podcast Peter Attia 2022-11-28 topics

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

Audio

Show notes

Alton Barron is an orthopedic surgeon specializing in the shoulder, elbow, and hand. In this episode, Alton breaks down the anatomy of the upper extremities and discusses the most common injuries associated with this area of the body. He explains in detail how he examines the shoulder, elbow, and hand to find the source of the pain and lays out the non-surgical and surgical treatment options as well as the factors that determine whether surgery is appropriate. Additionally, Alton describes the surgical procedures that, when done appropriately, can lead to tremendous reduction of pain and improvement in function.

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(See “Selected Links” section at the bottom of show notes for a list of all YouTube video clips created from this discussion)

We discuss:

Alton’s path to orthopedic surgery [3:45];
Evolution of orthopedics and recent advances [8:45];
Anatomy of the upper extremities [13:30];
Rotator cuff injuries, shoulder joint dislocation, and more [21:15];
Peter’s shoulder problems [31:30];
The structure of the biceps and common injuries [35:30];
Labrum tears in the shoulder and natural loss of cartilage with usage and time [38:15];
Shoulder evaluation with MRI vs. physical exam, diagnosing pain, and when to have surgery [41:30];
How anatomical variation can predispose one to injury and how screening may help [50:30];
Pain generators in the shoulder, and the important nuance of the physical exam [56:00];
Frozen shoulder [1:05:15];
Shoulder pain that originates in the neck [1:11:15];
Surgical treatments for a labral tear, and factors that determine whether surgery is appropriate [1:16:00];
Repairing the rotator cuff [1:29:15];
Are platelet-rich plasma (PRP) injections or stem cells beneficial for healing tears? [1:38:15];
Repair of an AC joint separation [1:45:15];
Total shoulder replacement [1:55:45];
The elbow: anatomy, pain points, common injuries, treatments, and more [2:05:30];
How Tommy John surgery revolutionized Major League Baseball [2:17:15];
History of hand surgery and the most significant advancements [2:22:15];
The hand: anatomy, common injuries, and surgeries of the hand and wrist [2:29:30];
Carpal tunnel syndrome [2:40:00];
Other common injuries of the hand and forearm [2:47:15];
Grip strength [2:55:15];
Arthritis in the hands [2:59:30];
Trigger finger [3:07:45];
Nerve pain, numbness, and weakness in the upper limbs [3:14:00];
The Musician Treatment Foundation [3:22:00];
Gratitude and rucking [3:34:15]; and
More.

Show Notes

*Notes from intro:

Alton Barron is a board certified, fellowship-trained shoulder, elbow, and hand surgeon
He has clinical practices in both Austin and New York
He specializes in both routine and complex problems in the upper limb
Alton was Peter’s surgeon Peter had shoulder surgery in March of 2022 He’s documented that recovery process along the way and promised to do a deep dive on the upper extremity
In this episode we focus on the upper limb Elbow, shoulder, hand, and wrist Nerves located throughout
Alton goes through the structure, anatomy, things that can cause pain and injury, and how and when to think about surgical intervention
In addition to our conversation on the podcast, Alton runs through what a typical physical exam looks like This is really important Certainly surgeons rely on MRI imaging, but any good orthopedist Peter knows has always said the same thing, “ The exam and the symptoms matter usually more than what the image shows ” This is also something you can do on yourself to understand if something you are feeling is problematic or is going to get better over time
This is one episode you are going to want to watch on video Due to the discussion of physical exams and sketches of anatomy
Due to long length of this podcast, we have broken it out into some specific videos Isolating the videos of the shoulder, elbow, hand, wrist, and the innervation Videos of the various exams Alton does, demonstrated on Peter You can find all of the videos on the show notes page or YouTube page
One other thing that comes up in this podcast is the foundation he founded, the Musician Treatment Foundation This is a nonprofit that provides direct orthopedic shoulder surgery/ hand interventions along with non-surgical care to uninsured/underinsured musicians Alton is incredibly passionate about this as he is also a musician He talks about the amazing work he has done so far, where they want to go with it, how they are putting funds to use The foundation has their big annual event in Austin, coming up on Dec. 2 Head over to their website to learn more
Peter had shoulder surgery in March of 2022
He’s documented that recovery process along the way and promised to do a deep dive on the upper extremity
Elbow, shoulder, hand, and wrist
Nerves located throughout
This is really important
Certainly surgeons rely on MRI imaging, but any good orthopedist Peter knows has always said the same thing, “ The exam and the symptoms matter usually more than what the image shows ”
This is also something you can do on yourself to understand if something you are feeling is problematic or is going to get better over time
Due to the discussion of physical exams and sketches of anatomy
Isolating the videos of the shoulder, elbow, hand, wrist, and the innervation
Videos of the various exams Alton does, demonstrated on Peter
You can find all of the videos on the show notes page or YouTube page
This is a nonprofit that provides direct orthopedic shoulder surgery/ hand interventions along with non-surgical care to uninsured/underinsured musicians
Alton is incredibly passionate about this as he is also a musician
He talks about the amazing work he has done so far, where they want to go with it, how they are putting funds to use
The foundation has their big annual event in Austin, coming up on Dec. 2 Head over to their website to learn more
Head over to their website to learn more

Alton’s path to orthopedic surgery [3:45]

Peter did general surgery, but outside of trauma, he knows very little about orthopedics This it probably true for a lot of doctors How much more is that true for patients?
Orthopedics is a broad field and pretty specialized at the same time
Alton agrees, in medical school we only do a subset of rotations He knows nothing about urology, brain surgery
It depends on the luck of the draw, on what we get exposed to
Then we narrow ourselves down like a funnel in terms of knowledge
There has been a knowledge explosion for the past 2 decades in terms of research and new science
There are subsets of orthopedics and then there are subsets of shoulder surgery that involves just research versus just clinical practice
Alton’s well informed patients ask him about things, and hopefully he knows a lot of it, but he doesn’t know all of it Some of them are very good at looking at true scientific articles and approach him with new articles He is learning every week from his patients about shoulder surgery
This it probably true for a lot of doctors
How much more is that true for patients?
He knows nothing about urology, brain surgery
Some of them are very good at looking at true scientific articles and approach him with new articles
He is learning every week from his patients about shoulder surgery

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

He didn’t know
Alton had a very circuitous path
He was an engineer at UT in Austin Mechanical and biomedical His dad was an engineer so he went that way
At the end, he wasn’t sure about going into industry
On a whim he went to dental school for a year He had 2 uncles that were dentists He didn’t like that at all, but he loved the science
He was exposed to the anatomy of the entire body His anatomy instructor at dental school was a MD, PhD and when he confided in her that he was leaving, she suggested he try medical school
He came back to Austin, TX and painted houses for a year, then applied to medical school
In med school he loved invasive cardiology All the aspects of the physiology and the electricity going on in our bodies
Then he was exposed to orthopedics and knew he liked it It felt so natural putting things together, like a jigsaw puzzle It felt all in perfect line with his engineering background
Mechanical and biomedical
His dad was an engineer so he went that way
He had 2 uncles that were dentists
He didn’t like that at all, but he loved the science
His anatomy instructor at dental school was a MD, PhD and when he confided in her that he was leaving, she suggested he try medical school
All the aspects of the physiology and the electricity going on in our bodies
It felt so natural putting things together, like a jigsaw puzzle
It felt all in perfect line with his engineering background

At the time when you went through orthopedics, was it common for people to also do a fellowship after 5 years of residency?

It was
He went to Tulane, this was pre- Katrina It was a big program They had 8 residents per year At the time, about 4 going to general practice
Fellowships were not ubiquitous then Now they’re almost mandatory because you need to have a special interest because the groups you’d apply to work for want you to have some subspeciality
Peter agrees, this is the case in medicine Even if you did general surgery and didn’t do a fellowship, you’d be hard pressed to go into the community and do everything You’d probably focus on one part of the body
It was a big program
They had 8 residents per year
At the time, about 4 going to general practice
Now they’re almost mandatory because you need to have a special interest because the groups you’d apply to work for want you to have some subspeciality
Even if you did general surgery and didn’t do a fellowship, you’d be hard pressed to go into the community and do everything
You’d probably focus on one part of the body

Where did you do your fellowship?

Upper extremity
He did a shoulder fellowship at Columbia in New York
Then he did a hand fellowship at Roosevelt Hospital in New York 2 separate fellowships Most people didn’t do that at the time, but he just really like both very much
He dabbled with spine during residency
The reason he wanted to do upper extremity is because there’s nothing cookie cutter about it There were very few cutting jigs, very few linear things There’s so much variability in the upper limb, both anatomy and the specific pathology It was more creative for him
2 separate fellowships
Most people didn’t do that at the time, but he just really like both very much
There were very few cutting jigs, very few linear things
There’s so much variability in the upper limb, both anatomy and the specific pathology
It was more creative for him

Evolution of orthopedics and recent advances [8:45]

What year did you finish your training?

He started practice in ‘96

When did minimally invasive orthopedic surgery become common for joints?

Peter recalls, there was a day when the shoulder surgery he had would have been done with a big open incision
Knee arthroscopy was the first big arthroscopic realm to develop
Dick Asbury was hugely innovative in that space
Shoulder arthroscopy was primitive by the time Alton was in residency They had the basic equipment to get into the shoulder, but they couldn’t do much
By the time he finished his shoulder fellowship, they were doing open shoulder arthroplasty
He was at one of the meccas of shoulder surgery, so everything advanced was being done there at the level it could be done
But it was open shoulder arthroplasty The incisions were smaller but it was still open They did open instability repairs, open labral repairs
They didn’t appreciate the slap tear They knew it existed, but they didn’t know the impact
There were certainly no arthroscopic repairs of the labrum (see the figure below) except these early devices where you’d get in there, see it, and you’d just drill a little hole and mallet in this big broad tack That was just so primitive, and they would fall out They had a high failure rate, but that was the state of the art at that time
They had the basic equipment to get into the shoulder, but they couldn’t do much
The incisions were smaller but it was still open
They did open instability repairs, open labral repairs
They knew it existed, but they didn’t know the impact
That was just so primitive, and they would fall out
They had a high failure rate, but that was the state of the art at that time

Figure 1. Shoulder anatomy and labrum . Image credit: Hospital for Special Surgery

Was any of this being done in clinical trials?

