injected for things that we've been talking about. And there's no data.

01:39:29.100 I'm not talking about the musculotendinous. That's different. I want to talk about that, but let's say

01:39:32.780 just a garden variety, small rotator cuff tear. There is no data ever. There are some, a few anecdotal

01:39:39.220 reports where people say, look, there was a tear there on that MRI. I injected PRP and it's healed. It's gone.

01:39:45.880 I don't know what to make of those. They're just one-offs.

01:39:48.960 Well, also, do we know what the natural history of that injury would have been without the PRP?

01:39:53.260 Of course not.

01:39:53.640 Do we know?

01:39:54.140 No, we don't.

01:39:54.900 So we don't have enough of a series to say, if you took a thousand people that had that tear

01:39:59.880 and you did nothing and came back and surveyed them two years later, this many, you wouldn't

01:40:05.280 see the tear again. Do we not know that?

01:40:07.060 We don't know that. One of my best scientific things that I can relate goes down to the elbow,

01:40:13.080 but I think it's important for this part of the conversation is I was speaking right

01:40:17.680 before COVID at the AOSSM, the American Association of Sports Medicine. These are non-surgical general

01:40:24.900 medicine doctors who do sports medicine and they're great. They're really knowledgeable.

01:40:28.900 They do tons of studies. I was waiting to speak and the two papers presented before me were back

01:40:34.480 to back. Really well done. Large numbers, over a thousand patients, double-blind randomized studies

01:40:41.720 comparing for tennis elbow, tennis elbow, lateral epicondylitis, comparing cortisone, PRP, and

01:40:51.140 placebo. And the placebo and the PRP were the same and the cortisone was much more effective.

01:40:58.580 These were back-to-back studies, different institutions, and it was informative for me

01:41:03.620 because I've read the literature. Our literature is replete with studies that say, oh, well,

01:41:08.820 PRP really helps. And I see patients all the time that have had PRP injections. Based on my current

01:41:14.360 knowledge of the literature for rotator cuff repairs, for tendon ruptures, for lateral epicondylitis,

01:41:22.080 certainly for Tommy John's and medial tendon ruptures. I have a PRP machine in my office in

01:41:28.480 Manhattan and I use it twice a year. For what? For when someone begs me to do it.

01:41:33.560 Again, not to be skeptical, I suppose a doctor can make more charging for PRP than cortisone. I mean,

01:41:39.840 cortisone's pretty cheap. Cortisone, well, one, it's covered by insurance and two, yes, it's a couple

01:41:45.360 hundred dollars for a shot. Typically, I mean, in my office, that's one of the reasons I don't use it is

01:41:50.660 a thousand dollars and it's not necessarily covered. And people charge a lot more. Some people charge

01:41:56.060 $2,500 for a PRP injection. And look, I'm not saying that it doesn't someday. PRP, the concept

01:42:02.880 is great. As you know, it has growth factors. It's our own bodily fluids. And so it's perfectly

01:42:10.080 reasonable, but it hasn't yet borne out to be a game changer. Now, if you take someone who's the

01:42:17.100 highest level athlete and they have bursitis, sure, inject some PRP in there, some stem cells,

01:42:22.600 whatever, maybe it'll be better. Who knows? There's not really good data on it, but there's

01:42:26.800 no downside to doing it. The only downside sometimes I see many more flare reactions from

01:42:32.380 PRP injected into tennis elbow where people are really painful for a couple of weeks and

01:42:37.520 they end up coming to me for either surgery or cortisone. They say, I don't want another

01:42:41.840 one of those. I don't want another one of those. And that's just anecdotal for me. I don't have

01:42:45.500 a comparative study.

01:42:46.820 And I probably need to spend more time in the literature, but I really, the few times I've

01:42:51.460 kind of looked with some interest, usually on the request of a patient who's kind of going

01:42:55.720 through this. I just haven't found data that are convincing enough, even though, again,

01:43:01.000 mechanistically, there's a high plausibility. But I think the problem is we don't have that

01:43:05.100 natural history. This is the problem is there's lots of anecdotes that say this injury was present,

01:43:10.980 stem cells were injected, the injury is gone radiographically. The problem is we don't have

01:43:16.000 the contrapositive case.

01:43:17.160 We don't. The best natural history study we have on, and this has nothing to do with treatment,

01:43:24.400 this is asymptomatic rotator cuff tears. It came out of WashU. One of my best friends in orthopedics,

01:43:30.880 Ken Yamaguchi, was the lead on that article. And they looked at ultrasounds, which was great because

01:43:35.660 they're non-invasive, non-costly, and very effective if you have a good ultrasonographer. And they looked at

01:43:42.080 the natural history of these asymptomatic tears. And they found that they obviously documented the

01:43:47.440 percentage of asymptomatic tears in the general population, but they looked at them longitudinally.

01:43:52.560 And they never repaired on their own. At very best, a subset of them stayed the same. The larger

01:43:59.040 the tear, the more likely it was to become even larger with time.

01:44:03.360 And become symptomatic?

01:44:04.400 And become symptomatic. A subset of those became symptomatic, yes. So it was really well done.

01:44:09.580 They got a lot of press.

01:44:10.400 So none got better spontaneously?

01:44:11.900 Correct.

01:44:12.380 So that would suggest that if people are saying, hey, here's my MRI pre and post stem cells,

01:44:18.020 and it got better, that would at least suggest that in that individual, it might've worked.

01:44:21.400 Yes. If you had enough and they were done, as you know, MRIs vary significantly from machine to

01:44:26.620 machine. So they would have to be very well controlled. If you showed me even 20 patients done by

01:44:32.380 someone that I know is legitimate, and they did that and showed comparative MRIs that even 10 out of 20

01:44:40.360 showed healing reconstitution, and I'd be in.

01:44:44.080 Well, I hope that study is being done. I suspect that there were a number of obstacles

01:44:47.840 to it if it's not being done. It's always possible it's being done. I'm just unaware of it. But one of

01:44:52.520 them would be you'd have to standardize the process of generating the stem cell.

01:44:55.840 Absolutely.

01:44:56.120 One of the challenges of doing a clinical trial is everybody has to get the same drug.

01:45:00.340 Yes.

01:45:00.720 And if the drug differs, it becomes problematic. Do you know how standardized the procedure is for

01:45:07.080 capturing and processing stem cells?

01:45:09.360 Yes. Non-standardized. It differs between the different companies that bring the machines in.

01:45:15.820 It differs between the individual clinicians and so forth. So yes, that's one of the things that

01:45:21.180 my colleagues and I discuss quite a lot can be apples and oranges.

01:45:24.520 A couple other injuries I want to talk about in the shoulder before we move to the elbow.

01:45:28.200 So the AC separation, when does it require a repair? When does it just get left alone and

01:45:33.780 you're stuck looking with a little bit of deformation?

01:45:36.000 That's a great question because they're so common, the injuries. So let me draw a picture.

01:45:40.240 I love these sketches.

01:45:42.280 Okay. So we have here, we've removed the glenohumeral joint and we just have the AC joint. This is the

01:45:48.580 clavicle coming across. These are the two stabilizers of the clavicle. One,

01:45:54.380 is that's the coracoid process. And these are the coracoclavicular ligaments.

01:45:59.720 And we're just looking at that end on, which is why it looks like a little nub, but of course it

01:46:03.700 runs. It's a thumb that sticks out from yet another weird part of that scapula.

01:46:08.120 It's got to be the weirdest looking bone in the body, right?

01:46:10.060 It is. Secondarily, we have the acromioclavicular joint that we were talking about. And those are the

01:46:15.280 ligaments that are circumferential around the acromioclavicular joint. So if you fall hard off your bike

01:46:21.440 and you sprain your AC joint, we call that a type one. You sprain your AC joint, you stretch a little

01:46:30.400 bit and injure these ligaments and maybe even stretch those a tiny bit, but it doesn't look

01:46:37.600 any different on x-ray. And that is a great one. Those can hurt and those can damage the cartilage

01:46:43.960 a little bit. And you can get a great one that persists and being painful, but generally they don't,

01:46:48.440 they go away. I did this recently on some slime out in Dripping Springs, riding a bike out there

01:46:53.600 and just low water crossing just went out like it was on ice. That's exactly what I had. And it hurt

01:46:59.320 for six weeks and then it was gone. It's completely normal, but it wasn't raised.

01:47:02.960 Sorry, that diagnosis, by the way, was just pressing right on it. That's how you know it?

01:47:06.380 Well, I know it because by pressing right on it, it hurt like heck, but it didn't blot. It didn't move

01:47:13.200 up and down and I could lift my shoulder. I could feel it not moving. So one of the things

01:47:17.960 that biomechanically interesting, we talked to the residents about when we're teaching

01:47:21.920 is it's not that the clavicle pulls up. It's that the shoulder falls away. These is the primary

01:47:32.240 suspension. One of the primary suspenders of the shoulder are these two ligamentous structures.

01:47:38.300 So if you tear them, the shoulder kind of falls away. So that's why we treat it by wearing a

01:47:43.620 sling and get that weight of that heavy weight of the arm off. Now down here, I have a shadow drawn.

01:47:50.760 Here's the clavicle. We have one acromion, which it's sitting up about 30% or so. That's where you've

01:47:57.860 clearly torn the AC ligaments and you've partially torn, maybe completely torn, but it just didn't

01:48:04.660 distort it too much where you have, you know, you have a complete tear, but it's only up about 30%.

01:48:10.060 That's a grade two. And that almost all those can be treated non-operatively. Occasionally those will,

01:48:18.180 again, like the ones they can hurt persist and you might have to do something later, but they're

01:48:22.520 basically stable. And when you treat it non-operatively, is the treatment that it will

01:48:27.140 return to its position with elevation? Sometimes, but usually not. Usually it stays a little elevated,

01:48:33.300 a little proud, but people don't really care. It's barely asymmetric. Then you get here where

01:48:38.740 you have a complete, it's completely up. And we measure that by the distance between the coracoid

01:48:44.920 and the clavicle. I've drawn it here to just express that difference there in the height. And that is

01:48:52.180 that coraco-cuvicular distance. If it's here, if it's up to 30% widening increase in that space, then that's

01:48:58.820 the grade two. If it's a hundred percent or more, then that's a grade three. If it gets up to a hundred

01:49:04.460 percent, even those, there was a good study done probably 20 years ago for NFL athletes who had

01:49:12.140 sustained these. And the prevailing wisdom for the doctors who were treating the NFL teams was that

01:49:18.400 most of that type threes did not need treatment, surgical treatment, but a subset of them did go

01:49:25.140 on to needing it later. Now, in reality, when they're up that high and people want to get back

01:49:30.220 sooner, we have better reconstructive techniques now. And so you can kind of get back on the bike

01:49:36.020 and if you're a professional cyclist, if you fix them, you can get back on the bike in three or four

01:49:41.100 weeks sort of thing. So there's a gray zone, but the type threes are that transition. Now, if they are

01:49:46.500 the four is more than a hundred percent cap. Yes. And then sometimes it could be trapped behind the

01:49:52.120 scapula and all sorts of other things, but the threes are the sweet spot. The vast majority of

01:49:57.240 the operative ones are in the three category. And I saw a guy the other day and I kind of presented

01:50:01.780 both options to him. He's an athlete. He's a weight lifter, but he's late forties. And I just gave him

01:50:07.660 the options. I said, look, one of the things you might consider, and this applies to a lot of what

01:50:12.640 I want to do is I said, look, yeah, we can fix this. We can fix it tomorrow or next week, but you could

01:50:18.240 also wait and see how you feel in three or four weeks. I can do the same repair in three or four

01:50:23.100 weeks. Yeah, you don't lose anything. You don't lose anything by waiting in that realm. Now you

01:50:26.600 do if you wait three months or six months because you have the same biology going on. And he ended up

01:50:31.800 not wanting it because he felt great. How far out was he from the injury?

01:50:35.400 He was four weeks when he started. The pain was already gone. Almost already gone. He saw the

01:50:39.320 trajectory being so good that he decided that he wanted to wait. And the only issue that he's going to

01:50:43.520 struggle with now is the asymmetry aesthetically. The asymmetry and- It won't have a functional

01:50:48.480 impairment. Generally not, except if you're doing certain types, like if you're heavy flies, heavy

01:50:54.780 bench, even people who rest, you know, do the- A high back squat. Yeah, high back squat. And those

01:51:00.640 could presume that could irritate them and be problematic. And so there are some- And so the

01:51:04.980 repair here is done how? This is where I differ from some. A lot of people just get in and get out

01:51:10.420 quickly and they will- Let me draw it here. So if you have it fairly fresh and you have good

01:51:16.980 ligamentous tissue in here, then we do what's called a dog bone, which is basically two titanium

01:51:22.860 grommets. This is heavy polyester suture. We drill through everything, drill through the clavicle,

01:51:28.540 drill through the coracoid, and then pass- It's just kind of using some little tricks- Pass the suture up

01:51:34.440 through, pull everything down, have your assistant pull it down. You tie that over and it is rock solid,

01:51:39.380 rock solid, and they really do well. Interesting. So in other words, you don't

01:51:44.220 do it by going back to the acromion process. You get the torn ligaments to be in continuity

01:51:50.680 again, and then they can heal. And is that a biodegradable polymer? No. So that'll stay

01:51:55.480 forever. And they're super strong. And so you can really, you don't let somebody go in a week,

01:52:00.460 but you can, depending on what their sport is, you can let them get back at maybe three or four

01:52:04.740 weeks, certainly six weeks. Six weeks, this thing is pretty strong where you can do most things.

01:52:08.500 Before we leave the clavicle, I only asked about this because I just had a patient that went through

01:52:13.160 it. When the clavicle and the mediastinum separate, I assume that's not as common.

01:52:18.320 No, it is not. It's way less common, but it can be very problematic. I'm going to draw a great

01:52:22.420 picture, I think, for that. Please, because while you're drawing that,

01:52:25.500 I'll explain the situation. This was a patient who, God, I'm trying to remember what caused the injury.

01:52:32.920 I wonder if it was a fall, a high fall. It might have even been off a horse or something. It's

01:52:39.040 possible. But what surprised me was the patient who was in New York basically called that morning

01:52:48.400 to say, look, I just saw two surgeons at HSS and they said, I need to have surgery right away.

01:52:55.900 And I guess it's interesting, right? There are some things in orthopedic surgery that are

01:52:59.880 need for an emergent case. This turned out to be one.

01:53:03.480 Yes. Okay. So this is a lordotic view basically of the manubrium sternum, which is our breastplate

01:53:11.660 there. We can follow our clavicle across to that and we can feel the little nubs right there at the

01:53:17.420 base. We can feel those sternoclavicular joints.

01:53:19.700 So I'll pull my shirt down so you can see my little nubs. 1.00

01:53:21.840 Exactly. So you can see it's even worse than the shoulder. It's a very shallow joint. So if you take

01:53:29.420 a hard blow laterally, hockey players get slammed up against the glass. It's a common, more common

01:53:36.600 injury in that. The football players, the quarterbacks that get tackled by these 300 0.85

01:53:41.480 pounders and their shoulders are wedged together like that. And it just so happens that that's what

01:53:47.480 the injury, not to this extent, but the injury that Quinn Ewers, the quarterback for UT suffered,

01:53:53.140 was knocked out in the Alabama game. He's now back. So he obviously didn't have this full

01:53:57.500 dislocation, but that's what can happen. In weird circumstances, that's what you were talking about.

