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

Hey everyone. Welcome to the Drive Podcast. I'm your host, Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in depth content. If you want to take your knowledge of this space to the next level, at the end of this episode, I'll explain what those benefits are. Or if you want to learn more now, head over to peterattiamd.com subscribe Now without further delay, here's today's episode. My guest this week is Alton Barron. Alton is a board certified fellowship trained shoulder, elbow and hand surgeon with clinical practices in both Austin and New York City. He specializes in both routine and complex problems of the upper limb. Alton is also my surgeon. Some of you may recall I had shoulder surgery in March of 2022 and I've kind of documented that recovery process along the way and promised to do kind of a deep dive on the upper extremity. In this episode, we focus our entire conversation on the upper limb, going from the elbow, the shoulder to the hand and the wrist, as well as the nerves located throughout that track. Now, for each of these, Alton goes through the structure, the anatomy, the various things that may cause pain and injury, and how and when to think about surgical interventions. In addition to our conversation in the podcast, Alton runs through what a typical physical exam looks like for each patient. And this is really important in the field of orthopedics. Certainly surgeons rely on imaging studies, you know, the MRI of the elbow, the shoulder, whatever, but any good orthopedist I know has always said the same thing, which is the exam and the symptoms matter usually more than what the image shows. So in that sense it's very important to understand those things. It's also something that you can even do on yourself to kind of help understand if something you're feeling is indeed problematic or maybe it's just going to get better over time due to the type of discussion that we've had here in the exams that he does. This is probably going to be the one episode that if you're not used to watching on video, you do watch on video. Also, given the length of the podcast, I think it's like over four hours or in that ballpark. And to make it more digestible, we've broken it out into some very specific videos including in isolating the sections of the shoulder, the elbow, hand, wrist, and the innervation, as well as isolating the videos of just the various exams that Alton does to demonstrate on me. Now, you can find all of these videos on the show notes page or on our YouTube page. Now, lastly, one other thing that comes up in this interview, and it's something that Alton is very passionate about, is a foundation that he started called the Musician Treatment Foundation. This is a nonprofit that provides direct orthopedic shoulder surgery hand interventions along with non surgical care to uninsured and underinsured musicians. This is something Alton is incredibly passionate about as he is also a musician. You'll hear him talk about the amazing work that he's done so far, where they want to go next, and basically how they're putting funds to use. Specifically, the foundation has their big annual event in Austin coming up on December 2nd. So if you're local to Austin, please check it out. And if you're not local to Austin, which many of you probably aren't, please head over to their website, www.mtfusa.org, where you can learn more about it and get involved if it's of interest to you. So without further delay, please enjoy my conversation with Dr. Alton Barron. Alton, so great to finally be sitting down with you. We talked about this even before you operated on me, which is at the time of this recording. I think we're coming up on seven months. But this is a topic that I can't tell you how many times I get asked about this by my patients. And I don't know, in some ways, medicine is so siloed. You think, well, I did general surgery. Surely I know something about orthopedics. But the reality of it is outside of trauma and even in the most basic sense, I know very little about orthopedics. And I think that's probably true for a lot of doctors, primary care and otherwise. And then how much more is that true for patients? So it's a pretty broad and specialized field at the same time, huh?

Yeah, I think that's a great point. I mean, I always have told people who've asked about medical school, well, don't you know all these things? And we only do a subset of rotations, so I know nothing about urology. I know nothing about brain surgery. It just depends on kind of the luck of the draw and what you get exposed to. And so I wholeheartedly agree. And then we just narrow ourselves down like a funnel in terms of knowledge because there's been such a knowledge explosion for the last, really the last two decades in terms of research, in terms of new science, a lot of which you've talked about and do talk about routinely and know a lot more about than me. But as it applies to orthopedics, even, there are subsets of orthopedics and then there are subsets of shoulder surgery that involves just research versus just clinical practice. And all of that is just an explosion of information. And you know, my well informed patients often ask me about things and I know hopefully a lot of it, but I don't know all of it. They sometimes find, because they're very good now at looking at true scientific articles, and they approach it and approach me with new articles. So I'm learning every week from my patients actually about shoulder surgery.

Now. When you went to med school, did you think you wanted to be an orthopedic surgeon?

I didn't know. I barely went to medical school. I just had a very circuitous path. But I was an engineer at UT here in Austin, and I'm an engineer as well.

I don't think I knew that. What kind of engineer were you?

I did mechanical and biomedical and so I didn't know anything about it. My dad was an engineer and so I just went that way. At the end I was a little edgy about going into industry. And so on a last whim, because I had two uncles that were dentists, I went to dental school for a year. And I actually didn't like that at all. But I loved the science, what was going on with the biomaterials. Dentistry has been at the forefront of biomaterials. And so I left after a year. But I was exposed to the entire anatomical body because the anatomy instructor for head and neck was actually an MD, PhD. And she said when I confided in her that I was leaving, she said, you know, you ought to try medical school. And so then I went back, came back to Austin, painted houses for a year, then applied to medical school and went, still didn't know.

And so you go there, you don't know what you're going to do, not even if you're going to do surgery or medicine.

Right. I liked it all. I loved invasive cardiology to all the aspects of the, the physiology and the electricity really going on in our bodies. But then I was exposed to orthopedics, fortunately, and it was like I knew all this stuff I didn't know at all. But it felt so natural putting things together, piecing them back together, the jigsaw puzzles. And it felt all in perfect line with my engineering background.

In the time when you went through orthopedics, was it common for people to also do a fellowship after the five years of residency?

It was. I think at our time. We had a big. I went to Tulane at that time. They had eight. This is pre Katrina. They had eight residents per year. So it was a big program. And at that time, about four were going to general practice. So fellowships were not ubiquit. Now they are almost mandatory. Just because you need to have a. I wouldn't call it a gimmick, but you need to have a special interest because the groups that you'd be applying to work for or the hospitals kind of want you to have some subspecialty.

That's the case in medicine. Even if you did something like general surgery and didn't do a fellowship after, like vascular, plastics, cardiac, et cetera, you'd be hard pressed to go even into the community and kind of do everything. You'd probably tend to focus on one part of the body. Where did you do your fellowship? Obviously upper extremity.

Yeah. So I did my shoulder fellowship at Columbia in New York, and then I did my hand fellowship in New York at Roosevelt Hospital.

Oh, two separate fellowships.

Two separate fellowships, yeah. And most people didn't do that at the time, but I just really liked both very much. It just evolved into that. I dabbled with spine during residency, and I think the reason I evolved into wanting to do upper extremity is because there's nothing cookie cutter about it. I'm not by any means demeaning any part of orthopedics, but for me, there were very few jigs, cutting jigs, very few linear things that you had to just. There's so much variability in the upper limb, both anatomy and also the specific pathology that you just have to be all over the place. And it was more creative for me, frankly.

What have been some of the big steps forward? Let's go back to. So what year did you finish your training?

I started practice in 96.

So at that time, what was the state of the art in terms of what was being done? So, for example, there was a day when, if you look at the surgery I had that would have been done with a big open incision. When did minimally invasive orthopedic surgery take over the joint space?

It's crazy. It's such a cool question. I'm glad you asked it, because I don't get to speak about it very much. But there was. Knee arthroscopy was the first Big arthroscopic realm to develop, and a fellow that most of my younger residents don't even know now, Dick Kaspari, was hugely innovative in that space. And so shoulder arthroscopy, by the time I was in residency, was primitive. We had the basic equipment to get into the shoulder, but we couldn't do much. So by the time I graduated, all we were doing arthroscopically. By the time I even finished my shoulder fellowship, we were doing open shoulder arthroplasty. And I was at one of the meccas of shoulder surgery. So everything advanced was being done there at the level that it could be done. But it was open shoulder arthroplasty, which is still open, but smaller incisions. It was open instability repairs, open labral repairs. But we didn't even appreciate what, for instance, the slap tear. We knew they existed, but we didn't know the impact. And what we started seeing there was. And there were certainly no arthroscopic repairs of the labrum except these early, early devices where you'd kind of get in there, see it, and you just mallet in, drill a little hole and mallet in this big, broad tack that was just now so primitive, and they would fall out. They had a high failure rate. And it was just. That was the state of the art at that time.

And was any of this being done in clinical trials or was it kind of like patients are saying, look, we have the tried and true way that we do this. The downside is you're going to have a big scar and we're going to have to tear a bunch of muscle and your recovery is going to be longer. But once we get in there, we know what to do versus we've got this minimally invasive way that has all of these advantages. But the drawback is high failure rate.

That was exactly discussion. There was a little bit of FDA going on approval at that time, but not a lot in terms of using these humanitarian devices and so forth, where you could go ahead and try it and the patients had to sign a release and it was all fine, and they were trusted surgeons that were doing it. So the. I wouldn't say there were clinical trials. There were a lot of retrospective analyses going on. Oh, yeah, we did this in 107 patients and 47% failed. In my early years of that, we were actually just still doing mostly open and then kind of waiting for the devices, for the science, for the industry to catch up with some better devices. And some of my colleagues and occasionally me were adding little bitty innovative aspects of these, whether they're application devices or the style of implants. So we've gone from today, we went from purely metal to now often purely braided polyester as an actual anchor device, which is super cool because there's no metal in your body. And the transition through that was plastic. And that plastic could be either hard plastic, which stays in your body, but it's still benign, or a bioabsorbable tax, which I have my own issues with because it does create an inflammatory response in the body and creates a little cavity in the bone and so forth. So that's kind of the spectrum. So now we are using tiny drills, tiny suture anchors, and you can put many in. And that's what's nice about if you have to do a revision of some failed repair, you've got plenty of real estate to work with, and it's nice. But one other aspect, which I think shows so much how we change, and I was right at that inflection point, not by choice, just by happenstance, was the slap tears were not appreciated as a clinically relevant entity. But a slap tear, which is meaning.

So we'll have to tell people what the labrum is in a second. And what a slap is meaning they just were viewed as just another type of labral tear.

Yes, but one that was benign, that didn't matter. I see. And people were coming in a lot of overhead. Athletes were coming in with secondary problems as a result of that, and the secondary problems were being treated without treating.

Without treating the underlying underlying.

And they were having recurrent pain.

So this is probably a good pivot for us to back up and make sure people understand the anatomy. You know, sometimes when I'm explaining to my patients, which exposes my own naivete, I sort of say, look, I don't know a lot about orthopedics, but to understand and appreciate the complexity of the upper extremity, you have to appreciate what we did during evolution, when we stood up, that became an enormous force multiplier. If you think about this through the lens of, like, warfare, People talk about having night vision as a force multiplier in war. Well, for us to be able to stand and walk with amazing efficiency on two legs was a force multiplier. And then also to have these incredible upper extremities. But you got to pay a price for it. So the price, the way I describe it, and feel free to correct me or make this more nuanced, the price was stability. We paid an enormous price in these joints. You know, not as strong, not as stable. Would you agree with that? Is that a fair assessment?

100%. And you're spot on on that. And frankly, that shows you do know something about orthopedics. But the fact is that, yeah, when we went from the ball and socket joints or the very stable simple hinge joints to these cup and saucer type joints, specifically the shoulder, which is intrinsically very unstable, and also our opposable thumb. Our opposable thumb is the basal joint is terribly unstable. We call it a biconcave saddle, but it's barely that. There's really no intrinsic bony stability. And similar to the shoulder, I mean, we use an analogy that's slightly 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 very flat and shallow. And so we can talk about the anatomy.

So let's do that in whatever way you think makes the most sense. Alton, let's assume the audience doesn't know the names of any of the bones, let alone they look like, doesn't know the vasculature, the musculature, the innervation. What would be a reasonable way? I know you and I spoke, we were going to do this with models. In the end, you thought you could probably do an easier job sketching for folks.

Yeah.

Let's have you explain slash sketch through any of this.

That'd be great. And we're prepared for that. We have some diagrams. So I'm going to take it off the visual and draw some quick pictures. And this is what I do, frankly, for all my patients, that I don't like the models because they're just models. So I'm not saying I'm a great artist, but if we just look at just the glenoid, that's the socket, that's the golf tee, if you will. And then you add a humeral head to it. And that is the humeral head. This portion to the right of the dotted line is what's covered by cartilage. So that's the nice smooth teflon cartilage and this space.

So just to orient folks, what you're looking at is head on to a person. If you're looking straight at them. This is the right humeral head. And that little space we're going to talk about, the glenoid fossa is that flat end of part of the scapula.

Yes.

Which is a real complex looking triangular bone with a big ridge on it and collarbone attaches to it and all that crazy stuff. The high level Point here is in the hip, you have the acetabulum, which creates a true socket for a big ball. And here the heavy lifting really is done by soft tissue, not bones.

Right. You've got a joint that's completely contained like that in the hip joint, versus a shallow one that just can slip and slide all over the place. So you've pointed out it's the best way to describe the shoulder joint being a delicate balance of mobility and stability. And it's very easy to get out of whack because it is biomechanically so complicated. So I'm going to add a few more things here. But this space that we see between here is not a space. It's the space radiographically, when you're looking, that's occupied by the cartilage. So you have a thick, nice layer of cartilage on both sides. I've left a little gap just to be able to see it. But it's the articular cartilage effectively there. So there's a layer of nice thick cartilage there that. And when we have arthritis, of course, that gets worn down, chipped away, and begins to fissure and then actually develop full thickness loss to the point where then at some point it's not really functioning very well and it's very painful. So if we have this basic bony cartilage structure here, it would just fall off if we were just left there. Let's say you had a. Well, if you had no ligaments, no. What we're going to call the labrum, which are some additional stabilizing structures, or if we had the muscle tendon units that support it. So I'm going to draw in a few more of that, of those.

And while you're doing that, we'll just remind people that ligaments and tendons are not the same. Tendons are the connective tissue that connects muscle to bone. Ligaments are connective tissue that connect bone to bone. Is labrum considered a ligament or is it kind of considered its own entity?

It's kind of its own entity. It has a transition zone between fibrous tissue to osseous bony tissue. So it's a fiber osseous structure, and I liken it to calamari. And it's rubbery just like that. And that's the best analogy that people seem to get. So I've drawn on two of the four rotator cuff muscles here. This is the one up above, and this is the one in front. And this is the big muscle that allows us to reach behind our back and pull our hand away from our back. And this is also the one that helps us, along with the pectoralis in front, to pull things together, like doing flies and so forth. The supraspinatus is the primary muscle that initiates elevation of the shoulder. So it's very, very. So what we see here is this zone in from here and about through here is where the muscle transitions into tendon and then it becomes pure tendon. And it just so happens that this tendon, the supraspinatus tendon, which is so commonly torn, is actually. There's some physiologic downsides to its location where it can be wrung out. It doesn't have a great blood supply. The key is it gets. Let me put here, where those two arrows are, is essentially where the tendon tears most of the time. And that is the part that attaches to the bone. It gets blood supply from that bone, it gets blood supply, gets nutrients, it gets growth factors. So our goal, and this is jumping ahead a little bit, our goal is to get that reattached to that bone so it can get all of those growth factors and that new healing back. And it absolutely can heal back. But there are certain limitations to that.

There's two other muscles. So we've got the supraspinatus and the subscapularis there. There's two other muscles that make up the rotator cuff. Everyone's heard of the rotator cuff and yet it's probably not obvious to people that it's really four muscles that are doing this. What are the other two?

So the other two are the infraspinatus and the teres minor. And you can kind of superimpose them on, over the subscapularis, but they're on the backside of the joint. And they are very important. They are the external rotators. They give us our backhand in tennis, they give us a lot of stability for the shoulder itself. And especially whether you're playing golf or lifting weights. They're a dynamic stabilizer. They're very important. Doing bench press, push ups, all sorts of activities like that.

Archery.

Archery, yes, very important.

So when a person, quote, unquote, tears their rotator cuff, that can be a very heterogeneous diagnosis. Technically, that diagnosis would apply to a tear in any of those four muscles which could be in the muscle, could be at the junction between the muscle and the tendon. And could it also be just a complete separation of the tendon from the osseous structure of the bone?

Yes. So that's critical to identify what that is, and you can somewhat predict it based on the age of the person and their physiology and the mechanism of the trauma. And we do broadly classify these into degenerative tears and traumatic tears. So younger people, it's rare to see a young person, really under the age of 40 to tear their rotator cuff. It's pretty proportionally rare, but it happens, and it happens traumatically. I had a young fellow who worked as a merchant marine years ago, and he was doing something with the anchor and the massive chain, and his glove got caught in that, and it basically, it almost ripped his arm off. But he was okay, except that he had torn traumatically as a young 20. I think he was 26 or so. It ripped off three of his four muscles, and, you know, they had to be repaired, but he was okay. But it's that rare, dramatic circumstance that leads to traumatic tears in young people.

Someone that young, where's the weak link? Does it tear at the muscle itself, or does it tear more at the tendon?

That's a great question, because the younger you are, the stronger that linkage of the tendon to the bone. So you often pull off some bone. Oh, my God. And so in the case of a skier's thumb, just a common injury in the hand from skiers, the younger you are, the more likely it is to pull off with a piece of bone. And that's actually great because bone heals to bone itself much better than tendon to bone if you can get away with that. There are fractures that occur that involve this area. There's. And I'll draw a picture here. Draw a squiggly line to represent a fracture, and then I'll show it coming off. That's a common fracture. So right here, what I've drawn is this chunk of bone coming off right here. That's the greater tuberosity. It's a prominence of the bone that the biggest portion of the rotator cuff attaches. The supraspinatus and the infraspinatus that you referenced, that pulls off. So I would rather have that. I would rather pull that off and have a good quality repair of that than have my supraspinate 2 tendons rip off that bone.

Tell me the type of athlete or person that presents with the fracture that you've depicted.

So these are generally that isolated, greater tuberosity is generally a fractured dislocation. So you have a pretty violent injury. You're rock climbing, you fall off, you maybe hit it directly your arm. Is wrenched back, or you have, let's say a football player who has a traumatic dislocation. They're hitting just the right way mechanically, and it shears that off. So it's often, most often associated with the dislocation as well. The dislocation goes back, but the two processes.

Dislocation, meaning a subluxation of the shoulder. Yep. And let's explain to folks what that is, how that happens. I didn't realize that we could use the word dislocation and subluxation interchangeably.

Well, technically we don't. Technically, a subluxation is an incomplete dislocation. It's the shoulder coming out, but it pops back in easily.

Got it. So dislocation is usually. It comes out and it needs to.

Be put back in most often. Unless it's recurrent. The more dislocations one has or subluxations, the more stretchy and compliant the tissues become.

Sort of like mine.

Yes. And so then it can kind of slip and slide back in and out with regularity. Let me draw a different picture. Okay. What I've done here is taken the. The humeral head away. So we're just looking at the socket and we're looking at it enf.

If you're looking at me, you took my humerus away. And now you are looking directly at the socket of this glenohumeral fossa.

Yes. And so the central.

So the front of the person is.

To the front, that's anterior, if we speak about that. And posterior is to the back. Superior is up above, inferior is down below. Oh. And so importantly, around the outside, that second circle is the outline of the labrum. So from here, here to here is the labrum and that's a rubbery calamari like structure.

I love that. I love that explanation.

It's sort of. You get some bad calamari. That's really chewy. That's kind of what. I haven't chewed on labrum myself. But it's what it imagined it would be behaving. And it's very strong. And what it does, it has an amazing. You were talking about the evolution when we became bipeds. It's super cool because it effectively developed as a way to decrease the depth of the socket. Not by very much, but it truly works like a suction cup. If you take a non arthritic cadaver specimen and dissect away all of the muscle, all the ligaments, and you stick it on the humeral head, on the labrum, it'll sit there.

So amazing.

Yeah, it's Crazy. It's fascinating. But just like a thermometer on a window, if you get your finger on that seal, lift it up, but break its seal, it falls away. Well, that's what happens here. So we get a lot of static stability in our shoulder from this superior, inferior, anterior and posterior labrum.

And just to be clear, Alton, in a non pathologic state, when you have that young person who has yet to be experiencing any trauma of the shoulder, is that a contained space of fluid that is between those two cartilaginous surfaces of the glenoid fossa, the humeral head, fully contained. Because usually to have a suction, there has to be a fluid that sort of contains it, or air that's incompressible, which is technically fluid. But I assume there is an aqueous fluid that's normally.

Absolutely. You have a nice viscous joint fluid in all of our joints like that. That's a great question. And yes, you couldn't have that suction. As soon as you poke a hole in that, you lose that suction.

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

Correct. And that's another huge point that factors into our treatment recommendations and mechanisms of injury. If you are a young woman playing soccer, generally young women have looser joints. Women in general have looser joints, which is part of difference in physiology. But. And actually because of the weird nature of the shoulders, there are men as well who have super loose shoulders. Baseline born that way. But in general, if you think of someone, whether male or female, who has super loose joints, then they can sublux out, in and out without tearing anything. They just ride up over that because it's just loosey goosey. So the tighter the shoulder is, the more you have to lose.

What happens to the fluid when they sublux?