The downside of the tried and true approach is patients would have a big scar and the surgery would tear a bunch of muscle, so the recovery would be longer But, once they got in there, they would know what to do
In contrast, the minimally invasive way that has all these advantages But the drawback is a high failure rate
This was the discussion that went on with patients
The FDA was involved a little with approval, but not a lot So you could go ahead a try these humanitarian devices and so forth The patients had to sign a release and it was all fine There were trusted surgeons that were doing it
There wasn’t clinical trials
There were a lot of retrospective analyses going on We did this in 107 patients and 47% failed
But, once they got in there, they would know what to do
But the drawback is a high failure rate
So you could go ahead a try these humanitarian devices and so forth
The patients had to sign a release and it was all fine
There were trusted surgeons that were doing it
We did this in 107 patients and 47% failed

The spectrum of Alton’s work, early on

In Alton’s early years, they were still doing mostly open surgery and waiting for the industry to catch up with better devices
Some of his colleagues (and occasionally him) were adding little bitty innovative aspects of these, whether they’re application devices or the style of implants

Today, we’ve gone from purely metal to now often purely braided polyester as an anchor device

This is super cool because there’s no metal in your body
And the transition through that was plastic That plastic could be either hard plastic (which stays in your body), but it’s still benign Or a bioabsorbable tacks that Alton has his my own issues with It create an inflammatory response in the body It creates a little cavity in the bone and so forth
That plastic could be either hard plastic (which stays in your body), but it’s still benign
Or a bioabsorbable tacks that Alton has his my own issues with It create an inflammatory response in the body It creates a little cavity in the bone and so forth
It create an inflammatory response in the body
It creates a little cavity in the bone and so forth

Now we are using tiny drills, tiny suture anchors, and you can put many in

Now if you have to do a revision of some failed repair, you’ve got plenty of real estate to work with (that’s nice)

One other aspect, which shows how much the field has changed, is that slap tears were not appreciated as a clinically relevant entity

Slap tears were just viewed as another type of labral tear, but a benign one that didn’t matter
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 the underlying stuff They were having recurrent pain
They were having recurrent pain

Anatomy of the upper extremities [13:30]

Peter thinks 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 warfare, people talk about having night vision as a force multiplier in war 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 pay a price for it, which is stability
When we stood up, that became an enormous force multiplier
If you think about this through the lens of warfare, people talk about having night vision as a force multiplier in war
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 pay a price for it, which is stability

We paid an enormous price in these joints, not as strong, not as stable

When we went from the ball on socket joints or the very stable, simple hinge joints to these cup and saucer type joints (specifically the shoulder, which is intrinsically very unstable)
Our opposable thumb at the basal joint is terribly unstable We call it a biconcave saddle, but it’s barely that There’s really no intrinsic bony stability
The shoulder is similar, Alton uses an analogy that’s slightly off, “ A golf ball on a tee ” The tee is a little bigger, but that’s what it is, very flat and shallow
Alton draws quick diagrams for his patients (see the figure below)
If we look at just the glenoid ‒ that’s the socket, that’s the “golf tee”
Then you add a humeral head to it This portion to the right of the dotted line is what’s covered by cartilage That’s the nice smooth Teflon cartilage in this space
For orientation, if you’re looking straight at a person, this is the right humeral head
That little space we’re going to talk about is the glenoid fossa This is the flat end of part of the scapula This is a real complex looking triangular bone with a big ridge on it and collarbone attaches to it
We call it a biconcave saddle, but it’s barely that
There’s really no intrinsic bony stability
The tee is a little bigger, but that’s what it is, very flat and shallow
This portion to the right of the dotted line is what’s covered by cartilage
That’s the nice smooth Teflon cartilage in this space
This is the flat end of part of the scapula
This is a real complex looking triangular bone with a big ridge on it and collarbone attaches to it

Figure 2. The right shoulder joint with bone and cartilage drawn in black, connective tissue drawn in red . Sketched by Alton Barron

Figure 3. The glenoid fossa on the shoulder, highlighted in red. Image credit: Wikipedia

Figure 4. The scapula . Image Credit: OpenStax Anatomy and Physiology

The high level point here is in the hip you have the acetabulum , which creates a true socket for a big ball Alton drew the hip joint above the right shoulder joint, 3 figures above
Here the heavy lifting really is done by soft tissue, not bones
The difference between the shoulder and the hip‒ the hip is a joint that is completely contained versus the shoulder, which is a shallow one that can slip and slide all over the place
Alton drew the hip joint above the right shoulder joint, 3 figures above

“ 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 ”‒ Alton Barron

The space between the humeral head and the glenoid is occupied by a nice thick layer or cartilage on both sides It’s effectively articular cartilage there
When you have arthritis , this 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
If we have this basic bony cartilage structure here, it would just fall off if it were just left there if there were no additional stabilizing structures (drawn in Alton’s figure above in red) Such as ligaments or labrum or muscle tendons
**Peter mentions 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
It’s effectively articular cartilage there
Such as ligaments or labrum or muscle tendons
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 considered its own entity?

Labrum is kind of its own entity
It has a transition zone between fibrous tissue to osseous bony tissue It’s a fibro-osseous structure Alton likens it to calamari, and it’s rubbery just like that
Alton has drawn on 2 of the 4 rotator cuff muscles here This is the one up above ( supraspinatus muscle ) This is the one in front ( subscapularis muscle ), the big muscle that allows us to reach behind our back and pull our hand away from our back This is also the one that helps us (along with the pectoralis ) in front to pull things together (like doing flies and so forth)
It’s a fibro-osseous structure
Alton likens it to calamari, and it’s rubbery just like that
This is the one up above ( supraspinatus muscle )
This is the one in front ( subscapularis muscle ), the big muscle that allows us to reach behind our back and pull our hand away from our back
This is also the one that helps us (along with the pectoralis ) in front to pull things together (like doing flies and so forth)

A tear in the supraspinatus tendon

The supraspinatus is the primary muscle that initiates elevation of the shoulders, so it’s very, very important
What we see here is this zone is where the muscle transitions into tendon (highlighted in green in Alton’s drawing above) And then it becomes pure tendon
For the supraspinatus tendon which is commonly torn, there are some physiologic downsides to its location It can be rung out It doesn’t have a great blood supply The key is it gets where those 2 arrows are (in the left of Alton’s drawing earlier) is essentially where the tendon tears most of the time And that is the part that attaches to the bone, and it gets blood supply from that bone (this includes nutrients and growth factors)
Surgically, the goal is to get that reattached to that bone so it can get all of those growth factors and that new healing back
And then it becomes pure tendon
It can be rung out
It doesn’t have a great blood supply
The key is it gets where those 2 arrows are (in the left of Alton’s drawing earlier) is essentially where the tendon tears most of the time
And that is the part that attaches to the bone, and it gets blood supply from that bone (this includes nutrients and growth factors)

4 muscles that make up the rotator cuff

The supraspinatus , the subscapularis , the infraspinatus , and the teres minor (shown in the figure below)

Figure 5. Muscles in the rotator cuff. Image credit: Wikipedia

The infraspinatus, and the teres minor are on the backside of the joint You can superimpose them over the subscapularis They are very important as the external rotators They give us our backhand in tennis They give a lot of stability to the shoulder, whether you’re playing golf or lifting weights They’re a dynamic stabilizer They’re very important doing bench press, pushups, archery, all sorts of activities like that
You can superimpose them over the subscapularis
They are very important as the external rotators
They give us our backhand in tennis
They give a lot of stability to the shoulder, whether you’re playing golf or lifting weights They’re a dynamic stabilizer
They’re very important doing bench press, pushups, archery, all sorts of activities like that
They’re a dynamic stabilizer

Rotator cuff injuries, shoulder joint dislocation, and more [21:15];

When a person “tears their rotator cuff,” that can be a very heterogeneous diagnosis

Technically it could apply to a tear in any of those 4 muscles Or a tear in the junction between the muscle and tendon Or a complete separation of the tendon from the osseous structure of the bone
Alton notes it is critical to identify what the tear is You can predict this somewhat based on the age of the person, their physiology, and the mechanism of the trauma
Tears are broadly classified into degenerative tears and traumatic tears
For younger people (under 40), it’s rare for them to tear their rotator cuff But it can happen traumatically
Alton 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 Basically, it almost ripped his arm off He was okay, except that he had torn traumatically as a young 26 year old It ripped off 3 of his 4 muscles and they had to be repaired But he was okay
It’s that rare, dramatic circumstance that leads to traumatic tears in young people
Or a tear in the junction between the muscle and tendon
Or a complete separation of the tendon from the osseous structure of the bone
You can predict this somewhat based on the age of the person, their physiology, and the mechanism of the trauma
But it can happen traumatically
Basically, it almost ripped his arm off
He was okay, except that he had torn traumatically as a young 26 year old It ripped off 3 of his 4 muscles and they had to be repaired But he was okay
It ripped off 3 of his 4 muscles and they had to be repaired
But he was okay

Where is the weak link in someone that young? Does it tear at the muscle itself or more at the tendon?

The younger you are, the strong the linkage of the tendon to the bone You often pull off some bone
In the case of a skier’s thumb (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 much better than tendon to bone
You often pull off some bone

Fracture of the greater tuberosity in the shoulder joint

There are fractures that occur that involve this area of the shoulder Alton draws a common fracture with a squiggly line, highlighted in yellow in the figure below
Alton draws a common fracture with a squiggly line, highlighted in yellow in the figure below

Figure 6. A fracture of the greater tuberosity in the shoulder joint. Sketched by Alton Barron

Alton drew a chunk of bone coming off 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 pulls off
Alton would rather pull that off and you have a good quality repair than have 2 tendons rip off that bone
That’s the greater tuberosity ‒ it’s a prominence of the bone that the biggest portion of the rotator cuff attaches

What type of athlete or person presents with this type of injury?

That isolated greater tuberosity is generally a fractured dislocation
You have a pretty violent injury Your rock climbing, you fall off, you maybe hit it directly, your arm is wrenched back Or let’s say a football player has a traumatic dislocation; they’re hit in just the right way mechanically, and it shears that off
It’s most often associated with the dislocation ( subluxation of the shoulder) Technically a subluxation is an incomplete dislocation; it’s the shoulder coming out, but it pops back in easily A dislocation is where the shoulder comes out and it needs to be put back in
The more dislocations (or subluxations) one has, the more stretchy and compliant the tissues become So then it can slip and slide back in and out with regularity
Your rock climbing, you fall off, you maybe hit it directly, your arm is wrenched back
Or let’s say a football player has a traumatic dislocation; they’re hit in just the right way mechanically, and it shears that off
Technically a subluxation is an incomplete dislocation; it’s the shoulder coming out, but it pops back in easily
A dislocation is where the shoulder comes out and it needs to be put back in
So then it can slip and slide back in and out with regularity

Stability of the shoulder joint

Figure 7. Right shoulder socket without the humeral head. Sketched by Alton Barron

In the figure above, Alton drew another picture but took the humeral head away We’re just looking at the right shoulder socket and we’re looking at it en fosse (from the side, facing forward), the glenohumeral fosse
The front of the person is the anterior (labeled Ant. in the figure above), and the posterior (labeled Post.) is to the back
Superior is up above, and inferior is down below
Importantly, around the outside (that second circle) is the outline of the labrum That’s a rubbery calamari-like structure, really chewy like bad calamari It’s very strong What is does is amazing because it effectively developed as a way to decrease the depth of the socket It works like a suction cup Alton adds, “ 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 .” But just like a thermometer held to the window with a suction cup, if you get your finger in there and break the seal, it falls away That’s what happens here
We’re just looking at the right shoulder socket and we’re looking at it en fosse (from the side, facing forward), the glenohumeral fosse
That’s a rubbery calamari-like structure, really chewy like bad calamari
It’s very strong
What is does is amazing because it effectively developed as a way to decrease the depth of the socket
It works like a suction cup
Alton adds, “ 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 .”
But just like a thermometer held to the window with a suction cup, if you get your finger in there and break the seal, it falls away That’s what happens here
That’s what happens here

We get a lot of static stability in our shoulder from this superior, inferior, anterior, and posterior labrum

In a nonpathologic state, when you have a young person (who has not experienced any shoulder trauma), is that contained space of fluid between those two cartilaginous surfaces of the glenoid fossa of the humeral head fully contained?