01:54:03.440 The mechanics can be that, and it happens a little more commonly in kids, but if the fall is just right

01:54:10.020 and the mechanics just right, it will open this up, tear everything, and then displace it behind the

01:54:15.880 manubrium. And that's where the major carotid artery and the drugular vein lives. And that can be

01:54:23.640 a huge, huge life-threatening. Well, it could be life-threatening for sure. So we have to be careful

01:54:30.480 with those. But this one where it subluxes out the front, those are also a problem. You can see that

01:54:36.960 there's no way it's going to fall back into place there. So either they stay out, they stabilize,

01:54:41.960 and people just don't do that much to irritate them, or they have to be reconstructed. And I've

01:54:47.720 had to go in and reconstruct these where I take a tendon from the forearm and make a figure of eight

01:54:52.920 across the front and basically rebuild those ligaments to hold it back in place.

01:54:56.500 And why do you do that as opposed to doing an anchor or something like that?

01:55:00.760 It's just stronger. You need some extra collagen there.

01:55:04.200 So what is it about the insult laterally that will determine a separation here versus here?

01:55:12.440 These are two weak points at each end of the clavicle.

01:55:15.620 Much more frequently.

01:55:16.940 Much more frequently here.

01:55:18.180 Well, much more frequently there, but that's usually a top-down. That's usually pitching forward

01:55:22.540 and landing and having it be that way. But what happens more commonly than the SC joint,

01:55:27.520 the sternoclavicular joint, is just a clavicle fracture, which are ubiquitous. And that just fractures

01:55:32.500 somewhere over there. And then we fix them some and we don't fix others. And those heal. But the

01:55:39.100 joint, a weird little joint, is very important. It's not common, but it's not rare.

01:55:44.060 Let's talk briefly about a total shoulder replacement. I think a lot of people are pretty

01:55:48.120 familiar with a total knee replacement, a total hip replacement. To me, the hip replacement has been

01:55:52.560 one of the modern marvels of orthopedic surgery in the last 30 years. When I think back to when I was

01:55:57.880 in medical school, that was a brutal procedure. And today, these patients getting total hip

01:56:04.780 replacements, I mean, they're laughing at everybody else.

01:56:08.320 Yeah, they do them outpatient. I mean, they walk out of the OR.

01:56:11.280 It is an outpatient procedure. I still don't... I have to save that for another discussion. I don't

01:56:15.440 understand how that procedure is so easy today. First off, what is the indication for the total

01:56:20.620 shoulder replacement? And then secondly, let's talk briefly about what is actually being replaced

01:56:26.280 and what that recovery is like and what limitations exist after the fact.

01:56:30.820 It is also an outpatient procedure unless you have comorbidities. I do most of these outpatient.

01:56:38.100 And I can even use a smaller picture now because the types of implants we're using now have evolved

01:56:43.840 significantly. So when you've worn down the cartilage completely, either on one or both of the

01:56:50.600 surfaces, that's incompatible with good function, usually because of pain. And you ask, what is

01:56:57.560 the primary indication? It's pain. I don't care. I see patients all the time who come in who have

01:57:03.540 the ugliest x-rays you've ever seen, to your point about the cervical spine, which is so important.

01:57:09.640 They have no pain and they can do whatever they want to do. As you know, the scapula,

01:57:14.480 scapulothoracic motion can give us a lot of function, so they're fine. Occasionally, they'll say,

01:57:19.840 hey, I'm going on a trip where I want to be able to play golf for three weeks or two weeks with my

01:57:24.840 family. Could you give me an injection? Sure. Give them a cortisone shot and they rock on. They get

01:57:29.880 three months, four months of relief and then they keep going. So it's only the very active people who

01:57:35.840 need to be able to do certain things. And age is not a factor. My oldest patient who I did shoulder

01:57:42.720 replacements on quite a long time ago, she was 97. And she was spry and healthy, walked the streets

01:57:50.480 of Manhattan up and down. She actually still worked at 97. I won't say where because I might give it

01:57:55.240 away. She was the oldest and longest standing employee of a famous place. And after I did that,

01:58:02.100 then back to back and I'd see her on the street, walking down 57th street and she'd say,

01:58:06.840 hey, doc, I'm doing great. And she was 97, 98, 99. I lost track of her at that point.

01:58:12.700 And it totally changed her life because she couldn't use her arms because they were hurting so

01:58:16.180 much. So age is not a factor to your- And just to be clear, was her arthritis the result

01:58:22.340 of likely a labral repair that never, like what caused so much degeneration in her?

01:58:30.020 Some people just get it. It's no different than you- Oh, so it's not constant subluxations

01:58:34.480 necessarily that are necessary. Not at all. Some people just have- One of my attendings when I was

01:58:39.260 in med school residence, he said, yeah, it's like a paint job. You can have a paint job that's a

01:58:43.780 Mercedes or you can have a paint job that's a Ford Pinto. And I'm not saying anything derogatory to

01:58:48.700 Pintos, but the quality of the paint job can- What you're born with. That's the main thing. And that's

01:58:54.300 the main source of garden variety, osteoarthritis of the shoulder. And then there are the athletes who

01:58:59.200 are separate categories based on what you're- Wear and tear. Yeah. And the youngest you've ever done this on?

01:59:03.260 The youngest I've ever done a replacement, a full replacement on was 55. I'm usually do a work

01:59:09.620 around. I saw a guy 15 years ago who came to me. He had pretty, you can see it visually,

01:59:16.600 but it wasn't terrible. And he said he was been booked for a replacement. I said, look,

01:59:20.320 you're a little young. He was about 48. And I said, you're too young for me. I think we should

01:59:25.300 at least give something else a shot. I said, what I would probably do, even though the data is not great,

01:59:30.160 it's one of the few things I do that I know, but I tell him at the outset that you have about a 50%

01:59:34.500 chance of getting better. And that's just a scope clean out. We know they have arthritis. They don't

01:59:40.100 have instability and just try to clean them out and buy them some more time, kick this can as far

01:59:45.060 down the road as possible. About 15 years later, he came back to me showing me shoulder motion was

01:59:50.980 fine. His x-rays hadn't advanced and he came for something else. So that was an example of what I

01:59:57.140 try to do, but he can't always affect that, but that was just an anecdotal and it's worth doing.

02:00:02.300 It's such a minimal operation, no recovery. And oftentimes if people have bilateral osteoarthritis,

02:00:09.040 they don't need both sides done. They're happy with one side. They have a good one that they can

02:00:13.700 reach over and do things. But an example of sort of a very active to our point about physiology and

02:00:20.920 biologic age and so forth, a really wonderful athletic woman who was an avid sailing. She 1.00

02:00:28.300 sailed in regattas, raced still at the age of about 75. She was still going racing all the time,

02:00:34.760 pulling lanyards, et cetera. And she said, I can't do this anymore. I just can't do it. And I want to

02:00:39.720 keep doing it. Can I keep doing that? And I said, sure. So I replaced both of her shoulders.

02:00:45.160 How much do you separate those two operations by?

02:00:47.160 She was about four months apart. It was kind of more, she said, I'm going to give up a year

02:00:51.480 of the sailing. Then I want to get back to it. So you could do them a little closer together if

02:00:55.620 you want. And she's still sailing. 1.00

02:00:57.300 So let's go over the anatomy here of the replacement. Obviously there's two pieces to

02:01:00.400 it. There's the humeral side and the glenoid side.

02:01:02.940 I'm going to draw another picture real fast that will show what a arthritic shoulder looks like.

02:01:07.840 And then that'll help. So in the little picture to the left, I've drawn an arthritic shoulder,

02:01:14.100 not well, but I've drawn it to make a point. So it kind of,

02:01:16.680 the head kind of flattens out. You have no space in there at all. You get a bone spur down here.

02:01:21.200 You get some spurring around the perimeter of the glenoid and all of that conspires to

02:01:26.820 greatly diminish the motion of the shoulder and cause pain. There's two reasons they come.

02:01:32.300 Dysfunction because they can't do what they desperately want to do, whether it's recreational

02:01:36.580 or work sometimes. And number two, pain. Either one of those is a solid indication for it when the

02:01:43.060 radiographic findings are there. And if we do that, then what we do is, is go in and now we do these

02:01:48.660 through incision that big. And it's just a very small anterior incision, anterior incision and take

02:01:54.680 down part or all or part or most of the subscapularis, the tendon in the front. We have to have a window

02:02:01.900 in. Now we can work through the interval, the space between the supraspinous and the subscapularis,

02:02:08.560 but only if it's a more limited replacement. But anyway, you take some of that off. You have a

02:02:13.800 window there, you have retractors in, and you use an oscillating saw and just take that arthritic head

02:02:19.280 off of there like that and all the bone spurs. Then with that space that that creates, you use another

02:02:26.780 retractor, push the head, the shaft. What's left of the shaft. What's left of the shaft away. And

02:02:32.400 then you get in and work on the glenoid. And you ream that down to where it's all smooth, get the

02:02:37.280 bone spurs out of the perimeter, and then put in this little high-density polyethylene socket.

02:02:42.560 Is this that ultra-high molecular weight polyethylene?

02:02:44.540 Yes, exactly. Very durable. I mean, they do wear out.

02:02:46.700 So it's the same thing that's the tibial plateau.

02:02:49.020 Exactly the same. It's great. And then these have little pegs. You drill holes. You maybe

02:02:52.940 usually cement those in just a little bit. Some are press-fit, but usually cement it in a little

02:02:58.180 bit, just that part. It's a perfect, nice, new Teflon surface. For them, this cobalt chromium or

02:03:03.840 whatever alloy it is for the head, the bone has a central core. And you clean that out, get it fixed.

02:03:10.540 And this is press-fit. We don't cement these anymore unless people have really bad bone or

02:03:14.380 vision. Just press-fit it into that Kinsella's bone. And it's super solid. The rotator cuff is kept

02:03:21.240 intact. The rotator cuff is still intact. On top, you're working around that. Reattach the

02:03:26.100 subscapularis. If you're going to transect the subscapularis, what is the least traumatic place

02:03:31.200 to do it? Completely within the muscle, I'm assuming? No, no. Actually, on the tendon where

02:03:35.360 it inserts on the bone. Oh, you have to because you're reattaching it. Yeah. We leave a sleeve so we

02:03:40.040 can suture tendon to tendon, but then we also put this heavy suture into bone. So you get bone

02:03:46.200 reinforcement and you've got tendon to tendon healing. You also, by doing that, you maintain

02:03:51.060 the normal length. So the only thing, I mean, this is an oversimplification, but the biggest

02:03:56.320 thing this person is missing is a labrum. Yeah. And they don't really need it. So what

02:04:01.100 stabilizes this joint? The fact that it's arthritic. It's already stabilized itself, unless it's a weird

02:04:07.180 dislocating joint, which is a different entity and you have to address that differently. For the

02:04:12.180 garden variety one, they've already kind of stiffened up all the tissues, even the... So what

02:04:15.880 does their capsule look like when you go in typically? It's thick. It's super thick. We

02:04:20.140 resect some of it even. It's so thick. It's kind of space occupying almost. And what is this person's,

02:04:26.080 in a good case, what is the limitation on this person a year out from surgery? Really nothing

02:04:32.420 except heavy weights. I don't want people doing bench press. I don't want them doing the iron cross

02:04:39.280 type things. And they're usually not. I had one patient. Can they throw a ball?

02:04:43.960 Yeah, they can throw a ball. They can play catch. Oh, they can play catch with their grandkids,

02:04:47.380 for sure. They can play tennis. They can play tennis? Yeah. They can play tennis. They can play golf.

02:04:52.360 They shoot a basketball? Yeah. Can they swim? Oh yeah. That's one of the big, big ones. People

02:04:57.660 love swimming. Later in life, it's such a good general exercise. Yeah, fantastic. And they can swim until

02:05:02.260 they're 100 and you can absolutely... Oh yeah, you can swim until the cows come home here. So this is just

02:05:06.620 another one of those game-changing operations, right? It's different than the hips and the knees.

02:05:11.820 The hips and the knees allow people to live in the world again. These are game-changer quality of life

02:05:18.260 things. And I won't do them if I know I can manage them and kick the can down the road and just inject

02:05:24.280 them once a year with cortisone. I want them to be dragging that arm in. I want them to be saying,

02:05:30.160 you got to do it now. I'm not getting enough relief from the cortisone and do it.

02:05:33.880 So let's pivot now to talk about another piece of anatomy down the arm, which is the elbow. Let's

02:05:40.120 take a moment and just go back to the anatomy. Do you want to draw a little sketch of how the

02:05:43.700 humerus lines up with the ulnar and the radius? Very much so.

02:05:48.020 So the big diagram is looking straight at the antecubital fossa. And then obviously the side

02:05:54.400 diagram is showing the arm flexed. So walk people through what these three bones are and then the

02:06:00.560 overlaying muscles. So this is, uh, as you said, the, and in front of the elbows here,

02:06:05.300 the humerus bone, which is the arm bone is coming down. And you see, it's a super weird

02:06:09.400 undulating structure there, which makes it intrinsically quite stable. So much because

02:06:15.240 there's more to dig into exactly. There's all these fun little almost jigsaw puzzle pieces that stick

02:06:21.500 together. We have the radial head, which is the rotating bone of the forearm. And then we have the

02:06:28.160 ulna, which is the fixed straight bone of the forearm. Then we have, what's cool about the elbow

02:06:34.920 is the tendons that go down to the forearm and to the hand originate above the joint, more or less,

02:06:42.700 right? Close, juxta articular, close to the joint, but above it. And then the ones that go from the

02:06:47.580 shoulder and arm down attach below the joint. And this is the biceps tendon here, the big biceps muscle

02:06:54.780 here, the biceps tendon attaching to the radius. And we'll talk about that. This is the lateral side,

02:07:01.160 the outside of your elbow. And the blue is the muscle tendon units that are attached there,

02:07:07.000 anchored to this little circle or oval. And then the red part is where tearing typically occurs in

02:07:13.420 tennis elbow. On the inside of the elbow, where our funny bone nerve is, the funny bone nerve is the

02:07:20.120 ulnar nerve. And that's the green structure in cross section. And then overlying that is the muscles,

02:07:25.860 the flexor pronator muscles that help bend the elbow and pronate the forearm. And those can tear

02:07:34.220 right in this region. And that's actually where we get golfer's elbow and what is known as golfer's

02:07:40.260 elbow, which is medial epicondylitis, medial. And then the lateral side, which is the tennis elbow

02:07:46.520 is lateral epicondylitis. And those are the most, these three, the biceps tendon, and these two are

02:07:53.360 the most common tendon injuries by far. The fourth, which is less common, is shown in the lateral,

02:08:01.060 which is the triceps coming down and attaching to the tip of our elbow. We talked about the bursa

02:08:07.120 before. And there is a bursa right here that lives over the tip of our elbow. And we can get the big

02:08:13.740 golf ball size filling of fluid, and that's the olecranon bursa. I think it's beyond what we're

02:08:20.680 talking about today to go into the fractures, but any parts of these can be broken. The elbow is a

02:08:26.500 very finicky joint. You can see because of, it's stable because of those undulating surfaces, but

02:08:31.600 because they're undulating, there's less wiggle room. There's less wiggle room. And if you don't get

02:08:36.080 those things perfect when you fix them, they can quickly lead to arthritis. And some of the, even the

02:08:40.920 subtle fracture patterns that happen and aren't seen or appreciated can lead to rapid destruction

02:08:47.020 of the joint. So it's a finicky joint. It is also, oh, I've drawn this blue structure here,

02:08:53.360 which is a very thick ligament on the inside of the elbow that is the Tommy John ligament. It's not

02:08:59.280 really Tommy John. Well, I'll clarify that in a minute, but that's the medial collateral ligament or

02:09:03.800 the ulnar collateral ligament. And that's the one that's torn in throwing athletes. And that can be

02:09:09.280 career ending, except now because of the reconstructive surgery, it's generally not.