Nothing, because they have a more capacious. It's the ligaments. The ligaments are stretchy and they are bigger. It's more like a balloon that you keep blowing up repeatedly. But if you have someone who has a. Basically a pretty stable joint, not loosey goosey, and then they sublux, the only way you can do that is either tearing the ligaments, but usually you also tear the labrum. And what I mean by tearing the labrum is you separate the labrum, the inner arc, from its hard, bony, cartilaginous, perfectly fused attachment. Very strong. It takes a massive force to dislocate the shoulder. It actually does. Or perfect mechanics. And so if you have the classic. You're reaching up to Get a rebound and someone grabs your arm and jerked it backwards. That's a leverage, an unnatural leverage that makes the head tend to go out this direction, anteriorly, inferiorly, like this.

So the head is going to go down this way?

Yeah, it just leverages it out.

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

Yes, very much so. And we'll get to that as dynamic stabilizers. But man, this labrum is tough, but it tears off. This is the classic location where you tear the labrum there. And it takes either a small tear that then is repetitively increased in size just from aggressive but repetitive use, or it takes a one time significant dislocation.

And again, just to show people the attachments of the four rotator cuffs are basically behind above. It's basically like you got a big one there kind of at nine o', clock, right?

That's a great question. You ask perfect questions that I forget to cover. So these are kind of the cross sections of the muscles that are just outside. So these encompass and enshroud the joint. And this is the cross sectional muscle bellies. And this is where they, as you come further out toward the head, which is out here, they taper down and form the tendon. Tendons. And that's so important because no shoulder can be stable alone just by these static stabilizer, the labrum and the ligaments. And the ligaments kind of lie in between the labrum and the rotator cuff in here.

When you're referring to a SLAP tear, you know, obviously SLAP stands for superior labral anterior posterior.

Yes, exactly. And that is up here. That is the super. And that's a odd injury that we. The first person that really taught this well to us was a fellow named Steve Snyder in Northern California. And he really kind of categorized these and started identifying these as really actually clinically relevant entities. Not for everybody, but certainly for younger, very athletic people, overhead athletes, weightlifters, people doing CrossFit, people doing all manner of more aggressive sports. So unlike if you have a tear here and you're active, you're going to keep redistribating, at least subluxating.

That was me. Correct. I was kind of all the way around and. But big, anterior, inferior.

So I don't know what your first injury was.

You've talked about this. I believe it was a subluxation in boxing when I was probably 17. So there's two injuries I remember having in high school. I can't remember which one was first. You might have a sense one was doing absurdly heavy Military press. I think that was the second one. Truthfully, I think the first subluxation was boxing and just bad timing. Hard punch, thrown, guy gets out of the way, probably smacked my arm on the way and out it came. And I believe that would have been followed up six months later. I'm doing very heavyweight for me overhead and I just remember, boom, it just popped out and down. And then from that point on, it was a vicious cycle of never ending subluxations with each couple of years having a really bad one. Another really bad one I had was in an open water swim race. We're swimming freestyle, right. So I'm in the reach phase with right arm in front and the swimmer in front of me kick down on that arm. I mean, that's a bit of force, but not absurd. But just the down kick of that arm took me out.

So it's so funny, you are describing so many great. I'm sorry you had suffered from them all, but, but so many great and differing types of mechanisms that happen. I agree with you that it probably was the boxing. I've seen a lot of those. The recoil and especially if you don't hit something your, your body is anticipating and it's tightened up and it is ready for contact and it doesn't have the contact. It's no different than there's an extra step in front of you that you don't know about. And you step and you go, whoa. And then you feel like it shutters your whole body. It's the same concept. Your body unconsciously knows what it needs to do. So you probably did have a posterior subluxation. I mean, I will say, and you know this, and this is why it was so important for you is you had a tear going all the way from posterior all the way around to there. So you had about a 240 degree tear. And that's. You don't get that from one injury. It's almost impossible.

So I basically became looser and looser over time and then it just now had too much laxity. It could basically move in any direction.

Exactly. And you were compensating well for most of the time because you're very fit, you're doing all the right things. Upper body, specifically, shoulder strengthening exercises. So you are using your dynamic stabilizers to compensate for the loss of the static stabilizers. And that's a critical, critical problem. And it fits too with your weightlifting. You had a tear, you weightlifting, you were fine. But what happens is if you're going kind of maxing out and you're doing it repetitively. The dynamic stabilizers, fatigue. And I see this. One of the most common scenarios is the young, more often female than male. But both swimmers, so they're competing, they need the stability, especially they're doing fly and backstroke, they really need that. And they acquire all this laxity in their shoulder and they're so strong dynamically they're fine. And it gives them that extra pull, that extra inch or two. But when they fatigue, but they start out fine on a Friday, if they have a, you know, a weekend long match and they have eight events in three days, the first two days they're fine. Maybe they have a little pain at the end of the second day. By the third day they're fatigued. And so then they start subluxing. Then they get all this secondary inflammation and pain. And that's when the damage occurs and they have to sit out and then we have to restrengthen, rehab, sometimes even tighten up the capsule when they get so loose.

And one of the things we're gonna talk about here is of course, the physical exam on this, because the other thing we haven't talked about on this diagram is that little pesky biceps head and that tendon. Boy, if anybody who's experienced tendinosis there, that can be incredibly painful. And I think to an average person, it's not entirely clear where that pain is coming from. If they feel pain here. Right, right.

So, yes, the biceps, which is a weird structure and it's absolutely part of that weird evolution that we have the biceps, one muscle in our arm, but it's two tendons at the origin, which in the shoulder, one of the tendons.

So starts down here, single point of attachment in the forearm, actually crosses the joint as one muscle and then kind of splits into two bellies with two.

Exactly. And it has the long head, which is the one that so often gets inflamed. And you're absolutely right, it can be quite painful and it can just affect everyday life with that. And the second tendon peels off over here and it goes outside the joint and attaches to a bony prominence in that weird scapula that you talked about, which is such a weird looking bone. And it attaches there that never tears. It literally never tears. But people often do tear this biceps. And it can be from wear and tear. It can be acute traumatically, but it leads to a classic Popeye muscle. Kind of half their muscle is balled up and looks weird. It's not really that much of a functional consequence. Usually it stops hurting when it ruptures. And if I'm not mistaken, I mean, this has been in the orthopedic anecdotes for a long time. Was the great quarterback from Denver, John Elway. John Elway, he was having shoulder pain and was even thinking about retiring. As far as I know, his ruptured pain went away and then he won two Super Bowls or two Super Bowls after that. So it's a structure that's not necessary. And there's a lot of argument in orthopedics, and I don't need to go into it about how important it really is, but the fact is it is anchored right up here at the superior labrum. So when you tear that superior labrum, that biceps does funky things. It becomes unstable and it gets more inflamed often, and then that you get all that secondary pain. So some people, I'm not one of them. Some people who fix a lot of these will automatically just snip that biceps and reattach it in the front so it's not no longer a pain generator.

So that's the tendinesis.

Yes, that's a tendencies. But I do that only when I see tearing, splitting, something structurally wrong with the biceps. I know that I can get a good repair, as any good surgeon can. A good repair of the superior labrum. Once that's stable, the biceps is fine again, it's no longer symptomatic, and I'm not going wood, but I haven't had to go back and tinnitus anyone who I had just repaired and left it intact as long as I got a good superior labral repair.

Because we've got the beautiful anatomy here. Let's go a little deeper into this because I feel like the torn labrum is to the MRI what the disc herniation there is to the shoulder what the disc herniation is to the back. You know, we tell our patients, I almost wish when I give you an MRI for another reason, I could ask the radiologist not to show me your spine. In other words, you take somebody who's not having no spine issues and you stick them in the skin. There's nothing that bugs me more than having to sit there and go through all of these asymptomatic herniations which mean nothing. And I suspect the shoulder with its labral tear has to be the same.

You're absolutely spot on. And it is such a point of frustration. Radiologists are doing their job. They're just reading abnormalities. The problem is that most of us walking around have, especially my age, have Plenty of positive findings, but they're asymptomatic. I mean I've never had a spine or originated symptom. It's a very double edged sword to get those MRIs. Same thing in the labrum. The labrum will naturally degenerate just by using, using it. So will the cartilage. And look, we know there's a genetic predisposition to arthritis and by arthritis I mean not just inflammation of the joint, but a true loss of the cartilage integrity. And that's kind of. Those two terms are used interchangeably by different people in different subspecialties. But for our purposes as an orthopedic surgeon, it's when the joint is degenerating and the cartilage surfaces are no longer pristine, just like you're chipping the paint on your car.

And does that occur preferentially on the humeral head or in the glenoid fossa or is it basically one of those things where the second you get one chip it's going to start happening on both sides?

We don't have a good natural history of that. We know that. I mean I've operated on, done total shoulders on people who had no cartilage left on their humeral head. It was perfectly round and smooth. There was no cartilage, it was just a bony, just, just pure soft, I mean pure hard ivory type bone with no cartilage on it. Whereas the glenoids still had cartilage on it. Now that's a case where to your point? The loss on the humerus was smooth enough and gradual enough to where it didn't dig in and sort of eat away at the socket. It doesn't matter. You still have to replace the socket. But we do for younger athletic people who have a humeral head that's been damaged and they have a big chunk, maybe a quarter size, maybe a 50 cent piece size of cartilage, full cartilage loss. That's not great because that man that just keeps sloughing off cartilage that keep getting inflamed, they're on the young side, you don't want to do a shoulder replacement on them. So we will do just a humeral head resurfacing. They have a, get a nice new smooth metal head. But we leave the glenoid intact and they have good cartilage there. So it's metal on natural cartilage.

What kind of metal is that by the way?

That's, it's cobalt chromium alloy.

So it's just like the hips and.

The nice Thing about those is if you can get five years. I have some people that have had those in 10 years and they're fine. They can be much more aggressive with their activities. And if it ever does wear down the glenoid side, then you just go back in and revise it and put a plastic cup for the glenoid.

So let's now talk about when you look at the MRI finding and what you're looking for in the mri and then how you're looking to contrast that with what you see on the physical exam. And in a moment 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 sense of this. Because I remember the very first time I saw you after having sent many patients to you, it was probably a year before I had my surgery. I said, look, Alton, I know I've got this labrum. It's been torn to shreds for years. I really don't want to have surgery unless I need to. You examined me and said, yeah, you're not ready yet. So, yeah, walk through how you start to test the surrounding structures to elicit sort of feedback on the labrum.

So I will preface that by saying I'm so glad you brought that up, because one should never make their clinical, especially surgical, decision making on just an mri. I've written a couple of book chapters on that included a very complete examination of the shoulder, the basic exam, the provocative maneuvers and so forth. And one of the things I've always stated, I've never done this study, I've always wanted to, but I believe that a good history and that involves the mechanics of injury and the mechanics of use, whether you're shooting a bow and arrow, whether you're driving a race car, whether you're playing basketball, whether you're just lifting weights, a combination of the mechanism, but also their symptoms when they have them, and then their examination. And I think if you do those compulsively and well, you will be 95% accurate without any MRI.

I remember one of the things that had changed because for me, remember archery the day before I'm having surgery, I'm out there taking 100 shots. That was never the issue. But in the months leading up to surgery, I couldn't serve a volleyball with my daughter. I couldn't shoot one basket. I could not do that. And I could pull a 75 pound bow back. Doesn't make sense.

It doesn't. And it's just the mechanics of each individual. And that's where The MRI does come in. I use MRIs more to corroborate. Maybe I'm a little more into sort of the concept of making an accurate diagnosis before the mri, kind of the old school kind of prove a point. But I always use it to corroborate because there are things that can be there, and especially even just the difference between a partial thickness rotator cuff tear and a full thickness or a full thickness small and a full thickness large. And those are variable based again on the patient's activity. We know from good studies done with ultrasound MRI that walking down the street, half the people age 60 have rotator cuff tears.

Half the people over 60 asymptomatic have an asymptomatic torn rotator cuff.

Yeah, it may not be big, but it can be. I've seen, I mean, I don't doubt.

It just based on what we see of herniations in the C spine and the L spine.

And that's where, to your point, it comes in. It's so important that we don't want to ignore something that can get much worse and make their treatment or recovery much more difficult. But at the same time, we need to be more circumspect about who we're operating and who we're not operating on.

Are there ever situations where I'm going to ask this question, obviously in the shoulder, but if a patient came in and had a totally asymptomatic aortic aneurysm of 6cm, everybody agrees you would operate because the mortality of a rupture is enormous and frankly, you don't want to wait till somebody's symptomatic. That can be lethal. So there are certainly indications where we operate on asymptomatic things. Are there any such indications in the shoulder?

I would say in general, no. Unless you have, obviously a tumor.

Yeah.

Not including oncology, just the standard garden variety structural injuries that can occur. There are very few, except if you've had someone who had. Well, I'll give you a good example. That's very personal to me. My dad, who passed away at 95, we were swimming in Lake Travis when he was 94 and a half. He's really vigorous, mentally fit, physically fit. But he did end up having pancreatic cancer and that's what killed him. At 95, great life, no complaints with anybody. But at 86, a guy who could still do pull ups, who was still swimming in the lake.

So this guy's my hero.

All his own yard work, everything, and he was running to get out of the way of the sprinkler, did a banana peel, had a dislocation of his shoulder, ripped off two and a half of his four tendons. And remember, one of them never tears. So almost as a complete functional rotator cuff. He was planning to come up to New York to visit, and we did a little FaceTime and he couldn't lift his arm. It was like this. And he's 86, but healthy, never took a medication, so forth. So I said, dad, you need to come up early. We're gonna need to fix this. So we'll get an mri. Come up here. So my partner and I fixed him and regional anesthesia. They didn't even give him much sedation. He was, like, talking to us during the surgery. Got a good six anchor repair. He had great tissue to the point that you've helped so many of us understand, but got a good solid repair at 95. At 94, you couldn't tell he ever had a tear. He healed it back. He went back to doing what would.

Have been the natural history, because I think a lot of doctors might have left him alone. How would he have evolved?

That was the point. He would have been miserable for the next nine years of his life because he couldn't lift his arm. It might not even have been that painful, but he wouldn't have been able to do everything he wanted to do that kept him.

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

No. And so what I would tell someone who came in, let's say someone had a bad, traumatic a motor vehicle accident and they tore their rotator cuff at badly, and there were 60, 65. Would I tell them you absolutely have to have it repaired? No. But I would also tell them, look, if you don't repair this, those muscles have lost their muscle tendon connection, so they're going to atrophy and later. I know you're not painful now, but if you want to still do the things you're doing in the way you do them before this accident, they need to have them repaired.

So this is effectively the discussion you had with one of the patients I sent you six months ago who tore a rotator cuff playing tennis many years ago. And basically, once this patient stopped playing tennis, they had no more pain. So today they do yoga and Pilates with no pain, but they can never pick up a racket again. I sent the person to you, and that's basically what you said was you don't have to have this fixed. But you will see a continued diminution of your function as you age.

Exactly. And the second caveat, which I'll tell them is, you know, you may start having symptoms in six months, even doing those other things. And if you do come back, don't ignore them. If you start having symptoms when you've been asymptomatic, something has changed anatomically, physiologically, or something, let's reassess. It's a dynamic state over a long period of time. And so you need to be flexible in that. And as a clinician, certainly when a.

Patient typically comes in, basically they're just saying, doc, my shoulder hurts again. On the exam, absent even an mri, we're going to show people how you can. Just based on where I'm weak or strong and what hurts, you probably have a pretty good sense of this person has an intact cuff versus they don't. This person has a labral instability versus they don't. This may actually just be bicep tendon injury versus not. What else is on your differential diagnosis in the exam. You don't have the MRI yet. The guy just says he's got shoulder pain.

I'm gonna draw another picture. Okay, so I've drawn the shoulder again. I've added on a couple of things. I've added on the clavicle, the collarbone, and I've added on this other structure up here, which is the bony structure. If you tap on the top of your shoulder, that's the bony roof of the shoulder. That's the acromion. Yet another part of that super weird scapula. Okay. So the joint that when you hear about someone separating their shoulder, it's this joint right here, which is the acromioclavicular joint. It only rotates about 20 degrees. It's just a. The way I liken this, especially being in Texas. You can talk about it because there are a lot of car lovers and you know about it as a major car lover driver is it effectively is a McPherson strut on a car. So it's a stabilizer bar. If you don't have those. And there are people that are born without.

Without that collarbones.

Without collarbones, they can bring their shoulders completely together right here in the center, just like this. It's kind of super cool, but it holds those out. So that's why it's the one most commonly injured in cyclists who wipe out because they fracture here, because they land on the outside of their shoulder. But the AC joint, the acromioclavicular joint, is what Happens when people separate their.

Shoulders, which is also different from a dislocation.

Different from dislocation. That's usually from a force coming down from the top. So we're pitched forward, we land on the point of our shoulder and it jams it down. And we can talk about that later. It's super interesting. But this acromion again is the bony roof. And under that roof is where the rotator cuff glides. And let me draw this. I've just drawn arrows back and forth, arrows here. So as the head rotates back and forth around, the rotator cuff is attached here and it goes back and forth here. So it's rubbing or moving underneath this. Any place in our body that there's two structures anatomically in the limbs that move differentially with one another, there's usually a bursa that forms in between. And so that bursa is here, I'll draw it in green. A bursa lives right in there. And so it's just a thin filmy structure that can thicken up and become very inflamed and become bursitis. And it's very painful. So that's a common. Common because otherwise the purpose of that.

Is to allow these things to glide past each other frictionally.

Yes, perfect. Yes, exactly. And then some of us are born with an extra kind of downsloping of that acromion or a bone spur, or we acquire it from repetitive athletic use. There are multiple reasons. If you have a big though bird beak coming down and pointing into that, you can imagine if this is running back and forth there, it's irritating the bursa, creating bursitis. And it's also frictionally rubbing against the rotator cuff tendon. And you can get bursal sided upper part rotator cuff tears from that alone. I know because I had one, I had a big spur like that in my shoulder.

So to be clear, the spur occurred because you were genetically predisposed to it based on the shape of the bursa.

Yes. That's really great that you said that. You know, you should have been an orthopedic surgeon. You can have a type one, a type two or a type three acromion. Type one is totally flat. That's the majority of people. Type two, the second most common. And type three is about. I don't remember the exact numbers, but certainly it's not rare, like 30% of people. And that's the one that really predispose you. But only if you're an overhead athlete or lifting weights overhead or doing all sorts of aggressive things. If you're sedentary actuary who doesn't exercise, then you'll never have a problem because you're just not repetitively loading it enough to wear down or cause a tear.

So interesting, because you'll often hear people talk about, well, I can do so and so, and I've never had an issue, therefore it's okay. If you have the top acromion there, you can probably get away with a lot more overhead activity. And you might look at somebody who's in category three who every time they do excessive overhead activity gets injured and you might be saying, well, look, there's something wrong with you. The route of it is. It would be interesting if we sort of knew these things in advance and we could maybe modify and temper our activity around our genetics effectively.

Absolutely. It's a super cool concept. I've always thought about that stuff, the predisposition. And I'm not talking about predisposition to arthritis. You're talking about. This is anatomics, mechanics. The mechanics and anatomy. And you're absolutely right. It's so important.

I'll give you another example of it. I know just from having MRIs for other reasons. I have a very congenitally narrow C spine. So I just don't have any wiggle room. And as a result of that, I take my sort of tech neck protocol very seriously.

Yes.

I also know that I already have two small herniations. Now, luckily they aren't doing anything to me, but I know that nobody's going to go in and remove one without doing the other, which means they'd fuse me out of the gate. I think knowing that is very helpful because what it tells me to do is you're going to do a lot of sort of rehabilitative exercises even before having the injury. And I actually think it's very fortunate that I'm no longer a surgeon because I think a lot of my colleagues from surgery have ended up having neck surgery.

Oh, yes.

Because you're in this position all the time. So I think this is a very interesting idea. I'd never thought about it in the orthopedic context, in the joint context.

That is the other thing I thought of when you said that is this has been studied in the spine a little bit. So if you have a congenitally narrow, a stenotic spine and you're playing football, you're way more at risk for catastrophic spinal cord injury.

One cord injury.

So if you've had. That's why when we were. I was team doctor for almost 15 years college up In New York, everybody doesn't screen these guys. But if you have your first stinger, then you need to be screened and see if you are. And if you are, then you have a very serious discussion about what you're subjecting your neck to. There are a lot of sports to play and you don't necessarily have to be butting heads at high velocity. So that's exactly true there. But you're right, it hasn't been done in the shoulder. And yeah, it'd be a simple, easy screen and say, oh, you know, I.

Mean, well, especially I think when you talk about kids who have lots of athletic potential and they're 11 years old and maybe there is a decision to be made. Are you going to be a pitcher? Are you going to be a tennis player? Are you going to be a basketball player? Are you going to play lacrosse? You're going to swim? If you knew you'd have a longer shelf life in one over the other, would that at least weigh into the decision making process?

That's fascinating. I love the way your mind works because yes, there are plenty of multi sport athletes who have ability and you could do an assessment. For instance, if you have super loose joints, then you're going to need to pick the ones that you can keep dynamically stabilized but are not going to be subjected directly to unnecessary forces. Unnecessary forces, yeah, It's a great concept.

So I'm guessing, Alton, you drew this to expand our understanding of the anatomy to then appreciate the shoulder pain that somebody shows up with.