Absolutely, you couldn’t have suction without an aqueous, viscous fluid And as soon as you poke a hole in that you lose suction
You have a nice viscous joint fluid in all of our joints like that
And as soon as you poke a hole in that you lose suction

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 Alton’s treatment recommendations and mechanisms of injury If you are a young woman playing soccer, women in general have looser joints Actually, because of the weird nature of the shoulders, there are men who also have super loose shoulders at baseline (they’re born that way)
If you are a young woman playing soccer, women in general have looser joints
Actually, because of the weird nature of the shoulders, there are men who also have super loose shoulders at baseline (they’re born that way)

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
The tighter the shoulder is, the more you have to lose

What happens to the fluid when they sublux?

Nothing, the ligaments are stretchy and they’re bigger “ It’s more like a balloon that you’ve kept blowing up repeatedly ”
“ It’s more like a balloon that you’ve kept blowing up repeatedly ”

Shoulder dislocation in someone with a stable joint

But if you have someone who has a pretty stable joint (not loosey-goosey) and then they sublux, the only way you can do that is by tearing the ligaments , but usually you also tear/ separate the labrum (the inner arc in the figure above) from its hard, bony cartilaginous, perfectly fused attachment This attachment is very strong It takes a massive force to dislocate the shoulder or perfect mechanics
For example, classically, if you’re reaching up to get a rebound and someone grabs your arm and jerks it backwards, that’s an unnatural leverage that makes the head tend to go out anteriorly inferiorly (in the bottom-left direction in the figure above) And that’s also a vulnerability based on where the muscles attach
This labrum is tough, but it tears off On the right side of the drawing above is the classic location where you tear the labrum 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
This attachment is very strong
It takes a massive force to dislocate the shoulder or perfect mechanics
And that’s also a vulnerability based on where the muscles attach
On the right side of the drawing above is the classic location where you tear the labrum
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

The attachments of the 4 rotator cuff muscles

Muscles are drawn as ovals around the outside of the rotator cuff in the previous figure
These are the cross-sections of the muscles that are just outside the joint These encompass and enshroud the joint This is the cross-sectional muscle bellies
As you’d come further out toward the head (to the left of the drawing), they taper down and form the tendons
These encompass and enshroud the joint
This is the cross-sectional muscle bellies

That’s so important because no shoulder can be stable alone just by these static stabilizers, the labrum and the ligaments

The ligaments lie in between the labrum and the rotator cuff on the right edge of the drawing

When you’re referring to a SLAP tear , SLAP stands for superior labral anterior posterior

That is on the top side of the diagram (the superior), the green line labeled SLAP
That’s an odd injury
The first person that taught us about this was a fellow named Steve Snyder in Northern California He was the first to categorize and identify these as clinically relevant entities
SLAP tears are not clinically relevant for everybody
They are relevant for younger, very athletic people (overhead athletes, weightlifters, people doing CrossFit, people doing all manner of more aggressive sports)
This is different from having a tear in the right side of the previous figure You’re active and you keep dislocating, subluxating in the direction of the arrow
This was Peter, he had a big anterior inferior tear
He was the first to categorize and identify these as clinically relevant entities
You’re active and you keep dislocating, subluxating in the direction of the arrow

Peter’s shoulder problems [31:30]

Peter had his first subluxation in boxing when he was about 17
He remembers 2 injuries in high school The 1st subluxation was boxing and just bad timing throwing a hard punch, and the guy gets out of the way and probably smacked his arm and it came out The 2nd one (6 months later) was doing an absurdly heavy military press, and he remembers boom, it just popped out (and down)
From then on, it was a vicious cycle of never ending subluxations with each couple of years having a really bad one
Another really bad one was during an open water swim race, swimming freestyle He’s in the reach phase with his right arm in front, and the swimmer in front of him kicked down on that arm with some force (but not absurd), and the down kick of that arm took him out
Alton notes Peter is describing so many great and different types of mechanisms that cause shoulder dislocation Especially boxing, he’s seen a lot of these‒ the recoil where you don’t hit something your body is anticipating and it’s tightened up and ready for a contact that doesn’t happen 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 Peter probably did have a posterior subluxation
Peter had a tear going all the way from posterior all the way around, about 240 degrees Indicated in the previous figure by the blue line You don’t get that from 1 injury
It became looser and looser over time and because Peter is so fit, he was compensating for it very well He was doing all the right upper body, shoulder strengthening exercises He was using his dynamic stabilizers to compensate for the loss of static stabilizers
The 1st subluxation was boxing and just bad timing throwing a hard punch, and the guy gets out of the way and probably smacked his arm and it came out
The 2nd one (6 months later) was doing an absurdly heavy military press, and he remembers boom, it just popped out (and down)
He’s in the reach phase with his right arm in front, and the swimmer in front of him kicked down on that arm with some force (but not absurd), and the down kick of that arm took him out
Especially boxing, he’s seen a lot of these‒ the recoil where you don’t hit something your body is anticipating and it’s tightened up and ready for a contact that doesn’t happen
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
Peter probably did have a posterior subluxation
Indicated in the previous figure by the blue line
You don’t get that from 1 injury
He was doing all the right upper body, shoulder strengthening exercises
He was using his dynamic stabilizers to compensate for the loss of static stabilizers

Dynamic stabilizers can compensate for the loss of static stabilizers but they will fatigue, leading to problems

What happens is when you are maxing out and doing it repetitively, the dynamic stabilizers fatigue This is one of the most common scenarios Alton sees in young swimmers (more often female) They’re competing and they need the stability, especially they’re doing flying fly and backstroke They acquire all this laxity in their shoulder and they’re so strong dynamically that they’re fine and it gives them that extra pull, that extra inch or two Fatigue is a problem If they have a weekend-long match (8 events in 3 days), they are fine the 1st 2 days, but by the 3rd day, they are fatigued and 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 Then we have to strengthen rehab, sometimes even tighten up the capsule when they get so loose
This is one of the most common scenarios Alton sees in young swimmers (more often female)
They’re competing and they need the stability, especially they’re doing flying fly and backstroke
They acquire all this laxity in their shoulder and they’re so strong dynamically that they’re fine and it gives them that extra pull, that extra inch or two
Fatigue is a problem If they have a weekend-long match (8 events in 3 days), they are fine the 1st 2 days, but by the 3rd day, they are fatigued and 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
Then we have to strengthen rehab, sometimes even tighten up the capsule when they get so loose
If they have a weekend-long match (8 events in 3 days), they are fine the 1st 2 days, but by the 3rd day, they are fatigued and 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

The structure of the biceps and common injuries [35:30]

The biceps tendon can be incredibly painful ( tendonosis )
Peter thinks for an average person, it’s not entirely clear where that pain is coming from if they feel pain there
Alton notes that the biceps are a weird structure, and it’s part of that weird evolution we have
The biceps is 1 muscle in our arm, but it’s 2 tendons at the origin in the shoulder (see the figure below)
It has a single point of attachment in the forearm, crosses the joint as 1 muscle and then splits into 2 bellies with 2 attachment points

Figure 8. Anatomy of the bicep muscle tendon. Image credit: OrthoVirginia

The long head (indicated in the figure above, also shown in Alton’s previous drawing) is the one that often gets inflamed
It can be quite painful and can affect everyday life
The 2nd tendon peels off and goes outside the joint (the short head in the figure above, also shown on the left most side of Alton’s previous drawing) It attaches to a bony prominence in that weird scapula that they talked about It attaches there and literally never tears
But people often do tear this biceps (labeled in Alton’s previous drawing) Due to wear and tear or acute trauma It leads to a classic Popeye muscle where 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 John Elway (the great quarterback from Denver) was having shoulder pain and was even thinking about retiring His biceps tendon ruptured, the pain went away, and then he won another 2 superbowls after that
It’s a structure that’s not necessary and there’s a lot of argument in orthopedics about how important it really is
It is anchored up at the superior labrum
When you tear that superior labrum, that biceps does funky things It becomes unstable and it gets more inflamed often Then you get all that secondary pain
Some people (not Alton) who fix a lot of these will automatically just snip that biceps and reattach it in the front so it’s no longer a pain generator ( tenodesis procedure )
Alton only performs a tenodesis when he sees tearing, splitting, something structurally wrong with the biceps He knows he can get a good repair of the superior labrum, and once that’s stable, the biceps is fine again (it’s no longer symptomatic)
It attaches to a bony prominence in that weird scapula that they talked about
It attaches there and literally never tears
Due to wear and tear or acute trauma
It leads to a classic Popeye muscle where 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
John Elway (the great quarterback from Denver) was having shoulder pain and was even thinking about retiring His biceps tendon ruptured, the pain went away, and then he won another 2 superbowls after that
His biceps tendon ruptured, the pain went away, and then he won another 2 superbowls after that
It becomes unstable and it gets more inflamed often
Then you get all that secondary pain
He knows he can get a good repair of the superior labrum, and once that’s stable, the biceps is fine again (it’s no longer symptomatic)

Labrum tears in the shoulder and natural loss of cartilage with usage and time [38:15]

Peter makes a comparison, “ The torn labrum is to the shoulder what the disc herniation is to the back ”
You could take a MRI of a person who has no spine issues and see many asymptomatic herniations, which mean nothing
He suspects a labral tear in the shoulder is the same Alton agrees, and this is such a point of frustration Radiologists do their job in reading abnormalities The problems is that most of us by middle age will have plenty of positive findings, but they’re asymptomatic
Alton agrees, and this is such a point of frustration
Radiologists do their job in reading abnormalities
The problems is that most of us by middle age will have plenty of positive findings, but they’re asymptomatic

“ It’s a very double-edged sword to get those MRIs. Same thing in the labrum .”‒ Alton Barron

The labrum will naturally degenerate just by using it, so will the cartilage
We know there’s a genetic predisposition to arthritis
By arthritis, Alton means not just inflammation of the joint, but a true loss of the cartilage integrity Those two terms are used interchangeably by different people in different subspecialty But for 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)
Those two terms are used interchangeably by different people in different subspecialty
But for 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)

Does loss of cartilage integrity occur preferentially on the humeral head or in the glenoid fossa? Or is it one of those things where the second you get one chip, it starts happening on both sides?

We don’t have a good natural history of that
Alton has done total shoulders on people who had no cartilage left on their humeral head It was perfectly round and smooth bone, there was no cartilage left Whereas the glenoid still had cartilage on it That’s a case where the loss on the humerus was smooth enough and gradual enough to where it didn’t dig in and eat away at the socket But it doesn’t matter, you still have to replace the socket
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 full cartilage loss, that’s not great That just keeps sloughing off cartilage and keeps getting inflamed They’re on the young side so you don’t want to do a shoulder replacement on them Instead, they will do a humeral head resurfacing (a nice, new, smooth metal head), but they leave the glenoid intact and they have good cartilage there So, it’s metal on natural cartilage
It was perfectly round and smooth bone, there was no cartilage left
Whereas the glenoid still had cartilage on it
That’s a case where the loss on the humerus was smooth enough and gradual enough to where it didn’t dig in and eat away at the socket
But it doesn’t matter, you still have to replace the socket
That just keeps sloughing off cartilage and keeps getting inflamed
They’re on the young side so you don’t want to do a shoulder replacement on them
Instead, they will do a humeral head resurfacing (a nice, new, smooth metal head), but they leave the glenoid intact and they have good cartilage there So, it’s metal on natural cartilage
So, it’s metal on natural cartilage

What kind of metal is used?