02:09:14.640 So let's talk just briefly about why the lateral epicondyle, if there's inflammation in that tendon,

02:09:21.920 we sort of think of that as the injury a tennis player gets, whereas inflammation in the medial

02:09:26.960 tendon is more attributed to what a golfer gets. Of course, people who have never played tennis or

02:09:31.200 golf often get these things, but it could be illustrative just to explain the movement pattern.

02:09:35.160 So those are not dissimilar from the supraspinatus tendon, where they have a little ringing out and

02:09:42.780 they can become degenerative and partially tear. Just like we talked about rotator cuffs, there are

02:09:49.020 tons of people walking down the streets with partial tears in those tendons and they're asymptomat.

02:09:54.720 Use patterns are significant for that. The reason the lateral was historically associated and called

02:10:00.880 tennis elbow is because of one-handed backhands. It's a much less mechanically sound and we have

02:10:09.180 less strength with our external rotators than we have with our pectoralis and our subscapularis for

02:10:14.580 forehand shots. So it's under more stress. You can get them at any age, but the sweet spot of seeing

02:10:20.700 treating this is 40 to 60. 40 to 60 now that is creeping up to the 70s and so forth because again,

02:10:27.280 people are so active. So that's why it's been associated with tennis elbow. Ironically, now

02:10:33.420 I'm seeing just as much in tennis players and competitive tennis players, I'm seeing just as

02:10:38.380 much medial epicondylitis, which is traditionally golfer's elbow. And the reason is because everybody

02:10:44.720 is trying to hit massive topspin and they are hit using their pronator so much more than they used to

02:10:52.720 when I was a kid and playing, I try to hit topspin now. And so that's a reason why it stimulated more.

02:10:58.860 Why does the golfer get it? I don't play golf, so I don't appreciate it enough.

02:11:02.720 Historically, even though golfers were getting it, I don't know why, because you're not supposed to be,

02:11:08.640 it's overhitting with your trailing arm. Most people play right-handed and they were getting it

02:11:13.660 on their right medial epicondylitis because they were overhitting, hitting stumps, hitting rocks,

02:11:19.300 duffing. And it was that jolt, again, the eccentric load on these tendons, which our tendons don't

02:11:24.960 like. But I'm seeing now, because people are hitting so much harder, they're hitting bigger

02:11:30.840 clubs, especially drivers and such, they're getting more left leading arm, lateral epicondylitis

02:11:38.760 in golfers.

02:11:39.720 On the leading arm.

02:11:40.740 On the leading arm. And that's more logical, actually. But they're just trying to hit harder

02:11:44.540 and farther. And once these big hitters are on there, they're trying to mimic them and so forth.

02:11:48.720 Is the first-line treatment for that rest?

02:11:52.380 Yes.

02:11:52.980 Rest and NSAIDs, presumably followed by cortisone and things of that nature?

02:11:57.660 So the first-line treatment is always rest, good stretching, just like you stretch your

02:12:01.860 hamstrings to keep from tearing them as frequently or injuring them as frequently. And usually just

02:12:06.180 NSAIDs by mouth. Rarely do I use physical therapy for these formally because it's just not much to do.

02:12:12.500 If they're just too painful to even, some people wake up in the morning, they can't even straighten

02:12:16.580 their elbow out. They're so painful. They're so spongy and really inflamed. So those, I still don't

02:12:22.220 splint them, but I have them stretch. But more often, because they can't use their arm, I will go

02:12:27.900 ahead and give them kind of a half dose of cortisone just to cool everything down.

02:12:31.600 Yeah. You injected me probably four or five years ago when I was sort of in the transition of really

02:12:38.120 learning how to control my scapula and had sort of overcooked too many pull-ups. And all this pull-up

02:12:46.440 pain was translating into tennis elbow. I was surprised at, and it was stubborn. This thing,

02:12:52.160 I came to you after six months of pain, but that one injection cooled it off.

02:12:56.240 And I'd never hurt again because basically I had already fixed the underlying movement pattern.

02:13:01.120 I just needed to cool the fire off. Is that a common scenario?

02:13:05.300 It really is. Again, I don't operate on, because it's so common, I ended up doing a lot of these

02:13:10.340 procedures, but I don't operate on, I'd say one out of five at the most, 20% at the most. Most people

02:13:17.260 get better. And so operating on the lateral versus the medial side, what are the indications?

02:13:23.300 The indications are the same. Failing conservative treatment, a lot of stretching, a lot of

02:13:29.040 strengthening. A lot of people get these. In your case, it was mechanics overdoing, but a lot of

02:13:34.860 people get these because they're getting back into something that they haven't been doing in a long

02:13:40.280 time and they overdo it. And it can be just weights and weightlifting, but honestly, it's something

02:13:44.860 that's mundane. I'll see these after people have gone traveling for two weeks, just lifting their

02:13:49.060 luggage, dragging their luggage around. It's all comers. But the theme is that conditioning,

02:13:56.580 if they've had it chronically, not in your case, of course, but a lot of people come in and they're

02:14:00.240 already kind of weak. They don't have strong grip strength. They don't have good tone. And so

02:14:04.140 strengthening is a critical component. If they can squeeze my, you know, I have one on my device,

02:14:09.800 if they can squeeze that without just a little pain, then I just have them do that first,

02:14:14.120 stretching and strengthening. And sometimes that'll cure it and often it'll cure it. But if they can't

02:14:19.440 squeeze it without undue pain, I give them a little dose of cortisone. If it's chronic like

02:14:23.480 yours was, then there's not that much to do. You're fit, you've got great tone and you've got full

02:14:28.960 motion. So it's only give it a little booster dose just to knock it out. We think sometimes,

02:14:34.760 we haven't ever done the study to prove it, but we think sometimes just sticking the needle in a few

02:14:40.340 times kind of stimulates a healing response. Yeah. I've certainly seen a lot of anecdotal

02:14:44.020 stuff around dry needling, just getting the dry needle in there. I believe in that. And just

02:14:48.500 increasing the influx of inflammatory cells and cleaning up, getting macrophages to come and clean

02:14:54.140 it up. So outside of fractures, how often are you seeing acute injuries to the elbow that ultimately

02:15:01.480 are surgical cases? So one of the common ones is the middle-aged, but very active fit person who

02:15:11.120 maybe had a little antecedent elbow pain or forearm pain. They didn't quite know what it was,

02:15:17.520 but they did workarounds and then they ruptured their distal biceps. And so they get a Popeye muscle.

02:15:23.120 It's all weird and even quivering. And they come in and they go, oh my God, you've got to do something.

02:15:28.240 And the cool thing about the bicep, we think of the biceps as, you know, we do biceps.

02:15:34.400 Right. It's an elbow flexor. And it is a secondary elbow flexor, but it's the primary supinator of the

02:15:39.780 forearm. So people come in and they lose, when they tear their biceps, they don't lose that much

02:15:45.540 flexion strength, but they lose most of their supination strength. So if they are used to turning

02:15:51.900 screwdrivers, wrenches, surgical instruments, maybe depending on what they do, then it can be really

02:15:58.140 disabling. That factors into the physical exam then, doesn't it? Oh yeah. It's funny. They'll

02:16:02.700 come in, they won't be painful. They'll say, I think it's better. And yeah, I've got this,

02:16:07.360 but I can live with the deformity, which I don't care about the deformity either.

02:16:10.080 And then I will pronate them to wrap that tendon kind of around the radius. And then I have them

02:16:16.380 pull up like they're doing a pronated curl and they scream, get it just isolated. And that's a very

02:16:22.100 good point about that. And then you test their supination. They didn't know that they didn't have 0.94

02:16:26.100 me supination strength. Then you test their other side and they can lift you off the table. And then

02:16:29.940 this side, they can't even do it. So when you surgically repair that, are you reattaching

02:16:34.560 the tendon? Yeah. Same place. So it's like a tendonesis. Yeah. It's a great operation.

02:16:38.820 So that's a good outcome operation. Oh yeah. I had a guy in the other day,

02:16:42.240 looks just like you, strong arms and everything. And he's doing this all the time. And he ruptured his,

02:16:47.600 he came back in for actually with his son. And he said, if you need anybody to, he said,

02:16:51.700 my arm is stronger than it's been in a long time. I'll speak to that. But he said, if you need

02:16:56.380 somebody to call anybody to talk to him about how great this operation is, just let me know.

02:17:01.060 But he said he was, a lot of them say, you know, I feel almost like I'm stronger than I was before.

02:17:06.780 Well, you're only putting it back where it came from, but they probably had a partial tear

02:17:10.580 for a long time. They were working around. They were little deconditioned in their biceps. They were

02:17:15.600 compensating with their brachialis, the big muscle underneath that. And then they get even stronger

02:17:20.960 because they have a good tendon again. Wow. You want to just briefly talk about the

02:17:25.360 Tommy John, which again has kind of revolutionized the Major League Baseball.

02:17:29.580 So when this tears the- On the medial side.

02:17:32.180 You all of, and in fact, it's super physiologic torques. That ligament is subjected to super

02:17:39.620 physiologic in throwers, in high level throwers who are throwing 90 plus miles per hour. It is

02:17:47.040 subjected to such forces, traction forces, that it will rupture. And the way they keep from rupturing

02:17:53.640 in general is by fitness, by steady long-term fitness. And that's flexor pronator fitness,

02:18:01.700 that's shoulder strengthening, biceps, triceps, and so forth. By strengthening everything around it,

02:18:07.240 you can protect that ligament. And if you don't, then it can rupture because it's being subjected

02:18:12.660 repetitively over and over and over again, year after year to super physiologic loads.

02:18:18.060 When it ruptures, it's easy. Instantaneously, they lose, they can throw, but they lose 10

02:18:22.800 miles per hour on their fastball. It just immediately downgrades their ability to throw.

02:18:28.120 That's so interesting because most of us, like, I don't think I could throw a ball 50 miles an hour.

02:18:32.720 So does that mean I would go from 50 to 40? Or it just means I could never get,

02:18:37.180 I wouldn't notice it. Is that the difference?

02:18:38.440 You wouldn't notice it. That's the common fallacy. I have people coming in all the time.

02:18:41.760 I mean, all of us playing tennis, playing certainly golf, throwing balls. If we're

02:18:46.940 playing catch, we don't need it. We don't need the ligament.

02:18:49.320 So that is literally an operation that is only designed for the most elite throwers.

02:18:53.760 Yes. Period. And that's a common misconception. Of course, one of the-

02:18:57.580 So are there some shady people, sorry to interrupt you. Are there some shady people out there that

02:19:01.200 are doing that operation on non-athletes?

02:19:03.760 Sure. But more importantly, and I say this, I'm sure they have love in their heart,

02:19:09.600 but there's some shady parents too, who will bring their kids in, who say, we know our kid

02:19:15.440 has this great potential. Can you do, because stories about Tommy John surgery, which this is

02:19:20.920 not Tommy John surgery anymore. What was done on Tommy John was not the same operation. It was the

02:19:26.820 same ligament, but it's totally different now. But it's good to refer to it as that. The guy who

02:19:31.380 invented it was brilliant. Parents will come in and say, you know, my kid needs five miles per hour on

02:19:35.600 the fastball. And because so many people like the biceps have had partial tears, they've finally

02:19:41.500 torn, had a reconstruction, and they gain six or seven miles faster than they've thrown as an adult.

02:19:49.000 It's because they had a partial tear and never could get that final extra velocity. And then once

02:19:54.720 they have a reconstruction, they can. And so that travels through the chat rooms and lore,

02:20:01.860 and then parents come in and say, hey, and their kid has no problem. Can we do it Tommy John so that

02:20:07.580 we can get more velocity? And you have to explain to them that there's nothing wrong with their kid's

02:20:11.720 elbow. There's just something that the kid is not destined to be Nolan Ryan. Yeah. Interesting.

02:20:17.700 It's with best of intentions, but things get distorted. What about the tricep tendon? What type of

02:20:23.720 injury will injure that tendon to the point where it's coming off the olecranon? You already know.

02:20:28.640 It's what you talk about all the time. It's the eccentric loading. They almost always tear

02:20:33.820 falling skein where they're trying to stop themselves from smashing their face. They rip 1.00

02:20:39.360 off like that. I see them every winter. And how clean a break is it? It varies. Some people,

02:20:44.660 if they've had chronic condition, will have little bone spurs in there and it'll pull off part of the

02:20:48.840 bone spur and everything. Usually it pulls off the bone or leaves a little stub there. It's pretty

02:20:54.360 clean usually. But man, the triceps is a huge muscle. Bigger than biceps. Yeah. Huge muscle.

02:21:00.800 And so it's really disabling. People can't even push up out of chairs. You have to fix those.

02:21:05.860 They're not ruptured in sedentary, non-low functioning people. They rupture in active

02:21:11.140 people and you've got to fix them. Okay. So maybe now we could just kind of have you examine my elbow

02:21:16.520 and go through all of these planes of motion. Because obviously you want to know how I'm flexing,

02:21:21.580 how I'm extending, supinating, and pronating, and my strength eccentrically and concentrically,

02:21:27.020 I guess. Yeah. That's right. And in the elbow, it's very distinct. There are very specific

02:21:32.400 stresses you can put on the elbow that will guide us directly to what is hurting. And again,

02:21:37.760 it goes back to a lot of middle-aged athletic people have some changes in the lateral epicondyle

02:21:43.920 muscles, the medial epicondyle muscles, some even in the triceps, in the distal biceps. You have to

02:21:49.980 isolate those and make sure they're symptomatic. At this point in the conversation,

02:21:55.140 Alton demonstrates on me what he'll do for a typical elbow exam on a patient. As this lends

02:21:59.620 itself much more to video, we decided not to include this in the audio version of the interview. If

02:22:04.000 you'd like to see what this exam looks like, you can head over to the show notes page or to our

02:22:08.460 YouTube page where we have the full exam videos very clearly broken out and available. Now back to

02:22:14.280 my conversation with Alton. All right. So we've got the shoulder and the elbow behind us that leaves

02:22:20.800 us with the hand and the wrist, which is effectively how we mediate contact with the outside world and

02:22:25.960 our extremities. I would say this to me is like a black box. I didn't actually do a rotation in

02:22:31.960 orthopedics or plastics. So no exposure to that. Now in general surgery, you'd cross cover plastic

02:22:38.000 sometimes. So new enough to know what not to do when someone came in with hand trauma, but it's

02:22:44.160 obviously a highly specialized field. You've done a fellowship just in hand, right? It basically seems

02:22:49.080 anybody who wants to operate on the hand has to not only complete the orthopedics program or plastics

02:22:53.500 program, but then go completely do that dedicated program. That's right. I suppose you could pick it

02:22:58.820 up, but to be able to do that in a, certainly a big city or a dense metropolitan area, you would need to

02:23:05.720 have fellowship training. And it's just, there's so much as we've talked about before, just like in

02:23:10.720 the shoulder, just like in biologics, just like in everything you do, there's such an explosion of

02:23:16.100 information and it's hard to keep track of everything. Before we get into the hand, what do we know today

02:23:21.980 about the hand in terms of repair or injury that you didn't know when you finished residency? And I don't

02:23:28.680 mean you personally, but I just mean, wasn't known then that is known today. That's a fascinating topic

02:23:33.280 because well before I started, starting in the fifties and sixties, they had developed microvascular

02:23:38.340 techniques. That was the Holy grail of so much in the hand. You could have a laceration or a war

02:23:45.340 injury or something, and there really wasn't much to do for many of those injuries, especially nerve

02:23:52.180 and blood vessel related. So you would do a lot of amputations that just were not reconstructable.