Yes. So all these things that I've drawn on here can be pain generators. And another one which is exactly to the point we are talking about is this right here, the AC joint. Almost everybody through wear and tear, middle age and beyond, has arthritis in the AC joint and like we were talking about in the neck, it's almost always asymptomatic, but it can be symptomatic.

And sorry, just to be clear, the little red structure you've drawn on there, that ligament that is connecting the clavicle to the acromion, there's no fluid within.

That space or it's a tiny amount. Any place there's cartilage, there's a tiny amount of fluid, but there's very little.

Got it.

But it can expand. And so if it's arthritic you can get more fluid. If you have, you know, young weightlifters like you were can. I'll draw it here. Can develop in the end of the clavicle from that repetitive abutment, doing heavy bench and other Types of activities can develop distal clavicle osteolysis, that repetitive jamming or bruising of the bone and cartilage causes the cartilage to disintegrate and the bone to lose its integrity. And it starts to kind of get very soft and it gets very inflamed. As soon as you start breaking up cartilage, all the macrophages from the body come in there and you get a big inflammatory response. You get a lot of extra fluid and a lot of pain.

So from a chronic perspective, are you going to see that more in somebody doing bench press or military press or which direction?

Both, but you'll also get it. I don't do these. I don't recommend my patients do them.

But the heavy lat raises.

Do heavy lat raises. That just jams up. It's just so much leverage on that joint.

And if you are to do it, I recall you're sort of more in favor of if you're going to do it. Thumbs are up, not down.

Yeah. And not directly lateral. More in.

Up in the natural plane of the scapula.

Exactly. That minimizes stresses. The other thing about it is that joint, you can imagine, it's like you're understanding the biomechanics. You lie directly on the point of your shoulder and it jams that against. So they have a lot of pain there. That pain comes right down the front, kind of follows the biceps. So you have to differentiate that between the two. Then you look at an X ray without an MRI or anything, and you see these spurs that are down there. Well, those spurs aren't ever going to tear the rotator cuff because that tendon is out there. It never gets gets that far, but it rubs. We see it as an indentation in the muscle. So, you know, every time you're working out, you know, you hypertrophy your muscles. So if you have that constantly rubbing there and then you hypertrophy around it, it's a true.

So that's an athlete who complains that when they're lifting, it hurts more.

Exactly. And that's a crystal clear. When they're relaxed, they haven't been exercising. They have rock solid strength. If you get them up into positions or if they've been working out, you test them, they'll actually be weak. Not because they're truly weak, but because their brain is saying, no, I'm not going to give you that. It's going to hurt me, it's going to hurt my body. So I'm not going to give you enough electrical current. To give you a full strength there. Wow.

You know, this reminds me when I was in medical school, once I decided I was going to go into surgery. I read a book, and I wish I could remember the name of it, but it was a book written by a general surgeon who had long since passed away. But the entire book was based on diagnosing appendicitis.

Cope's appendicitis.

That's right.

Early diagnosis of appendicitis.

And. And I thought this was the most fascinating thing in the world because you had this old school general surgeon who said this is before anyone was using a CT. But he was like, this is 100% a clinical diagnosis. Nobody today training would ever dream you could waste an entire book to diagnose something that, by the way, incredibly prevalent. It's the single most prevalent condition in general surgery when you just shove everybody in the scanner and get the answer today. But the reality of it is this makes me think of Koch's appendicitis. A, this is more complicated. And two, I don't think there'll ever be a substitute for the nuance of the exam and the history, both the history of the injury and the history of what causes pain.

That's fascinating.

I love that we're going to come up with Barron's.

Well, the guy that was my Cope was our professor of cardiology at Tulane. He was super old when he was teaching us. He was in his 80s at that time. That's not super old, but back then it was. It was. He had had thyroid cancer. So he spoke in a very hushed tone. His name was C. Thorpe Ray, and he was a cardiologist. He could tell you exactly what was wrong with which valve just by listening to. With his test. Cope with his hand. Sometimes he just put his ear up there and. Exactly. He could tell by the nature of the subtle variations in the heart murmurs what the dinosaurs. What. I just.

This is a little off topic, but I do sort of lament the fact that that's a dying art. And look, the reality of it is, I'm sure that today, with echo and stuff, we're better. And he was probably such an outlier that most people could never rise to that level, just like most people could have never attained the clinical acumen of Cope. But it is a little bit sad to think that we can't have both. You have to think it would be great to have both. So it's interesting to think that in orthopedics it might be one of those specialties where this judgment of the exam is still really, really relevant.

That's right. Obviously you get pinpoint diagnoses with the various tests. And in orthopedics there's plenty of things you find that aren't symptomatic. But still, thinking back to, I do lament that as well about the loss of the clinical acumen that comes with all the advanced imaging. But I think that if you have both, and I don't say this self servingly in the sense of I want to keep doing what I do as long as I can because I love it, but our patients need us to be able to still diagnose, listen to them, hear what they're saying. Because I mean, I don't know anything about general surgery, but there's got to be things that come up positive that you don't necessarily have to have surgery on.

Absolutely.

And so you want to still be hearing and perhaps examining, but certainly hearing the patient's story and knowing what's really going on to determine whether they need surgical or non surgical care or what kind of care they need.

I feel like that was something that was. If you were paying attention in residency, I think that was a very important message. I think when you start residency, you're just so preoccupied with mastering the technical side of things. I mean, there's so much to learn. It's like learning to master an instrument and learn a new language at the same time. And you've only got five years to do it. But I definitely remember the wisdom that was spoken down to us, which is the single most important thing that you will learn is when to operate and when not to operate.

That's true.

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

I don't want to go down this rabbit hole too much, but unfortunately there's.

And there's some people who don't learn that.

Some people don't learn it or ignore it. And there are plenty of people who will operate on any mri, whether it's orthopedics or probably general surgery.

We had one surgeon who, the joke was if you rubbed Betadine on the wall, he would operate on the wall. Don't let Betadine near the wall because he'll start cutting it.

That's a perfect way to say it without being too pejorative. And there are economic incentives. There are even, and these are a version of economic incentive. But there is even incentives in big institutions where it's an RVU concept where you're going to do more because that's how you get your promotion and so forth, and I have to just suppress that information because it makes me too cynical and sad. But it's actually happens. And I'm sure you did when you were doing surgery, and I certainly do now. I see patients that walk in with their MRI all the time and say, I'm scheduled for this surgery in my shoulder or my elbow. My friend said I should just come get one more opinion. And I say, look, I'm looking at you. I examine them. I do everything. I go through, and I say, look, I wasn't there at the time of your examination, so I can't speak for what that person saw and what their statement is. But today, based on your mri, your history, and your physical exam, which I've done, I will not operate on you. If your friend said you should come to me because I have decent operative skills, I'm sorry, but I can't in good conscience operate on you. Maybe someday, but not now.

I feel like I've sent you patients that have come from out of the country, and it's been, hey, I know that this surgeon is saying so. I just want Alton to have a second look. I've never met a patient who didn't appreciate that, by the way. I mean, sometimes it creates more confusion.

And I say that. I say, look, I'm sorry if this confuses you. I'm sorry if this is complicating your trajectory of what you planning for. But that's just the truth.

The thing you always have to remember as a patient, and I think of this myself, is once you commit to doing something, the inertia to do it is huge. And you can always just say, look, there's an asymmetry in this. Decision to not have surgery doesn't remove any options. You get to have surgery again later if it was the right thing to do.

Yes.

Once you have surgery, it's not that you can't have surgery again, but the operative field never looks the same a second time.

That's a very good point.

And so you want to keep in mind the asymmetry of a pause. All right, so let's go back to our shoulder pain patient. I think one thing we've established so far is a patient that has shoulder pain can have so many things going on, their AC joint can be the problem. They could have bursitis. They could have a rotator cuff injury. They could have a labral injury. They could have bicep tendon inflammation, and let's just leave it at that. They could have arthritis. We've Got all of these things that are going now. Arthritis would usually be accompanied by one of these other things that predisposed it. So we're going to go through an exam and you're going to basically run me through. These are the things you do. And this is what you look to see on the MRI to basically correlate your findings and give you a set of confidence as you go into the operating room.

You named the bulk of them. I want to add two things to that before we do our exam. One of them I've drawn just kind of a red arc down there. And what I'm showing there is the capsule. That's the best place to see the capsule when you're looking at an MRI because it's thicker there and it's more distinct. There's not other structures obscuring it. Normally if you have a super loose joint, you're going to have a very capacious capsule like that that allows it to flop down and even sublux or dislocate when it's very high and tight and thick there. That can be representative of something called adhesive capsulitis. And the reason I say that is because that's so common. One and two, it can conflate all sorts of diagnoses. And the frozen shoulder, there's the layman term for adhesive capsulitis. We don't know why this happens. It's super common. I see probably two or three new cases every week in my office. It's that common. But it's multifactorial. It's worse. Like many things are, if you have diabetes, but you don't get it with more frequency if you have diabetes. But it is, and it's a full spectrum. And there's a lot of misinformation about it because the original old literature said that, oh, all of these just get better with time. Well, they don't all, we know they don't all. And even a subset of them in my practice, about only one out of five actually ever need surgery. And we never do that at the beginning. And it's just a simple little 30 minute release of the capsule and a reduction in the inflammation. And then they're so happy. But that's the exception. 80% do not need any surgery. They need some way to control the inflammation. They need really good physical therapy and a home program.

For mostly mobility.

Yes, for mobility. That's why I'm saying that is because you can get a stiff shoulder if you have impingement, if you have a big bone spur, because your Brain says, I'm not going to let you move it there. And then it just gradually stiffens up. That's a secondary stiffness or adhesive capsulitis. It's not the weird primary adhesive capsulitis that could happen to you or me just suddenly. And it just happens. It's a spontaneous, intense inflammation in the lining, inner lining. If you take a little camera and stick it in there and just look, you see, it's beet red. Normally, everything, when you're in arthroscopy, everything's kind of off white, but in the case of it's just beet red and it's crazy. And people have done all sorts of laboratory tests, biopsies, evaluations have happened over a long period of time. I mentioned to you there's a colleague of mine in Northern California that wants to talk to you because you're so smart in this, about frozen shoulder, because that maybe thinks some of the things you've said might overlap with that biochemically.

I was going to say, what are the. I mean, do these respond to NSAIDs, or is this a part of the body that doesn't have enough of a vascular supply in the capsule that you don't get enough penetration?

It has a rich vascular supply. But I think in this case, I give NSAIDs when people want them and they're afraid of an injection, but because it's that inner lining and it's so robust. I mean, if you look at it microscopically, it's just the angry red fronds. And I think it's just not strong enough. So I like to put a small dose of cortisone into the joint.

Where do you inject?

One time, I always inject from the back.

Okay.

For two reasons. One, this part is more richly supplied by the brachial plexus, so it's more sensitive. And two, people kind of see you coming at them with a needle. So I always go in the back and I never use an ultrasound. That's a whole nother thing that a lot of clinicians use the ultrasound just to see, but you can feel where you're going. You just get it in there. And what's super cool about this is people come in with a lot of stiffness and a lot of pain. And then you inject them and put local anesthetic as well in there.

They're free in 10 seconds.

Oh, my gosh. They walk out, they're saying, oh, my gosh. It's amazing. They still probably need physical therapy, but the fact that they got Such dramatic relief with some just simple treatment is.

So do you recommend that a patient with frozen shoulder err on the side of earlier intervention with a cortisone shot to then allow them to do more rehab sooner? Or do you say, I don't want to do a cortisone shot until you've done three months of rehab?

It's purely based, again, on their exam, their exam and their history, how long they've had it and how acutely symptomatic it is. When I'm examining them, if I can stretch them and they start kind of saying, oh, that hurts a little bit at the end, but they've got decent.

Motion, they're tight, and go back and.

Do the rehab, go to pt, go to good pt, who will really stretch you out? You don't need anything. You don't even need insets. But if I can't get them to move and they're screaming, they're not going to get anywhere in PT because it's going to hurt too much to do it. So I'll inject them, then send them to pt, and I always see them back at about six weeks. Most of them are dramatically better, but not all of them. Very rarely they need a second shot. And then some of them are just recalcitrant and they just stay stiff, and then I'll do the little procedure on them.

So there was one other thing you wanted to mention.

Oh, yes. A big source of neck pain, which you and I have discussed multiple times, is referred pain from the spine, from the neck. And so we'll include that in our exam because it's so important, because you.

At least have to rule that out.

Well, especially because someone comes in with shoulder pain. And I see that, you know, I take care of a lot of professional musicians. Their necks are doing all sorts of crazy things from all the violinists and the philharmonic or et cetera, just all types of musical instruments that lead to having to maintain these certain postures that sometimes are very counterproductive to their overall musculoskeletal health. But they'll come in with shoulder pain going down their arm, maybe even down to their hand. And they'll have already gotten a shoulder MRI, and they're 55, and they have four findings on their MRI, but it's not coming from their shoulder, it's coming from their neck. And so we have to make sure and differentiate that, because the worst thing I could do to them is have them take time off from music to fix what doesn't need to be fixed in their shoulder, and then they have them return and they still have the pain.

And in that situation, is there something you see on exam that makes you think, we better go look at your neck first with the mri? Because the symptoms fit as something I'm expecting to see. And then you look and you see. Well, I do see that. So now that's.

Yes, exactly. So intrinsic shoulder pathology, whether it's a rotator cuff, whether it's impingement, whether it's arthritis, almost never does the pain radiate down below the elbow. Whereas neck origin, whether it's pinched nerves at any. The lower cervical spine, where it's more common to have pathology, almost always goes down below the elbow and into the hand. One oddball is C7, and I learned this not that long ago from some really great cervical spine surgeons, is that if you have a deep posterior pain under your scapula, that can be C7, and that's right where it goes. And so I've had two musicians whom, you know, recently, both with that diagnosis.

Yeah, it's funny, the only time I've ever had a complaint of a neck issue, what turned out to be a neck issue was not. Didn't present as neck pain. And this was several years ago. Now, again, in the back of my mind, I've always known, I'm susceptible, I'm susceptible, I'm susceptible. And I woke up one morning and my left trap felt like it was in spasm and kind of ignored it. I was like, oh, I slept wrong. You know, whatever. This is super uncomfortable. You know, the next day, it was still in spasm. I just sort of ignored it. I might have taken some NSAIDs. This went on for, like, two weeks. Maybe not two weeks. It might have gone on week at that point. And at this point, I'm thinking, I've never had a muscle that's this tense for this long. And at about that time, very abruptly, I started to notice a loss of tricep strength.

Wow. Yes.

You know, I noticed it in the gym because. And it was subtle at first because I was doing, you know, skull crushers, where you have two dumbbells. So now the right arm can't compensate for the left because using two dumbbells. And all of a sudden, I couldn't move the weight with this arm. That's weird. I can move it this way. And then it progressed so rapidly that within about two days, I couldn't pull my bow back because this arm couldn't support here. So at that point, I was kind of freaking out. I'm now down to, you know, only being able to do a couple pounds. So I know, hey, once you have those motor symptoms. But here's the thing. Zero pain. Not a lick of pain. No numbness, tingly, no paresthesias anywhere. My neck doesn't feel a thing. I just have this trap on fire. Make a long story short, I see a person who says, look, we could operate on you, but unfortunately this is a surgeon who shares your ethos. And she said, look, let's rehab the heck out of this. I think if you want, we could do an injection. I wasn't excited about it because it was an anterior injection, and I said, no way. I'd rather do prednisone and traction. And so we did prednisone traction, and sure enough, within three months, the strength was back. It's never returned. But that was a real wake up call to me that I had a cervical symptom that didn't present with any neck pain.

That's a great story. It's so instructive and you're absolutely spot on when I see especially the musicians. As long as you don't have. Now you did have some. So you were absolutely right. Getting more deeply studied to make sure because you had triceps, but if you have no weakness, maybe you do have a little tingling or something, but I just know it's coming from the neck. I won't lurch in and get MRIs of the neck. X rays and MRIs in the neck. I'll often just give them one very low dose of prednisone and it usually goes away. They don't have to worry about it and they don't go down the rabbit hole of worry and anxiety about that.

At this point in the conversation, Alton demonstrates on me what he'll do for. For a typical physical exam of the shoulder. This includes what he looks for as well as what might be the root cause of any pain or issues. As this lends itself much more to video, we decided not to include this in the audio version of the interview. If you'd like to see what this exam looks like, you can head over to the Show Notes page or to our YouTube page where we have the full exam videos very clearly broken out and available. Now back to my conversation with Alden. So now we have a sense of. Of how complicated and nuanced the exam is. So now let's assume we have the diagnosis. So let's walk through some of the surgical treatments here. Again, let's start with the operation I had. So a labral repair Is the approach significantly different whether it's a slap versus a complete tear like mine? I assume it's just the number of ports or how does it.

It's just a little more technically to do. And you need a few more little. And we do most of these now as I was talking about the technology earlier, the. We can do these percutaneously. So we don't need five big. I mean these are only a centimeter and a half. The biggest ones are only about a centimeter centimeter and a half. But the others, they can be percutaneous, tiny little holes that we use little cannulas through and then put the drill through and so forth. So that's right. It's more just adding a little time. You know, it takes 10 minutes to do each anchor sort of thing. And so you just add on and you needed a bunch.

Seems like the first thing. If I recall that exam under anesthesia is crucial, right?

Oh, I'm glad you mentioned that. Yes. So even with a good exam, remember that a dynamic exam, your brain has been dealing with this problem for a long time. You're naturally. Well, not naturally, you work, but have good muscle tone. So if I'm examining you, I probably can't sublux your shoulder. I have to kind of jump up on top of it to do it. The rare case is somebody who's had such long standing instability that their body's no longer responding to it. And usually I can get. Get one or two subluxations, but then they tense up, but I can usually get one or two. So that's one subset. So great thing about an exam under anesthesia is once you're in your position where you're going to have the surgery, you've got a regional block where your arm is super numb and you're sedated so that you're relaxed and you can't control anything. And then I can just. It's as if your muscles aren't really there. I mean, they have a little effect on it. But mainly I'm testing the static stabilizers. In your case, I could take it pretty far out back and way I could completely dislocate your shoulder out front.

Still hurts for me to watch that video. It's interesting.

It's super cool. And so then, you know, then that tells me, okay, I need to be careful when I'm looking on the inside. I need to assess not just the labrum, which I know is torn. I need to. In the case of the anterior, you've been like the balloon. You're Blowing up repeatedly. You've been also stretching out your capsule. You're still compensating. Well, less well and less well with the muscles, but you are compensating. So if that is stretched out in the front, I need to know that in addition to just repairing the labrum itself, I need to gather up some of this capsule which has become too capacious and do what we call a capsuloraphy, which is to gather and tighten that up too. And that's kind of a judgment call. When you've done a lot of them, you kind of know how much to gather. You don't want to gather too much because then it tightens them up too much to that point. And this is a caveat about. Well, yeah, unnecessary surgery. Had a lovely violinist, professional violinist, who I treated her whole family. They're all violinists. And she had been up in Vermont, farther enough away to where when she had a frozen shoulder or shoulder pain. She got an MRI, saw a sports doctor who saw. And again, she's 60 at that time, 62, 63, and had some degenerative labral tearing. Well, he said she needed to have a repair of that.

And she presented with what? Pain?

Just pain, a little stiffness. Okay, so just read the mri. It said labral tearing. Didn't really have anything else, so said you need a repair of your labrum. Did a repair of the labrum. She came to me about six months later in tears, had not been playing for six months, had the stiffest shoulder I think I've ever seen, Basically didn't move.

So he tightened the hell out of.

The capsule and did a labor repair that in a 62 year old who's not an athlete, would never be necessary. Sort of universally true. So I had to go in and scope her. It was really hard because it was so tight. Had to just bit by bit release everything that had been done and release the capsule that was all crunched up and tightened up. Even had to take some of the sutures out to free up her shoulder.

Do you have a sense of what her initial injury was even caused by? I mean, do you think it was just capsular?

I think she just had just a stiff cap. Classic frozen shoulder.

So someone that should have had PT plus or minus, at most a single injection to reduce the inflammation has the exact opposite. They get a complete tightening of the capsule. And there's a school of thought in orthopedics that says we just don't like repairing labrums and doing capsule repairs in older people because that's the Outcome you get.

Yes, and that's completely valid.

I remember some people that I spoke with who said, wow, at your age, Peter, you're basically 50, you're having a labral repair. Are you crazy? Now, of course, in my case, I think I haven't lost any mobility, which is kind of remarkable.

No. And in fact, you and I discussed that some.

That was one of my biggest fears.

So one has to pay extra attention to that. For me, if we want to be specific about your case, as just a case example, I don't think we had a choice because your subluxation, you're so active, your subluxation with all the different activities, you already had some arthritis, you were already wearing down some cartilage. It's either that or the inevitability of having a shoulder replacement in another 10 years.

I think when I saw the little bit of arthritis there, I kind of wished I'd done it sooner. Knowing what I know today, I almost wish I had more pain sooner. I really had a ton of pain 10 or 15 years ago. But with a lot of good tissue work and a lot of training, I kind of got out of it and I made some modifications. Like there were certain things I just decided I couldn't do.

But another component of that is, especially now, people are so much younger, mainly because they're all rucking now. No, people are so much younger, physiologically in better condition. And we know that from whether it's cancer treatments and everything else and the advancements of science. That a 50 year old, now that would have applied to that data that we have 20 years ago is misleading. So I base it on. You were kind of an outlier.