Cobalt-chromium alloys Just like the hips
The nice thing about those is, if you can get 5 years, they can be much more aggressive with their activities Aton has some people who get 10 years and are fine
If it does wear down the glenoid side, then you just go back in and revise it and put a plastic cup for the glenoid
Just like the hips
Aton has some people who get 10 years and are fine

Shoulder evaluation with MRI vs. physical exam, diagnosing pain, and when to have surgery [41:30]

The contrast between MRI findings and the physical exam

Peter remembers the first time he saw Alton (about a year before his surgery), he knew his labrum had been torn to shreds for years but didn’t want to have surgery unless he really needed to In that first exam, Alton agreed, he wasn’t ready for surgery yet
In that first exam, Alton agreed, he wasn’t ready for surgery yet

How do you test the surrounding structures to elicit feedback on the labrum?

Alton is glad Peter asked, “ Because one should never make their clinical, especially surgical decision-making on just an MRI ”
Alton has written a couple of book chapters on this, including complete examination of the shoulder with provocative maneuvers and so forth
It’s important to get a good history of the mechanics of the injury Whether it was from shooting a bow and arrow, playing basketball, lifting weights, etc
Whether it was from shooting a bow and arrow, playing basketball, lifting weights, etc

You need to know a combination of the mechanism of injury, the symptoms, and the physical exam, and if you do those compulsively and well, you will be 95% accurate without any MRI

When to have surgery

Peter remembers one of the things that changed before his surgery He couldn’t serve a volleyball with his daughter He couldn’t shout one basket But he could pull a 95-lb bow back and take 100 shots This didn’t make sense to him
It all comes down to the mechanics of each individual and this is where the MRI does come in
Alton uses MRIs more to corroborate things that can be there The difference between a partial thickness rotator cuff tear and a full thickness or a full thickness small and a full thickness large Those are variable based again on the patient’s activity
Alton adds, “ We know from good studies done with ultrasound MRI that walking down the street, half the people age 60 have rotator cuff tears ” They’re asymptomatic It may not be a big tear, but it can be
He couldn’t serve a volleyball with his daughter
He couldn’t shout one basket
But he could pull a 95-lb bow back and take 100 shots
This didn’t make sense to him
The difference between a partial thickness rotator cuff tear and a full thickness or a full thickness small and a full thickness large Those are variable based again on the patient’s activity
Those are variable based again on the patient’s activity
They’re asymptomatic
It may not be a big tear, but it can be

It’s so important that we don’t ignore something that can get much worse and make 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 indications where we operate on asymptomatic things in the shoulder?

In general, no
Unless you have a tumor
Alton was swimming with his dad about 6 months before he passed away (at age 95) His dad was really vigorous, mentally and physically fit He ended up having pancreatic cancer that killed him at 95 He had a great life, no complaints At 86, he was a guy who could still do pull-ups, who was swimming in the lake Peter adds, “ This guy is my hero ” He did all his own yard work, everything He never took medication He was running to get out of the way of the sprinkler, did a banana peel, and had a dislocation of his shoulder, ripped off two and a half of his four tendons Remember, one of them never tears, so he tore almost his complete functional rotator cuff Alton did a little FaceTime with his dad and noticed he couldn’t lift his arm He urged his dad to visit and get an MRI Alton and his partner fixed him They didn’t give him much sedation, just regional anesthesia, and he got a good 6 anchor repair At age 94, you couldn’t tell he ever had a tear He healed and went back to doing everything
His dad was really vigorous, mentally and physically fit
He ended up having pancreatic cancer that killed him at 95
He had a great life, no complaints
At 86, he was a guy who could still do pull-ups, who was swimming in the lake Peter adds, “ This guy is my hero ”
He did all his own yard work, everything
He never took medication
He was running to get out of the way of the sprinkler, did a banana peel, and had a dislocation of his shoulder, ripped off two and a half of his four tendons Remember, one of them never tears, so he tore almost his complete functional rotator cuff
Alton did a little FaceTime with his dad and noticed he couldn’t lift his arm
He urged his dad to visit and get an MRI
Alton and his partner fixed him
They didn’t give him much sedation, just regional anesthesia, and he got a good 6 anchor repair
At age 94, you couldn’t tell he ever had a tear He healed and went back to doing everything
Peter adds, “ This guy is my hero ”
Remember, one of them never tears, so he tore almost his complete functional rotator cuff
He healed and went back to doing everything

What would have been the natural history for Alton’s dad if he didn’t have this surgery?

A lot of doctors might have left him alone, and then he would have been miserable for the next 9 years of his life Because he couldn’t lift his arm It might not have been that painful, but he wouldn’t have been able to do everything he wanted
Because he couldn’t lift his arm
It might not have been that painful, but he wouldn’t have been able to do everything he wanted

Pain shouldn’t be the only symptom we look for‒ we have to look for function

If someone came in with a traumatic motor vehicle accident where they tore their rotator cuff badly at age 60, 65
Alton would tell them it’s not necessary to have them repaired
But if you don’t repair it, those muscles that lost their muscle-tendon connection are going to atrophy
It may not be painful, but if you want to do things you were doing before the accident, they need to be repaired
The 2nd caveat is you may start having symptoms in 6 months even doing those other things If you do, don’t ignore it, go back to the orthopedist
It’s a dynamic state over a long period of time; so you need to be flexible
If you do, don’t ignore it, go back to the orthopedist

If you start having symptoms when you’ve been asymptomatic, something has changed (anatomically, physiologically or something), and it’s time to reassess

When a person comes in with shoulder pain, what is on your differential diagnosis in the exam (before the MRI)?

Figure 9. Front view of shoulder anatomy . Image credit: Alton’s drawing and Wikipedia

Alton drew the shoulder again and added the clavicle (collarbone) and the acromion (the bony roof of the shoulder, another part of the weird scapula), see the figure above
When you hear about someone separating their shoulder, this is the acromioclavicular joint (AC joint) Circled in red at the top of the drawing above It only rotates about 20 degrees
The collarbone is a stabilizer bar For car lovers, it’s effectively a MacPherson strut on a car
Some people are born without collarbones and they can bring their shoulders completely together in the center
In cyclists, collarbones are the most commonly injured because they land on the outside of their shoulder
The AC joint is what happens when people separate their shoulder (also super common) It’s different from a dislocation It’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 (we can talk about that later)
Circled in red at the top of the drawing above
It only rotates about 20 degrees
For car lovers, it’s effectively a MacPherson strut on a car
It’s different from a dislocation
It’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 (we can talk about that later)

How anatomical variation can predispose one to injury and how screening may help [50:30]

The acromion is that bony roof, and under that roof is where the rotator cuff glides
As the head rotates back and forth around, the rotator cuff is attached here and it goes back and forth here, and it’s rubbing or moving underneath this See the arrows back and forth in the previous diagram
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 So, that bursa is drawn in green (in the previous figure) That bursa is just a thin filmy structure that can thicken up and become very inflamed and become bursitis (very painful) That’s a common, common diagnosis Otherwise, the purpose of the bursa is to allow these things to glide past each other frictionless
Then some of us are born with an extra kind of downsloping of that acromion (shown in the figure below), or a bone spur, or we acquire it from repetitive athletic use (there are multiple reasons) Also indicated in Alton’s drawing by the red shaded area at the top left, on top of the bursa (which is green)
See the arrows back and forth in the previous diagram
So, that bursa is drawn in green (in the previous figure)
That bursa is just a thin filmy structure that can thicken up and become very inflamed and become bursitis (very painful) That’s a common, common diagnosis
Otherwise, the purpose of the bursa is to allow these things to glide past each other frictionless
That’s a common, common diagnosis
Also indicated in Alton’s drawing by the red shaded area at the top left, on top of the bursa (which is green)

Figure 10. The acromion on the shoulders and left scapula highlighted in red . Image credit: Wikipedia

It’s as though you have a big bird beak coming down and pointing into the bursa
You can imagine if this is running back and forth, it’s irritating the bursa, creating bursitis
And it’s also frictionally rubbing against the rotator cuff tendon
You can get bursal-sided upper part rotator cuff tears from that alone Alton knows because he had a big spur like that in his shoulder
Alton knows because he had a big spur like that in his shoulder

For Alton, the spur occurred because he was genetically predisposed to it based on the shape of his bursa

Figure 11. Front view of shoulder anatomy with 3 types of acromion (in blue). Sketched by Alton Barron

You can have a type I, a type II, or a type III acromion (drawn in blue, at the top of the figure above) Type I is totally flat (this is the majority of people) Type II is the second most common Type III predisposes you to this problem (about 30% of people have this type) You’re only at risk of you are an overhead athlete, lift weights overhead or do aggressive things If you’re sedentary and never exercise, you’ll never have a problem because you’re not repetitively loading it enough to wear it down or cause a tear
Peter relates that people often say “ Well, I can do so and so and I’ve never had an issue. Therefore, it’s okay. ” If you have the type I acromion, you can probably get away with a lot more overhead activity But for somebody who’s in category III, every time they do excessive overhead activity they might get injured
Peter thinks it would be interesting if we knew these things in advance and we could maybe modify and temper our activity around our genetics effectively
Alton agrees, the anatomic/ mechanical predisposition to injury is interesting
Type I is totally flat (this is the majority of people)
Type II is the second most common
Type III predisposes you to this problem (about 30% of people have this type) You’re only at risk of you are an overhead athlete, lift weights overhead or do aggressive things If you’re sedentary and never exercise, you’ll never have a problem because you’re not repetitively loading it enough to wear it down or cause a tear
You’re only at risk of you are an overhead athlete, lift weights overhead or do aggressive things
If you’re sedentary and never exercise, you’ll never have a problem because you’re not repetitively loading it enough to wear it down or cause a tear
If you have the type I acromion, you can probably get away with a lot more overhead activity
But for somebody who’s in category III, every time they do excessive overhead activity they might get injured

Peter’s personal example of anatomical predisposition

Peter had an MRI for other reasons and discovered he has a narrow C-spine (there’s no wiggle room)
As a result, he takes” tech neck protocol” very seriously
He know he already has 2 small herniations Luckily, they aren’t doing anything to him But nobody’s going to go in and remove one without doing the other, which means they’d fuse him out of the gate
Knowing this is helpful It tells him to do a lot of rehabilitative exercises even before having an injury
He thinks he’s fortunate he’s no longer a surgeon, because a lot of his surgery colleagues ended up having neck surgery (resulting from working in a certain position all the time)
Peter never thought about this from a joint context
Alton adds, “ If you have a congenitally narrow stenotic spine and you’re playing football, you’re way more at risk for catastrophic spinal cord injury ”
Luckily, they aren’t doing anything to him
But nobody’s going to go in and remove one without doing the other, which means they’d fuse him out of the gate
It tells him to do a lot of rehabilitative exercises even before having an injury

Screening for anatomical predispositions to injury

Alton was team doctor for almost 15 years a college up in New York But if you have your first stinger, then you need to be screened, and see if you are at high risk 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
But it hasn’t been done in the shoulder It’d be a simple, easy screen
This could be important for kids who have a lot of athletic potential, and at age 11 are going to decide what to focus on If you knew you’d have a longer shelf life in one sport over another, that should weigh into the decision-making process
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
But if you have your first stinger, then you need to be screened, and see if you are at high risk
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
There are a lot of sports to play, and you don’t necessarily have to be butting heads at high velocity
It’d be a simple, easy screen
If you knew you’d have a longer shelf life in one sport over another, that should weigh into the decision-making process

Pain generators in the shoulder, and the important nuance of the physical exam [56:00]

Pain generators in the shoulder

Figure 12. Front view of shoulder anatomy with 3 types of acromion. Sketched by Alton Barron

A type III acromion can be a pain generator Drawn in blue at the top of the drawing above
The AC joint is another one Circled in red in the drawing above
Drawn in blue at the top of the drawing above
Circled in red in the drawing above

“ Almost everybody through wear and tear, middle age and beyond, has arthritis in the AC joint… it’s almost always asymptomatic, but it can be symptomatic ”‒ Alton Barron

The little red structure you’ve drawn, that ligament that is connecting the clavicle to the acromion, is there fluid within that space?