02:23:57.600 The war experience actually did develop that. And one of my forebears, J. William Littler, who was

02:24:03.920 one of the most famous, if not the most famous living hand surgeon for a few decades in the world,

02:24:10.200 was exposed to that at Valley Forge and elsewhere during the war. And that's how he and other really

02:24:16.680 luminaries in the field developed these techniques that brought us where we are today. I'd say the most

02:24:21.420 significant advancement since I graduated and went into private practice has been the hand

02:24:27.900 transplantation, the complete hand transplantation, which is a very, very, as you know, it involves

02:24:33.500 general surgeons. It involves hand surgeons. It involves so many, a huge team to be able to do that

02:24:41.220 and to achieve that. And the results are mixed.

02:24:45.220 How many have been done?

02:24:46.380 I don't even know now. As recently as five years ago, only a few had been done. So it's all been

02:24:52.360 in these last several years that these teams have been built up at the larger institutions to be able

02:24:58.240 to handle that. But even there, it's fraught with peril in that you have to have a perfect patient,

02:25:04.900 physiologically speaking, and comorbidities greatly decrease the likelihood of success there.

02:25:10.760 And it requires a huge investment for the patients themselves. And so even a single hand

02:25:17.020 amputation is not nearly as reasonable of an indication as a bilateral hand amputee. Those

02:25:24.040 are the ones that generally can qualify and they have to meet all the physiologic parameters. I don't

02:25:29.600 even know that much about it. One of my partners has been on one of those teams and he knows much

02:25:34.100 more about it. Luke Catalano.

02:25:36.220 Are they joined at the midpoint of the wrist?

02:25:39.180 Right. Is that the distal forearm where you can get that, you're beyond that transition zone and you

02:25:44.140 can link up tendon to tendon usually. And then of course the nerves can be linked as well. Yeah,

02:25:49.600 it's fascinating. So that's the biggest.

02:25:51.140 And it's the same immunologic process. You have to HLA match these things because they're all

02:25:55.800 cadaveric of course.

02:25:56.680 Exactly. Exactly. And that's, as you well know, and you know way more about that than I do because of

02:26:01.500 the general surgical background, but obviously the immunologic suppression to allow these things

02:26:05.920 to not be a graft versus host disease. And it's a wild, wild time. Really, we will get better.

02:26:11.960 I think the other thing, the only other thing that's changed a lot is that relates so much to

02:26:17.340 the hand, as you mentioned, it's how we interact with the world is the spinal implants and the various

02:26:23.500 types of full muscle transfers that can restore function in the hand for someone who previously

02:26:31.140 had no ability to control even a prosthesis, these electrical prostheses now that are linked to the

02:26:37.680 brain. So it's cool.

02:26:39.180 What type of injuries does someone have in the forearm that, are there injuries where they will

02:26:43.380 take a muscle from the leg or something like a sartorius and attach it there?

02:26:47.140 Absolutely. And it's really intended to just give some primitive function back to be able to flex the

02:26:53.340 elbow, for instance, or extend the elbow or flex the wrist. And so it's really more the elbow more than

02:26:58.720 anything because most of these injuries, the patients can still control the shoulder, can position

02:27:03.760 the arm somewhere. But as you know, I mean, if you just even forget about a very devastating injury,

02:27:10.340 but if you just have an elbow extension contracture where you cannot flex better than 90 degrees,

02:27:14.980 you can't get your hand to your mouth, to your hair, to your face. You can't do a lot. There's many,

02:27:20.980 many limitations to that. And that's just to get through an average day, not anything specialized,

02:27:26.280 such as playing an instrument or throwing a football or something.

02:27:29.780 So when we talked about the shoulder and the elbow, do you have a sense of what fraction of

02:27:34.780 those injuries that require surgical intervention are the result of an acute trauma versus chronic

02:27:40.940 injury where, now obviously a lot of the chronic stuff is on top of an acute event, like a subluxation

02:27:46.340 that happened over and over and over again leads to, for example, my injury. But do you have a sense

02:27:51.460 of what that division is? I do, but it also varies depending on where you are. In my practice now,

02:27:57.720 I took trauma call for a couple of decades, but I no longer take. So I see cold trauma that still

02:28:03.860 needs plenty of surgery, but it's not acute, it's subacute and it needs to be fixed in a delayed

02:28:09.040 fashion. So if you are in a practice such as a county hospital where there's trauma coming in,

02:28:15.060 whether it's hunters, whether it's highways, et cetera, then you're a much higher percentage

02:28:21.040 of your day and your week is spent repairing acute traumatic, often polytrauma injuries. And I've

02:28:27.760 been there and done that. And someone who has a mature metropolitan type practice, it's more in the

02:28:35.220 area of 50-50. There's plenty of arthritic conditions of wear and tear conditions, whether it's from

02:28:42.200 any sort of gym work or getting back into various forms of exercise or the weekend warrior phenomenon.

02:28:49.400 And those are sometimes injuries, but they're not dramatic, traumatic injuries. And then there are

02:28:54.820 the people that are falling off the scooters and water skiing, dislocating their shoulders,

02:28:58.740 all that spectrum. But the actual acute and something as mundane as cutting avocados. I see tons

02:29:06.080 of nerve injuries and tendon injuries in the palm. The Sunday morning bagel injury. Yeah.

02:29:11.620 But it's usually spread pretty evenly between arthritic and sports related ruptures and injuries and

02:29:20.320 then fractures and dislocations and ruptures due to traumatic events. Well, if the bony anatomy of the

02:29:28.360 shoulder is a little more straightforward, it starts to get a little more complicated in the elbow and it

02:29:32.580 gets a little more rigid. I mean, the hand is really complex. So how do you even go about beginning

02:29:37.140 to explain the anatomy of the hand, which has how many bones does the hand have?

02:29:40.860 That even varies. But if you think about it, you have five fingers and you have in those,

02:29:45.980 each finger has three bones, except for the thumb, which has two. There you've got the 12 plus two is

02:29:51.160 14. And then you have the next layer, which are the metacarpals. And that's of course, five of those.

02:29:56.520 And then the carpal bones, which are all these small bones. We had a resident used to make fun of

02:30:03.780 hand surgeons who would say, never operate on a bone you can swallow. So he was just in a fun way,

02:30:10.780 pilloring the fine, smaller caliber things that we're dealing with in the hand and wrist region.

02:30:16.880 And the wrist has the bones that are held tightly together. And there are multiple bones there.

02:30:23.080 Some of them are often what are called coalitions where they're fused together. So that's why I mean

02:30:27.260 that it varies, but the wrist owns the one bone that is the hardest to heal in the body. And that's

02:30:34.740 the scaphoid bone. It's like a carob coated cashew. It's almost all encompassed by cartilage. So there's

02:30:41.960 only a couple of little areas where tiny blood vessels can get into that bone. And unlike almost

02:30:48.500 all the other, if not all the other bones in our body, we don't have what we call anti-grade flow

02:30:54.100 into that bone, leaving the heart going down through the arteries and the capillaries and going

02:30:59.140 into the bone from point A distally to point B, it goes in retrograde. So if you crack that bone in

02:31:07.500 the middle, at baseline, it has very little blood supply. Then you crack it and disrupt-

02:31:11.980 You probably disrupt the blood supply.

02:31:13.560 Exactly. And so there's a high risk of non-union. It takes the average bone in the body in an adult,

02:31:18.760 takes six weeks to heal. And these generally take 10 to 12 weeks to heal the scaphoid bone.

02:31:25.280 And what's the common injury that breaks the scaphoid?

02:31:27.960 It's mainly a hard fall with the, just the right position of the wrist where it's leveraging

02:31:32.960 on that. The scaphoid spans the two rows of bones in the wrist that we call the distal row and the

02:31:40.480 proximal row of these arcs of bones. And it spans that. So it gets leveraged on in a certain way

02:31:46.500 with certain positions and then a directed force. Usually it's a wrist extension force.

02:31:52.100 Does that patient typically present with a lot of pain or-

02:31:55.000 That's a great question. So no. Often they know they injured their wrist and they'll get

02:31:59.440 some swelling there, but it's not that bad. There's no great distortion of the wrist. When you fracture

02:32:04.600 your distal radius and it's this place-

02:32:06.200 Swells up like a balloon.

02:32:07.100 Swells up and it looks like a dinner fork and you know something's wrong and you, sometimes people get

02:32:11.520 lightheaded and pass out and they just look at their wrist. This doesn't happen with the scaphoid.

02:32:15.480 And it's often young athletes. So they don't, they shake it off. They shake it off. They're used to

02:32:20.780 pain. And then they come in. Often they'll come in at six weeks. They can't lift weights. They can't

02:32:24.860 do a clean and jerk. They can't shuck somebody on the offensive line. Then they get evaluated and we 0.98

02:32:31.540 find the scaphoid fracture and we've already lost six weeks there.

02:32:35.520 Am I remembering correctly? Is the scaphoid fracture the one that's really easy to miss on an

02:32:39.440 x-ray? You kind of need the MRI to see it or is it a CT? Which one is the modality of choice?

02:32:44.040 MRI is where we detect occult, hidden fractures of the scaphoid.

02:32:48.960 And why is that by the way? Because normally CT is the imaging of choice for bone.

02:32:53.560 It's just that you don't have enough bone.

02:32:55.700 Bone's not big enough.

02:32:56.720 And so we can see edema.

02:32:59.020 I've seen a number of people who have had that issue missed. And a lot of times they don't even

02:33:03.620 necessarily tie it back to the fall.

02:33:06.320 Right.

02:33:06.980 If it's been long enough. So what is the treatment plan for that patient?

02:33:10.000 So it's evolved a little. Historically, we treated all of these non-operatively. And then there was a

02:33:16.740 period and actually an Australian fellow named Herbert came up with a really ingenious screw that

02:33:23.060 had two sets of threads on it and they were different pitch. So when you'd screw it down the

02:33:28.800 middle of the bone and turn it and when it engaged both bones, it would actually compress them

02:33:34.520 together because they were a different pitch. And that was called the Herbert's screw. And that was

02:33:39.660 a game changer for us to be able to treat, especially athletes.

02:33:44.060 Show folks where this bone is and where you access it operatively.

02:33:47.300 There are different schools of thought on that. When I was coming out of training,

02:33:51.440 everybody made an incision down here to fix these. A full incision to expose everything. And you had

02:33:57.300 jigs that you can put those screws down. I do almost all of mine percutaneously. I mean,

02:34:02.280 literally an incision this big. And I'll go either retrograde often or anti-grade. It's really a 3D

02:34:09.140 effort to just get it in the right position, get a central core guide wire down, and then you use a

02:34:15.160 little drill, hand drilled, to drill out that and then put the screw down over the wire. And it's

02:34:19.960 really great because patients hardly feel that they've had any surgery. They heal very quickly,

02:34:26.060 faster, and you can even start movement earlier so that when it is healed, you already have your

02:34:31.400 movement back so you're not stiff and then having to do a lot of physical therapy on top of that.

02:34:36.440 Are there scenarios when you would not operate on a scaphoid fracture?

02:34:39.680 There are many. If they're non-displaced, then we can expect them to heal.

02:34:43.720 Would you put a cast on or what do you do?

02:34:45.480 Put at least a splint. We know that you can just basically, as long as you immobilize the wrist,

02:34:49.900 even if you leave the thumb and fingers free, that these will heal. Then you look at comorbidities and you

02:34:55.240 look at life needs. So the athletes often get a screw because they just can get back faster,

02:35:02.080 even with protection. Surgeons often want to have them fixed, fixed a number because they just want

02:35:07.620 to get back to be able to operate, which they can do.

02:35:09.460 And what would be the time course to recovery? Let's just say you're in that lucky camp where

02:35:13.560 the day it falls, you're smart enough to know that it's the scaphoid and you go and get the MRI,

02:35:19.040 confirm it. You have surgery the next day. How long until you're catching a ball again?

02:35:24.160 Catching a ball, generally about six weeks for that.

02:35:27.120 Operating if you're a surgeon?

02:35:28.780 A week.

02:35:29.600 Oh, wow.

02:35:30.240 It's really fast.

02:35:30.720 As long as it's not contact, you're doing it within a week.

02:35:33.260 Right. That's the game changer really that we have now.

02:35:36.740 A moment ago, alluded to something that is one of the few things I do remember from residency,

02:35:40.860 which was the position to make the splint. What is it about having the wrist in this position

02:35:46.840 that for us general surgeons would be basically, let's just let the hand guys look at this

02:35:52.620 tomorrow morning. We don't have to call them at two o'clock in the morning if this is a

02:35:56.340 non-operative or non-urgent issue, but let's at least put them in this safe position. What

02:36:00.360 is it about that position that's safe?

02:36:02.260 The essentially neutral position, which looks like actually, as you've shown, some wrist

02:36:06.500 extension, but it's really neutral in terms of the carpus. What that does is that one of the

02:36:12.140 important things it does is when we are in too much flexion, and we see this occasionally

02:36:15.920 where people just aren't thinking about it. They just slap a splint on and don't really know

02:36:19.720 that which you're talking about, too much flexion or too much extension, then that increases the

02:36:24.980 pressure on the median nerve and the carpal tunnel. So people can get, especially with

02:36:29.200 some extra swelling from the injury, they can get actually acute carpal tunnel syndrome that

02:36:34.260 can be quite substantial in those more extreme positions. So a neutral position is great for

02:36:40.000 that. It's also best for function in terms of just if you're in a splint, but at least trying

02:36:45.420 to get some finger movement, maybe typing at a keyboard or something, then that's a good

02:36:48.860 neutral position. I will, on occasion, if I have to immobilize someone, a musician, for

02:36:54.360 example, I will immobilize them in the position they need, for instance, to be able to at least

02:36:59.240 play their electric bass. I just had a patient the other day who plays both upright bass and

02:37:04.120 electric bass. I said, well, how are you just playing electric bass? He said, fine. I said,

02:37:08.460 then show me the position of your hand, and I'll put you in that splint, in that position.