Yeah. You base it on biological age.

Not even. And even. Look, there are some people that have. I'll scope them, I'll say, look, I don't have any other way than looking and seeing what's there. And in some cases they have better cartilage than what the MRI is indicating, medicating. And then I can go ahead and do a repair. And some of them are. I've done a couple. Maybe I shouldn't say this on air. I've done a couple of like 58 year olds, 60 year olds, but their joint was pristine. I mean it looked as good as a 25 year old. They just had a discrete labral tear.

This is to me an extension of what I think of as precision medicine, which is we use evidence based medicine, which is incredibly heterogeneous, to make population based assertions and general broad recommendations. But ultimately the only Patient that really matters for most doctors is the one right in front of them. And therefore you have to be able to make evidence, informed decisions based on the appropriate physiology that you see.

And it's also a conversation. It's a conversation with that patient, not a unilateral decision. It's okay, what do you want to do? What do you know about this? Here's what I know about this, here's what I'm seeing with you. And we need to say here are the possibilities and what do you want to do?

So how often when you go in for, I guess just explain to people. So the biggest port puts the camera and then you have like a few working ports, obviously.

Yeah. So typically, since more of the pathology is superior and anterior, although you had some in the back, if you're working in the superior in the front, you go in through the back with a camera. So you just have a good panoramic view of everything. We have two different kinds of angled lenses, so we can see around corners if we need to. Usually don't need them for most things. But then I can see the superior labrum, I can see the biceps.

In general surgery, we insufflate with carbon dioxide.

Right.

So you're shooting carbon dioxide to blow everything up. I assume you're using saline to do the same thing. So you're making that capsule bigger.

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. Some people use around 50 millimeters of mercury pressure. I use 35.

And that means less post operative pain.

Presumably it's less going. Yes, less distension, distension of the whole shoulder and so forth. So that's what I do. And you can still put in little retractors, kind of pull tissue out of the way and so forth. So that's just a technique that's more of an extension of what I do in the elbow because there's a lot more peril because of the nerves being so close. So then usually you need two working portals in the front, which are just cannulas that are just basically the canals to get in with instruments that are long enough to fit through the. And do the work. And then in the case of, for instance, a superior labrum, we use a percutaneous right through the top, just underneath the kind of right here, actually right through here where that red arrow is going. And that just gets you to the superior labrum. So that's a little percutaneous. You make A tiny little hole in the rotator cuff, kind of muscle tendon junction. It just spreads the fibers apart so it doesn't do any damage to. To that. And then you've got a perfect bird's eye direction for the drilling and putting in those few anchors in the top. And then that's really it.

And explain how that works. So you drill a little hole in the glenoid fossa. What's the diameter of that hole?

It depends on what kind of anchor you're doing. Usually roughly not more than 3 millimeters. And now we're down to 1.8.

Okay. Even three seems big.

Three seems big, but that's what you fit the plastic or the absorbable anchor in that. You just kind of tap in with the mallet. All of them. You tap in with the mallet and you're drilling into the bone. You're drilling around here, kind of this angle here, and you have to get the angle right. It's a very three dimensional. But you put them in so that you're drilling into hard bone and then the anchor inserts through that.

So they're not circumferential? No, they're just straight in.

If we did them open, we used to do them even with like a suture drill holes and a suture going through circumference.

So what holds the anchor in? Is it just the pressure you're putting an anchor in that is bigger than the hole. And so it's sort of like a nail.

Yes, exactly. And. Or a tent. Oh, not a screw. But they're not a screw. There were historically some that we screw in, but not anymore. And now the ones that are purely basically braided polyester, those go in, the suture goes in. And then as you carefully pull it back out, the way they're designed, they ball up and it creates a. I mean, they're super strong. You can lift the shoulder off the table. So it's super cool to use those.

Wow, that's so interesting. So you have a lot of confidence in the integrity of that repair.

Yes, I know that if I tug on it multiple times, it's not going to come out. I mean, it would take a fully traumatic force to do that.

So before you do this, I assume you do an exam of the cuff while you're in there.

Absolutely. So you go through and do a survey of the joint. You look at the cartilage surfaces from the nooks and crannies. Cartilage surface. You look at the rotator cuff inserting on the bone from inside out. And you can see that being smooth. If it's frayed, if it's notably frayed, you can probe it and you can see, oh, that, you know, actually has a. Also, and I occasionally see that because they're athletes, a small, almost full thickness tear. Then I may put a stitch or two in that to fix that. You look at the biceps, you can pull the kind of the biceps into the joint and see a pretty good segment of it and see if it's inflamed, torn, something abnormal there.

And you can see the tendon of the bicep really well.

Oh, yes.

To see, obviously. Is it frayed?

Yes.

So how much damage do you need to see to do the tendinesis?

Not a lot. If I see a combination of a modest amount of fraying and a lot of inflammation around it, and when I pull it in the joint that extends further out, then I'll tend to eck.

It's interesting, I think, for people to understand how much your eyes are helpful here. Right, as you say.

Oh, yes.

When you look at these images and we'll link to some images in the show, notes of what these pictures look like. In fact, we can include my pictures and just other pictures we'll find online. It is just a very plain, banal, sort of gray, white, normal thing. And to think that inflammation just shows up is like, wow, that's really red.

Exactly. And for me, some people don't like to waste the time, but I get a little electrocautery wand and I paint the internal and get rid of all that pink because it's inflammatory, it hurts. And that's part of one of the big pain generators. So I just do that automatically. Now, theoretically, if you fix everything, that's going to go away anyway, but it helps them, I think. Early post op, a recent patient I had, I did a pretty significant repair on and he after five days said, I haven't had any pain. What's going on? Do you do anything to my shoulder? So I said, yeah, I did repair it, but I think part of it is just getting rid of that inflammation and so forth.

So now contrast that with the pure rotator cuff repair. Let's do two examples. Let's talk about a patient. What is the most common athlete's tear? Which one is it going? Did we say it's going to be subscapularis or supraspinatus? It depends on if they're an overhead athlete.

If they're an overhead athlete, then it's going to be supraspinatus. Almost always and sometimes it can be the infraspinatus.

Right. So if a guy just has a straight up supraspinatus tear, you don't even need to enter the capsule necessarily, depending on how close it is.

No, you do, because you want to. First of all, you want to still want anything. You want to make sure that you're not missing anything, which is common in the athletes. There's a couple of interesting various. I'm going to draw some pictures. Okay. So here I've drawn three sequential axillary views, which are a bird's eye view looking straight down on the top of your shoulder, fiber sitting on top, looking straight down. So we've got the glenoid, the socket here toward the head, and we've got the ball out here toward the outside where the deltoid lives. This is the supraspinatus I've drawn in here on the top. In the back, as we talked about before, that's the infraspinatus. And then in the front is the subscapularis.

Those are the three, the teres minor, which is the fourth muscle of the rotator cuff. It's not really a relevant player in the pathology.

Very true. It almost never tears.

This is actually really a cool way to look at it. It's not normal that we usually look at them from front and back. But the bird's eye view is what allows you to see how the subscapularis and the infraspinatus are stabilizing the front and the back, while the supraspinatus is coming in over the top. Is the supraspinatus that wide? Relatively speaking?

Yes, pretty wide.

Wow, that's so interesting.

More about here. Here it is. I drew it a little wide there.

Okay. But that's interesting again in anatomic diagrams because you're looking at it from the front. It looks like a tiny little muscle.

Yes. But it's broad, it has three dimensionality. And that's about three, roughly three and a half centimeters of width going front to back. And so there's three different views. The most common one is the middle one because that's anterior, the biceps is here. That's an anterior superior tear. That's the one that the overhead athletes get a lot non throwing athletes, but tennis players, volleyball players and weightlifters. And that is one of the critical zones where it can get wrung out and not have good blood supply. And that's where they tear. That's where I had my little tears on both shoulders. But that's the garden variety one, that's also the one that can be caused by the spur pushing down on it. And I've drawn a little arc because that's kind of. They'll tear off, and then they'll form a little arc of smooth tissue. And you freshen that up, freshen up the bone and then put the sutures in that leading edge of the tendon and put it back just like you'd put a tarp with a tent stake back in. And that's how you repair it. You get it back to the good bony bed and you get that good biologic healing. And that's a small tear that I've drawn there. And they can be bigger and bigger, if you imagine, and more chronic. Now, the one down below shows the subscapularis in the front, and that is the one that can tear in young people or older people based on mechanism. So if you have a linebacker who has. He's going forward at full velocity, and then somebody is knocked into him and shoots him across. He's got his arms out there ready to go, and he gets eccentrically loaded into external rotation like that. That's how you can tear the subscapularis. The other way is people falling downstairs and grabbing the banister and wrenching back that way. That's the common. It's commonly torn with eccentric stretch.

Got it.

Abnormal weird stretch where they're contracting and then it's just torqued on it. Now, this upper one is very interesting because we were talking about throwing athletes. So the throwing athletes, baseball players and football players, they externally rotate dramatically. That's how they get their extra angular velocity to really get that zip on the ball. So they acquire external rotation starting at a young age. Their arms are very asymmetric. Their shoulders, one side will externally rotate to 90, the other one will go back another 45 degrees. And that's how they get that whip. One of the consequences of that in a subset of them is that as this rotates and follows this area around that area, the rotator cuff, which is at the junction of the infraspinatus and the supraspinatus, abuts up against the hard bony rim of the glenoid, and they get an internal impingement, ultimately get small partial thickness or even full thickness tears there. So we have to be super cautious with those. We have to repair those. But you have to be really careful because if they lose 10 or 15 degrees of external orientation, they lose.

So where does the Tommy John fit into this?

Yeah, so that's the elbow but it does. No, it's. Maybe that was just intuitive since you are a good orthopedic surgeon is actually it fits in because a lot of people add torque on their elbow because they have shoulder pathology. If they have a little weakness or something going on in their shoulder, they will overthrow with their forearm and their flexor pronator mass. They'll overthrow with the torque and then they'll tear their medial collateral ligament of their elbow. It's crazy, but true. And vice versa. If they have a weak. If they have a partially torn medial collateral ligament that hasn't yet been identified, they can overthrow with their shoulder to compensate to get more angular velocity on that because they can't muster it through the elbow.

How many years ago would it have been the case that a torn rotator cuff was the end of a pitcher's career or a quarterback's career at the professional level?

I would say easily not more than 20 years ago, probably even not 15 years ago. Probably 15.

And today that's not the case.

No, no.

What has been the advance that has changed? Because I can't think of anything that could be possibly more stressful. I mean, to me, throwing a baseball seems even more stressful than throwing a football because you do it more times in a game.

Right.

So what has changed that has made that.

What's changed this earlier diagnosis now at certainly at the Division 1 collegiate level and the professional level, there's any pain is evaluate, kind of over evaluated and that can be good for them. I mean it's used a lot of resources, but it identifies these very early. So that's one way. So you get to them earlier.

So in other words, quarterback, pitcher says, you know what, it's starting to hurt a little bit. You see a very small tear in the cuff. You're saying it's better to go in and repair that than let it become a bigger tear?

Yes and no. It depends. You'd certainly watch it carefully and you correlate the symptoms with. Sometimes it's not the tear, it's just some inflammation that's related to it. If you can cool that down. The tear is not biomechanically significant yet. I've said this to many people. I have full thickness tears in people that are minimally symptomatic and partial thickness tears that are very symptomatic. It kind of depends on what you.

And I think one thing that's kind of missing from this picture in the subscapularis and the infraspinatus is how long they are. So we're looking at the top, but these muscles cover the scapula totally. So when you say a full thickness tear, I want to make sure people understand the size of the tear.

Yes. So when I say full thickness, I mean like when we were looking on that other view. Draw that again. Oh, actually I can just go back to the previous one that I drew. So when I've drawn the supraspinatus tendon, that perpendicular distance through there is the thickness, the full thickness. It varies depending on the size of the patient.

But it could be across the entire 4cm. It could be a whole 4cm by half a centimeter.

Yes. So you could have, when we speak typically about full thickness, we mean the depth of it this way so that you can have a partial thickness tear. That's maybe half the tendon there or full thickness. Now if you have half the tendon torn, you've lost enough biomechanics that if you're a high level throwing athlete, no way.

Whereas a partial thickness tear off the tendon could easily be ignored.

Correct. So then when we talk about this, that yes, those muscle bellies are huge. Now the reason you jog my thinking about that is you can have, especially if you have these guys are so strong, like the football players and so forth. Sometimes they have that wrenching injury, they don't rip the tendon off the bone, but they interstitially tear at the muscular tendonitis junction and they have a tremendous amount of edema, weakness, pain. But that will heal. That will heal without any intervention, Just some tincture of time and some anti inflammatory and just time to heal.

What role do stem cells or PRP play in any of this? Certainly anecdotally there are a lot of people saying, look, stem cells aren't going to replace a labrum, they're not going to work there. But you have a tear in the muscle, stem cells can be valuable. Now I'm not really aware of RCTs that have looked at this, but I also haven't scoured the literature on the rotator cuff. Are there people running clinical trials on stem cells in that indication?

I think so. I don't know that literature as well as maybe I should. I tend to, you know, I go to all the meetings and I stay fairly abreast. There is obviously a lot of activity going on, but there's a lot of terribly designed studies all around that are being used to justify using whether PRP or stem cells. So one has to be careful to extrapolate it to your individual practice. And there's a lot of money involved in it too. I mean, I have patients routinely that fly to various places, including Germany, including. And I'm not pillaring by any means because they exist everywhere. I just happen to know a couple that just got back and they pay a lot of money to get stem cells injected for things that we've been talking about and there's no data. I'm not talking about the muscular tendinous. That's different. I want to talk about that. But let's say just a garden variety small rotator cuff tear. There is no data ever. There are some, a few anecdotal reports where people say, look, there was a tear there on that mri. I injected PRP and it's healed, it's gone. I don't know what to make of those. They're just one offs.

Well, also, do we know what the natural history of that injury would have been without the, the prp?

Of course not.

Do we know?

No, we don't.

So we don't have enough of a series to say if you took a thousand people that had that tear and you did nothing and came back and surveyed them two years later, this many, you wouldn't see the tear again. Do we not know that?

We don't know that. One of my best scientific things that I can relate goes down to the elbow. But I think it's important for this part of the conversation is I was speaking right before COVID at the aossm, the American association of Sports Medicine. These are non surgical general medicine doctors who do sports medicine. And they're great, they're really knowledgeable, they do tons of studies. I was waiting to speak and the two papers presented before me were back to back, really well done. Large numbers, over a thousand patients, double blind, randomized studies comparing for tennis elbow, tennis elbow, lateral epicondylitis, comparing cortisone, PRP and placebo. And the placebo and the PRP were the same and the cortisone was much more effective. These were back to back studies, different institutions, and it was informative for me because I've read the literature. Our literature is replete with studies that say, oh well, PRP really helps. And I see patients all the time that have had PRP injections based on my current knowledge of the literature, for rotator cuff repairs, for tendon ruptures, for lateral epicondylitis, certainly for Tommy John's and medial tendon ruptures. I have a PRP machine in my office in Manhattan and I use it twice a year.

For what?

For when Someone begs me to do it.

Again, not to be skeptical. I suppose a doctor can make more charging for PRP than cortisone. I mean, cortisone's pretty cheap.

Cortisone? Well, one, it's covered by insurance, and two, yes, it's a couple hundred dollars for a shot, typically. I mean, in my office, that's one of the reasons I don't use it is a thousand dollars and it's not necessarily covered. And people charge a lot more. Some people charge $2,500 for a PRP injection. And look, I'm not saying that it doesn't someday prp, the concept is great, as you know, it has growth factors, it. It's our own bodily fluids. And so it's perfectly reasonable. But it hasn't yet borne out to be a game changer. Now, if you take someone who's the highest level athlete and they have bursitis, sure, inject some PRP in there, some stem cells, whatever. Maybe it'll be better, who knows? There's not really good data on it, but there's no downside to doing it. The only downside, sometimes I see many more flare reactions from PRP injected in the tennis elbow, where people are really painful for a couple of weeks and they end up coming to me for either surgery or cortisone. They say, I don't want another one of those. I don't want another one of those. And that's just anecdotal for me. I don't have a comparative study and.

I probably need to spend more time in the literature. But I really. The few times I've kind of looked with some interest, usually on the request of a patient who's kind of going through this, I just haven't found data that are convincing enough. Even though, again, mechanistically, there's a high plausibility and. But I think the problem is we don't have that natural history. This is the problem is there's lots of anecdotes that say this injury was present, stem cells were injected, the injury is gone radiographically. The problem is we don't have the contrapositive case.

We don't. The best natural history study we have on. And this has nothing to do with treatment. This is asymptomatic rotator cuff tears came out of Washu. One of my best friends in orthopedics, Ken Yamaguchi, was a lead on that article. And they looked at ultrasounds, which was great because they're non invasive, non costly, and very effective. If you have a good ultrasonographer, and they looked at the natural history of these asymptomatic tears, and they found that they obviously documented the percentage of asymptomatic tears in the general population, but they looked at them longitudinally, and they never repaired on their own. At very best, a subset of them stayed the same. The larger the tear, the more likely it was to become even larger with.

Time and become symptomatic.

And become symptomatic. A subset of those became symptomatic? Yes. So it was really well done. It got a lot of press.

So none got better. Spontaneously.

Correct.

So that would suggest that if people are saying, hey, here's my MRI pre and post stem cells, and it got better, that would at least suggest that in that individual it might have worked.

Yes, if you had enough and they were done. As you know, MRIs vary significantly from machine to machine, so they would have to be very well controlled. If you showed me even 20 patients done by someone that I know is legitimate, and they did that and showed comparative MRIs that even 10 out of 20 showed healing reconstitution, man, I'd be in.

Well, I hope that study is being done. I suspect that there were a number of obstacles 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 them would be, you'd have to standardize the process of generating the stem cell.

Absolutely.

One of the challenges of doing a clinical trial is everybody has to get the same drug.

Yes.

And if the drug differs, it becomes problematic. Do you know how standardized the procedure is for capturing and processing stem cells?

Yes. Non. Non. Standardized. It differs between the different companies that bring the machines in. It differs between the individual clinicians and so forth. So, yes, that's one of the things that my colleagues and I discuss quite a lot. Can be apples and oranges.

A couple other injuries I want to talk about in the shoulder before we move to the elbow. So the AC separation, when does it require a repair? When does it just get left alone and you're stuck looking with a little bit of deformation?

That's a great question. Because they're so common, the injuries. So let me draw a picture.

I love these sketches.

Okay, so we have here. We've removed the glenohumeral joint, and we just have the AC joint. This is the clavicle coming across. These are the two stabilizers of the clavicle. One is. That's the coracoid process. And these are the coracoclavicular ligaments.

And we're just looking at that and straight on, which is why it looks like a little nub. But of course it runs.

It's a thumb that sticks out from, from yet another weird part of that scapula.

It's got to be the weirdest looking bone. It is.

Secondarily we have the acromioclavicular joint that we were talking about and those are the ligaments that are circumferential around the chroma clavicular joint. So if you fall hard off your bike and you sprain your AC joint, we call that a type one. You sprain your AC joint, you stretch a little bit and injure these ligaments and maybe even stretch those a tiny bit. But non displaced, but it doesn't look any different on X ray and that is a grade one. Those can hurt and those can damage the cartilage a little bit and you can get a grade one that persists and being painful, but generally they don't, they go away. I did this recently on some slime out in Dripping Springs, riding a bike out there and just low water crossing just went out like it was on ice. That's exactly what I had. And it hurt for six weeks and then was gone. It's completely normal.

But it was that diagnosis by the way, was just pressing right on it. That's how you know it.

Well, I know it because by pressing right on it, it hurt like heck. But it didn't blot, it didn't move up and down and I could lift my shoulder, I could feel it not moving. So one of the things that biomechanically understand we talked to the residents about when we're teaching is it's not that the clavicle pulls up, it's that the shoulder falls away. These are the primary suspension. One of the primary suspenders of the shoulder are these two ligamentous structures. So if you tear them, the shoulder kind of falls away. So that's why we treat it by wearing a sling and get that weight of that heavy weight of the arm off. Now down here I have a shadow drawn. Here's the clavicle. We have one Acromion which it's sitting up about 30% or so. That's where you've clearly torn the AC ligaments and you've partially torn, maybe completely torn, but it just didn't distort it too much. Where you have, you know, you have a complete tear, but it's only up about 30%. That's a grade two and that almost all those can be treated non operative. Occasionally those will again, like the ones they can hurt, persist. You might have to do something later, but they're basically stable.

And when you treat it non operatively, is the treatment that it will return to its position with elevation?