There’s a tiny amount of fluid, but very little
Any place there’s cartilage, there’s a tiny amount of fluid
But it can expand, and if it’s arthritic, you can get more fluid
Young weightlifters can develop fluid in the end of the clavicle from repetitive use This end of the clavicle is shaded in red in the previous drawing Doing heavy bench press and other activities can result in distal clavicle osteolysis Repetitive jamming or bruising of the bone and cartilage causes the cartilage to disintegrate and the bone to lose its integrity It starts to 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 then you get a big inflammatory response You get a lot of extra fluid and a lot of pain
This end of the clavicle is shaded in red in the previous drawing
Doing heavy bench press and other activities can result in distal clavicle osteolysis
Repetitive jamming or bruising of the bone and cartilage causes the cartilage to disintegrate and the bone to lose its integrity It starts to 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 then you get a big inflammatory response You get a lot of extra fluid and a lot of pain
It starts to get very soft and it gets very inflamed
You get a lot of extra fluid and a lot of pain

From a chronic perspective, does this occur more in somebody doing bench press or military press or which direction?

Yes (in both) and also with heavy lat raises
Lat raises puts so much leverage on that joint, it just jams up Alton does not recommend his patients do these If you are to do it and want to minimize stress, Peter is in favor of thumbs going up (not down), and not directly laterally but more in the natural plane of the scapula
Alton does not recommend his patients do these
If you are to do it and want to minimize stress, Peter is in favor of thumbs going up (not down), and not directly laterally but more in the natural plane of the scapula

More about the biomechanics of this joint

If you lie directly on the point of your shoulder and it jams that again, and causes a lot of pain there
That pain comes right down the front and kind of follows the biceps
So, you have to differentiate that between the 2
Then you look at an X-ray (without an MRI), and you see these spurs that are down there The area of the previous drawing circled in red, near the AC joint Well, those spurs aren’t ever going to tear the rotator cuff, because that tendon is out there (to the left)‒ it never gets that far But it rubs, and we see it as an indentation in the muscle Every time you’re working out, you hypertrophy your muscles, so if you have that constantly rubbing there and then you hypertrophy around it, it hurts Peter notes, “ That’s an athlete who complains that when they’re lifting, it hurts more ” Yet when they’re relaxed and haven’t been exercising, they have rock solid strength But if you get them up into positions, or if they’ve been working out and you test them, they’ll be weak (their brain stops them to prevent pain)
The area of the previous drawing circled in red, near the AC joint
Well, those spurs aren’t ever going to tear the rotator cuff, because that tendon is out there (to the left)‒ it never gets that far
But it rubs, and we see it as an indentation in the muscle
Every time you’re working out, you hypertrophy your muscles, so if you have that constantly rubbing there and then you hypertrophy around it, it hurts Peter notes, “ That’s an athlete who complains that when they’re lifting, it hurts more ” Yet when they’re relaxed and haven’t been exercising, they have rock solid strength But if you get them up into positions, or if they’ve been working out and you test them, they’ll be weak (their brain stops them to prevent pain)
Peter notes, “ That’s an athlete who complains that when they’re lifting, it hurts more ”
Yet when they’re relaxed and haven’t been exercising, they have rock solid strength
But if you get them up into positions, or if they’ve been working out and you test them, they’ll be weak (their brain stops them to prevent pain)

The nuance of the shoulder exam

This reminds Peter of a book he read once he decided he was going into surgery, Cope’s Early Diagnosis of the Acute Abdomen The entire book was based on diagnosing appendicitis Peter thought it was the most fascinating thing in the world, because you had this old school general surgeon who said, “ This is 100% a clinical diagnosis ” This was before anyone was using a CT An appendicitis is the single most prevalent condition in general surgery Nobody training today would ever dream you could waste an entire book to diagnose something where you could just shove somebody in the scanner and get the answer
This exam makes Peter thinks of Coope’s Appendicitis because things are more complicated
Peter doesn’t think there will ever be a substitute for the nuance of the exam and the history of the injury and of what causes pain
For Alton, the guy who was his Cope was his Professor of Cardiology at Tulane, C. Thorpe Ray He was in his 80s at the time He had thyroid cancer and spoke in a very hushed tone He could tell you exactly what was wrong with which heart valve just by listening to you with a stethoscope, with his hands, sometimes he just put his ear up there He could tell by the nature of the subtle variations in the heart murmurs what the diagnosis was
The entire book was based on diagnosing appendicitis
Peter thought it was the most fascinating thing in the world, because you had this old school general surgeon who said, “ This is 100% a clinical diagnosis ” This was before anyone was using a CT
An appendicitis is the single most prevalent condition in general surgery
Nobody training today would ever dream you could waste an entire book to diagnose something where you could just shove somebody in the scanner and get the answer
This was before anyone was using a CT
He was in his 80s at the time He had thyroid cancer and spoke in a very hushed tone
He could tell you exactly what was wrong with which heart valve just by listening to you with a stethoscope, with his hands, sometimes he just put his ear up there He could tell by the nature of the subtle variations in the heart murmurs what the diagnosis was
He had thyroid cancer and spoke in a very hushed tone
He could tell by the nature of the subtle variations in the heart murmurs what the diagnosis was

“ I do lament the fact that that’s a dying art ”‒ Peter Attia

Peter acknowledges, the reality of it is that today with echo and stuff we’re better
He was probably such an outlier that most people could never reach that level Just like most people could have never attained the clinical acumen of Cope
It would be great to have both
Peter adds, “ 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 ”
Alton agrees and adds, you get pinpoint diagnoses with the various tests
There are plenty of things you find with tests that aren’t symptomatic
Alton points out, “ But our patients need us to be able to still diagnose, listen to them, hear what they’re saying ” You want to hear the patient’s story and know what’s really going on to determine whether they need surgical or non-surgical care or what kind of care they need
Peter felt like this was a very important message in residency, “ The single most important thing that you will learn is when to operate and when not to operate ”
When you start residency, you’re just so preoccupied with mastering the technical side of things (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 5 years to do it
Alton agrees, but unfortunately there are plenty of people who will operate on any MRI
Peter adds, “ 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 .”
Alton agrees, there are economic incentives
He has to suppress that information because it makes him too cynical and sad, but it happens
He sees 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 .” Alton does the exam and does not find a need to operate He tells them, “ 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, I will not operate on you… Maybe someday, but not now. ” Sometimes this is confusing for patients
Peter notes, “ 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 ” There is an asymmetry in this decision‒ to not have surgery doesn’t remove any options You can have surgery later if it is the right thing to do Once you have surgery, the operative field never looks the same the second time So, you want to keep in mind the asymmetry of a pause
Just like most people could have never attained the clinical acumen of Cope
You want to hear the patient’s story and know what’s really going on to determine whether they need surgical or non-surgical care or what kind of care they need
It’s like learning to master an instrument and learn a new language at the same time, and you’ve only got 5 years to do it
Alton does the exam and does not find a need to operate
He tells them, “ 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, I will not operate on you… Maybe someday, but not now. ” Sometimes this is confusing for patients
Sometimes this is confusing for patients
There is an asymmetry in this decision‒ to not have surgery doesn’t remove any options You can have surgery later if it is the right thing to do Once you have surgery, the operative field never looks the same the second time So, you want to keep in mind the asymmetry of a pause
You can have surgery later if it is the right thing to do
Once you have surgery, the operative field never looks the same the second time
So, you want to keep in mind the asymmetry of a pause

Frozen shoulder [1:05:15]

Shoulder pain can have many causes

The AC joint can be the problem
Bursitis
A rotator cuff injury
A labral injury
Bicep tendon inflammation
Arthritis
Adhesive capsulitis (discussed next)
Neck pain from the spine (discussed later)

Frozen shoulder (adhesive capsulitis)

Figure 13. The capsule in the shoulder joint. Sketched by Alton Barron

The best place to see the capsule is with a MRI because it’s thicker there and more distinct (there’s not other structures obscuring it)
Normally, if you have a super loose joint, you can 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 This is very common, and it can conflate all sorts of diagnoses He sees 2-3 new cases every week The frozen shoulder is the layman term for adhesive capsulitis
We don’t know why this happens but it’s multifactorial Like many things, it’s worse if you have diabetes But you don’t get it with more frequency if you have diabetes There’s a lot of misinformation about it because the old literature says it will get better with time (not true) Only about 1 out of 5 of Alton’s patients actually ever need surgery, and he never does this at the beginning Surgery would be a simple, 30-minute release of the capsule and reduction of the inflammation 80% do not need surgery, they need some way to control the inflammation along with really good physical therapy and a home program To restore mobility
You can get a stiff shoulder if you have impingement If you have a big bone spur and your brain says “ I’m not going to let you move it there ”, 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 It’s a spontaneous intense inflammation in the inner lining If you take a little camera and stick it in there and just look, you see it’s beet red Normally in an arthroscopy, everything’s kind of off white
This is very common, and it can conflate all sorts of diagnoses He sees 2-3 new cases every week
The frozen shoulder is the layman term for adhesive capsulitis
He sees 2-3 new cases every week
Like many things, it’s worse if you have diabetes But you don’t get it with more frequency if you have diabetes
There’s a lot of misinformation about it because the old literature says it will get better with time (not true)
Only about 1 out of 5 of Alton’s patients actually ever need surgery, and he never does this at the beginning Surgery would be a simple, 30-minute release of the capsule and reduction of the inflammation
80% do not need surgery, they need some way to control the inflammation along with really good physical therapy and a home program To restore mobility
But you don’t get it with more frequency if you have diabetes
Surgery would be a simple, 30-minute release of the capsule and reduction of the inflammation
To restore mobility
If you have a big bone spur and your brain says “ I’m not going to let you move it there ”, 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 It’s a spontaneous intense inflammation in the inner lining If you take a little camera and stick it in there and just look, you see it’s beet red Normally in an arthroscopy, everything’s kind of off white
That’s a secondary stiffness or adhesive capsulitis
It’s a spontaneous intense inflammation in the inner lining
If you take a little camera and stick it in there and just look, you see it’s beet red
Normally in an arthroscopy, everything’s kind of off white

Does a frozen shoulder 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
Alton gives NSAIDs when people want them and are afraid of an injection
But he thinks NSAIDs aren’t strong enough That inner lining is so robust He likes to put a small dose of cortisone into the joint 1 time
He always injects cortisone from the back for 2 reasons 1 – This part is more richly supplied by the brachial plexus, so it’s more sensitive 2 – People kind of see you coming at them with a needle He never uses an ultrasound, you can feel where you’re going
He puts local anesthetic in there as well People come in with a lot of stiffness and pain, and they walk out saying “ Oh my gosh, it’s amazing ” So for these patients they’re free in 10 seconds
They probably still need physical therapy, but they feel dramatic relief from such a simple treatment
That inner lining is so robust
He likes to put a small dose of cortisone into the joint 1 time
1 – This part is more richly supplied by the brachial plexus, so it’s more sensitive
2 – People kind of see you coming at them with a needle
He never uses an ultrasound, you can feel where you’re going
People come in with a lot of stiffness and pain, and they walk out saying “ Oh my gosh, it’s amazing ”
So for these patients they’re free in 10 seconds

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 want them to do 3 months of rehab first?