02:37:11.460 So he's able to keep playing and even doing gigs that way. Everybody's different. It's an

02:37:15.820 important consideration. All right. So what do we need to understand about the anatomy of the

02:37:21.200 radial bone, ulnar bone, and these two big nerves? I'm guessing the median nerve, if I recall, runs

02:37:26.980 there, and the ulnar nerve runs on the pinky side, correct? That's right. And we'll see that in our

02:37:32.920 exam shortly. But yes. And then the third nerve, which completes the hand, is the radial nerve. And

02:37:38.120 that's purely sensory along here. But it is important and provides sensory on the backside of the hand and

02:37:43.340 the thumb, most of the backside of the hand. But the ulnar nerve, you're right. And both of those

02:37:48.920 are at risk for lacerations. And they're at risk even when you distort the anatomy with through a

02:37:55.260 fracture. And so those are the two big ways that they're in. I kind of remember the median nerve

02:38:00.480 being bigger than I expected. What's the approximate size of the median nerve? It's an oval shape and

02:38:06.480 cross-section. And it varies obviously among the size. I feel like it's about three or four millimeters

02:38:10.180 wide by two millimeters deep. Even bigger. That would be a smaller petite person would have about 1.00

02:38:16.000 that size. And I've seen them as large as almost a centimeter wide and four or five millimeters thick

02:38:22.040 in a large hand. Oh yeah. I mean, just insane. Which I guess speaks to the innervation of this

02:38:29.500 unbelievable part of our body that occupies so much of our homunculus. Yes. So I've always said this

02:38:36.220 because, you know, I've talked about this in terms of using meaningful hand use is so important for

02:38:42.300 cognitive development and well-being. And over 60% of our higher cortical neurons are devoted just to

02:38:49.400 our hand through the homunculus. You know, you've seen that homunculus. I know you and I've seen it

02:38:53.580 many times, but it's big lips, big ears, big eyes, but huge hands, and then a tiny torso,

02:39:00.560 shriveled up tiny torso. So that's what's super cool. So yes, I mean, we need to keep using our

02:39:06.800 hands to keep our minds vital in whatever form we're doing. And actually some great studies have

02:39:13.080 been done on that to show what's the effect of just typing at a keyboard. And it doesn't stimulate

02:39:18.200 our cortex very much at all typing, nor does texting. Handwriting, which is an art form, even

02:39:25.640 though it doesn't feel like it for many of us, but handwriting still does stimulate our brain.

02:39:31.840 They did a study a long time ago at Virginia, I think, or maybe Indiana. And they looked at kids

02:39:37.420 who were asked to handwrite versus type the answers to essay questions. And the kids who were handwriting

02:39:45.220 used longer sentences, bigger words, more ideas, and produce it faster than the kids who were typing.

02:39:51.940 And they were measuring their cortical activity, and their cortical activity was way more with the

02:39:56.100 handwriting. That's digression, but it's important to your point that there's so many nerve endings

02:40:00.900 concentrated in our hands that we really need to keep them functioning and get them back to function

02:40:06.520 as quickly as possible. So you mentioned already the carpal tunnel. Let's talk about what this

02:40:11.460 carpal tunnel syndrome is. It's come up a couple of times, and obviously there's technically what's

02:40:17.200 carpal tunnel syndrome, and then there's the symptoms of it, which can be produced by compression or

02:40:21.600 injury elsewhere. But what creates the tunnel per se? It's super cool. When you look in cross

02:40:27.500 section, if you took a cross section through the hand right here, the carpal tunnel is created by

02:40:33.340 a Roman arch of bones, just like the Roman arch is where that central core, I can't remember the name

02:40:38.180 of the bone, keystone maybe, it wedges in and keeps that arch intact. And that's exactly what we have

02:40:44.140 in the reverse. Then we have a tie bar across the top, which is a very thick transverse carpal

02:40:49.740 ligament, and it holds that together. And that creates a U-shaped parabolic inverted parabola

02:40:56.380 tunnel through which the nine flexor tendons and the median nerve pass, and occasionally a

02:41:02.380 medium-sized artery. Now explain why there are nine flexor tendons. So there's two to each finger,

02:41:08.080 lesser finger, and then there's only one to the thumb. It's fascinating to look into that and see.

02:41:14.040 It just so happens that position-wise, if we look at our palm up, the median nerve is running down

02:41:20.580 almost the center of the wrist, and it is the most superficial. So that if we then flex our wrist

02:41:28.180 down, those flexor tendons are trying to bowstring down, they will press that median nerve up against

02:41:34.680 that rigid transverse carpal ligament. If we have swelling edema, inflammatory tissue, such as in

02:41:42.240 rheumatoid arthritis, where that builds up, that becomes a space-occupying lesion in a fixed, confined

02:41:48.840 cross-sectional area, and then it compresses that nerve. The nerve, the tendons aren't really vulnerable

02:41:54.400 in that way, but the nerve is very vulnerable to compression. That's why it's such a ubiquitous problem.

02:41:59.480 So from a motor standpoint, the median nerve controls which function versus the ulnar nerve?

02:42:06.160 So important of a question. And by the way, there is some confusion. People very often come to me and

02:42:11.780 say, I think I have median nerve. I mean, I think I have carpal tunnel syndrome. And because it's such a

02:42:17.420 ubiquitous bandied about term, but you must have numbness and tingling in the median nerve distribution,

02:42:24.340 which is the palm side of the thumb, index, middle, and usually half of the ring finger. If you don't

02:42:30.880 have numbness and tingling there, you're very unlikely to have carpal tunnel syndrome. However,

02:42:36.220 if you have an arthritic process, you can, without having as much numbness and tingling, you can have

02:42:42.980 isolated atrophy of the muscles, the thenar, the thumb muscles here that give us our opposable thumb.

02:42:51.420 You can have atrophy that looks like an indentation right there. And some people can have that quietly.

02:42:57.020 It can be just a very gradual, just from the encroachment on that nerve of the bone spurs that

02:43:02.920 grow through the arthritic process. So that's the exception where sometimes you can have isolated

02:43:07.980 motor. And very rarely in a younger person, I will see where they have an odd motor branch,

02:43:14.700 which is the nerve that comes off the median nerve that goes to those muscles. They'll have a weird

02:43:19.300 compression of just that. So a younger person who doesn't have any numbness and tingling and then

02:43:24.280 has isolated atrophy. So that needs to be addressed surgically as well. But the thing that fits with

02:43:29.620 the carpal tunnel is that if you're pregnant, often in the third trimester, when women are dealing with- 0.98

02:43:35.680 This is just because of swelling?

02:43:36.700 Just because of swelling. The fluid imbalances that are going on there, that's a possibility.

02:43:40.960 People who use jackhammers or people who are cyclists, and they're always pressing down and putting 0.57

02:43:46.100 extra pressure on that area can get carpal tunnel syndrome only when they're cycling. So it's a

02:43:51.440 dynamic situation. Weightlifters can get it depending on what the style of what they're doing.

02:43:56.760 But the stereotype is people who are typing a lot, isn't it?

02:43:59.420 Yeah, that is.

02:44:00.600 Is that a true carpal tunnel syndrome?

02:44:02.140 So generally speaking, most people don't get carpal tunnel just from typing. There was a massive

02:44:08.180 class action lawsuit against IBM 100 years ago. I don't know how long. And they lost because they

02:44:13.600 couldn't prove- IBM didn't lose the class. They lost the case because they couldn't prove that it

02:44:19.180 was caused. There was no data to suggest that it was caused by just using a keyboard. However,

02:44:24.800 if you already have it, absolutely that activity will exacerbate it. That's why ergonomics are so

02:44:30.220 important. How you're sitting. I mean, during COVID, everybody went back home and worked from home

02:44:35.420 and worked at sometimes random, the kitchen table or their bed with their laptop and their

02:44:40.940 crunched up. So there's a lot more of these, both wrist tendonitis and carpal tunnel syndrome after

02:44:46.840 that. That doesn't affect the ulnar nerve, which is the other nerve that we're talking about. The

02:44:51.180 ulnar nerve is so important because while our opposable thumb is critically important, that's

02:44:56.740 governed mostly by the median nerve. The ulnar nerve supplies almost all the rest of the muscles,

02:45:03.420 small muscles of the hand. And those we call the intrinsic muscles of the hand,

02:45:07.480 which are basically what allow us to spread our fingers apart, pull our fingers together,

02:45:13.380 do these weird funky positions that we do, like the intrinsic plus position there. That position,

02:45:19.340 being able to do that with your hand is almost all ulnar nerve. And if you cut the ulnar nerve right

02:45:25.100 here at the wrist, your hand will do just that. And you will not be able to do anything but a little

02:45:31.100 bit of that. You can't. So the flexors of each finger are all ulnar? Well, the intrinsic flexors

02:45:38.040 are ulnar. The extrinsics are split between the median, more proximally in the forearm, or split

02:45:43.540 between the median and the ulnar. But lifting a finger this way is intrinsic. Yes, this way at this

02:45:49.360 knuckle level is all intrinsic. And we don't have extenders, extensors, or we do? We do, but not

02:45:56.200 intrinsically. Well, and not for the level, the MP joints, that's extrinsic extension. I'd love to

02:46:02.480 draw a picture of the finger mechanism. I just find it so cool. It's so much more complicated

02:46:08.840 biomechanically than the flexors. The flexors are pretty simple. And what's fascinating about the hand

02:46:15.040 is despite being able to play Rachmaninoff or a violin concerto, or be able to build a watch,

02:46:22.520 the hand is actually more primitive. It's pretty much unchanged. Except for the opposable thumb,

02:46:28.800 it's a pretty primitive structure in the sense of evolutionarily speaking. Our foot is a fantastically

02:46:36.320 adapted and modified over evolution to walk. We were talking about that before. When we stood up

02:46:42.560 and became bipeds, our foot completely changed. I mean, I know we joke about it, but is the opposable

02:46:47.100 thumb the primary difference between us and a primate? Yes. Well, it depends on, we're part of the

02:46:51.940 higher primates. Yeah. Between the lower primates. The lower primates. Exactly. That's why once we

02:46:56.260 were no longer arboreal, where our thumb was in the plane of the palm and we would hang from tree

02:47:01.820 limbs, then when we came around, we could start making tools and developing our, that's the thing,

02:47:07.480 our brains grew when we started using our hands and making tools. That's when our brains, our heads

02:47:12.300 enlarged. It's just so cool. I mean, I can sit here and talk about the hand all day, especially given

02:47:16.180 how little I understand it. So what are some of the other injuries that are pretty common? Either, again,

02:47:22.680 the injury you'll see more commonly in the 60, 70 year old versus in the athlete, the kind of the

02:47:28.500 wear and tear injuries. What are the most common fractures? I think we would break it up into the

02:47:33.560 acute traumatic events, which are most often fractures, but can be also dislocations. Then we would say

02:47:40.200 the wear and tear type injuries, which are usually start in middle age and go on into older age.

02:47:48.920 And then the actual degenerative arthritic types of problems that are inevitable for many of us.

02:47:54.320 And they vary among individuals based on genetics and lifestyle and so forth. So the fractures,

02:48:00.260 the most common by far is the distal radius fracture. That's just the big bone of the radius.

02:48:04.900 Now the radius, the form is super cool because we already talked about the elbow. We looked at that

02:48:09.540 really complex, weird undulating structure there. The ulna that we talked about is the elbow bone

02:48:16.500 that we feel the prominence of our elbow, and that's a straight bone. And that goes down and it forms the

02:48:21.920 bump here that we see on the back of our wrist. And that's the ulna. The radius is a curved arcing bone

02:48:28.420 that is curved so it can get around the radius as we pronate and supinate. So the radius is flared and

02:48:36.860 provides the biggest structure at the wrist level, but it's much smaller at the elbow level. And so

02:48:43.360 it rotates around through a fixed ulna. The ulna never moves. I mean, it moves this way, but it

02:48:49.340 doesn't move rotationally. And the radius just rotates back and forth. So any disruption of that

02:48:54.320 can dramatically alter our ability to hold a bowl of soup or to pronate and type and write. And that can be

02:49:01.660 disrupted in many ways. The fractures, the radius is super common to fall and have a bending moment

02:49:08.100 on that and it fractures and displaces. But then you can often, you know, something falls hard on you,

02:49:14.680 you fall. I mean, we see them commonly in kids who are falling off the jungle gyms. They'll have a both

02:49:19.060 bone forearm fracture in the mid forearm. And that's just another bending moment. Those bones break in

02:49:24.560 half or sometimes they bend. One of them breaks, one of them bends. The kids are young enough.

02:49:29.080 And so that can very much disrupt the function there. And so at any different point along the form,

02:49:36.600 depending on the mechanism, these bones can break. And when they do, if they're displaced, we have to

02:49:42.060 often fix them, except in very young kids. That reminds me, by the way, I don't know what it is. I vaguely

02:49:48.400 remember this from medical school and I never saw them in residency, although I told it was very common, but I

02:49:53.280 guess I just didn't do enough to see it. Where a parent grabs a kid by the arm to yank him across the

02:49:58.680 road. And what is that injury that's supposed to be pretty common?

02:50:01.240 Yeah, that's nursemaid's elbow. And that is a subluxation of that round radial head at the elbow. 0.64

02:50:08.060 And I had the, I guess, interesting and informative experience to create one in my own daughter.

02:50:14.060 My first daughter, I would spin her around, you know, like you see people. And I remember spinning

02:50:19.240 her around, she was giggling and so forth. And then I felt just the tiniest little weird movement

02:50:24.940 in her elbow, it kind of threw her hand. And I saw her face start to scrunch up. I set her down 0.67

02:50:31.240 and then I just had this vision. I knew what it was. I quickly did the reduction maneuver

02:50:36.640 so fast that she hadn't even started crying. And then it just immediately stopped hurting.

02:50:42.640 I could tell she was getting ready to start crying, but then she had no reason to because

02:50:47.860 it didn't hurt. So it was kind of, we were in that.

02:50:49.880 And remind me what that reduction is again. So what's happening? So the radius, which is on

02:50:54.020 this side, the outer side.

02:50:56.080 Exactly. When you pronate and you pull and kind of give a various moment, it will cause that radial

02:51:02.260 head just to slip out this way a little bit. So the easy maneuver, because the stable position

02:51:07.500 is just, you supinate and you put a little pressure on that, you supinate and then flex the elbow up.

02:51:14.060 So this is the most stable position of that bone.

02:51:16.580 So it just, it'll pop right back in every time. Now, if there's stay out and then you go sit in

02:51:22.320 an emergency room for eight hours or six hours, harder to get back in. You often have to do it

02:51:27.020 under anesthesia. To this day, I am still paranoid anytime I have to grab one of my boys

02:51:31.600 that I'm going to do it. And I'm always like trying to figure out a ginger.

02:51:34.520 You're ready.

02:51:35.040 Now I'm ready to reduce it if I ever screw it up. I've seen a lot of radial fractures in friends and

02:51:40.600 kids. And it really seems like one of those awful luck things sometimes. Like if you fall out of a

02:51:45.420 tree, you fall out of a tree. If you slip on ice that you don't see and you're totally not ready

02:51:50.080 for that fall, it can happen to the best. And then the older we get, of course, if we have a

02:51:54.300 little osteoporosis, osteopenia on x-ray and osteoporosis, then it takes less and less force

02:52:00.540 to fracture those bones. What breaks the ulnar bone? Does it ever break on its own?