Sometimes, but usually not. Usually it stays a little elevated, a little proud, but people don't really care. It's barely asymmetric. Then you get here where you have a complete. It's completely up. And we measure that by the distance between the coracoid and the clavicle. I've drawn it here to just express that difference there in the height. And that is that coracoclavicular distance. If it's here, if it's up to 30% widening increase in that space, then that's the grade two. If it's 100% or more, then that's a grade three. If it gets up to 100%. Even though there was a good study done probably 20 years ago for NFL athletes who had sustained these, and the prevailing wisdom for the doctors who were treating the NFL teams was that most of that type threes did not need treatment, surgical treatment, but a subset of them did go on to needing it later. Now, in reality, when they're up that high and people want to get back sooner, we have better reconstructive techniques now. And so you can kind of get back on the bike. And if you're a professional cyclist, if you fix them, you can get back on the bike in three or four weeks sort of thing. So there's a gray zone. But the type threes are that transition. Now, if they are, the 4 is.

More than 100% cap.

Yes. And then sometimes it could be trapped behind the scapula and all sorts of other things. But the threes are the sweet spot. The vast majority of the operative ones are in the three category. And I saw a guy the other day and I kind of presented both options to him. He's an athlete, he's a weightlifter, but he's late 40s. And I just gave him the options. I said, look, one of the things you might consider, and this applies to a lot of what I do, is I said, look, yeah, we can fix this, we can fix it tomorrow or next week, but you could also wait and see how you feel in three or four weeks. I can do the same repair in three or four weeks.

You don't lose anything.

You don't lose anything by waiting in that realm. Now you do if you wait three months or six months, because you have the same biology going on. And he ended up not wanting it because he felt great.

How far out was he from the injury?

He was four weeks when he started.

The pain was already gone, almost already gone.

He saw the trajectory being so good that he decided that he wanted to wait.

And the only issue that he's going to struggle with now is the asymmetry.

Aesthetically asymmetry.

And it won't have a functional impairment.

Generally not. Except if you're doing certain types. Like if you're heavy flies, heavy bench, even people who rest, you know, do.

The high back squat.

Yeah, high back squat. And those could presume that could irritate them and be problematic. And so there is some.

And so the repair here is done how.

This is where I differ from some. A lot of people just get in and get out quickly, and they will let me draw it here. So if you have it fairly fresh and you have good ligamentous tissue in here, then we do what's called a dog bone, which is basically two titanium grommets. This is heavy polyester suture. We drill through everything. Drill through the clavicle, drill through the coracoid, and then pass. It's just kind of using some little tricks. Pass the suture up through, pull everything down, have your assistant pull it down. You tie that over, and it is rock solid. Rock solid. And they really do well.

Interesting. So in other words, you don't do it. By going back to the acromion process.

You get the tornado ligaments to be in continuity again, and then they can heal.

And is that a biodegradable polymer?

No.

So that'll stay forever.

And they're super strong. And so you can really. You don't let somebody go in a week, but you can, depending on what their sport is, you can let them get back at maybe three or four weeks. Certainly six weeks. Six weeks. This thing is pretty strong where you.

Can do most things before we leave the clavicle. I only ask about this because I just had a patient that went through it. When the clavicle and the mediastinum separate, I assume that's not as common.

No, it is not. It's way less common, but it can be very problematic. I'm gonna draw a great picture.

I think, of that, please. Because, you know, while you're drawing that, I'll explain the situation. This was a patient who. God, I'm trying to remember what caused the injury. I wonder if it was a fall, a high fall. It might have even been off a horse or something. It's possible but what surprised me was the patient who was in New York basically called that morning to say, look, I just saw two surgeons at HSS and they said I need to have surgery right away. And I guess it's interesting, right? There are some things in orthopedic surgery that are need for an emergent case.

This very few turned out to be one. Yes. Okay, so this is a lordotic view basically of the manubrium sternum, which is our breastplate there. We can follow our clavicle across to that and we can feel the little nubs right there at the base. We can feel those sternoclavicular joints.

So I'll pull my shirt down so you can see my little nubs.

Yeah, exactly. So you can see it's even worse than the shoulder. It's a very shallow joint. So if you take a hard blow laterally, hockey players get slammed up against the glass. It's a common, more common injury in that the football players, the quarterbacks that get tackled by these 300 pounders and their shoulders are wedged together like that. And it just so happens that that's what the injury, not to this extent, but the injury that Quinn Ewers, the quarterback for UT suffer was knocked out in the Alabama game. He's now back. So he obviously didn't have this full dislocation. But that's what can happen in weird circumstances. That's what you were talking about. The mechanics can be that. And it happens a little more commonly in kids. But if the fall is just right and the mechanics just right, it will open this up, tear everything, and then displace it behind the manubrium. And that's where the major carotid artery in the jugular artery, jugular vein lives. And that can be a huge, huge life threatening.

Well, it could be life threatening for sure.

So we have to be careful with those. But this one, where it subluxes out the front, those are also problem. You can see that there's no way it's going to fall back into place there. So either they stay out, they stabilize, and people just don't do that much to irritate them, or they have to be reconstructed. And I've had to go in and reconstruct these where I take a tendon from the forearm and make a figure of eight across the front and basically rebuild those ligaments to hold it back in place.

And why do you do that as opposed to doing an anchor or something like that?

It's just stronger. You need some extra collagen there.

So what is it about the insult laterally that will determine a separation here versus here. These are two weak points at each end of the clavicle.

Much more frequently.

Much more frequently here.

Well, much more frequently there. But that's usually a top down. That's usually pitching forward and landing and having it be that way. But what happens more commonly than the SC joint? The sternoclavicular joint is just a clavicle fracture, which are ubiquitous, and that just fractures somewhere over there. And then we fix them some and we don't fix others, but. And those heal. But the joint, a weird little joint, is very important. It's not common, but it's not rare.

Let's talk briefly about a total shoulder replacement. I think a lot of people are pretty familiar with the total knee replacement, a total hip replacement. To me, the hip replacement has been one of the modern marvels of orthopedic surgery in the last 30 years. When I think back to when I was in medical school, that was a brutal procedure. And today, these patients getting total hip replacements, I mean, they're laughing at everybody else.

They do them outpatient.

I mean, they walked out of the OT procedure. I still don't. I have to save that for another discussion. I don't understand how that procedure is so easy today. First off, what is the indication for the total shoulder replacement? And then secondly, let's talk briefly about what is actually being replaced and what that recovery is like and what limitations exist after the fact.

It is a also an outpatient procedure unless you have comorbidities. I do most of these outpatient, and I can even use a smaller picture now because the types of implants we're using now have evolved significantly. So when you've worn down the cartilage completely, either on one or both of the surfaces, that's incompatible with good function, usually because of pain. And you ask what is the primary indication it's pain? I don't care. I see patients all the time who come in who have the ugliest X rays you've ever seen. To your point about the cervical spine, which is so important, they have no pain and they can do whatever they want to do. As you know, the scapula, scapulothoracic motion can give us a lot of function, so they're fine. Occasionally they'll say, hey, you know, I'm going on a trip where I want to be able to play golf for three weeks or two weeks with my family. Could you give me an injection? Sure. Give them a cortisone shot and they rock on they get three months, four months of relief and then they keep going. So it's only the very active people who need to be able to do certain things. And age is not a factor. My oldest patient, who I did shoulder replacements on quite a long time ago, she was 97 and she was spry and healthy, walked the streets of Manhattan up and down. She actually still worked at 97. I won't say where, because it might give it away. She was the oldest and longest standing employee of a famous place, you know, and after I did that, then back to back, and I'd see her on the street walking down 57th street, and she'd say, hey, doc, I'm doing great. And she was 97, 98, 99.

I lost track of her, I believe.

And it totally changed her life because she couldn't use her arms because they were hurting so much. So age is not a factor to your.

And just to be clear, was her arthritis the result of likely a labral repair that never like what caused so much degeneration in her.

Some people just get it. It's no different than you.

Oh, so it's not constant subluxations necessarily that are necessary?

Not at all. You know, some people just have. One of my attendings when I was in med school residency said, yeah, it's like a paint job. You can have a paint job that's a Mercedes or you have a paint job that's a Ford Pinto. And I'm not saying anything derogatory to Pintosh, but the quality of the paint job can. What you're born with, that's the main thing. And that's the main source of garden variety osteoarthritis of the shoulder. And then there are the athletes who are separate categories based on what you're.

Wear and tear.

Yeah.

And the youngest you've ever done this on.

The youngest I've ever done a replacement, a full replacement, almost 55. I usually do a workaround. I saw a guy 15 years ago who came to me. He had pretty. You could see it visually, but it wasn't terrible. And he said he was been booked for a replacement. I said, look, you're a little young. He was about 48. And I said, you're too young for me. I think we should at least give something else a shot. I said what I would probably do, even though the data is not great, it's one of the few things I do that I know. But I tell them at the outset that you have about a 50% chance of getting better, and that's just a scope clean out. We know they have arthritis. They don't have instability. And just try to clean him out and buy him some more time. Kick this can as far down the road as possible. About 15 years later, he came back to me showing me shoulder motion was fine. His X rays hadn't advanced and he came for something else. Wow. So that was an example of what I try to do, but you can't always affect that. But that was just an anecdotal and it's worth doing. It's such a minimal operation, no recovery. And oftentimes if people have bilateral osteoarthritis, they don't need both sides done. They're happy with one side. They have good one that they can reach over dominant arm or things like that. But an example of sort of a very active, to our point about physiology and biologic age and so forth. A really wonderful athletic woman who was an avid sailing. She sailed in regattas, raced. Still at the age of about 75, she was still going racing all the time, pulling lanyards, et cetera. And she said, I can't do this anymore. I just can't do it and I want to keep doing it. Can I keep doing that? And I said, sure. So I replaced both of her shoulders.

And how much she separate those two.

Operations by, she was about four months apart. It was kind of more. She said, I'm going to give up a year of the sailing, then I want to get back to it. So you could do them a little closer together if you want. And she's still sailing.

So let's go over the anatomy here of the replacement. Obviously there's two pieces to it. There's the humeral side and the glenoid side.

I'm going to draw another picture real fast that will show what a arthritic shoulder looks like and then that'll help. So in the little picture to the left, I've drawn an arthritic shoulder. Not well, but I've drawn it to make a point. So it kind of the head kind of flattens out. You have no space in there at all. You get a bone spur down here, you get some spurring around the perimeter of the glenoid. And all of that conspires to greatly diminish the motion of the shoulder and cause pain. There's two reasons they come dysfunction, because they can't do what they desperately want to do, whether it's recreational or work sometimes. And number two, pain. Either one of those is a solid indication for it. When the radiographic findings Are there. And if we do that, then what we do is go in. And now we do these through incision that big. And it's just a very small anterior incision. Anterior incision and take down part or all or part or most of the subscapularis. The tendon in the front, we have to have a window in. Now we can work through the interval, the space between the supraspinatus and the subscapularis, but only if it's a more limited replacement. But anyway, you take some of that off, you have a window there, you have retractors in and you use an oscillating saw and just take that arthritic head off of there like that and all the bone spurs. Then with that space that that creates, you use another retractor. Push the head, the shaft and what's left of the shaft, what's left of the shaft away. And then you get in and work on the glenoid and you ream that down to where it's all smooth. Get the bone spurs out of the perimeter and then put in this little high density polyethylene.

Ultra high molecular weight polyethylene.

Exactly. Very durable. I mean do wear.

So it's the same thing that's the tibial plateau and exactly the same.

It's great. And then these have little pegs, you drill holes. You maybe usually cement those in just a little bit. Some are press fit, but usually cemented in a little bit. Just that part. It's a perfect nice new Teflon surface for then this cobalt chromium or whatever alloy it is for the head. The bone has a central core and you clean that out, get it fixed. And this is press fit. We don't cement these anymore unless people have really bad bone or really vision. We just press fit it into that cancellous bone and it's super solid. The rotator cuff is kept intact. The rotator cuff is still intact on top. You're working around that. Reattach the subscapularis.

If you're going to transect the subscapularis, what is the least traumatic place to do it? Completely within the muscle, I'm assuming?

No, no, actually on the tendon where it inserts.

Oh, you have to because you're reattaching it.

Yeah. We leave a sleeve so we can suture tendon to tendon. But then we also put this heavy suture into bone so you get bone reinforcement and you've got tendon to tendon healing you also by doing that, you maintain the Normal length.

So the only thing, I mean, this is an oversimplification, but the biggest thing this person is missing is a labrum.

Yeah. And they don't really need it.

So what stabilizes this joint?

The fact that it's arthritic. It's already stabilized itself. Unless it's a weird dislocating joint, which is a different entity. And you have to address that differently. For the garden variety one, they've already kind of stiffened up all the tissues, even the.

So what does their capsule look like when you go in? Typically it's thick.

It's super thick. We resect some of it even it's so thick, it's kind of space occupying almost.

And what is this person's in a good case, what is the limitation on this person?

A year out from surgery, really nothing except heavy weights. I don't want people doing bench press. I don't want them doing the iron cross type things. And they're usually not. I had one patient.

Can they throw a ball?

Yeah, they throw a ball.

They can play catch.

Oh, they can play catch with their grandkids. Sure. They can play tennis.

They can play tennis, yeah.

And play tennis. And play golf.

They shoot a basketball.

Yeah.

Can they swim?

Oh, yeah, that's one of the big, big ones. People love swimming, you know, later in life. It's a. Such, such good general exercise. And they can swim until they're 100. And you can absolutely. Oh, yeah, you can swim till the cows come home here.

So this is just another one of those game changing operations. Right.

It's different than the hips and the knees. The hips and the knees allow people to live in the world again. These are game changer quality of life things. And I won't do them if I know I can manage them and kick the can down the road and just inject them once a year with cortisone. I want him to be dragging that arm in. I want him to be saying, you got to do it now. I'm not getting enough relief from the cortisone. And do it.

Let's pivot now to talk about another piece of anatomy down the arm, which is the elbow. Let's take a moment and just go back to the anatomy. Do you want to draw a little sketch of how the humerus lines up with the ulna and the radius?

Very much so.

So the big diagram is looking straight at the antecubital fossa. And then obviously the side diagram is showing the arm flexed. So walk people through what these three bones are and then the overlaying muscles.

So this is, as you said, the front of the elbows here, the humerus bone, which is the arm bone, is coming down. You see, it's a super weird undulating structure there, which makes it intrinsically quite stable. So much different because there's more to dig into. Exactly. There's all these fun little almost jigsaw puzzle pieces that stick together. We have the radial head, which is the rotating bone of the forearm. And then we have the ulna, which is the fixed straight bone of the forearm. Then we have. What's cool about the elbow is the tendons that go down to the forearm into the hand originate above the joint, more or less right close juxter articular close to the joint, but above it. And then the ones that go from the shoulder and arm down attach below the joint. And this is the biceps tendon here, the big biceps muscle here, the biceps tendon attaching to the radius. And we'll talk about that. This is the lateral side, the outside of your elbow. And the blue is the muscle tendon units that are attached there, anchored to this little circle or oval. And then the red part is where tearing typically occurs in tennis elbow on the inside of the elbow, where our funny bone nerve is. The funny bone nerve is the ulnar nerve. And that's the green structure in cross section. And then overlying that is the muscles, the flexor pronator muscles that help bend the elbow and pronate the forearm. And those can tear right in this region. And that's actually where we get golfer's elbow, what is known as golfer's elbow, which is medial epicondylitis, medial. And then the lateral side, which is the tennis elbow, is lateral epicondylitis. And those are the most. These three, the biceps tendon. And these two are the most common tendon injuries by far. The fourth, which is less common, is shown in the lateral, which is the triceps coming down and attaching to the tip of our elbow. We talked about the bursa before and there is a bursa right here that lives over the tip of our elbow. And we can get the big golf ball size filling of fluid. And that's the olecranon bursa. I think it's beyond what we're talking about today to go into the fractures, but any parts of these can be broken. The elbow is a very finicky joint, you can see because it's stable, because of those undulating surfaces, but because they're.

Undulating, there's less wiggle room.

There's less wiggle room and if you don't get those things perfect when you fix them, they can quickly lead to arthritis. And some of the, even the subtle fracture patterns that happen and aren't seen or appreciated can lead to rapid destruction of the joint. So it's a finicky joint. It is also. Oh, I've drawn this blue structure here, which is a very thick ligament on the inside of the elbow. That is the Tommy John ligament. It's not really Tommy John. Well, I'll clarify that in a minute. But that's the medial collateral ligament or the ulnar collateral ligament. And that's the one that's torn in throwing athletes. And that can be career ending. Except now because of the reconstructive surgery, it's generally not.

So let's talk just briefly about why the lateral epicondyle. If there's inflammation in that tendon, we sort of think of that as the injury a tennis player gets. Whereas inflammation in the medial tendon is more attributed to what a golfer gets. Of course, people who have never played tennis or golf often get these things, but it could be illustrative just to explain the movement patterns.

So those are not dissimilar from the supraspinatus tendon where they have a little ringing out and they can become degenerative and partially tear, just like we talked about rotator cuffs. There are tons of people walking down the streets with partial tears in those tendons and they're asymptomatic. Use patterns are significant for that. The reason the lateral was historically associated and called tennis elbow is because of one handed backhands. It's a much less mechanically sound and we have less strength with our external rotators than we have with our pectoralis and our subscapularis for forehand shots. So it's under more stress. You can get them at any age. But the sweet spot of seeing, treating this is 40 to 60, 40 to 60. Now that is creeping up to the 70s and so forth because again, people are so active. So that's why it's been associated with tennis elbow. Ironically now I'm seeing just as much in tennis players and competitive tennis players. I'm seeing just as much medial epicondylitis, which is traditionally golfer's elbow. And the reason is because everybody is trying to hit massive top spin and, and they are hit using their pronator so much more than they used to When I was a kid and playing. I try to hit topspin now. And so that's a reason why it's stimulated more.

Why does the golfer get It I don't play golf, so I don't appreciate it enough.

Historically, even though golfers were getting it, I don't know why, because you're not supposed to be. It's over hitting with your trailing arm. Most people play right handed and they were getting it on their right medial epicondylitis because they were overhitting, hitting stumps, hitting rocks, duffing. And it was that Joel. Again, the eccentric load on these tendons, which our tendons don't like, but I'm seeing now because people are hitting so much harder, they're hitting bigger clubs, especially drivers and such. They're getting more left leading arm lateral epicondylitis in golfers.

On the leading arm.

On the leading arm. And that's more logical actually. But they're just trying to hit harder and farther and once these big hitters are on there, they're trying to mimic them and so forth.

So is the first line treatment for that rest? Yes, rest and NSAIDs, presumably followed by cortisone and things of that nature.

So the first line of treatment is always rest. Good stretching, just like you stretch your hamstrings to keep from tearing them as frequently or injuring them as frequently. And usually just NSAIDs by mouth. Rarely do I use physical therapy for these formally because it's just not much to do if they're just too painful to even some people wake up in the morning, they can't even straighten their elbow out. They're so painful, they're so spongy and really inflamed. So those I still don't splint them, but I have them stretch. But more often because they can't use their arm. I will go ahead and give them kind of a half dose of cortisone just to cool everything down. Down.

Yeah. You injected me probably four or five years ago when I was sort of in the transition of really learning how to control my scapula and had sort of overcooked too many pull ups and all this pull up pain was translating into tennis elbow. I was surprised at and it was stubborn. This thing I came to you after six months of pain, but that one injection cooled it off. That never hurt again because basically I had already fixed the underlying movement pattern. I just needed to cool the fire off. Is that a common scenario?

It really is. Again, I don't operate on because it's so common. I end up doing a lot of these procedures, but I don't operate on. I'd say one out of five at the most, 20% at the most. Most People get better.

And so operating on the lateral versus the medial side. What are the indications?

The indications are the same. Failing conservative treatment. A lot of stretching, a lot of strengthening. A lot of people get these. In your case, it was mechanics overdoing, but a lot of people get these because they're getting back into something that they haven't been doing in a long time and they overdo it. And it can be just weights and weightlifting. But honestly, it's something as mundane. I'll see these after people have gone traveling for two weeks, just lifting their luggage, dragging their luggage around. It's all comers, but the theme is that conditioning, if they've had it chronically, not in your case, of course, but a lot of people come in and they're already kind of weak. They don't have strong grip strength, they don't have good tone. And so strengthening is a critical component. If they can squeeze my, you know, I have one of my devices. If they can squeeze that without just a little pain, then I just have them do that first stretching and strengthening. And sometimes that'll cure it. And often it'll cure it. But if they can't squeeze it without undue pain, I give them a little dose of cortisone. If it's chronic like yours was, then there's not that much to do. You're fit, you've got great tone and you've got full motion. So it's only give it a little booster dose just to knock it out. We think sometimes. We haven't ever done the study to prove it, but we think sometimes just sticking the needle in a few times kind of stimulates a healing process.

Yeah, I've certainly seen a lot of anecdotal stuff around dry needle, just getting the dry needle in there, I believe in that and just increasing the influx of inflammatory cells and cleaning up, getting macrophages to come and clean it up. So outside of fractures, how often are you seeing acute injuries to the elbow that ultimately are surgical cases?

So one of the common ones is the middle aged but very active fit person who maybe had a little antecedent elbow pain or forearm pain. They didn't quite know what it was, but they did workarounds and then they ruptured their distal biceps. And so they get a Popeye muscle. It's all weird and even quivering. And they come in, they go, oh my God, you've got to do something. And the cool thing about the bicep, we think of the biceps as, you know, we do biceps, right? It's an Elbow flexor, and it is a secondary elbow flexor, but it's the primary supinator of the forearm. So people come in and they lose when they tear their biceps, they don't lose that much flexion strength, but they lose most of their supination strength. So if they are used to turning screwdrivers, wrenches, surgical instruments, maybe depending on what they do, then it can be really disabling.