It depends on their exam, their history and how long they’ve had it, and how acutely symptomatic it is
When examining them, if Alton can stretch them and they say it hurts a little at the end, but they have decent motion They are simply tight and need PT to really stretch them out They don’t need anything else, not even NSAIDs
But if he can’t get them to move and they’re screaming, they’re not going to get anywhere in PT (because it will hurt too much to do it) So he’ll inject them and send them to PT
He always sees them back in about 6 weeks
Much of them are dramatically better, but not all of them
Very rarely they need a second shot
Then some of them are just recalcitrant and they just stay stiff, and then Alton will do the little surgical procedure on them
They are simply tight and need PT to really stretch them out
They don’t need anything else, not even NSAIDs
So he’ll inject them and send them to PT

Shoulder pain that originates in the neck [1:11:15]

A big source of shoulder pain is referred pain from the neck Alton includes this in his shoulder exam
Alton takes care of a lot of professional musicians; their necks are doing all sorts of crazy things (think of a violinist)
All types of musical instruments lead to having to maintain these certain postures that sometimes are very counterproductive to one’s overall musculoskeletal health
People will come in with shoulder pain going down their arm, maybe even down to their hand They’ve already gotten a shoulder MRI They’re 55, and they have 4 findings on their MRI, but the pain is not coming from their shoulder, it’s coming from their neck Alton has to make sure and differentiate that, because the worst thing he 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 have them return
Alton includes this in his shoulder exam
They’ve already gotten a shoulder MRI
They’re 55, and they have 4 findings on their MRI, but the pain is not coming from their shoulder, it’s coming from their neck
Alton has to make sure and differentiate that, because the worst thing he 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 have them return

What in the exam makes you think to look at the neck first with the MRI?

For intrinsic shoulder pathology, almost never does the pain radiate down below the elbow

Whether it’s a rotator cuff, whether it’s impingement, or whether it’s arthritis

Whereas neck origin almost always goes down below the elbow and into the hand

Whether it’s a pinched nerves at any the lower cervical spine (where it’s more common to have pathology)
One odd ball is C7
Alton learned this not that long ago from some really great cervical spine surgeons‒ if you have a deep posterior pain under your scapula, that can be C7 He’s had two musicians recently, both with that diagnosis
He’s had two musicians recently, both with that diagnosis

Figure 14. Cervical vertebrae highlighted in red, numbered from top to bottom C1, C2, C3, C4, C5, C6, C7. The C7 vertebra is highlighted in the second panel . Image credit: Wikipedia

Peter understands as the only time he ever had a neck issue, the pain didn’t present as neck pain One morning he woke up and his left trap felt like it was in spasm He ignored it thinking he slept wrong The next day it was super uncomfortable and still in spasm This went on for a week He realized he had never had a muscle this tense for this long About this time he started to notice a abrupt loss of tricep strength in the gym He was doing skull crushers where you have 2 dumbbells All of a sudden, he couldn’t move the weight with his left arm It progressed rapidly so that in about 2 days he couldn’t pull his bow back because he couldn’t extend his left arm He had these motor symptoms but had zero pain in his neck No numbness, tingling, no paresthesias anywhere He saw a surgeon who shared Alton’s ethos and recommended rehab first She wanted to do an injection, but Peter wasn’t excited about it because it was an anterior injection So he tried prednisone and traction Within 3 months his strength was back and the problem never returned
One morning he woke up and his left trap felt like it was in spasm
He ignored it thinking he slept wrong
The next day it was super uncomfortable and still in spasm
This went on for a week
He realized he had never had a muscle this tense for this long
About this time he started to notice a abrupt loss of tricep strength in the gym He was doing skull crushers where you have 2 dumbbells All of a sudden, he couldn’t move the weight with his left arm It progressed rapidly so that in about 2 days he couldn’t pull his bow back because he couldn’t extend his left arm
He had these motor symptoms but had zero pain in his neck No numbness, tingling, no paresthesias anywhere
He saw a surgeon who shared Alton’s ethos and recommended rehab first
She wanted to do an injection, but Peter wasn’t excited about it because it was an anterior injection So he tried prednisone and traction
Within 3 months his strength was back and the problem never returned
He was doing skull crushers where you have 2 dumbbells
All of a sudden, he couldn’t move the weight with his left arm
It progressed rapidly so that in about 2 days he couldn’t pull his bow back because he couldn’t extend his left arm
No numbness, tingling, no paresthesias anywhere
So he tried prednisone and traction

“ That was a real wake-up call to me that I had a cervical symptom that didn’t present with any neck pain ”‒ Peter Attia

Alton thinks this story is so instructive
He won’t get MRIs or x-rays of the neck; instead often gives one very low dose of prednisone, and it usually goes away

Shoulder exam:

Discussion about the shoulder + shoulder eam:

Surgical treatments for a labral tear, and factors that determine whether surgery is appropriate [1:16:00]

Peter had repair of a complete labral tear. Is the approach the same for repairing a SLAP tear?

There’s just a little more to do, technically
The largest incisions are 1-1.5 cm
The others are small percutaneous holes to put cannulas in and then drill through
It takes 10 minutes to do each anchor, and Peter needed a bunch
Peter recalls, the exam under anesthesia is crucial
Alton points out that with a dynamic exam, your brain has been dealing with this problem for a long time Peter has been exercising and has good muscle tone, so if Alton is examining him, he probably can’t sublux his shoulder Usually, he can get 1-2 subluxations before the patient tenses up
Alton points out, the great thing about an exam under anesthesia is he can move the patient’s arm freely The patient is on a regional block where their arm is super numb (they’re in a position where they’re going to have the surgery) They are so sedated and relaxed, they can’t control anything The patient’s muscles have very little effect
Alton tests the static stabilizers For Peter he could take it pretty far out back and could completely dislocate his shoulder out the front This tells Alton important information and what to look for on the inside
Now when he looks on the inside, he needs to asses not just the labrum (which he knows is torn) but also the capsule In the case of the anterior, Peter had been like the balloon you’re blowing up repeatedly He’d also been stretching out his capsule
He was still compensating, less well and less well with the muscle
So if that is stretched down the front, Alton needs to know that
In addition to just repairing the labrum itself, he needs to gather up some of this capsule (which has become too capacious), and do what we call a capsulorrhaphy (which is to gather and tighten that up too) 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
Peter has been exercising and has good muscle tone, so if Alton is examining him, he probably can’t sublux his shoulder
Usually, he can get 1-2 subluxations before the patient tenses up
The patient is on a regional block where their arm is super numb (they’re in a position where they’re going to have the surgery)
They are so sedated and relaxed, they can’t control anything
The patient’s muscles have very little effect
For Peter he could take it pretty far out back and could completely dislocate his shoulder out the front
This tells Alton important information and what to look for on the inside
In the case of the anterior, Peter had been like the balloon you’re blowing up repeatedly
He’d also been stretching out his capsule
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

Caveat about unnecessary surgery

Alton had a professional violinist in her early 60s who had shoulder pain
She saw a sports doctor, got an MRI
She had some degenerative labral tearing that he said needed to be repaired Her MRI didn’t really say anything else
She presented with shoulder pain and a little stiffness
The sports doctor did a repair of the labrum and she came to Alton about 6 months later in tears She had not been playing for 6 months and had the stiffest shoulder he had ever seen (it didn’t move)
The doctor did a labral repair in a 62-year-old, who’s not an athlete, and really tightened the capsule In someone who’s not an athlete it would never be necessary
Alton had to go in and scope her It was really hard because it was so tight
He had to bit by bit, release everything that had been done and release the capsule that was all crunched up and tightened up He even had to take some of the sutures out to free up her shoulder
Her MRI didn’t really say anything else
She had not been playing for 6 months and had the stiffest shoulder he had ever seen (it didn’t move)
In someone who’s not an athlete it would never be necessary
It was really hard because it was so tight
He even had to take some of the sutures out to free up her shoulder

What was her initial injury?

-Alton thinks she simply had the classic frozen shoulder

Maybe she should have had PT plus a single injection of cortisone to reduce the inflammation (at most)
The surgery was the exact opposite; it produced a complete tightening of the capsule
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, ” and that’s valid

How does age factor into the decision to operate?

Some people thought Peter was crazy to have a labral repair at age 50 But he hasn’t lost any mobility, which is remarkable
In Peter’s case, Alton doesn’t think there was a choice because of his subluxation with all the different activities He already had some arthritis He was wearing down some cartilage It was this surgery or the inevitability of having a shoulder replacement in another 10 years
For Peter, knowing what he knows now (that there is a little arthritis there), he wishes he had had surgery sooner
He had a ton of pain 10-15 years ago, but got out of it with a lot of good tissue work and training He made some modifications and decided there were certain things he couldn’t do
Alton notes that people now are so much younger physiologically (in better condition)
We know that a 50-year-old now cannot be compared to data of 50-year-olds 20 years ago So Peter is not a typical 50-year-old from the literature
But he hasn’t lost any mobility, which is remarkable
He already had some arthritis
He was wearing down some cartilage
It was this surgery or the inevitability of having a shoulder replacement in another 10 years
He made some modifications and decided there were certain things he couldn’t do
So Peter is not a typical 50-year-old from the literature

Alton based his decision on biological age, not chronological age

There are some people he scopes because there’s no other way than looking to see what’s there Sometimes they have better cartilage than what the MRI is indicating and he can go ahead and do a repair He’s done a couple of 58-year-olds, 60-year-olds, but their joint was pristine, it looked as good as a 25-year-old They just had a discrete labral tear
For Peter this is an extension of what he thinks of as precision medicine 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 Therefore, you have to be able to make evidence-informed decisions based on the appropriate physiology that you see
Alton agrees and adds it’s a conversation with the patient and not a unilateral decision Physicians need to say, “ Here are the possibilities, and what do you want to do? ”
Sometimes they have better cartilage than what the MRI is indicating and he can go ahead and do a repair
He’s done a couple of 58-year-olds, 60-year-olds, but their joint was pristine, it looked as good as a 25-year-old They just had a discrete labral tear
They just had a discrete labral tear
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
Therefore, you have to be able to make evidence-informed decisions based on the appropriate physiology that you see
Physicians need to say, “ Here are the possibilities, and what do you want to do? ”

Scope imaging

The biggest ports are for the camera, and there are a few working ports in the front and back
Pathology is superior and anterior
You’re working in the superior in the front and go in through the back with a camera (to get a good panoramic view of everything)
They have 2 different kinds of angled lenses, so they can see around corners if needed
He can see the superior labrum; he can see the biceps

Do you insufflate with carbon dioxide?