02:52:05.500 The most common one is a direct blow. It can be in football. It can be a weight falling. It can be

02:52:11.700 a door smashing into you is what's called a nightstick fracture. And it's named for that

02:52:16.660 because especially the billy clubs in the UK where you would strike you when your hand was up

02:52:21.300 and it cracks the ulna along there. That's the most common, but it can often be fractured also

02:52:27.620 in association with the distal radius. The styloid part can come off. It's attached to a ligament

02:52:32.980 or they can just both snap at the same time. Then that complicates the treatment. So those are the

02:52:38.460 most common ones. And then the other one, which is really more of an elbow fracture, but it's the

02:52:43.220 ulna, is the olecranon. And that's a common, common fracture. And that's really simple. I see

02:52:48.720 those in very young- That's when you fall on your elbow. Exactly. You fall on your elbow. The only

02:52:52.100 other way you can kind of pull that bone off is if you fall really hard, say snow skiing, you're

02:52:57.440 falling hard. And as you've talked about the eccentric load, that triceps pulls it right off.

02:53:03.400 Yeah. I mean, you're the expert on eccentric loading. And I love the fact that you educate so many

02:53:07.400 people about that because it's way more injurious in a way. What about the chronic sort of injuries

02:53:14.320 of the hand and wrist that ultimately require surgical care? You can break them down into sort

02:53:19.420 of overuse patterns, which are more tendonitis. And if you have a long enough standing tendonitis,

02:53:25.060 you can start to, the tendonitis is an antinosynovitis. So those are subtle differences.

02:53:32.380 A tendonitis is just inflammation in the tendon. And if it's beginning to wear and tear and

02:53:37.040 degenerate, you'll get some longitudinal fissuring in those collagen fibers, and then

02:53:41.920 it fills in with some inflammatory tissue. And then that can envelop the tendon. And so

02:53:46.880 you're getting kind of a constant rubbing and further degeneration of that. You get chronic

02:53:52.840 pain. You can inject it with cortisone, but then ultimately they can rupture. And depending

02:53:57.800 on how much and how much force they're being subjected to and for how long it's been there.

02:54:01.800 So that's one. Then the tenosynovitis is a subset of that where we have these effectively watertight

02:54:09.540 tubes, specifically in our flexor tendons. And those tendons are gliding beautifully in there.

02:54:15.860 There's a little bit of fluid our body produces to keep them gliding smoothly. And a little bit of

02:54:20.400 what we call tenosynovium, which is just a filmy structure that gives them some lubricating,

02:54:24.820 teflon-y feel. If that gets inflamed from overuse, whether you're a violinist or a heavy weightlifter

02:54:31.440 doing all sorts of things over and over again, you can develop inflammation there. And then that

02:54:36.560 becomes trapped in there. And it really hurts. It can eliminate mobility. And it can even cause them

02:54:42.240 sometimes to lock down. And those are super common. And we can often cure them with just cortisone

02:54:49.060 shots or rest or both. But then ultimately, a subset of them, because they're so ubiquitous,

02:54:54.800 require surgery, which is very minor. But it's important because the hand function,

02:54:59.620 if you have one finger that's really stiff, whether you dislocated it or even just sprained it,

02:55:05.700 the other fingers, they're all linked so indelibly together that actually it will make your whole

02:55:10.840 hand feel stiff. Yeah. So it's funny you say that. So as you know, I'm really obsessed with grip

02:55:15.140 strength and all sorts of crazy shenanigans. Maybe about a year ago, I started experimenting

02:55:20.620 kind of like training sort of the way that rock climbers do where you're using only finger strength.

02:55:26.580 And what blew me away was how much weaker I felt all the way through my lats when I would restrict

02:55:36.220 the amount of fingers I could use to pull up. If you just said, do pull-ups, you can use your whole

02:55:41.340 hand, do pull-ups, no problem. You just barely notice that. I feel like I'm perfectly connected

02:55:46.500 from the bar to my lats. And now you say, okay, Peter, you're not going to get to use your whole

02:55:52.020 hand or your thumb. Just use your four fingers. Actually, that gets a little harder.

02:55:56.440 Way harder.

02:55:56.800 It took me a while to work up to 10 four-finger pull-ups.

02:56:00.920 Well, that's impressive that you can do that because, yeah, I know exactly what you're talking about.

02:56:03.940 It took a long time. I mean, it took a couple months.

02:56:05.780 Then I moved to three-finger pull-ups. I mean, it's an order of magnitude harder.

02:56:12.120 It's crazy, right?

02:56:13.060 I don't know that I even got to try two-finger because I was still really

02:56:15.820 nowhere near getting to 10 three-finger pull-ups. Why is that? Because I'm no less strong

02:56:23.360 in my lats, in my biceps, in all these other muscles. Why is it that simply take... And by the

02:56:29.880 way, it was the pinky that I was removing of all fingers. You'd think it does nothing.

02:56:34.040 Why, when I can only have these three fingers, does all of my strength fade away?

02:56:39.640 I've never been asked that directly, but I have a couple of theories on that.

02:56:43.460 One is, and it applies to sort of the weakness I feel and detect asymmetrically in, let's say,

02:56:51.260 a rotator cuff. If you have a small partial thickness rotator cuff tear, well, that's tiny,

02:56:56.320 mechanically not relevant, and yet you can be quite weak. Your brain is so smart. It knows.

02:57:02.980 It doesn't want to overstress that area. So my instinct is that the first reaction,

02:57:09.700 especially when you've never done that before, is for your brain to say, whoa, that's putting way

02:57:13.960 too much tension on the other one. So I'm going to relax everything. I'm not going to give you what

02:57:18.280 you need because they may rupture. Interesting.

02:57:20.540 I think that's probably the biggest explanation for that. But specifically, when you're talking

02:57:25.680 about grip strength, what's ironic is that the ulnar nerve, which is only these two fingers,

02:57:32.000 is much more important for grip strength than these. So if you have these, let's say you have

02:57:40.300 an ulnar nerve that's completely in and a median nerve that's out, you're going to be pretty strong

02:57:45.680 still. Whereas if you have an ulnar nerve out and a median nerve that's still in, you're going to be

02:57:51.020 much weaker. Wow. So just for people listening to us, which hopefully nobody's just listening to

02:57:55.060 this podcast because it's hard to, you're saying pinky and ring finger matter more to grip than

02:58:01.300 middle finger, forefinger, thumb, which is under the median distribution. That even just feel,

02:58:06.700 I feel like I can engage my forearms much more with my pinky and ring finger. Oh yeah, for sure.

02:58:12.380 Absolutely. Why is that?

02:58:14.140 I mean, it's evolution, I guess.

02:58:15.560 That's insane. You know what? It makes me wonder if I should be doing these three fingers.

02:58:21.320 That's what I think.

02:58:22.240 Because I was doing, I'm going to try that today.

02:58:24.700 Good. Report back to me. I'll let you learn that rather than me having to learn it.

02:58:28.640 That is amazing. I'm endlessly fascinated by what our hands are capable of. And I think of it as such a,

02:58:35.100 well, such a force multiplier for our species. It's an unbelievable asset and our ability to carry

02:58:42.340 things. You know, Michael Easter has written about this at length in his book, The Comfort Crisis,

02:58:46.820 which of course is what has introduced us all to rucking. But, you know, other animals can carry

02:58:51.800 a lot if they're domesticated and you put it on their back. We can carry our body weight in our

02:58:56.060 hands. It's crazy. I know.

02:58:57.560 That is mind boggling. And it speaks to kind of remarkable engineering. And to think that a lot

02:59:02.220 of that is made possible by this opposable thumb as well is pretty cool.

02:59:05.980 And even going back to the elbow, anatomically, when you look at the Vitruvian man and when you look at

02:59:11.100 the standard anatomic position of, in medicine, the elbow has a carrying angle built into it to

02:59:17.760 get whatever we're carrying away from our body. So we can carry more. So we have a 12 to 15 degree

02:59:23.020 natural built in what's called valgus or away from our bodies to give us more area to carry heavy

02:59:30.440 things with. Super cool.

02:59:32.060 So let's talk about the final category of these, which are the arthritics. And here you have really

02:59:36.980 two, you have this rheumatoid or autoimmune form of arthritis, which anybody who's seen patients

02:59:43.140 with that recognize it is, it just looks like an awful affliction where it's not only functionally

02:59:49.060 impeding, but also physically deforming of the fingers and the joints versus the much more common

02:59:54.180 osteoarthritic, which I assume is more aware and tear, you know, it doesn't have that autoimmune

02:59:58.640 component. So first of all, what's the distribution and breakdown of those and which one of those

03:00:02.460 ultimately can require surgical intervention of sorts? So historically, just in my orthopedic

03:00:08.360 lifetime, I see very few now rheumatoid, arthritic, and what we would call the RA negative, where the

03:00:17.280 testing, we know they have the visible, but they don't necessarily have all the lab abnormalities to

03:00:23.360 back them up. But I see less than I ever saw before because of the- 0.74

03:00:28.460 Because the medical therapy is just so much better too.

03:00:30.360 They're so amazing. They've been absolute game changers and keep people normal for such a long

03:00:35.700 time. So that's one thing. But in general, when I started practice, I would have to operate as often

03:00:42.760 in a patient with rheumatoid arthritis and those deformities that happen. And you're trying to

03:00:48.100 beat the body to addressing the deformities so they don't get bad enough to where they really require

03:00:54.720 joint replacements and much more complicated recoveries and so forth. So it was always a battle.

03:01:00.060 Kind of like you racing a car. You're just trying to get just a little bit ahead and just do whatever

03:01:05.060 you can do to win that. Now, I probably see maybe one a month that needs surgery. And that's pretty rare.

03:01:14.780 And the surgery is because of such a significant functional limitation?

03:01:18.660 Yeah. It's always in the case, it can be in the elbow, can be in the shoulder, but usually in the

03:01:23.860 hand. And it's a tendon subluxation, joint deviation that then weakens their hand and decreases their

03:01:32.860 ability to remain independent. The goal, obviously, and to the point of what our hands do for us,

03:01:38.940 if we maintain reasonably good hand function, we can remain independent. As soon as we lose our hand

03:01:44.220 function, we become dependent on others, period. And so that's what our whole goal is, to maintain

03:01:50.340 that fierce independence. That's that. But then on the other hand, then we have the wear and tear

03:01:56.220 osteoarthritis concept. And that varies among individuals. Some people have really good hands

03:02:03.600 till the very end. I liken it to a job on a car, a cheap one. And we talked about that before,

03:02:09.940 and versus a very nice thick paint job that holds up. But there is a big genetic component. I see

03:02:15.240 patients come in that'll maybe be only 50, very young. They'll come in and they'll already have

03:02:21.220 a lot of the visible alterations, not terrible functionally, but they're getting the knobbiness,

03:02:27.320 they're getting a little bit of inflammation in the joints out here, maybe down at their thumb base.

03:02:32.320 And they'll say, what can you do? My hands look exactly like my mom's did or my dad's did. There's

03:02:40.320 real evidence to support that. Some people are more predisposed than others. Now, the one exception

03:02:46.300 is the ubiquitous, about 50% of all of us will develop arthritis at the base of our thumb. And that's

03:02:53.540 that opposable thumb. The problem with that is it's all about biomechanics. It has to do too much.

03:02:59.540 There's six degrees of freedom. It's just this biconcave saddle joint that in order to come back

03:03:06.020 and forth this way, radial and ulnar deviation, then straight up palmar abduction that way, and then

03:03:14.180 rotating around and pronating in order to oppose the thumb tip to the fingertips. It's doing three

03:03:22.580 different directional movements. And this joint is doing this and this and this. And it just

03:03:29.500 wears out. It's just subjected to so many odd stresses and it's unstable like the shoulder by

03:03:36.100 definition. We couldn't have it. It gives it that amazing mobility. Yeah. So 50% of people in their

03:03:41.260 lifetime, if I'm hearing it correctly, will experience osteoarthritis of that joint. Yes.

03:03:45.420 In what fraction of those people will it pose a functional limitation that is not something that's

03:03:51.720 just treatable with some aleve here and there? Obviously, we don't know what percentage of the

03:03:55.720 population that all of us as a group are treating. What we do know is that we don't know the exact

03:04:01.340 subset. We know there's many people walking around with basal arthritis that never have pain. They have

03:04:05.800 some stiffness, some deformity, and they don't hurt. We know that. We don't know that exact number.

03:04:10.400 However, what we do know that, and we've published papers on this, is that of the people that present with

03:04:15.940 some pain, about 25% of those, which would be, I guess, 12 and a half percent of the overall

03:04:21.900 population potentially, are going to need surgery on that at some point. That's a staggering number.

03:04:28.100 One-fourth of the people that present with pain in the thumb are going to need surgery.

03:04:32.100 And what is the surgical procedure? It varies depending on what stage they present at,

03:04:36.560 and we've done staging systems and so forth, but it's some form of reconstruction. Unlike the hips and

03:04:44.140 knees that are so ubiquitous and so wonderful, they've kept people back to their fully active

03:04:49.640 lives by doing them, we don't have those kind of great implants for this. They don't work. There's

03:04:55.700 very high failure rates. If a hip replacement or a knee replacement has a 5% failure rate at 5 or 10

03:05:02.300 years, the thumbs are 70% failure rate of all the previous. So what we do, and it was invented by my

03:05:10.640 forebearers and we've modified them over time, but it's basically doing a reconstruction using your

03:05:15.900 own tissue. And that's what's super cool, which we didn't mention, is because of the way our limbs

03:05:23.980 evolved, we have so much protective redundancy. We have so many tendons, like all of the flexor

03:05:30.760 tendons that flex the fingers also flex the wrist and give us strength, just like you were talking

03:05:34.820 about with the pull-ups. Well, you have wrist flexors that only attach right here that also give you

03:05:39.640 that flexion. And those all are housed in the forearm. And then you have the extensors that do

03:05:44.620 that. And then you have some that are just, we have multiple tendons that pull the thumb out. They do

03:05:49.100 subtle differences, but we can use those. And we do use those to transfer and to use them as tendon

03:05:57.460 grafts. Now, a cool thing that goes back to the evolution is if you look at your hand, hold your hands

03:06:03.240 out and pull and flex your wrist a little bit. You can see here, you can look on yourself. You can see

03:06:09.040 here I have this big tendon that comes up when I, so on this side, I don't have one. It's just

03:06:14.340 missing. Oh, I have huge ones. I have huge ones on both sides. Yeah. Okay. So evolutionarily,

03:06:19.260 that's the palmaris longus. Those are hugely developed in quadrupeds and horses and so forth.

03:06:25.080 The big important muscle. Don't do anything in us. They don't do anything. So we use that as a tendon

03:06:29.640 graft all the time. We just take it. It's attached to a little whip, small muscle. I'm closer to the

03:06:33.940 horses. Closer to horses. I knew that about when you were. So mine, we're evolving away. 15% of

03:06:39.440 people don't have any. So does that mean you're not actually addressing the surface of the saddle

03:06:44.600 joint, which is arthritic in this procedure? Good point. You're not recreating some artificial

03:06:49.500 joint. What we're creating is a pseudo arthrosis. We stabilize it, get it stabilized back on top. In my

03:06:56.400 case, I take a little bit of the bone off to create a space and then I roll up the rest of that

03:07:00.520 tendon and put it in there. And that relieves the pain and restores function. Yes. So this is a high

03:07:04.940 success operation. Very high success. I don't know how I didn't realize. You could make a case that

03:07:09.580 roughly 5% to 10% of the population will require this at some point in their life. Obviously,

03:07:15.500 a subset are very sedentary and don't do much and they're not going to need it. And they'll wear a

03:07:19.680 splint for the rest of their days. But if they're presenting with the pain, that's the point. We don't

03:07:24.800 know what the N is, but other than being the general population as a whole, but people who present

03:07:30.060 with pain are active enough. So would you say this is the single most common non-traumatic

03:07:34.580 surgical repair of the hand? Non-traumatic other than a, well, and even a trigger finger you could

03:07:40.740 attribute to. So of the major surgery done in the hand, yes, by far. You mentioned trigger finger.