That factors into the physical exam then, doesn't it?

Oh, yeah. It's funny. They'll come in, they won't be painful. They'll say, I think it's better. And, yeah, I've got this, but I can live with the deformity, which I don't care about the deformity either. And then I will pronate them to wrap that tendon kind of around the radius. And then I have them pull up like they're doing a pronated curl, and they scream. You get it? Just isolated. And that's a very good point about that. And then you test their supination. They didn't know that they didn't have any supination strength. Then you test their other side, and they can lift you off the table. And then this side, they can't even do it.

So when you surgically repair that, are you reattaching the tendon? Yeah, same place. So it's like a tendinesis.

Yeah, it's a great operation.

So that's a good outcome operation.

Oh, yeah. Had a guy in the other day, looks just like you, strong arms and everything. And he's doing this all the time. And he ruptured his. He came back in for actually with his son, and he said, if you need anybody to. He said, my arm is stronger than it's been in a long time. I'll speak to that. But he said, if you need somebody to call anybody to talk to him about how great this operation is, just let me know. But he said he was. A lot of them say, you know, I feel almost like I'm stronger than I was before. Well, you're only putting it back where it came from. But they probably had a partial tear. For a long time. They were working around. They were little deconditioning their biceps. They were compensating with their brachialis, the big muscle underneath that. And then they get even stronger because they have a good tendon again.

Wow. You want to just briefly talk about the Tommy John, which again, has kind of have revolutionized Major league baseball.

So when this tears the.

On the medial side, you.

All of and in fact it's super physiologic torques. That ligament is subjected to super physiologic in throwers, in high level throwers who are throwing 90 plus miles per hour, it is subjected to such forces, traction forces, that it will rupture. And the way they keep from rupturing in general is by fitness, by steady long term fitness, and that's flexor pronator fitness. That shoulder strengthening biceps, triceps and so forth. By strengthening everything around it, you can protect that ligament. And if you don't, then it can rupture because it's being subjected repetitively over and over and over again, year after year to supraphysiologic loads. When it ruptures, it's easy. Instantaneously they lose. They can throw, but they lose 10 miles per hour on their fastball. It just immediately downgrades their ability to throw.

That's so interesting because most of us like, I don't think I could throw a ball 50 miles an hour. So does that mean I would go from 50 to 40 or it just means I could never get. I wouldn't notice it. Is that the difference?

You wouldn't notice it. That's the common fallacy. I have people coming in all the time, all of us playing tennis, playing certainly golf, throwing balls. If we're playing catch, we don't need it, we don't need the ligament.

So that is literally an operation that is only designed for the most elite throwers.

Yes, period. And that's a common misconception, of course. One of the.

So are there some shady people. Sorry to interrupt you. Are there some shady people out there that are doing that operation on non athletes?

Sure. But more importantly, and I say this, I'm sure they have love in their heart, but there's some shady parents, parents too, who will bring their kids in who say, we know our kid has this great potential. Can you do. Because stories about Tommy John surgery, which this is not Tommy John surgery anymore. What was done on Tommy John was not the same operation. It was the same ligament, but it's totally different now. But it's good to refer to it as that. The guy who invented it was brilliant. Parents will come in and say, you know, my kid needs five miles per hour on the fastball. And because so many people, like the biceps have had partial tears, they've finally torn, had a reconstruction and they gain six or seven miles faster than they've thrown as an adult. It's because they had a partial tear and never could get that final extra Velocity. And then once they have a reconstruction, they can. And so that travels through the chat rooms and lore and then parents come in and say, hey. And their kid has no problem. Can we do it, Tommy John. So that we can get more velocity.

And you have to explain to them that there's nothing wrong with their kid's elbow.

There's just something that the kid is not destined to be. Nolan Ryan.

Yeah, interesting.

It's with best of intentions, but things get distorted.

What about the tricep tendon? What type of injury will injure that tendon to the point where it's coming off the olecranon?

You already know. It's what you talk about all the time. It's the eccentric loading. They almost always tear falling skiing where they're trying to stop themselves from smashing their face, they rip off like that. I see them every winter.

And how clean a break is it?

It varies. Some people, if they've had chronic condition, will have little bone spurs in there and it'll pull off part of the bone spur and everything. Usually it pulls off the bone or leaves a little stub there. It's pretty clean usually. But, man, the triceps is a huge muscle.

Muscle bigger than biceps?

Yeah, huge muscle. And so it's really disabling. People can't even push up out of chairs. You have to fix those. They're not ruptured in sedentary, non low functioning people. They rupture in active people. You've got to fix them.

Okay, so maybe now we could just kind of have you examine my elbow and go through all of these planes of motion, because obviously you want to know how I'm flexing, how I'm extending, supinating and pronating, and my strength to eccentrically and concentrically, I guess.

Yeah, that's right. And in the elbow, it's. It's very distinct. There are very specific stresses you can put on the elbow that will guide us directly to what is hurting. And again, it goes back to. A lot of middle aged athletic people have some changes in the lateral epicondyle muscles, the medial epicondyle muscles, some even in the triceps in the distal biceps. You have to isolate those, make sure they're symptomatic it.

At this point in the conversation, Alton demonstrates on me what he'll do for a typical elbow exam on a patient. As this lends itself much more to video. We decided not to include this in the audio version of the interview. If you'd like to see what this exam looks like, you can Head over to the show notes page or to our YouTube page where we have the full exam videos very clearly broken out and available. Now back to my conversation with Alton. All right, so we've got the shoulder and the elbow behind us. That leaves us with the hand and the wrist, which is effectively how we mediate contact with the outside world and our extremities. I would say this to me is like a black box. I didn't actually do a rotation in orthopedics or plastics, so no exposure to that. Now, in general surgery, you'd cross cover plastic sometimes, so knew enough to know what not to do when someone came in with hand trauma. But it's obviously a highly specialized field. You've done a fellowship just in hand.

Right.

It basically seems anybody who wants to operate on the hand has to not only complete the orthopedics program or plastics program, but then go completely do that dedicated program.

That's right. I suppose you could pick it up. But to be able to do that in a, certainly a big city or a dense metropolitan area, you would need to have fellowship training. And it's just there's so much as we talked about before, just like in the shoulder, just like in biologics, just like in everything you do, there's such an explosion of information and it's hard to keep track of everything before we.

Get into the hand. What do we know today about the hand in terms of repair or injury that you didn't know when you finished residency? And I don't mean you personally, but I just mean wasn't known then. That is known today.

That's a fascinating topic because well, before I started, starting in the 50s and 60s, they had developed microvascular techniques weeks that was the holy grail of so much in the hand. You could have a laceration or a war injury or something, and there really wasn't much to do for many of those injuries, especially nerve and blood vessel related. So you would do a lot of amputations that just were not reconstructable. The war experience actually did develop that. And one of my forebears, J. William Littler, who was one of the most famous, if not the most famous living hand surgeon for a few decades in the world, was exposed to that at Valley Forge and elsewhere during the war. And that's how he and other really luminaries in the field developed these techniques that brought us where we are today. I'd say the most significant advancement since I graduated and went into private practice has been the hand transplantation, the complete hand transplantation. Which is a very, very. As you know, it involves general surgeons, it involves hand surgeons. It involves so many a huge team to be able to do that and to achieve that. And the results are mixed.

How many have been done?

I don't even know now. As recently as five years ago, only a few had been done. So it's all been in these last several years that these teams have been built up at the larger institutions to be able to handle that. But even there, it's fraught with peril in that you have to have a perfect patient, physiologically speaking. And comorbidities greatly decrease the likelihood of success there. And it requires a huge investment for the patients themselves. And so even a single hand amputation is not nearly as reasonable of an indication as a bilateral hand amputee. Those are the ones that generally can qualify and they have to meet all the physiologic parameters. I don't even know that much about it. One of my partners has been on one of those teams and he knows much more about it. Lou Catalano.

Are they joined at the midpoint of the wrist?

Right. It's at the distal forearm where you can get that you're beyond that transition zone and you can link up tendon to tendon, usually. And then, of course, the nerves can be linked as well. Yeah, it's fascinating. So that's the biggest.

And it's the same immunologic process. You have to HLA match these things because they're all cadaveric, of course.

Exactly, exactly. And that's, as you well know, and you know way more about that than I do because of the general surgical background. But obviously the immunologic suppression to allow these things to not be graft versus host disease. And it's a wild, wild time, really. We will get better. I think the other thing, the only other thing that's changed a lot is that relates so much to the hand, as you mentioned, it's how we interact with the world is the spinal implants and the various types of full muscle transfers that can restore function in the hand. For someone who previously had no ability to control even a prosthesis, these electrical prostheses now that are linked to the brain. So it's cool.

What type of injuries does someone have in the forearm that. Are there injuries where they will take a muscle from the leg or something like a sartorius and attach it there?

Absolutely. And it's really intended to just give some primitive function back, to be able to flex the elbow, for instance, or extend the elbow or flex the wrist. And so it's really more the elbow more than anything because most of these injuries, the patients can still control the shoulder, can position the arm somewhere. But as you know, I mean, if you just, just even forget about a very devastating injury, but if you just have an elbow extension contracture where you cannot flex better than 90 degrees, you can't get your hand to your mouth, to your hair, to your face, you can't do a lot. There's many, many limitations to that. And that's just to get through an average day, not anything specialized such as playing an instrument or throwing a football or something.

So when we talked about the shoulder and the elbow, do you have a sense of what fraction of those injuries that require surgical intervention are the result of an acute trauma versus chronic injury wear and tear. Now, obviously a lot of the chronic stuff is on top of an acute event like a subluxation that happened over and over and over again leads to, for example, my injury. But do you have a sense of what that division is?

I do, but it also varies depending on where you are. In my practice now, I took trauma call for a couple of decades, but I no longer take. So I see cold trauma that still needs plenty of surgery, but it's not acute, it's subacute and it needs to be fixed in a delayed fashion. So if you are in a practice such as a county hospital, where there's trauma coming in, whether it's hunters, whether it's highways, et cetera, then you're a much higher percentage of your day and your week is spent repairing acute traumatic, often poly trauma injuries. And I've been there and done that. In someone who has a mature metropolitan type practice, it's more in the area of 50 50, there's plenty of arthritic conditions of wear and tear conditions, whether it's from any sort of gym work or getting back into various forms of exercise or the weekend warrior phenomenon. And those are sometimes injuries, but they're not dramatic traumatic injuries. And then there are the people that are falling off the scooters and water skiing, dislocating their shoulders, all that spectrum. But the actual acute and something as mundane as cutting avocados. I see tons of nerve injuries and.

Tendon injuries in the palm, the Sunday morning bagel injury.

Yeah, but it's usually spread pretty evenly between arthritic and sports related ruptures and injuries, and then fractures and dislocations and ruptures due to traumatic events.

Well, if the bony anatomy of the shoulder is a little more straightforward, it Starts to get a little more complicated in the elbow and it gets a little more rigid. I mean, the hand is really complex. So how do you even go about beginning to explain the anatomy of the hand which has. How many bones does the hand have?

That even varies. But if you think about it, you have five fingers and you have. In those, each finger has three bones, except for the thumb, which has two. There you've got the 12 plus 2 is 14. And then you have the next layer, which are the metacarpals and that's of course, five of those. And then the carpal bones, which are all these small bones. We had a resident used to make fun of hand surgeons who would say never operate on a bone you can swallow. So he was just in a fun way, pillorying the fine, smaller caliber things that we're dealing with in the hand and wrist region. And the wrist has the bones that are held tightly together. And there are multiple bones there. Some, there are often what are called coalitions where they're fused together. So that's why, I mean, that it varies. But the wrist owns the one bone that is the hardest to heal in the body, and that's the scaphoid bone. It's like a carob coated cashew. It's almost all encompassed by cartilage. So there's only a couple of little areas where tiny blood vessels can get into that bone. And unlike almost all the other, if not all the other bones in our body, we don't have what we call antegrade flow into that bone, leaving the heart going down through the arteries and the capillaries. And going into the bone from point A distally to point B, it goes in retrograde. So if you crack that bone in the middle at baseline, it has very little blood supply. Then you crack it and disrupt.

You probably disrupt the blood supply.

Exactly. And so there's a high risk of non union. It takes. The average bone in the body in an adult takes six weeks to heal. And these generally take 10 to 12 weeks to heal. The scaphoid bone.

And what's the common injury that breaks the scaphoid?

It's mainly a hard fall with just the right position of the wrist where it's leveraging on that. The scaphoid spans the two rows of bones in the wrist that we call the distal row and the proximal row of these arcs of bones. And it spans that. So it gets leveraged on in a certain way with certain positions and then a directed force. Usually it's a Wrist extension force.

Does that patient typically present with a lot of pain or.

That's a great question. So no. Often they know they injured their wrist and they'll get. Get some swelling there, but it's not that bad. There's no great distortion of the wrist when you fracture your distal radius and it swells up like a balloon swells up and it looks like a dinner fork and you know something's wrong. And you. Sometimes people get lightheaded and pass out and they just look at their wrist. This doesn't happen with Escape White. And it's often young athletes. So they don't. They shake it off. They shake it off. They're used to pain and then they come in. Often they'll come in at six weeks. They can't lift weights, they can't do a clean and jerk, they can't shuck somebody on the offensive line. Then they get evaluated and we find the scaphoid fracture and we've already lost six weeks there.

Am I remembering correctly? Is the scaphoid fracture the one that's really easy to miss on an X ray? You kind of need the MRI to see it. Or is it a ct? Which one is the modality of choice?

MRI is where we detect occult hidden fractures of the scaphoid.

And why is that, by the way? Because normally CT is the imaging of choice for bone.

It's just that you don't have enough.

Bone's not big enough.

And so we can see edema.

I've seen a number of people who have had that issue missed. And a lot of times they don't even necessarily tie it back to the fall.

Right.

If it's been long enough. So what is the treatment plan for that patient?

So it's evolved a little historically. We treated all of these non operatively, and then there was a period. And actually an Australian fellow named Herbert came up with a really ingenious screw that had two sets of threads on it. And they were different pitch. So when you'd screw it down the middle of the bone and turn it, and when it engaged both bones, it would actually compress them together because they were different pitch. And it was called the Herbert screw. And that was a game changer for us to be able to treat.

Especially athletes, show folks where this bone is and where you access it operatively.

There are different schools of thought on that. When I was coming out of training, everybody made an incision down here to fix these, a full incision to expose everything. And you had jigs that you can put Those screws down. I do almost all of mine percutaneously. I mean, literally an incision this big and I'll go either retrograde often or antigrade. It's really a 3D effort to just get it in the right position. Get a central core guide wire down and then you use a little drill, hand drilled to drill out that and then put the screw down over the wire. And it's really great because patients hardly feel that they've had any surgery. They heal very quickly, faster, and you can even start movement earlier so that when it is healed, you already have your movement back so you're not stiff. And then having to do a lot of physical therapy on top of that.

Are there scenarios when you would not operate on a scaphoid fracture?

There are many. If they're non displaced, then we can expect them to heal.

Would you put a cast on or.

Would you put at least a splint? We know that you can just basically as long as you immobilize the wrist, even if you leave the thumb and fingers free, that these will heal. Then you look at comorbidities and you look at life needs. So the athletes often get a screw because they just can get back faster even with protection. Surgeons often want to have them fixed. I fixed a number because they just want to get back to be able to operate, which they can do.

And what would be the time course to recovery? Let's just say you're in that lucky camp where the day it falls, you're smart enough to know that it's the scaphoid and you go and get the mri, confirm it, you have surgery the next day. How long until you're catching a ball again?

Catching a ball? Generally about six weeks if you're operating.

If you're a surgeon, a week.

Oh wow. It's really fast.

As long as it's not contact, you're doing it within a week.

Right. That's the game changer really that we.

Have now a moment ago alluded to something that is one of the few things I do remember from residency, which was the position to make the splint. What is it about having the wrist in this position that for us general surgeons would be basically, let's just let the hand guys look at this tomorrow morning. We don't have to call them at 2 o' clock in the morning if this is a non operative or non urgent issue, but let's at least put them in this safe position. What is it about that position that's.

Safe, the essentially neutral position? Which looks like actually, as you've shown, some wrist extension, but it's really neutral in terms of the carpus. What that does is that one of the important things it does is when we are in too much flexion and we see this occasionally where people just aren't thinking about it. They just slap a splint on and don't really know that what you're talking about, too much flexion or too much extension, then that increases the pressure on the median nerve and the carpal tunnel. So people can get, especially with some extra swelling from the injury, they can get actually acute carpal tunnel syndrome. That can be quite substantial in those more extreme positions. So a neutral position is great for that. It's also best for function in terms of just if you're in a splint, but at least trying to get some finger movement, maybe typing at a keyboard or something, then that's a good neutral position. I will, on occasion, if I have to immobilize someone, a musician, for example, I will immobilize them in the position they need, for instance, to be able to at least play their electric bass. I just had a patient the other day who plays both upright bass and electric bass. I said, well, how are you? We're just playing electric bass. He said, fine. I said, then show me the position of your hand. I'll put you in that splint, in that position. So he's able to keep playing and even doing gigs that way. Everybody's different. It's an important consideration.

All right, so what do we need to understand about the anatomy of the radial bone, the ulnar bone, and these two big nerves? I'm guessing the median nerve, if I recall, runs there, and the ulnar nerve runs on the pinky side, Correct?

That's right. And we'll see that in our exam shortly. But yes. And then the third nerve, which is. Completes the hand, is the radial nerve. And that's purely sensory along here, but it is important and provides sensory on the backside of the hand and the thumb, most of the backside of the hand. But the ulnar nerve, you're right. And both of those are at risk for lacerations, and they're at risk even when you distort the anatomy through a fracture. And so those are the two big ways that they're interested.

I kind of remember the median nerve being bigger than I expected. What's the approximate size of the median nerve?

It's an oval shape and cross section. And it varies, obviously, among the size.

3 or 4 millimeters wide by 2.

Millimeters deep, even bigger. That would be a small, smaller, petite person would have about that size. And I've seen them as large as almost a centimeter wide and 4 or 5 millimeters thick in a large hand.

Oh yeah. I mean, just insane. Which I guess speaks to the innovation of this unbelievable part of our body that occupies so much of our homunculus.

Yes. So I've always said this because you and I've talked about this in terms of using meaningful hand use is so important for cognitive development and well being. And over 60% of our higher cortical neurons are devoted just to our hand through the homunculus. You know you've seen that homunculus. I know you and I have seen it many times, but it's. Yeah, we'll link big ears, big eyes, but huge hands and then a tiny torso, shriveled up, tiny torso. So that's what's super cool. So, yes, I mean we need to keep, keep using our hands to keep our minds vital in whatever form we're doing. And actually some great studies have been done on that to show what's the effect of just typing at a keyboard. And it doesn't stimulate our cortex very much at all typing, nor does texting, handwriting, which is an art form, even though it doesn't feel like it for many of us. But handwriting still does stimulate our brain. They did a study a long time ago at Virginia, I think, or maybe Indiana. And they looked at kids who were asked to handwrite versus type the answers to essay questions. And the kids who were handwriting used longer sentences, bigger words, more ideas, and produce it faster than the kids who were typing. And they were measuring their cortical activity. And their cortical activity was way more with the handwriting. That's, that's digression. But it's important to your point that there's so many nerve endings concentrated in our hands that we really need to keep them functioning and get them back to function as quickly as possible.

So you mentioned already the carpal tunnel. Let's talk about what this carpal tunnel syndrome is. It's come up a couple of times and obviously there's technically what's carpal tunnel syndrome? And then there's the symptoms of it, which can be produced by compression or injury elsewhere. But what creates the tunnel per se?

It's super cool when you look in cross section, if you took a cross section through the hand right here, the carpal tunnel is created by a Roman arch of bones. Just like the Roman arch is where that central core, I can't remember the name of the bone keystone maybe. It wedges in and keeps that arch intact. And that's exactly what we have in the reverse. Then we have a tie bar across the top, which is a very thick, thick transverse carpal ligament. And it holds that together. And that creates a U shaped parabolic inverted parabola tunnel through which the nine flexor tendons and the median nerve pass and occasionally a medium sized artery.

Now explain why there are nine flexor tendons.

So there's two to each finger, lesser finger, and then there's only one to the thumb. It's fascinating to look into that and see. It just so happens that position wise, if we look at our palm up, the median nerve is running down almost the center of the wrist and it is the most superficial. So that if we then flex our wrist down, those flexor tendons are trying to bowstring down, they will press that median nerve up against that rigid transverse carpal ligament. If we have swelling, edema, inflammatory tissues, such as in rheumatoid arthritis, where that builds up, that becomes a space occupying lesion in a fixed, confined cross sectional area and then it compresses that nerve, the nerve. The tendons aren't really vulnerable in that way, but the nerve is very vulnerable to compression. That's why it's such a ubiquitous problem.

So from a motor standpoint, the median nerve controls which function versus the ulnar nerve.