Yes, you’re shooting carbon dioxide to blow everything up
And he uses water to do the same thing, but not at high pressure (35 mmHg) It makes the capsule bigger Lower pressure means less postoperative pain and less distention
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 Alton does in the elbow Because there’s a lot more peril because of the nerves being so close
Usually you need 2 working portals in the front Which are just basically canals to get in with instruments, that are long enough to fit through and do the work
In the case of a superior labrum, we use a percutaneous hole right through the top, just underneath… right under where that red arrow is going (highlighted in yellow in the figure below) And that just gets you to the superior labrum So that’s a little percutaneous, a tiny little hole in the rotator cuff muscle-tendon junction It just spreads the fibers apart, so it doesn’t do any damage to that And then you’ve got a perfect bird’s eye direction for the drilling and putting in a few anchors in the top And then that’s really it
It makes the capsule bigger
Lower pressure means less postoperative pain and less distention
Because there’s a lot more peril because of the nerves being so close
Which are just basically canals to get in with instruments, that are long enough to fit through and do the work
And that just gets you to the superior labrum
So that’s a little percutaneous, a tiny little hole in the rotator cuff muscle-tendon junction
It just spreads the fibers apart, so it doesn’t do any damage to that
And then you’ve got a perfect bird’s eye direction for the drilling and putting in a few anchors in the top
And then that’s really it

Figure 15. Front view of shoulder anatomy with highlighted arrows indicating direction of holes made during surgery. Sketched by Alton Barron

Explain how the surgical repair works

You drill a little hole in the glenoid fossa The diameter depends on what kind of anchor you are doing Usually not more than 3 mm, and now we’re down to 1.8 mm 3 mm seems big, but that’s what you fit the plastic or the absorbable anchor in that you tap in with the mallet
You’re drilling into the bone, and you have to get the angle right Indicated with arrows pointed right (see the small red arrows highlighted in blue in the figure above) And then the anchor inserts through that They’re not circumferential, they’re straight in If we did them open as we used to, we’d drill holes and use a suture going through circumferentially
The diameter depends on what kind of anchor you are doing
Usually not more than 3 mm, and now we’re down to 1.8 mm
3 mm seems big, but that’s what you fit the plastic or the absorbable anchor in that you tap in with the mallet
Indicated with arrows pointed right (see the small red arrows highlighted in blue in the figure above)
And then the anchor inserts through that
They’re not circumferential, they’re straight in If we did them open as we used to, we’d drill holes and use a suture going through circumferentially
If we did them open as we used to, we’d drill holes and use a suture going through circumferentially

What holds the anchor in?

Is it the pressure of putting in an anchor that is bigger than the hole?

Yes
Historically there were some that we screw in, but not anymore
Now they are purely basically braided polyester The suture goes in, and then as you carefully pull it back out, the way they’re designed, they ball up It’s super strong; you can lift the shoulder off the table Alton knows if he tugs on it multiple times, it’s not going to come out It would take fully traumatic force to dislodge it
The suture goes in, and then as you carefully pull it back out, the way they’re designed, they ball up
It’s super strong; you can lift the shoulder off the table
Alton knows if he tugs on it multiple times, it’s not going to come out It would take fully traumatic force to dislodge it
It would take fully traumatic force to dislodge it

Do you examine the cuff while you’re in there?

Absolutely, he goes through and does a survey of the joint
He looks at the cartilage surfaces, all the nooks and crannies
He looks at the rotator cuff inserting on the bone, from inside out And you can see if it’s smooth, if it’s frayed If it’s notably frayed, you can probe it Occasionally he may see a small, almost full-thickness tear (because they’re athletes) Then I might put a stitch or two in that to fix that You look at the biceps You can pull the biceps into the joint and see a pretty good segment of it and see if it’s inflamed, torn, something abnormal there You can see the tendon of the biceps really well too, and if it’s frayed
And you can see if it’s smooth, if it’s frayed
If it’s notably frayed, you can probe it
Occasionally he may see a small, almost full-thickness tear (because they’re athletes) Then I might put a stitch or two in that to fix that
You look at the biceps You can pull the biceps into the joint and see a pretty good segment of it and see if it’s inflamed, torn, something abnormal there
You can see the tendon of the biceps really well too, and if it’s frayed
Then I might put a stitch or two in that to fix that
You can pull the biceps into the joint and see a pretty good segment of it and see if it’s inflamed, torn, something abnormal there

How much damage do you need to see to do the tenodesis ?

Not a lot
If he sees a combination of a modest amount of fraying and a lot of inflammation around it
And when he pulls it in the joint, that extends further out, then he’ll tenodese it

It’s important to understand how much your eyes are helpful here

When you look at Peter’s intra-op images, it is very plain, banal sort of gray-white (normal) * See photos as an addendum at the end of the show notes *
Inflammation shows up as really red
Alton likes to get a little electrocautery wand, and he paints the internal and gets rid of all that pink because it’s inflammatory It hurts, and that’s part of one of the big pain generators
Now, theoretically, if you fix everything, that’s going to go away anyway But it helps patients early post-op
A recent patient that Alton did a pretty significant repair on, after 5 days, he said, “I haven’t had any pain. What’s going on? Did you do anything to my shoulder? ” Alton repaired it, but he thinks part of it is just getting rid of that inflammation and so forth
- See photos as an addendum at the end of the show notes *
It hurts, and that’s part of one of the big pain generators
But it helps patients early post-op
Alton repaired it, but he thinks part of it is just getting rid of that inflammation and so forth

Repairing the rotator cuff [1:29:15]

What is the most common athlete’s tear to the rotator cuff?

It depends on if they’re an overhead athlete In that case, the supraspinatus is usually torn Sometimes it can be the infraspinatus
In that case, the supraspinatus is usually torn
Sometimes it can be the infraspinatus

If a guy has a straight-up supraspinatus tear, do you even need to enter the capsule necessarily, depending on how close it is?

You do, you need to make sure that you’re not missing anything, which is common in the athletes
There are a couple of interesting variations
Alton drew 3 sequential axillary views, which are a bird’s eye view looking straight down on the top of your shoulder proper (see the figure below) We’re sitting on top looking straight down 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 These muscles are shown in the second figure below 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
We’re sitting on top looking straight down
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 These muscles are shown in the second figure below
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
These muscles are shown in the second figure below

Figure 16. Three sequential axillary views of the shoulder with tears indicated in red. Sketched by Alton Barron

Figure 17. Anatomy of muscles of the shoulder A. deltoid , B. supraspinatus , C. infraspinatus , (D) subscapularis . Image credit: Wikipedia

The teres minor (the fourth muscle of the rotator cuff) is not really a relevant player in the pathology because it almost never tears
Peter likes Alton’s birds-eye view of the shoulder as it 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 We usually look at them from front and back
We usually look at them from front and back

Is the supraspinatus that wide, relatively speaking?

In anatomic diagrams it looks like a tiny little muscle, because you’re looking at it from the front
But it’s broad and has three-dimensionality, and it has roughly 3.0-3.5 centimeters of width going front to back

Back to the 3 bird’s eye views of the shoulder in Alton’s drawing (above)

2 – The most common one is the middle one because that’s anterior The biceps is indicated with 3 blue arrows That’s an anterior-superior tear That’s the one that the overhead athletes get a lot (non-throwing athletes)‒ 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 tea r” The arrows indicate where they tear, that’s where Alton had little tears on both shoulders That’s also the one that can be caused by a spur pushing down on it
Alton drew a little arc in red on #2 because they’ll tear off, and then they’ll form a little arc of smooth tissue You repair it, you 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 You get it back to the good bony bed, and you get that good biologic healing He’s drawn a small tear in red, but they can be bigger and more chronic
3 – The one down below shows the subscapularis in the front That is the one that can tear in young people or older people based on mechanism If you have a linebacker who is 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 That’s how you can tear the subscapularis The other way is people falling downstairs and grabbing the banister and wrenching back It’s commonly torn with eccentric load
1 – This upper one occurs in throwing athletes Baseball players and football players externally rotate dramatically, and 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, and their arms/ shoulders are very asymmetric One side will externally rotate to 90 while 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 (indicated by the red arrow in #1), that area of the rotator cuff (circled in black on the left) 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 they get small partial-thickness or even full-thickness tears there 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 rotation, they lose
The biceps is indicated with 3 blue arrows
That’s an anterior-superior tear
That’s the one that the overhead athletes get a lot (non-throwing athletes)‒ 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 tea r”
The arrows indicate where they tear, that’s where Alton had little tears on both shoulders
That’s also the one that can be caused by a spur pushing down on it
You repair it, you 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 You get it back to the good bony bed, and you get that good biologic healing
He’s drawn a small tear in red, but they can be bigger and more chronic
You get it back to the good bony bed, and you get that good biologic healing
That is the one that can tear in young people or older people based on mechanism
If you have a linebacker who is 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 That’s how you can tear the subscapularis
The other way is people falling downstairs and grabbing the banister and wrenching back
It’s commonly torn with eccentric load
He’s got his arms out there ready to go, and he gets eccentrically loaded into external rotation
That’s how you can tear the subscapularis
Baseball players and football players externally rotate dramatically, and 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, and their arms/ shoulders are very asymmetric One side will externally rotate to 90 while 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 (indicated by the red arrow in #1), that area of the rotator cuff (circled in black on the left) 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 they get small partial-thickness or even full-thickness tears there
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 rotation, they lose
One side will externally rotate to 90 while the other one will go back another 45 degrees, and that’s how they get that whip
We have to repair those, but you have to be really careful because if they lose 10 or 15 degrees of external rotation, they lose

Where does the Tommy John surgery fit into this?

That’s the elbow
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 And vice versa, 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
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
And vice versa, 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?

Probably 15
But not today
Peter can’t think of anything that could be more stressful, “ throwing a baseball seems even more stressful than throwing a football because you do it more times in a game ” and Alton agrees

What has changed is earlier diagnosis

Now at the Division 1 collegiate level, any pain is almost over-evaluated This uses a lot of resources but can be good for the players because it identifies these things very early
This uses a lot of resources but can be good for the players because it identifies these things very early

Do they repair very small tears before they become a bigger tear?

It depends
You’d certainly watch it carefully
Sometimes it’s not the tear that causes symptoms It could be just some inflammation related to it and if you can cool that down, the tear is not biomechanically significant yet
It could be just some inflammation related to it and if you can cool that down, the tear is not biomechanically significant yet

Alton has had patients with full-thickness tears that are minimally symptomatic and others with partial-thickness tears that are very symptomatic

So it depends on what you have

Back to Alton’s drawing of muscles in the shoulder, explain a full-thickness tear

Figure 18. Shoulder joint with the supraspinatus tendon highlighted in yellow. Sketched by Alton Barron

Peter notes, “ I think one thing that’s kind of missing from this picture in the subscapularis, in the infraspinatus, is just how long they are ” We are looking at the top, but these muscles cover the scapula
We are looking at the top, but these muscles cover the scapula
Back to an earlier picture Alton drew of the supraspinatus tendon, that perpendicular distance through there is the full thickness It varies depending on the size of the patient
It varies depending on the size of the patient

Could it be a tear across the entire 4 cm by 0.5 cm?

When we speak typically about full thickness, we mean the depth of it this way (going up and down), 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 can this be ignored Whereas a partial-thickness tear off the tendon could easily be ignored
Those muscle bellies are huge
In football players and guys who are so strong, sometimes they have that wrenching injury, and they don’t rip the tendon off the bone, but they interstitially tear at the musculotendinous junction And they have a tremendous amount of edema, weakness, pain, but that will heal without any intervention With just some some anti-inflammatory and just time to heal
Whereas a partial-thickness tear off the tendon could easily be ignored
And they have a tremendous amount of edema, weakness, pain, but that will heal without any intervention With just some some anti-inflammatory and just time to heal
With just some some anti-inflammatory and just time to heal

Are platelet-rich plasma (PRP) injections or stem cells beneficial for healing tears? [1:38:15]

What role do stem cells or PRP play in any of this?