03:07:47.360 What's that? Well, trigger finger is what we were talking about before where the inflammation of the

03:07:50.700 sheath. And then right in the middle here, there's a series of pulleys. And these are super cool.

03:07:55.880 I'm going to draw a picture if I may. Okay. So we're looking at the side of the hand of the

03:08:02.720 finger, right? And let's just say this is the middle finger. It's the longest. And this is

03:08:06.840 the metacarpal. This is the first of the three bones of the finger proper. And what I've drawn here,

03:08:13.460 this black line coming underneath is the flexor tendon. And that's the one that does curls. All our

03:08:19.240 curl allows you to do all your pull-ups. So there's four bones there, just so people can see.

03:08:24.280 I don't want them to miss the one at the very front. This one is kind of hidden within the hand

03:08:27.440 because that's through here. And so then there's the three successive. And so if you had a muscle

03:08:34.340 attached to this and you pulled on it and didn't have those blue structures, then this would bowstring,

03:08:40.800 just like a fishing pole. If you don't put the fishing line through the eyelets, then it just stays

03:08:46.780 way away. And it's actually stronger that way, but you lose all the mobility. So you lose the capacity

03:08:54.160 to really curl your fingers tightly. So that's what they're gliding through. And those are fibroosseous

03:09:00.480 tunnels and just fibrous tissue, very strong, which you mentioned rock climbing. They can rupture

03:09:06.700 because you're putting so much force on those in such funky positions and isolating two fingers,

03:09:12.840 one finger and so forth. So I see that a lot in rock climbers. But the point here is that as you're

03:09:20.040 rubbing constantly going back and forth, whether you're playing a concerto or you're rock climbing,

03:09:25.040 you can get inflamed along that sheath. This particular pulley here is down in the palm.

03:09:30.860 And that's the most common site to have inflammation to where you can even get some nodular swelling in

03:09:36.340 the tendon and that thickening up of that pulley. And then it just actually catches. And we call it a

03:09:40.960 trigger finger because it's like pulling a trigger on a gun. It has that feeling. And we frequently

03:09:46.880 have to inject those with cortisone and frequently have to operate on them. They're ubiquitous.

03:09:52.160 And about half of them recover with just a cortisone injection?

03:09:55.100 If you take someone who presents within, say, six weeks of onset, there's about a 75% cure rate

03:10:00.180 with one or two injections.

03:10:02.220 So the longer you wait, the more potential damage you cause and the more chronic inflammation that ensues?

03:10:08.800 Correct. And this applies kind of a general consensus. I think we talked about this before

03:10:13.460 when we were talking about cortisone shots is in these types of soft tissue procedures,

03:10:18.540 we don't keep injecting cortisone, cortisone, cortisone, because it can lead to soft tissue

03:10:24.140 degradation and ultimately even tendon ruptures. I've never seen one in my practice, but we know

03:10:28.640 they can exist.

03:10:29.440 And what do you use as a rule of thumb for how many times you'll put cortisone?

03:10:32.220 Three.

03:10:32.540 Three in the lifetime of the joint?

03:10:33.840 Three in the lifetime of that tendon sheath, unless it's very, very broad. Usually you

03:10:39.380 don't see someone back 10 years later who needs another injection. But if I did, I'd be willing

03:10:43.300 to do that again because everything has normalized physiologically at that point.

03:10:47.820 Now, the other cool thing that I was talking about before when we were talking about the,

03:10:51.160 you asked about the extensors versus the flexors. So if we look at the red, this is the extrinsic

03:10:58.680 extensor tendon that will straighten up the knuckles. But then we look further out and we

03:11:04.020 see, well, that only stops, that tendon stops at the middle knuckle. But what allows, what

03:11:09.940 pulls the whole finger straight? And it's actually this intrinsic muscle here that's tapering

03:11:16.100 down and has a very thin tendon. It turns into a lateral band and it travels from the palm

03:11:24.740 side up above the middle knuckle, above that axis of rotation, and then it goes all the

03:11:31.480 way out and attaches to the tip. And so it's a super cool mechanism that through a series

03:11:38.220 of mechanical placements, it's able to extend the finger even though-

03:11:43.200 By contracting.

03:11:43.880 By contracting. It's crazy.

03:11:45.360 It's very counterintuitive.

03:11:46.680 Most people wouldn't immediately get that. You have great biomechanical sense because yes,

03:11:50.940 by contracting, it's straightening up the finger. It's super cool. But it doesn't take much. Like

03:11:55.960 if you take a direct blow to that knuckle right there and that tendon just slips because you've

03:12:02.280 disrupted some soft tissue, it can slip below the axis of rotation. Then it becomes a flexor and

03:12:08.120 you get a boutonniere deformity, which looks like that. You cannot straighten your finger up because

03:12:13.360 those lateral bands that are used to extending the finger have slipped down. Now they become a

03:12:17.860 flexor, just like you said. So it's super cool and just so intricate.

03:12:22.400 And I vaguely remember one sort of surgical emergency in the hand where that sheath would

03:12:26.780 become infected.

03:12:27.800 Yes. Very good. Yes. It's one of the few really orthopedic emergencies in the hand, which is

03:12:33.640 tenosynovitis and then it becomes suppurative or infected and pus in there. And those people,

03:12:40.240 I mean, there's so many nerves in our hand anyway. When you get even a few drops of purulent

03:12:44.960 pus in the finger sheath, it hurts like crazy. And your posture is down like this. You can't

03:12:50.840 straighten your finger up at all. And it's exquisitely tender and it looks swollen just

03:12:55.540 along that sheath. And yeah, it's an operative urgency or emergency.

03:13:01.160 How does a person get that infection? Is it usually an open injury or?

03:13:03.900 Yeah. Sometimes just a little, it can even be a pinprick. It's sometimes an insect bite

03:13:08.060 with a stinger and often just a tiny little. If you're using sports equipment, you can get a

03:13:13.900 little graphite, tiny stiff graphite puncture.

03:13:17.260 How many times a year do you see one of those?

03:13:19.020 I don't see them as much now because I'm not in the ER. They're ubiquitous. I mean,

03:13:23.080 they're coming all the time, year round.

03:13:25.660 Okay. Should we do an exam of the hand and wrist now?

03:13:27.780 Yes, let's do it.

03:13:28.720 Okay, great.

03:13:29.320 At this point in the conversation, Alton demonstrates on me what he will do for a typical

03:13:35.280 hand, wrist, and forearm exam on a patient. As this lends itself much more to video,

03:13:39.800 we decided not to include this in the audio version of the interview. If you'd like to see

03:13:43.540 what this exam looks like, you can head over to the show notes page or to our YouTube page,

03:13:48.100 where we have the full exam videos very clearly broken out and available. Now,

03:13:52.820 back to my conversation with Alton.

03:13:54.300 Okay. So the final thing you wanted to talk about was all of the nerve pains that can

03:14:01.520 presumably not just wreak havoc down here from a pain and suffering standpoint, but also from a

03:14:07.820 diagnostic standpoint.

03:14:09.320 Yes. So many people present with numbness, tingling, weakness, or pain in the upper limb.

03:14:17.720 It can start from the neck where the nerve roots exit and travel under our collarbone through the

03:14:24.880 brachial plexus in between the scalene muscles, and then travels through our armpit and then comes

03:14:30.740 down in through the arm and into the hand. It can be confounding. A perfect example of how

03:14:37.220 confounding it can be is a now more commonly known, although it's, I wouldn't call it rare,

03:14:43.100 but it's uncommon, is Parchinage-Turner syndrome. It's a fascinating study in that whole process from

03:14:51.020 the neck down. And the other term for it is a brachial neuritis, as in brachial plexus neuritis.

03:14:59.200 And it's an inflammation of those nerves. We think it's probably viral related because there's

03:15:05.600 usually a viral prodrome associated, but it doesn't have to be, but it's an acute dramatic onset of pain

03:15:13.160 all through here. And then some, what we call mixed plexopathy, some mixed bag of palsy, weakness,

03:15:23.160 numbness, and it can be in multiple different nerves. It can even lead to, and one of the most

03:15:29.140 common presenting ways is long thoracic nerve, which is part of the brachial plexus, and you get

03:15:34.700 scapular winging. So you lift your arm up and it just falls down because your scapula cannot support

03:15:42.220 the shoulder and arm weight because the muscle of the shoulder girdle cannot support that.

03:15:48.220 And it's super cool. And it presents as a mix. So it affects multiple nerves because those nerves

03:15:54.640 are more common up here, and then they diverge into the different nerves, which I still, you remember

03:16:01.660 in med school trying to learn the brachial plexus, and it was brutal because it's really complicated.

03:16:06.480 So these are people who show up, but you certainly couldn't attribute what they're experiencing to any

03:16:11.100 one thing. That's the point. It's not like they have one or two discs that could be bulging and

03:16:17.540 causing that symptom. It's not like they could have even transected their long thoracic nerve, like

03:16:21.600 a woman who has a mastectomy, you're always looking out for that post-mastectomy. 1.00

03:16:25.840 It's like they would have to have six lesions simultaneously.

03:16:29.060 Exactly. And it just doesn't happen except with that. So that's a great lead-in to what

03:16:33.360 the majority...

03:16:34.840 By the way, is that just a self-limited thing, or do you give these people steroids?

03:16:37.980 Steroids. Yeah. They make the diagnosis if you send them to them, and we give steroids. And

03:16:42.700 most of them recover completely. A few have some residual deficits forever, at least long-term.

03:16:48.320 That takes us to people presenting. I have a ton of patients who present with shoulder

03:16:53.880 pain, and they may have a little something on their MRI that they may have brought in

03:16:58.740 with them. But that shoulder pain is actually coming from their neck. Then I'll have someone

03:17:05.340 who will present with carpal tunnel syndrome, but there's a little extra stuff going on.

03:17:10.700 Maybe some ulnar nerve in the little finger. Maybe some shoulder pain. Maybe some arm pain.

03:17:16.680 And the cool thing about, diagnostically speaking, is an intrinsic shoulder problem, such as

03:17:22.960 a rotator cuff tear or inflammation, bursitis, et cetera, usually travels down underneath the

03:17:29.740 pain, underneath the big deltoid muscle, but almost never goes below the elbow. So if I

03:17:35.640 see pain that's in the shoulder going below the elbow, I'm thinking maybe neck or maybe

03:17:40.560 something else. Secondarily, if someone complains of, let's say they come in and they say, I've

03:17:47.900 got numbness here, but I've also got some numbness on the back of the hand. The radial nerve is

03:17:52.320 rarely involved in association with carpal tunnel or cubital tunnel. And, oh yeah, my neck's been

03:17:59.240 really stiff. Just subtle little cues that you can get by speaking with them. Well, they could

03:18:04.860 have something that I know you know about and that can be called double crush. And that is where you

03:18:11.140 get pinching of the nerve in the neck, maybe through a disc, maybe through a foraminal osteophyte

03:18:16.740 that narrows that little canal it passes through. And then because the axoplasmic flow or the nerve tube,

03:18:27.240 the communication of it is disrupted or compressed, it renders them more susceptible to milder compression

03:18:35.280 down at the carpal tunnel or the cubital tunnel at the elbow. So they're getting a double crush.

03:18:41.840 Now, for those, I don't treat necks other than treating them initially with some PT and maybe 1.00

03:18:46.740 steroids or something. And I refer those out, but many patients will then see a neck surgeon who will

03:18:52.780 say, well, you don't really need surgery. Yes, I think you do have double crush, but you can go

03:18:57.220 ahead and treat. I can go ahead and treat. Let's say they have moderate carpal tunnel. I can do a

03:19:01.980 carpal tunnel release and they'll still get better. May not get all the way better though. All their

03:19:06.580 carpal tunnel will go away, but they'll still have some of the upper nerve pain. So the double crush

03:19:12.280 phenomena is real and true. And that's another category of patient. Then there's the weird lower

03:19:19.880 cervical that I just learned not that long ago from a really smart neck surgeon is it's pretty

03:19:27.100 consistent at the lower level, the C7 nerve root level. If they have compression down there,

03:19:31.780 that goes deep under the scapula and gives them that deep scapular plane and problem there. And 0.87

03:19:37.620 what's been so great for me to learn this later in my career is I often would see patients will

03:19:43.240 develop scapulothoracic bursitis, and you can clearly get that from lifting weights, especially

03:19:48.760 if you've been out of the weight room for a long time, you go back into it. You can get a lot of

03:19:52.840 upper trapezius, periscapular rhomboid type pain from overuse, and those overlap. So you really

03:19:59.160 have to do the diagnostic work and talk to the patients and listen to the patients to differentiate

03:20:03.920 that. And then of course, in our exam, we can see that too. I think that's more or less what I would

03:20:10.340 want to say. The one patient that I think illustrates this, how complicated it can be with someone who had

03:20:17.980 a bad shoulder fracture, was treated in the emergency department, put into a sling, but then also may be

03:20:23.680 told to do pendulum exercises. Well, it was an unstable fracture, very unstable. And so the weight

03:20:29.500 of our arm, I mean, I'm sure you've did that in general surgery way more than me. The weight of the

03:20:33.040 arm is enormous if you have to amputate an arm for a tumor or something. And all that weight pulling on

03:20:38.580 an unstable fracture, well, that put tremendous traction on the nerves, ended up killing his ulnar and

03:20:45.940 median nerve. Ulnar and median nerve were out. He came in, his hand was like that. He couldn't pose

03:20:51.520 his thumb. He couldn't do anything. And all I had left to work with was the radial nerve innervated,

03:20:58.040 which are the wrist extensors and the supinators. And I was able to transfer some things and give him

03:21:03.920 back some pretty good function. But it was all just due to traction. What was that length of time it

03:21:09.200 took for those nerves to under traction die? Fast, super fast. Probably within, I saw him eight

03:21:15.680 weeks post-op. So he was fully there, but he started saying he started losing hand function

03:21:19.920 at about three weeks, within three weeks of the fracture. And no one picked up on this?

03:21:25.060 No, it was pretty tragic. Do you want to do an exam and kind of go over some of those things

03:21:29.140 as well before we wrap up? Yeah, let's do that. Great. Let's do that.

03:21:33.100 At this point in the conversation, Alton demonstrates on me what he'll do for a typical nerve exam for a

03:21:38.860 patient. As this lends itself much more to video, we decided not to include this in the audio version of

03:21:43.800 the interview. If you'd like to see what this exam looks like, you can head over to the show notes

03:21:47.720 page or to our YouTube page, where we have the full exam videos very clearly broken out and

03:21:53.460 available. Now, back to my conversation with Alton. So Alton, the last thing I want to talk about,

03:21:58.920 we've been talking for quite a while, so I really appreciate you making the time, is I want to talk

03:22:02.720 about the Musician Treatment Foundation, which you founded almost six years ago. In fact, I feel like

03:22:09.480 it's indirectly how we met because one of the doctors who introduced me to you in New York City

03:22:17.240 got to know you, I think, indirectly through your involvement with taking care of some of the best

03:22:23.600 musicians in the world. And that led to us meeting and such and such. And obviously, I've been to some

03:22:29.920 of the concerts you've held. So just tell folks a little bit about what is it about music that has

03:22:34.580 been such a passion. It seems to be as much a passion for you as orthopedic surgery.