So important of a question. And by the way, there is some confusion. People very often come to me and say I think I have median nerve. I mean, I think I have carpal tunnel syndrome. And because it's such a ubiquitous bandied about term. But you must have numbness and tingling in the median nerve distribution, which is the palm, side of the thumb, index, middle and usually half of the ring finger. If you don't have numbness and tingling there, you very unlikely to have carpal tunnel syndrome. However, if you have an arthritic process, you can, without having as much numbness and tingling. You can have isolated atrophy of the muscles, the thenar, the thumb muscles here that give us our opposable thumb. You can have atrophy that looks like an indentation right there. And some people can have that quietly. It can be just a very gradual, just from the encroachment on that nerve of the bones, spurs that grow through the arthritic process. So that's the exception where sometimes you can have isolated motor and very rarely in a younger person I will see where they have an odd motor branch, which is the Nerve that comes off the median nerve that goes to those muscles, they'll have a weird compression of just that. So a younger person who doesn't have any numbness and tingling and then has isolated atrophy. So that needs to be addressed surgically as well. But the thing that fits with the carpal tunnel is that if you're pregnant, often in the third trimester, when women.

Are dealing with this is just because of swelling.

Just because of swelling. The fluid imbalances that are going on there, that's a possibility. People who use jackhammers or people who are cyclists and they're always pressing down and putting extra pressure on that area, can get carpal tunnel syndrome only when they're cycling. So it's a dynamic situation. Weightlifters can get it depending on what the style of what they're doing.

But the stereotype is people who are typing a lot, isn't it?

Yeah, that is.

Is that a true carpal tunnel syndrome?

So generally speaking, most people don't get carpal tunnel just from typing. There was a massive class action lawsuit against IBM 100 years ago, I don't know how long, and they lost because they couldn't prove IBM didn't lose. The. They lost the case because they couldn't prove that it was caused. There was no data to suggest that it was caused by just using a keyboard. However, if you already have it, absolutely, that activity will exacerbate it. That's why ergonomics are so important how you're sitting. I mean, during COVID everybody went back home and worked from home and worked at sometimes random, the kitchen table or their bed with their laptop and their crunched, odd angles. So a lot more of these, both wrist tendinitis and carpal tunnel syndrome after that, that doesn't affect the ulnar nerve, which is the other nerve that we're talking about. The ulnar nerve is so important because while our opposable thumb is critically important, that's governed mostly by the median nerve. The ulnar nerve supplies almost all the rest of the muscles, small muscles of the hand and those we call the intrinsic muscles of the hand, which are basically what allow us to spread our fingers apart, pull our fingers together, do these weird funky positions that we do, like the intrinsic plus position there. That position, being able to do that with your hand, is almost all ulnar nerve. And if you cut the ulnar nerve right here at the wrist, your hand will do just that. And you will not be able to do anything but a little bit of that. You can't.

So the flexors of each finger are all ulnar.

Well, the intrinsic flexors are ulnar. The extrinsics are split between the median more proximally, and the forearm are split between the median.

But lifting a finger this way is intrinsic.

Yes. This way, at this knuckle level is all intrinsic.

And we don't have extenders, extensors or. We do.

We do, but not intrinsically. Well, and not for the level. The MP joints, that's extrinsic extension. I'd love to draw a picture of the finger mechanism. I just find it so cool. It's so much more complicated biomechanically than the flexors. The flexors are pretty simple. And what's fascinating about the hand is despite being able to play Rachmaninoff or a violin concerto or be able to build a watch, the hand is actually more primitive. It's pretty much unchanged except for the opposable thumb. It's a pretty primitive structure in the sense of evolutionarily speaking. Our foot is a fantastically adapted and modified over evolution to walk. We were talking about that before. When we stood up and became bipeds, our foot completely changed.

I mean, I know we joke about it, but is the opposable thumb the primary difference between us and a primate?

Yes. Well, it depends on. We're part of the higher primates.

Yeah, between the lower primates.

The lower primates, exactly. That's why once we were no longer arboreal, where our thumb was in the plane of the palm and we would hang from tree limbs, then when we came around, we could start making tools and developing our. That's the thing. Our brains grew when we started using our hands and making tools. That's when our brains, our heads enlarged. It's just so cool.

I mean, I could sit here and talk about the hand all day, especially given how little I understand it. So what are some of the other injuries that are pretty common either? Again, the injury you'll see more commonly in the 60, 70 year old versus in the athlete, the kind of. The wear and tear injuries. What are the most common fractures?

I think we would break it up into the acute traumatic events, which are most often fractures, but can be also dislocations. Then we would say the wear and tear type injuries, which are usually start in middle age and go on into older age. And then the actual degenerative arthritic types of problems that are inevitable for many of us, and they vary among individuals based on genetics and lifestyle and so forth. So the fractures, the most common by far is the Distal radius fracture, that's just the big bone of the radius. Now the radius, the form is super cool because we already talked about the elbow. We looked at that really complex, weird undulating structure there. The ulna that we talked about is the elbow bone that we feel the prominence of our elbow and that's a straight bone and that goes down and it forms the bump here that we see on the back of our wrist. And that's the ulna. The radius is a curved arcing bone that is curved so it can get around the radius as we pronate and supinate. So the radius is flared and provides the biggest structure at the wrist level, but it's much smaller at the elbow level. And so it rotates around through a fixed ulna. The ulna never moves. I mean, it moves this way, but it doesn't move rotationally. And the radius just rotates back and forth. So any disruption of that can dramatically alter our ability to, to hold a bowl of soup or to pronate in type and write. And that can be disrupted in many ways. The fractures. The radius is super common. To fall and have a bending moment on that and it fractures and displaces. But then you can often, you know, something falls hard on you, you fall. I mean, we see them commonly in kids who are falling off the jungle gyms. They'll have a both bone forearm fracture in the mid forearm and that's just another bending moment. Those bones break in half or sometimes they bend, one of them breaks, one of them bends. The kids are young enough and so that can very much disrupt the function there. And so at any different point along the form, depending on the mechanism, these bones can break. And when they do, if they're displaced, we have to often fix them. Except in very young kids.

That reminds me, by the way, I don't know what it is, I, I vaguely remember this from medical school and I never saw them in residency, although I told it was very common. But I guess I just didn't do enough to see it. Where a parent grabs a kid by the arm to yank him across the road. And what is that injury? That's supposed to be pretty common.

Yeah, that's nursemaid's elbow. And that is a subluxation of that round radial head at the elbow. And I had the, I guess interesting and informative experience to create one in my own daughter, my first daughter, I would spin her around, you know, like you see people, and I remember spinning her around, she was giggling and so forth. And then I felt just the tiniest Little weird movement in her elbow, kind of through her hand. And I saw her face start to scrunch up. I set her down, and then I just had this vision. I knew what it was. I quickly did the reduction maneuver so fast that she hadn't even started crying. And then it just immediately stopped hurting. I could tell she was getting ready to start crying, but then she had no reason to because it didn't hurt. So it was kind of. We were in that.

And remind me what that reduction is again. So what's happening? So the radius, which is on this side, the outer side.

Exactly. When you pronate and you pull and kind of give a varus moment, it will cause that radial head just to slip out this way a little bit. So the easy maneuver, because the stable position is just you supinate and you put a little pressure on that, you supinate, and then flex the elbow up. So this is the most stable position of that bone.

So it just pop back in.

It'll pop right back in every time. Now, if they stay out and then you go sit in an emergency room for eight hours or six hours, harder to get back in, you often have to do it under anesthesia.

To this day, I am still paranoid. Anytime I have to grab one of my boys that I'm going to do it. And I'm always, like, trying to figure out a ginger, you're ready now. I'm ready to reduce it if I ever screw it up. I've seen a lot of radial fractures in friends and kids, and it really seems like one of those awful luck things sometimes. Like if you fall out of a tree, you fall out of a tree. If you slip on ice that you don't see and you're totally not ready for that fall, it can happen to the best.

And then the older we get, of course, if we have a little osteoporosis, osteopenia on X ray and osteoporosis, then it takes less and less force to fracture those bones.

What breaks the ulnar bone, does it ever break on its own?

The most common one is a direct blow. It can be in football. It can be a weight falling. It can be a door smashing into you is what's called a nightstick fracture, and it's named for that because especially the billy clubs in the uk, where you'd strike you when your hand was up and it cracks the ulna along there. That's the most common. But it can often be fractured also in association with the distal radius. The styloid part can come off, it's attached to a ligament, or they can just both snap at the same time. Then that complicates the treatment. So those are the most common ones. And then the other one, which is really more of an elbow fracture, but it's the ulna, is the olecranon, and that's a common, common fracture. And that's really simple. I see those in very young. Exactly. You fall on your elbow. The only other way you can kind of pull that bone off is if you fall really hard, say, snow skiing, you're falling hard. And as you talked about the eccentric load, that triceps pulls it right off. Yeah. I mean, you're the expert on eccentric loading. And I love the fact that you educate so many people about that, because it's way more injurious in a way.

What about the chronic sort of injuries of the hand and wrist that ultimately require surgical care?

You can break them down into sort of overuse patterns, which are more tendinitis. And if you have a long enough standing tendinitis, you can start to. The tendinitis is antinosynovitis. So those are subtle differences. A tendonitis is just inflammation in the tendon. And if it's beginning to wear and tear and degenerate, you'll get some longitudinal fissuring in those collagen fibers, and then it fills in with some inflammatory tissue, and then that can envelop the tendon. And so you're getting kind of a constant rubbing and further degeneration of that. You get chronic pain. You can inject it with cortisone, but then ultimately they can rupture, and depending on how much and how much force they're being subjected to and for how long it's been there. So that's one. Then the tenocynovitis is a subset of that where we have these effectively watertight tubes, specifically in our flexor tendons. And those tendons are gliding beautifully in there. There's a little bit of fluid our body produces to keep them gliding smoothly, and a little bit of what we call tenosynovium, which is just a filmy structure that gives them some lubricating Tefloni feel if that gets inflamed from overuse. Whether you're a violinist or a heavy weightlifter doing all sorts of things over and over again, you can develop inflammation there, and then that becomes trapped in there, and it really hurts. It can eliminate mobility, and it can even cause them sometimes to lock down. And those are super common. And we can often cure Them with just cortisone shots or rest or both. But then ultimately a subset of them, because they're so ubiquitous, require surgery, which is very minor. But it's important because the hand function, if you have one finger that's really stiff, whether you dislocated it or even just sprained it, the other fingers, they're all linked so indelibly together that actually it will make your whole hand feel stiff.

Yeah. So it's funny you say that. So as you know, I'm really obsessed with grip strength and all sorts of crazy shenanigans. Maybe about a year ago, I started experimenting, kind of like training sort of the way that rock climbers do, where you're using only finger strength. And what blew me away was how much weaker I felt all the way through my lats when I would restrict the amount of fingers I could use to pull up. If you just said do pull ups, you can use your whole hand. Do pull ups. No problem. You just barely notice that I feel like I'm perfectly connected from the bar to my lats. And now you say, okay, Peter, you're not going to get to use your whole hand or your thumb. Just use your four fingers. Actually, that gets a little harder.

Way harder.

It took me a while to work up to ten four finger pull ups.

Well, that's impressive that you can do that because, yeah, I know exactly what you're talking about.

It took a long time. I mean, it took a couple months. Then I moved to three finger pull ups. I mean, it's an order of magnitude harder.

It's crazy, right?

I don't know that I even got to try two finger because I was still really nowhere near getting to ten three finger pull ups.

Why is that?

Because I'm no less strong in my lats, in my biceps, in all these other muscles. Why is it that simply take. And by the way, it was the pinky that I was removing of all fingers.

Right. You'd think it does nothing.

Why, when I can only have these three fingers, does all of my strength fade away?

I've never been asked that directly, but I have a couple of theories on that. One is, and it applies to sort of the weakness I feel and detect asymmetrically in, let's say a rotator cuff. If you have a small partial thickness rotator cuff tear, well, that's tiny. Mechanically not relevant. And yet you can be quite weak. Your brain is so smart, it knows it doesn't want to overstress that area. So my instinct is that the first reaction Especially when you've never done that before, is for your brain to say, whoa, that's putting way too much tension on the other ones. So I'm going to relax everything. I'm not going to give you what you need because they may rupture.

Interesting.

I think that's probably the biggest explanation for that. But specifically, when you're talking about grip strength, what's ironic is that the ulnar nerve, which is only these two fingers, is much more important for grip strength than these. So if you have these, let's say you have an ulnar nerve that's completely in and a median nerve that's out, you. You're gonna be pretty strong still. Whereas if you have an ulnar nerve out and a median nerve that's still in, you're gonna be much weaker.

Wow. So just for people listening to us, which hopefully nobody's just listening to this podcast because it's hard to. You're saying pinky and ring finger matter more to grip to grip than middle finger, forefinger, thumb, which is under the median distribution. That even just feel. I feel like I can engage my forearms much more with my pinky and ring finger. Oh, yeah, for sure. Absolutely. Why is that?

I mean, it's evolution, I guess.

That's insane. You know what? It makes me wonder if I should be doing these three fingers.

That's what I think, because I was doing.

I'm going to try that today.

Good. Report back to me. I'll let you learn that rather than me having to learn it.

That is amazing. I'm endlessly fascinated by what our hands are capable of. And I think of it as such a. Well, such a force multiplier for our species. It's an unbelievable asset and our ability to carry things. You know, Michael Easter has written about this at length in his book the Comfort Crisis, which of course is what has introduced us all to rucking. But, you know, other animals can carry a lot if they're domesticated and you put it on their back. We can carry our body weight in our hands.

It's crazy. I know.

That is mind boggling. And it speaks to kind of remarkable engineering. And to think that a lot of that is made possible by this opposable thumb as well is pretty cool.

And even going back to the elbow, anatomically, when you look at the Vitruvian man and when you look at the standard anatomic position of in medicine, the elbow has a carrying angle built into it to get whatever we're carrying away from our body so we can carry more so we have a 12 to 15 degree natural built in what's called valgus, or away from our bodies to give us more area to carry heavy things with. Super cool.

So let's talk about the final category of these, which are the arthritics. And here you have really two. You have this rheumatoid or autoimmune form of arthritis, which anybody who's seen patients with that recognize. It just looks like an awful affliction where it's not only functionally impeding, but also physically deforming of the fingers and the joints versus the much more common osteoarthritic, which I assume is more wear and tear. It doesn't have that autoimmune component components. So first of all, what's the distribution and breakdown of those and which one of those ultimately can require surgical intervention of sort?

So historically, just in my orthopedic lifetime, I see very few now, rheumatoid, arthritic, and what we would call the RA negative, where the testing. We know they have the visible. Yeah, the phenotype, but they don't necessarily have all the lab abnormalities to back them up. But. But I see less than I ever saw before because.

Because the medical therapy is just so much better.

The biologics are so amazing. They've been absolute game changers and keep people normal for such a long time. So that's one thing. But in general, when I started practice, I would have to operate as often in a patient with rheumatoid arthritis and those deformities that happen and you're trying to beat the body to addressing the deformities so they don't get bad enough to where they really require joint replacements and much more complicated recoveries and so forth. So it was always a battle. And kind of like you racing a car, you know, you're just trying to get just a little bit ahead and just do whatever you can do to win that. Now I probably see maybe one a month that needs surgery and it's pretty rare.

And the surgery is because of such a significant functional limitation.

Yeah, it's always in the case. It can be in the elbow, it can be in the shoulder, but usually in the hand. And it's a tendon subluxation, joint deviation that then weakens their hand and decreases their ability to remain independent. The goal, obviously, and to the point of what our hands do for us, if we maintain reasonably good hand function, we can remain independent. As soon as we lose our hand function, we become dependent on others, period. And so that's what our whole goal is, to maintain that fierce independence. That's that. But then on the other hand, then we have the wear and tear osteoarthritis concept, and that varies among individuals. Some people have really good hands till the very end. I liken it to a job on a car, a cheap one, and we talked about that before, and versus a very nice thick paint job that holds up. But there is a big genetic component. I see patients come in that'll maybe be only 50, very young. They'll come in and they'll already have a lot of the visible alterations. Not terrible functionally, but they're getting the knobbiness. They're getting a little bit of inflammation in the joints out here, maybe down at their thumb base. And they'll say, what can you do? My hands look exactly like my mom's did or my dad's did. There's real evidence to support that some people are more predisposed than others. Now, the one exception is the ubiquitous. About 50% of all of us will develop arthritis at the base of our thumb. And that's that opposable thumb. The problem with that is it's all about biomechanics. It has to do too much. There's six degrees of freedom. It's just this biconcave saddle joint that in order to come back and forth this way, radial and ulnar deviation, then straight up, palmar abduction that way, and then rotating around and pronating in order to oppose the thumb tip to the fingertips. It's doing three different directional movements. And this joint is doing this and this and this, and it just wears out. It's just subjected to so many odd stresses and it's unstable like the shoulder. By definition, we couldn't have an opposing mobility.

So 50% of people in their lifetime, if I'm hearing it correctly, will experience osteoarthritis of that joint.

Yes.

In what fraction of those people will it pose a functional limitation? That is not something that's just treatable with some aleve here and there.

Obviously, we don't know what percentage of the population that all of us as a group are treated. What we do know is that we don't know the exact subset. We know there's many people walking around with basal arthritis that never have pain. They have some stiffness, some deformity, and they don't hurt. We know that. We don't know that exact number. However, what we do know, that, and we've published papers on this, is that of the people that present with some pain. About 25% of those, which would be, I guess 12 and a half percent of the overall population potentially are going to need surgery on that at some point.

That's a staggering number.

One fourth of the people that present with pain in the thumb are going to need surgery.

And what is the surgical procedure?

It varies depending on what stage they present at. And we've done staging systems and so forth, but it's some form of reconstruction. Unlike the hips and knees that are so ubiquitous and so wonderful, they've kept people back to their fully active lives by doing them. We don't have those kind of great implants for this. They don't work. There's very high failure rates. If a hip replacement or a knee replacement has a 5% failure rate at 5 or 10 years, the thumbs are 70% failure rate of all the previous. So what we do and was invented by my forebears and we've modified them over time, but it's basically doing a reconstruction using your own tissue. And that's what's super cool, which we didn't mention, is because of the way our limbs evolved, we have so much protective redundancy. We have so many tendons, like all of the flexor tendons that flex the fingers, also flex the wrist and give us strength. Just like you were talking about with the pull ups. Well, you have wrist flexors that only attach right here that also give you that flexion. And those all are housed in the forearm. And then you have the extensors that do that. And then you have some that are just. We have multiple, multiple tendons that pull the thumb out. They do subtle differences, but we can use those, and we do use those to transfer and to use them as tendon grafts. Now a cool thing that goes back to the evolution is if you look at your hand, hold your hands out and pull and flex your wrist a little bit. You can see here, you can look on yourself. You can see here. I have this big tendon that comes up when I.

Yes.

So on this side I don't have one. It's just missing.

Oh, I have huge ones. I have huge ones on both sides. Yeah.

Okay. So evolutionarily, that's the Palmaris longus. Those are hugely developed in quadrupeds and horses and so forth. Big important muscle.

Don't do anything in us.

They don't do anything. So we use that as a tendon graft all the time. We just take it. It's attached to a little whip small muscle.

I'm closer to the horses, closer to horses. I knew that about me.

So mine. We're evolving away. 15% of people don't have.

So does that mean you're not actually addressing the surface of the saddle joint, which is arthritic in this procedure?

Good point. You're not recreating some artificial joint. What we're creating is a pseudo arthrosis. We stabilize it, get it stabilized back on top. In my case, I take a little bit of the bone off to create a space and then I roll up the rest of that tendon and put it in there.

And that relieves the pain and restores function.

Yes.

So this is a high success operation.

Very high success.

I don't know how I didn't realize you could make a case that roughly 5 to 10% of the population will require this at some point in their life.

Obviously a subset are very sedentary and don't do much and they're not going to need it. And they'll wear a splint for the rest of their days. But if they're presenting with the pain, that's the point. We don't know what the N is. But other than being the general population as a whole. But people who present with pain are active enough.

So would you say this is the single most common non trauma traumatic surgical repair of the hand?

Non traumatic other than a well and even a trigger finger you could attribute to. So of the major surgery done in the hand. Yes, by far.

You mentioned trigger finger. What's that?

Well, trigger finger is what we were talking about before, where the inflammation of the sheath. And then right in the middle here there's a series of pulleys. And these are super cool. I'm going to draw a picture if I may.

Okay, so we're looking at the side of the hand of the finger, right?

And let's just say this is the middle finger, it's the longest. And this is the metacarpal. This is the first of the three bones of the finger proper. And what I've drawn here, this black line coming underneath is the flexor tendon and that's the one that does curls all our curl allows you to do all your pull ups.

And so there's four bones there just so people can see, I don't want them to miss the one.

This one is kind of hidden within the hand because that's through here. And so then there's the three successive. And so if you had a muscle attached to this and you pulled on it and didn't have those blue structures, then this would bowstring just like a fishing pole. If you don't put the fishing line through the eyelets, then it just stays way away, and it's actually stronger that way. But you lose all the mobility, so you lose the capacity to really curl your fingers tightly. So that's what they're gliding through. And those are fibro osseous tunnels and just fibrous tissue, very strong, which you mentioned, rock climbing. They can rupture because you're putting so much force on those in such funky positions and isolating two fingers, one finger, and so forth. So I see that a lot in rock climbers, but the point here is that as you're rubbing constantly, going back and forth, whether you're playing a concerto or you're rock climbing, you can get inflamed along that sheath. This particular pulley here is down in the palm, and that's the most common site to have inflammation to, where you can even get some nodular swelling in the tendon. And that thickening up of that pulley, and then it just actually catches. And we call it a trigger finger because it's like pulling a trigger on a gun. It. It has that feeling. And we frequently have to inject those with cortisone and frequently have to operate on.

They're ubiquitous, and about half of them recover with just a cortisone injection.

If you take someone who presents within, say, six weeks of onset, there's about a 75% cure rate with one or two injections.

So the longer you wait, the more likely potential damage you cause and the more chronic inflammation that ensues.

Correct. And this applies kind of a general consensus. I think we talked about this before when we were talking about cortisone shots, is in these types of soft tissue procedures, we don't keep injecting cortisone. Cortisone. Cortisone. Because it can lead to soft tissue degradation and ultimately even tendon ruptures. I've never seen one in my practice, but we know they can exist.

And what do you use as a rule of thumb for how many times you'll put cortisone?

3.

3 in the lifetime of the joint.

3 in the lifetime of that tendon sheath. Unless it's very, very broad. Usually you don't see someone back 10 years later who needs another injection. But if I did, I'd be willing to do that again because everything has normalized physiologically at that point. Now, the other cool thing that I was talking about before, when we were talking about the. You ask about the extensors versus the flexors. So if we look at the red, that this is the extrinsic extensor tendon that will straighten up the knuckle knuckles. But then we look further out and we see, well, that only stops, that tendon stops at the middle knuckle. But what allows, what pulls the whole finger straight. And it's actually this intrinsic muscle here that's tapering down and has a very thin tendon. It turns into a lateral band and it travels from the palm side up above the middle knuckle, above that axis of rotation, and then it goes all the way and attaches to the tip. And so it's super cool mechanism that through a series of mechanical placements, it's able to extend the finger even though by contracting. By contracting. It's crazy.

Very counterintuitive.

Most people wouldn't immediately get that. You have great biomechanical sense because yes, by contracting, it's straightening up the finger. It's, it's super cool. But it doesn't take much. Like if you take a direct blow to that knuckle right there and that tendon just slips because you've disrupted some soft tissue, it can slip below the axis of rotation. Then it becomes a flexor and you get a bout near deformity, which looks like that you cannot straighten your finger up because those lateral bands that are used to extending the finger have slipped down. Now they become a flexor, just like you said. Said. So it's super cool and just so intricate.

And I vaguely remember one sort of surgical emergency in the hand where that sheath would become infected.

Yes, very good. Yes. It's one of the few really orthopedic emergencies in the hand, which is tenosynovitis. And then it becomes supperative or infected and pus in there. And those people, I mean, there's so many nerves in our hand anyway. When you get even a few drops of purulent pus in the finger sheath, it hurts like crazy. And your posture is down like this. You can't straighten your finger up at all. And it's exquisitely tender and it looks swollen just along that sheath. And yeah, it's an operative urgency or emergency.

How does a person get that infection? Usually an open injury or.

Yeah, sometimes just a little. It can even be a pin prick. It's sometimes an insect bite with a stinger and often just a tiny little. If you're using sports equipment, you can get a little graphite, tiny stiff graphite puncture.

How many times a year do you see one of those, I don't see.

Them as much now because I'm not in the er. They're ubiquitous. I mean, they come in all the time, year round.

Okay, should we do an exam of the hand and wrist?

Yes, let's do.

Okay, great. At this point in the conversation, Alton demonstrates on me what he will do for a typical hand, wrist and forearm exam on a patient. As this lends itself much more to video, we decided not to include this in the audio version of the interview. If you'd like to see what this exam looks like, you can head over to the show notes page or to our YouTube page, where we have the full exam videos very clearly broken out and available. Now back to my conversation with Alton. Okay, so the final thing you wanted to talk about was all of the nerve pains that can presumably not just wreak havoc down here from a pain and suffering standpoint, but also from a diagnostic standpoint.

Yes. So many people present with numbness, tingling weakness, or pain in the upper limb. It can start from the neck where the nerve roots exit and travel under our collarbone, through the brachial plexus, in between the scalene muscles, and then travels through our armpit and then comes down in through the arm and into the hand. It can be confounding. A perfect example of how confounding it can be is a. Now more commonly known, although it's. I wouldn't call it rare, but it's uncommon, is parsonage Turner syndrome. It's a fascinating study in that whole process from the neck down. And the other term for it is a brachial neuritis, as in brachial plexus neuritis. And it's an inflammation of those nerves. We think it's probably viral related because there's usually a viral prodrome associated, but doesn't have to be, but it's an acute dramatic onset of pain all through here. And then some what we call mixed plexopathy, some mixed bag of palsy, weakness, numbness. And it can be in multiple different nerves. It can even lead to. And one of the most common presenting ways is long thoracic nerve, which is part of the brachial plexus. And you get scapular winging. So you lift your arm up and it just falls down because your scapula cannot support the shoulder and arm weight, because the muscle of the shoulder girdle cannot support then. And it's super cool. And it presents as a mix. So it affects multiple nerves because those nerves are more common up here. And then they diverge into the different nerves, which I still. You remember in med school trying to learn the brachial plexus. And it was brutal because it's really complicated.

So these are people who show up and you certainly couldn't attribute what they're experiencing to any one thing.

That's the point.

It's not like they have one or two discs that could be bulging and causing that symptom. It's not like they could have even transected their long thoracic nerve. Like a woman who has a mastectomy. You're always looking out for that post mastectomy. It's like they would have to have six lesions simultaneously.

Exactly. And it just doesn't happen except with that. So that's a great lead in to what the majority, by the way, is.

That just a self limited thing or do you give these people steroids?

Steroids, yeah. They make the diagnosis if you send them to them and we give steroids. And most of them recover completely. A few have some residual deficits forever, at least long term. That takes us to people presenting. I have a ton of patients who present with shoulder pain, and they may have a little something on their MRI that they may have brought in with them, but that shoulder pain is actually coming from their neck. Then I'll have someone who will present with carpal tunnel syndrome, but there's a little extra stuff going on. Maybe some ulnar nerve in the little finger, maybe some shoulder pain, maybe some arm pain. And the cool thing about diagnostically speaking is an intrinsic shoulder problem, such as a rotator cuff tear or inflammation, bursitis, et cetera, usually travels down underneath the pain, underneath big deltoid muscle, but almost never goes below the elbow. So if I see pain that's in the shoulder going below the elbow, I'm thinking maybe neck or maybe something else. Secondarily, if someone complains of, let's say they come in and they say, I've got numbness here, but I've also got some numbness on the back of the hand. The radial nerve is rarely involved in association with carpal tunnel or cubital tunnel. And oh yeah, my neck's been really stiff. Just subtle little cues that you can get by speaking with them. Well, they could have something that I know you know about, and that can be called double crush. And that is where you get pinching of the nerve in the neck, maybe through a disc, maybe through a foraminal osteophyte that narrows that little canal it passes through. And then because the axoplasmic flow or the nerve tube, the communication of it is disrupted or compressed. It renders them more susceptible to milder compression down at the carpal tunnel or the cubital tunnel at the elbow. So they're getting a double crush. Now, for those, I don't treat necks, other than treating them initially with some PT and maybe steroids or something, and I refer those out. But many patients will then see a neck surgeon who will say, well, you don't really need surgery. Yes, I think you do have double crush, but you can go ahead and treat. I can go ahead and treat. Let's say they have moderate carpal tunnel. I can do a carpal tunnel release, and they'll still get better. May not get all the way better, though. All their carpal tunnel will go away, but they'll still have some of the upper nerve pain. So the double crush phenomenon is real and true. And that's another category of patient. Then there's the weird lower cervical that I just learned not that long ago from a really smart neck surgeon, is it's pretty consistent at the lower level, the C7 nerve root level. If they have compression down there that goes deep under the scapula and gives them that deep scapular plane and problem there. And what's been so great for me to learn this later in my career is I often would see patients will develop scapulothoracic bursitis. And you can clearly get that from lifting weights, especially if you've been out of the weight room for a long time, you go back into it, you can get a lot of upper trapezius, periscapular rhomboid type pain from overuse, and those overlap. So you really have to do the diagnostic work and talk to the patients and listen to the patients to differentiate that. And then, of course, in our exam, we can see that too. I think that's more or less what I would want to say. The one patient that I think illustrates this, how complicated it can be, was someone who had a bad shoulder fracture, was treated in the emergency department, put into a sling, but then also may be told to do pendulum exercises. Well, it was an unstable fracture, very unstable. And so the weight of her arm, I mean, I'm sure you've did that in general surgery way more than me. The weight of the arm is enormous. If you have to amputate an arm for a tumor or something, and all that weight pulling on an unstable fracture, well, that put tremendous traction on the nerves, ended up killing his ulnar and median nerve, ulnar and median Nerve were out. He came in his hammers like that. He couldn't pose his thumb, he couldn't do anything. And I. All I had left to work with was the radial nerve innervated, which are the wrist extreme extensors and the supinators. And I was able to transfer some things and give him back some pretty good function. But it was all just due to traction.

What was that length of time it took for those nerves to under traction die?

Fast. Super fast. Probably within I saw him eight weeks post op. So he was fully there. But he started saying he started losing hand function at about three weeks, within three weeks of the fracture.

And no one picked up on this?

Uh, no. It was pretty tragic.

Do you want to do an exam and kind of go over some of those things as well before we wrap up?

Yeah, let's do that.

Great. Let's do that. At this point in the conversation, Alton demonstrates on me what he'll do for a typical nerve exam for a patient. As this lends itself much more to video, we decided not to include this in the audio version of the interview. If you'd like to see what this exam looks like, you can head over to the show notes page or to our YouTube page where we have the full exam videos very clearly broken out and available. Now back to my conversation with Alton. So, Alton, the last thing I want to talk about. We've been talking for quite a while, so I really appreciate you making the time is I want to talk about the Musician Treatment foundation, which you founded almost six years ago. In fact, I feel like it's indirectly how we met, because one of the doctors who introduced me to you in New York City got to know you, I think, indirectly, through your involvement with taking care of of some of the best musicians in the world. And that led to us meeting and such and such. And obviously I've been to some of the concerts you've held. So just tell folks a little bit about what is it about music that has been such a passion? It seems to be as much a passion for you as orthopedic surgery. It is.

And thank you for bringing it up. Thank you for wanting to talk a little bit about it. I'm always happy to talk about it. I was lucky enough. We historically, as orthopedic surgeons, treat a lot of athletes. But I was fortunate enough to start my practice in New York City, and I was lucky enough to sort of inherit the carrying of the New York Philharmonic and the Metropolitan Opera orchestras, which are mainstays of that classical music echelon.

Really.

And that spilled over into Broadway, the musicians who are all manner of genres because there's so many diverse shows there, and then the jazz musicians in rock and roll and so forth. So yes, I've always had a passion for music and love it. And to be able to take care of these is both very stressful initially and also incredibly rewarding. I mean they're like athletes in that they're doing this day in and day out. It's their livelihood and if it's disrupted their way of being and then their, both their mental health and their financial health is greatly jeopardized. And like athletes who give us so much entertainment in the world, musicians speak the universal language of medicine, which obviously bypasses some of the horrible political infighting that goes on. And it's just beautiful.

Of music.

Of music. And they give it back to us. But if you're not in the Philharmonic or not in the Metropolitan Opera Orchestra or in a long running show on Broadway, you're a freelance and you're a freelance who doesn't know when your next gig is going to happen and you can't afford insurance. For my whole career I've been taking care of freelance musicians and some of them maybe have spouses or significant others who have insurance. So some of them have, but many of them don't. Most of them don't, frankly. And so I was always discounting my cost, sometimes down to nothing, depending on who it was. Or I'd take a chicken or a signed CD or something that they would bring to me some home baked cookies. But the costs are absolutely exorbitant for healthcare.

Right. Because you can't. Waiving your cost is one thing. You can't waive the anesthesia's cost, you can't waive the surgeon center cost.

Thank you. That's exactly right. And the average cost for a rotator cuff repair is about currently, if you pay out of pocket, about the best you can do through a surgery center, which is less cost less hospital, is about $25,000. Well the average income for a fully professional but freelance musician in Austin Pre Covid was $16,000 a year. 1616 so they can't even think about it. So this was what was going on for years and it was always in my mind, always upsetting me. As a culture, we don't support the arts more and I don't need to get political about that. It's not political, it's just cultural. So then I had my cousin Thor, who's a mainstay of The Austin music scene cut his digital nerve, his finger. He's a percussionist, of course, because his name is Thor. And he couldn't play because it was so he had such a neuroma that had formed and he didn't have insurance. And he called me weeks after. He just had a simple closure. And he said, I can't feel my finger and I can't play. I said, well, you have miles. And he said, yeah, I've got plenty of miles to that tour. I said, we'll fly up to New York and we'll fix it. Since I know the surgery center and know the anesthesiologist. I said, look, this is my cousin Thor. I need you to throw him a bone. So they didn't charge him. And of course I didn't either. And so fixed it. He was fine. He was my patient zero, if you will.

And that was kind of your aha moment.

That was the aha moment. And then I'm lucky enough, as you said, to treat a lot of other musicians and know a lot of other musicians. So one day Elvis Costello and Diana Krall were in and I just kind of said, hey, look, I'm thinking about doing this officially. Would you guys help me in some way? Anyway, I didn't care. Just put your name on a website or something. They said, sure. What do you have in mind? I said, said, well, I could just be an advisor or if I could just use your name. You're so well loved and beloved. And they said, well, let us be full board members. He said, my only stipulation is I have to do all the voting because Diana's the busiest woman in show business. So I said, yes. And in 2017, we got IRS nonprofit status. And then Elvis said, I'm going to do the first concert. I love the Paramount Theater in Austin. Let's do it in Austin. I'll do a two hour solo show. And we raised about a quarter of a million dollars with that. And that was our seed money. And people came pouring in here in Austin. HAM is a big organization that does so much and has for so long. You know, it's the health alliance for Austin musicians, but they don't provide the actual care. We're struggling to get specialists to actually discount their care or provide the care. And orthopedically speaking, not having your upper limb, your shoulder, elbow or hand, you can't make music.

Give us a brief sense, because I know you and I have talked about this so much because I'm so fascinated by this topic. Help people understand the physical demand of playing a violin or playing the drum. I mean drums. I know, you see, my daughter plays the drums, so I'm getting some sense of that. But a. It's a very asymmetric activity. But what are the types of injuries that you're seeing the high level musicians come in with that are a threat to their livelihood?

Well, one of the things I say, I've lectured on this quite a bit. As I say, you know, musicians are people too. So they do all the stupid things that we all do to injure ourselves. That's a separate category. And those are injuries and they need to be treated. Though the unique aspect of that is.

That they can't necessarily take the same rest when they've injured something.

And they have to be 100%. If you're a violinist in the Philharmonic, there are 15 other highest level musicians waiting in the ranks, waiting for you to screw up once little schadenfreude there. They don't think ill of you, but they would love to have the opportunity to just sit in your seat, your chair on the stage. So there's all that tension, all that stress of having worked so hard and then having it. And you have to be 100%. You can't be. I can do surgery with probably three fingers, but if you can't flex down your index finger or whatever on the fret, then you can't make the music. So that's one aspect of it. And the other aspect is that by comparison, they're not trying to jump higher, hit the ball farther, drive the car faster. All the different ways that athletes like you are trying to maximize your output. They are submaximal athletes, but they, but.

They have to be there constantly.

Repetitious. I think what there's. In a standard NFL game, there are about 30 passes, 35 passes. Well, in a typical one. Mozart Violin Concerto it's 20,000 bow strokes in one playing violin concerto and they do that repeatedly over and over and over again. And to your point. Yeah, it's a lot of these are very unnatural positions. And we think about violinists, we think indeed their hands, well, their shoulders, they are adducted, they are externally rotated. Their other one is up in the impingement zone. We see from our exam, they're living eight hours a day doing this. That is terrible for the shoulders. And then you think of the drummers, high hats and every which way they're going and going massively for three hours straight. It's just uncanny that they even survive, in my opinion. So it's Very, very different. I mean I don't even know how many passes Tom Brady has thrown in his career. But. But it's not that huge of a.

Number relative to this.

So anyway, we were flooded with patients. Initially there was this backlog of patients who hadn't played for six months, nine months and they were just fallow. They were trying to get odd jobs. They weren't getting any gigs, they couldn't take gigs. I had one patient, the very first patient who we've talked about so I can mention her name, Jennifer Jackson. She's a great singer songwriter in Austin and tours around.

Did she play last year at the concert?

She did. No, I'm sorry, she did not. She was on our movie about it. She had bilateral full thickness rotator cuff tears. Bilateral. And she came in, she had already gone to try to see somebody. It was going to cost her $10,000 or more. She had some very minimal insurance. And I said look, we need to fix it, let's do it, get you back. And she goes well how much is it going to cost me? I said it's not going to cost you anything, anything. And she just start crying. So no, it's not going to cost you anything. So we've in five years almost now coming up. Well yeah, five plus years. We've provided over $2 million in free care to under and uninsured professional musicians.

How many musicians have had surgery?

We've had probably I've done four dozen, around 50 musicians. And that doesn't include the ones that I've been discounting. These are the ones that we've actually funneled through the mtf but we've got hundreds of non operative because a non operative is just as bad. I mean, right.

So if you can get a cortisone shot in there and get them totally better.

So we have hundreds more of that. It's been mind boggling. And the cool thing, we have an upcoming concert in December with Elvis, with Roseanne Cash, John Leventhal, Jason Isbell, a bunch of great people. The cool thing about our situation is that I've now been able to recruit over 60 colleagues who I know, I trust they have the same ethic, they want to give back. Who are shoulder, elbow and hand surgeons at the best places around the country. We're launching that in December. It's called the P4M, the physicians for Musicians Network. They're going to be doing. So far I've provided all the care. Now they're going to be helping provide care.

So now really we just need More dollars coming in to help cover the other costs because you're always getting the physicians to waive their fee. You now need to be able to basically use the non profit resources to fund the surgis centers and anesthesia fees. And I'm sure you're getting some anesthesiologists who are musicians as well.

We've been unsuccessful on that. It's ironic and a little embittering for me, but I know we will be able to.

Once again, people listening to this who are anesthesiologists, someone's going to be like, wait a minute, I need to find fellow anesthesiologists and we can start to pair those services.

And nice thing is that most surgeons, including myself, have some either participation or partial ownership of a surgery center. So I happen to have built one here in Austin and we provide that at 1, I think it's 1/10 of Medicare. So it's basically nothing. Our biggest cost by far is the anesthesia.

What's your vision for how big this can get and what has to get there? I mean, so you have the big fundraiser every year, which is a huge concert gala. Amazing. Each year it seems to be getting more and more incredible. What type of fundraising goes on outside of that per year?

I'm kind of a one man fundraising machine because of all my generous patients, especially in New York and in Austin too. And I tell everybody I can't, I scream it from the mountaintops. But we're starting to get some grants, we're applying for grants, which is great, but anybody who knows any organizations that provide community grants and so forth, we are right in the thick of communities because it holds communities together, it develops relationships that weren't there before. And it's all ages.

This is a huge deal this year, Alton, is that you've now recruited other doctors because the scalability of this was limited when you were the only surgeon. But now that you've got how many.

More surgeons we have over 60 signed on now.

Amazing.

Yeah. So that's going to be a game changer.

That's an amazing success.

And my idea. And they all have their own pods of. I mean, I treat more musicians than maybe anybody, but they all treat some and they can access those, they can access donors in the different towns. We have Seattle, we have la, we have Nashville, we have New York, of course, Chicago, New Orleans, the list goes on and on. And so yeah, when we can access that, it will build the support, I think, significantly.

Well, Alton, I could sit here and talk for about another two hours But I know you have a flight to catch to New York. It's probably apparent to people listening to this, but you practice bicoastally.

Yes.

Or not bicoastally rather, but you practice in two cities. So you're Monday, Friday, you see patients in clinic and operate in Austin. And then Tuesday, Wednesday, Thursday, you're in New York City and you do this over and over and over again.

I do.

I've had the privilege of seeing you in both cities. I've had the privilege of sending patients to you in both cities. I don't know how you do it. I used to do that and I can't do it anymore. But I'm so grateful for this discussion. I think a lot of people are going to help from it and obviously I'm just so grateful for you personally for the help in my life and obviously that of my patients. So thank you.

Yeah, the gratitude is likewise actually. I just want to give you a shout out you at some point in one of our many meetings you said, you know, you mentioned rucking and you know, I didn't really know that much about it, but you gave me the link. I bought it. I'm only carrying £35.

That's awesome.

But I've been actually run rucking because I love running. Running, I've always run. It has changed my body in. I've only been doing it about three months and I only get to do it two or three times a week. It's changed my body. I feel so much lighter, so much stronger and better. And although I'm pretty old, I feel great. I commend you and I thank you because it's been a game changer for me.

Yeah, I'm the rucking evangelist right now. Well, thank you very much, Alan. This was fantastic.

Great, thanks.

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