03:22:39.040 It is. And thank you for bringing it up. Thank you for wanting to talk a little bit about it.

03:22:42.560 I'm always happy to talk about it. I was lucky enough, we historically, as orthopedic surgeons,

03:22:47.460 treat a lot of athletes, but I was fortunate enough to start my practice in New York City.

03:22:52.160 And I was lucky enough to sort of inherit the caring of the New York Philharmonic and the

03:22:56.800 Metropolitan Opera Orchestras, which are mainstays of that classical music echelon, really.

03:23:02.300 And that spilled over into Broadway, the musicians who are all manner of genres, because there's so

03:23:07.900 many diverse shows there, and then the jazz musicians and rock and roll and so forth. So

03:23:12.160 yes, I've always had a passion for music and love it. And to be able to take care of these

03:23:16.840 is both very stressful initially, and also incredibly rewarding. I mean, they're like athletes,

03:23:23.180 and that they're doing this day in and day out, it's their livelihood. And if it's disrupted

03:23:27.140 their way of being, and then both their mental health and their financial health is greatly

03:23:33.520 jeopardized. And like athletes who give us so much entertainment in the world, musicians speak

03:23:39.780 the universal language of medicine, which obviously bypasses some of the horrible political infighting

03:23:46.040 that goes on, and it's just beautiful.

03:23:47.640 Of music.

03:23:48.540 Of music, and they give it back to us. But if you're not in the Philharmonic, or not in the

03:23:54.400 Metropolitan Opera Orchestra, or in a long-running show on Broadway, you're a freelance. And you're

03:24:00.540 a freelance who doesn't know when your next gig is going to happen, and you can't afford

03:24:04.800 insurance. For my whole career, I've been taking care of freelance musicians, and some

03:24:10.700 of them maybe have spouses or significant others who have insurance, or some of them have, but

03:24:15.960 many of them don't. Most of them don't, frankly.

03:24:17.880 And so I was always discounting my cost, sometimes down to nothing, depending on who it was. Or I'd

03:24:26.220 take a chicken, or a signed CD, or something that they would bring to me, some home-baked

03:24:31.120 cookies. But the costs are absolutely exorbitant for healthcare.

03:24:35.180 Right. Because you can't, waiving your cost is one thing. You can't waive the anesthesia's

03:24:38.860 cost. You can't waive the surgery center cost.

03:24:40.620 Thank you. That's exactly right. And the average cost for a rotator cuff repair is about currently,

03:24:46.000 if you pay out of pocket, about the best you can do through a surgery center, which

03:24:49.960 is less cost than a hospital, is about $25,000. Well, the average income for a fully professional

03:24:58.160 but freelance musician in Austin pre-COVID was $16,000 a year.

03:25:02.700 One-six.

03:25:03.400 One-six. So they can't even think about it. So this was what was going on for years, and

03:25:09.020 it was always in my mind, always upsetting me. As a culture, we don't support the arts more.

03:25:14.740 And I don't need to get political about that. It's not political. It's just cultural.

03:25:20.100 So then I had my cousin Thor, who's a mainstay of the Austin music scene, cut his digital nerve

03:25:26.020 of his finger. He's a percussionist, of course, because his name is Thor. And he couldn't play

03:25:30.160 because he had such a neuroma that it formed, and he didn't have insurance. And he called

03:25:36.260 me weeks after he had just had a simple closure. He said, I can't feel my finger, and I can't

03:25:40.840 play. I said, well, you have miles? And he said, yeah, I've got plenty of miles to that

03:25:44.940 tour. I said, we'll fly up to New York, and we'll fix it. Since I know the surgery center

03:25:49.960 and know the anesthesiologist, I said, look, this is my cousin Thor. I need you to throw

03:25:53.220 him a bone. So they didn't charge him, and of course, I didn't either. And so fixed it.

03:25:56.640 He was fine. He was my patient zero, if you will.

03:25:59.280 And that was kind of your aha moment.

03:26:00.940 That was the aha moment. And then I'm lucky enough, as you said, to treat a lot of other

03:26:04.580 musicians and know a lot of other musicians. So one day, Elvis Costello and Diana Kral were

03:26:09.980 in, and I just kind of said, hey, look, I'm thinking about doing this officially. Would

03:26:15.420 you guys help me in some way? Anyway, I didn't care. Just put your name on a website or something.

03:26:19.500 They said, sure. What do you have in mind? I said, well, I could just be an advisor, or if

03:26:23.260 I could just use your name, you're so well-loved and beloved. And they said, well, let us be

03:26:27.820 full board members. And he said, my only stipulation is I have to do all the voting because

03:26:32.020 Diana's the busiest woman in show business. So I said, yes. And in 2017, we got IRS nonprofit

03:26:39.600 status. And then Elvis said, I'm going to do the first concert. I love the Paramount Theater

03:26:43.560 in Austin. Let's do it in Austin. I'll do a two-hour solo show. And we raised about a quarter

03:26:48.840 of a million dollars with that. And that was our seed money. And people came pouring in.

03:26:53.760 And here in Austin, HAM is a big organization that does so much, as for so long. It's the

03:27:00.540 Health Alliance for Austin Musicians. But they don't provide the actual care. We're struggling

03:27:04.540 to get specialists to actually discount their care or provide the care. And orthopedically

03:27:10.380 speaking, not having your upper limb, your shoulder, elbow, or hand, you can't make music.

03:27:15.880 Give us a brief sentence, because I know you and I have talked about this so much because

03:27:19.040 I'm so fascinated by this topic. Help people understand the physical demand of playing a

03:27:25.440 violin or playing the drums. I mean, drums, I know. You see my daughter plays the drums,

03:27:28.580 so I'm getting some sense of that. But A, it's a very asymmetric activity. But what are the types

03:27:33.580 of injuries that you're seeing the high-level musicians come in with that are a threat to

03:27:38.480 their livelihood?

03:27:39.480 Well, one of the things I say, I've lectured on this quite a bit, is I say, you know, musicians

03:27:43.420 are people too. So they do all the stupid things that we all do to injure ourselves. That's a 0.99

03:27:49.080 separate category. And those are injuries. And they need to be treated, though. The unique aspect

03:27:54.220 of that is that...

03:27:55.880 They can't necessarily take the same rest when they've injured something.

03:27:58.620 No. And they have to be 100%. If you're a violinist in the Philharmonic, there are 15 other

03:28:04.300 highest-level musicians waiting in the ranks.

03:28:07.020 Waiting for you to screw up once.

03:28:08.300 A little schadenfreude there. They don't think ill of you, but they would love to have the opportunity

03:28:12.340 to just sit in your seat, your chair on the stage. So there's all that tension, all that

03:28:17.420 stress of having worked so hard and then having it. And you have to be 100%. You can't be...

03:28:22.260 I can do surgery with probably three fingers, but if you can't flex down your index finger

03:28:28.820 or whatever on the fret, then you can't make the music. So that's one aspect of it. And the

03:28:35.040 other aspect is that by comparison, they're not trying to jump higher, hit the ball farther,

03:28:41.380 drive the car faster, all the different ways that athletes like you are trying to maximize

03:28:46.960 your output. They are sub-maximal athletes, but they are so repetitious.

03:28:53.580 I think what? In a standard NFL game, there are about 30 passes, 35 passes. Well, in a typical one

03:29:02.180 Mozart violin concerto, it's 20,000 bow strokes in one playing violin concerto. And they do that

03:29:12.540 repeatedly over and over and over again. And to your point, yes, a lot of these are very unnatural

03:29:18.240 positions. And we think about violinists, we think indeed their hands, well, their shoulders,

03:29:23.760 they are adducted, they are externally rotated. Their other one is up in the impingement zone,

03:29:29.420 who we see from our exam. They're living eight hours a day doing this. That is terrible for the

03:29:35.860 shoulders. And then you think of the drummers, high hats, and every which way they're going and

03:29:40.260 going massively for three hours straight. It's just uncanny that they even survive, in my opinion.

03:29:47.120 So it's very, very different. I mean, I don't even know how many passes Tom Brady has thrown in his

03:29:52.900 career, but it's not that huge of a number. Relative to this.

03:29:56.260 So anyway, we were flooded with patients initially. There was this backlog of patients

03:30:01.040 who hadn't played for six months, nine months, and they were just fallow. They were trying to

03:30:07.580 get odd jobs. They weren't getting any gigs. They couldn't take gigs. I had one patient,

03:30:11.520 the very first patient, who we've talked about, so I can mention her name, Jennifer Jackson. She's

03:30:15.500 a great singer-songwriter in Austin and tours around. Did she play last year at the concert?

03:30:20.740 She did. No, I'm sorry. She did not. She was on our movie about it. She had bilateral full

03:30:27.420 thickness rotator cuff tears. Bilateral. And she came in. She had already gone to try to see somebody

03:30:34.260 it was going to cost her $10,000 or more. She had some very minimal insurance. And I said,

03:30:40.980 look, we need to fix it. Let's do it. Get you back. And she goes, well, how much is it going to

03:30:45.260 cost me? I said, it's not going to cost you anything. And she just started crying. I said,

03:30:49.340 no, it's not going to cost you anything. So we've, in five years, almost now coming up,

03:30:54.240 well, yeah, five plus years, we've provided over $2 million in free care to under and uninsured

03:31:00.580 professional musicians. How many musicians have had surgery?

03:31:03.620 Oh, we've had probably, I've done four dozen, around 50 musicians. And that doesn't include

03:31:10.060 the ones that I've been discounting. These are the ones that we've actually funneled through the MTF.

03:31:14.280 But we've got hundreds of non-operative because a non-operative is just as bad.

03:31:19.920 Right. So if you can get a cortisone shot in there and get them totally better.

03:31:22.640 Yeah. So we have hundreds more of that. It's been mind boggling. And the cool thing,

03:31:28.620 we have an upcoming concert in December with Elvis, with Roseanne Cash, John Leventhal,

03:31:34.100 Jason Isbell, a bunch of great people. The cool thing about our situation is that

03:31:39.560 I've now been able to recruit over 60 colleagues who I know, I trust, they have the same ethic,

03:31:47.020 they want to give back, who are shoulder, elbow, and hand surgeons at the best places around the

03:31:51.700 country. We're launching that in December. It's called the P4M, the Physicians for Musicians 0.60

03:31:57.200 Network. They're going to be doing it. So far, I've provided all the care. Now they're going to be

03:32:01.800 helping provide care.

03:32:02.760 So now really, we just need more dollars coming in to help cover the other costs because you're

03:32:09.440 always getting the physicians to waive their fee. You now need to be able to basically use

03:32:13.720 the non-profit resources to fund the surgery centers and anesthesia fees. And I'm sure you're

03:32:18.680 getting some anesthesiologists who are musicians as well.

03:32:21.460 We've been unsuccessful in that. It's ironic and a little embittering for me, but I know we will be

03:32:26.140 able to once we get the right moment.

03:32:27.220 I'm hoping that people listening to this who are anesthesiologists, someone's going to be like,

03:32:30.220 wait a minute, I need to find fellow anesthesiologists and we can start to pair those services.

03:32:36.120 And nice thing is that most surgeons, including myself, have some either participation or partial

03:32:42.840 ownership of a surgery center. So I happened to have built one here in Austin and we provide that at

03:32:49.160 one, I think it's one-tenth of Medicare. So it's basically nothing. Our biggest cost by far is the

03:32:54.540 anesthesia.

03:32:55.260 What's your vision for how big this can get and what has to get there? I mean, so you have the big

03:32:59.160 fundraiser every year, which is a huge concert, gala, amazing. Each year it seems to be getting

03:33:04.480 more and more incredible. What type of fundraising goes on outside of that per year?

03:33:08.620 I'm kind of a one-man fundraising machine because of all my generous patients, especially in New York

03:33:13.440 and in Austin too. And I tell everybody I can't, I scream it from the mountaintops, but we're starting

03:33:17.820 to get some grants. We're applying for grants, which is great. But anybody who knows any organizations

03:33:22.780 that provide community grants and so forth, we are right in the thick of communities because it

03:33:28.700 holds communities together. It develops relationships that weren't there before and

03:33:33.840 it's all ages.

03:33:35.100 This is a huge deal this year, Alton, is that you've now recruited other doctors because

03:33:38.820 the scalability of this was limited when you were the only surgeon. But now that you've got how many

03:33:43.900 more surgeons?

03:33:45.060 We have over 60 signed on now.

03:33:46.900 Amazing.

03:33:47.480 Yeah. So that's going to be a game changer.

03:33:49.060 That's an amazing success.

03:33:49.820 And my idea, and they all have their own pods of, I mean, I treat more musicians than

03:33:54.920 maybe anybody, but they all treat some and they can access those. They can access donors in the

03:34:01.440 different towns. We have Seattle, we have LA, we have Nashville, we have New York, of course,

03:34:05.960 Chicago, New Orleans, the list goes on and on. And so, yeah, when we can access that, it will build

03:34:12.540 the support, I think, significantly.

03:34:14.780 Well, Alton, I could sit here and talk for about another two hours, but I know you have a flight to

03:34:19.680 catch to New York. It's probably apparent to people listening to this, but you practice

03:34:23.800 bi-coastally.

03:34:24.700 Yes.

03:34:25.100 Or not bi-coastally, rather, but you practice in two cities. So you're Monday, Friday, you see

03:34:30.160 patients in clinic and operate in Austin. And then Tuesday, Wednesday, Thursday, you're in New York

03:34:34.520 City. And you do this over and over and over again.

03:34:36.460 I do.

03:34:36.700 I've had the privilege of seeing you in both cities. I've had the privilege of sending patients to you

03:34:40.140 in both cities. I don't know how you do it. I used to do that and I can't do it anymore.

03:34:44.240 But I'm so grateful for this discussion. I think a lot of people are going to help from it. And

03:34:49.820 obviously, I'm just so grateful for you personally, for the help in my life and obviously that in my

03:34:53.200 patients. So thank you.

03:34:54.360 Yeah. The gratitude is likewise. Actually, I just want to give you a shout out. You,

03:34:58.500 at some point in one of our many meetings, you said, you know, you mentioned rucking and,

03:35:03.400 you know, I didn't really know that much about it, but you gave me the link. I bought it. I'm only

03:35:08.100 carrying 35 pounds.

03:35:09.340 That's awesome.

03:35:09.780 But I've been actually run rucking because I love running. I've always run. It has changed my

03:35:14.720 body. And I've only been doing it about three months and I only get to do it two or three times

03:35:19.200 a week. It's changed my body. I feel so much lighter, so much stronger and better. And although

03:35:23.620 I'm pretty old, I feel great. I commend you. And I thank you because it's been a game changer for me.

03:35:29.000 Yeah. I'm the rucking evangelist. Well, thank you very much all. And this was fantastic.

03:35:33.240 Great. Thanks.

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The Peter Attia Drive - November 28, 2022

#232 ‒ Shoulder, elbow, wrist, and hand： diagnosis, treatment, and surgery of the upper extremities ｜ Alton Barron, M.D.

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