Peter doesn’t think stem cells are going to replace a labrum, but if you have a tear in the muscle, they can be valuable

Are people running randomized clinical trials on stem cells in that indication?

Alton thinks so, but he doesn’t know that literature
There are a lot of terribly designed studies all around that are being used to justify using stem cells or PRP So one has to be careful to extrapolate it to your individual practice
There’s a lot of money involved too Alton has patients that routinely fly to various places (including Germany) and pay a lot of money to get stem cells injected for things we’ve been talking about
And there’s no data on there
There are a few anecdotal reports where people say there was a tear on the MRI, they injected PRP and it’s healed, gone Alton doesn’t know what to make of those They’re just one-offs We also don’t know what the natural history of that injury would have been without the PRP
One of the best scientific things Alton can relate goes down to the elbow He was speaking just before COVID at the American Association of Sports Medicine to non-surgical, general medicine doctors who do sports medicine 2 papers (listed in the selected links section) were presented before his talk, back-to-back on over a thousand patients Double-blind, randomized studies on tennis elbow (lateral epicondylitis) , comparing cortisone, PRP, and placebo The placebo and the PRP were the same, while the cortisone was much more effective These were back-to-back studies at different institutions
The literature is replete with studies that say PRP really helps
Alton sees patients all the time that have had PRP injections
So one has to be careful to extrapolate it to your individual practice
Alton has patients that routinely fly to various places (including Germany) and pay a lot of money to get stem cells injected for things we’ve been talking about
Alton doesn’t know what to make of those
They’re just one-offs
We also don’t know what the natural history of that injury would have been without the PRP
He was speaking just before COVID at the American Association of Sports Medicine to non-surgical, general medicine doctors who do sports medicine
2 papers (listed in the selected links section) were presented before his talk, back-to-back on over a thousand patients Double-blind, randomized studies on tennis elbow (lateral epicondylitis) , comparing cortisone, PRP, and placebo The placebo and the PRP were the same, while the cortisone was much more effective
These were back-to-back studies at different institutions
Double-blind, randomized studies on tennis elbow (lateral epicondylitis) , comparing cortisone, PRP, and placebo
The placebo and the PRP were the same, while the cortisone was much more effective

Alton has a PRP machine in his office in Manhattan, and based on his current knowledge of the literature for rotator cuff repairs, for tendon ruptures, for lateral epicondylitis, certainly for Tommy Johns and medial tendon ruptures, he uses it twice a year (when someone begs him to do it)

Is there a financial incentive for giving PRP instead of cortisone?

Cortisone is covered by insurance, and it’s only a couple hundred dollars for a shot
PRP is $1,000 and it’s not necessarily covered by insurance
Some people charge a lot more ($2,500) for a PRP injection
The concept of PRP is great‒ it has growth factors, it’s our own bodily fluids But it hasn’t yet borne out to be a game changer
But it hasn’t yet borne out to be a game changer

There’s not enough data to support benefits from PRP injection

Now, if you take someone who’s the highest-level athlete and they have bursitis, and you inject some PRP in there, some stem cells, maybe it will be better, who knowns
There’s not really good data on it
But there’s no downside to doing it
The only downside Alton sometimes sees is more flare reactions from PRP injected into tennis elbow, where people are really painful for a couple of weeks They end up coming to him for either surgery or cortisone This is just anecdotal, he doesn’t have a comparative study
Peter needs to spend more time in this literature, and notes the problem is we don’t have that natural history There are a lot of anecdotes that say, “ This injury was present. Stem cells were injected. The injury is gone radiographically. ” We don’t have the contra positive case
Alton knows of a natural history study on asymptomatic rotator cuff tears that came out of WashU Ken Yamaguchi was the lead on that article They looked at ultrasounds which is great because they’re non-invasive, non-costly, and very effective if you have a good ultrasonographer They looked at the natural history of these asymptomatic tears, and they found that 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 a subset become symptomatic None got better spontaneously
This suggests to Peter that if people are saying, “ Here’s my MRI pre and post stem cells, and it got better ,” that would suggest in that individual it might have worked
Alton agrees, but points out that MRIs vary significantly from machine to machine That 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 and reconstitution, man, I’d be in .”
Peter hopes that study is being done
Another thing to standardize is the process of generating the stem cell One of the challenges of doing a clinical trial is everybody has to get the same drug
They end up coming to him for either surgery or cortisone
This is just anecdotal, he doesn’t have a comparative study
There are a lot of anecdotes that say, “ This injury was present. Stem cells were injected. The injury is gone radiographically. ”
We don’t have the contra positive case
Ken Yamaguchi was the lead on that article
They looked at ultrasounds which is great because they’re non-invasive, non-costly, and very effective if you have a good ultrasonographer
They looked at the natural history of these asymptomatic tears, and they found that 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 a subset become symptomatic
None got better spontaneously
And a subset become symptomatic
That 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 and reconstitution, man, I’d be in .”
One of the challenges of doing a clinical trial is everybody has to get the same drug

How standardized is the procedure for capturing and processing stem cells?

It’s non-standardized
It differs between different companies that bring the machines in
It differs between individual clinicians

“ It can be apples and oranges ”‒ Alton Barron

Repair of an AC joint separation [1:45:15]

When does it just get left alone and you’re stuck with a little bit of deformation?

AC separations are common injuries
Alton sketched the AC joint with the glenohumeral joint removed (see the figure below) The clavicle is coming across There are the 2 stabilizers of the clavicle, one is the coracoid process There are the coracoclavicular ligaments We’re looking at it straight on It’s a thumb that sticks out from yet another weird part of that scapula
The clavicle is coming across
There are the 2 stabilizers of the clavicle, one is the coracoid process
There are the coracoclavicular ligaments
We’re looking at it straight on
It’s a thumb that sticks out from yet another weird part of that scapula

Figure 19. Separation of the AC joint . Sketched by Alton Barron

Secondarily, we have the acromioclavicular (AC) joint that we were talking about, and those are the ligaments that are circumferential around the acromioclavicular joint
So if you fall hard off your bike and you sprain your AC joint, we call that a type I You stretch a little bit and injure these ligaments (drawn in red in part A of the figure above) and maybe even stretch those a tiny bit It doesn’t look any different on x-ray Those can hurt, and those can damage the cartilage a little bit You can get a grade I that persists in being painful, but generally they don’t They go away
Alton did this recently on some slime out in Dripping Springs on a bike ride There was a low-water crossing and he just went out like it was on ice It hurt for 6 weeks, and then it was gone It wasn’t braced and now it’s completely normal
You stretch a little bit and injure these ligaments (drawn in red in part A of the figure above) and maybe even stretch those a tiny bit
It doesn’t look any different on x-ray
Those can hurt, and those can damage the cartilage a little bit
You can get a grade I that persists in being painful, but generally they don’t
They go away
There was a low-water crossing and he just went out like it was on ice
It hurt for 6 weeks, and then it was gone
It wasn’t braced and now it’s completely normal

Did you diagnose it just by pressing on it?

Yes, he knew by pressing right on it, it hurt like heck, but it didn’t blot It didn’t move up and down, and he could lift his shoulder He could feel it not moving
This is one of the things that’s biomechanically and we talk to the residents about when we’re teaching‒ it’s not that the clavicle pulls up, it’s that the shoulder falls away 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 heavy weight of the arm off
Back to the figure Alton drew, in part B. there is a shadow (drawn as a dotted line) Here’s the clavicle We have one acromion, which it’s sitting up about 30% or so, and that’s where you have torn the AC ligaments
A grade II is where you’ve clearly torn the AC ligaments and it’s up by about 30% This could be a partial or complete tear, but it just didn’t distort it too much Almost all those can be treated nonoperatively Again, like the I’s, they can hurt, persist, and you might have to do something later, but they’re basically stable
It didn’t move up and down, and he could lift his shoulder
He could feel it not moving
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 heavy weight of the arm off
Here’s the clavicle
We have one acromion, which it’s sitting up about 30% or so, and that’s where you have torn the AC ligaments
This could be a partial or complete tear, but it just didn’t distort it too much
Almost all those can be treated nonoperatively
Again, like the I’s, they can hurt, persist, and you might have to do something later, but they’re basically stable

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, but people don’t really care It’s barely asymmetric
Grade III is where you it’s completely up We measure that by the distance between the coracoid and the clavicle In part B of the figure above, Alton drew a second coracoid process and a red arrow to express the difference in height (the coracoclavicular distance) If it’s up to 30% widening, increase in that space, then that’s the grade II If it’s 100% or more, then that’s a grade III
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 III’s did not need 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
If you’re a professional cyclist and you fix them, you can get back on the bike in 3-4 weeks
So there’s a gray zone, but the type III’s are that transition
The vast majority of the operative ones are in the III category
Alton saw a weightlifter the other day and gave him the options We can fix this tomorrow or next week But you could also wait and see how you feel in 3-4 weeks because you can have the same repair then You don’t lose anything by waiting But you will lose something by waiting 3-6 months because you don’t have the same biology going on This guy felt great 4 weeks later and ended up not wanting surgery The pain was almost gone
Asymmetry won’t have a functional impairment, generally speaking Except if you’re doing certain exercises‒ heavy flys, heavy bench, high back squat
It’s barely asymmetric
We measure that by the distance between the coracoid and the clavicle
In part B of the figure above, Alton drew a second coracoid process and a red arrow to express the difference in height (the coracoclavicular distance) If it’s up to 30% widening, increase in that space, then that’s the grade II If it’s 100% or more, then that’s a grade III
If it’s up to 30% widening, increase in that space, then that’s the grade II
If it’s 100% or more, then that’s a grade III
But a subset of them did go on to needing it later
We can fix this tomorrow or next week
But you could also wait and see how you feel in 3-4 weeks because you can have the same repair then You don’t lose anything by waiting But you will lose something by waiting 3-6 months because you don’t have the same biology going on
This guy felt great 4 weeks later and ended up not wanting surgery The pain was almost gone
You don’t lose anything by waiting
But you will lose something by waiting 3-6 months because you don’t have the same biology going on
The pain was almost gone
Except if you’re doing certain exercises‒ heavy flys, heavy bench, high back squat

How the repair is done

This is where Alton differs from some people, a lot of people get in and get out quickly
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 2 titanium grommets See the blue lines in part A of the drawing above This is heavy polyester suture We drill through everything, drill through the clavicle, drill through the coracoid, and then, pass (these are some of his little tricks) Pass the suture up through, pull everything down, have your assistant pull it down and you tie that over Then it is rock solid, and they really do well
See the blue lines in part A of the drawing above
This is heavy polyester suture
We drill through everything, drill through the clavicle, drill through the coracoid, and then, pass (these are some of his little tricks)
Pass the suture up through, pull everything down, have your assistant pull it down and you tie that over
Then it is rock solid, and they really do well

So in other words, you don’t do it by going back to the acromion process

You get the torn ligaments to be in continuity again and then they can heal
The polymer is not biodegradable It will stay forever They’re super strong
You don’t let somebody go back to regular activity in a week, but depending on their sport, you can let them get back in maybe 3-4 weeks Certainly 6 weeks as by then, everything is pretty strong
It will stay forever
They’re super strong
Certainly 6 weeks as by then, everything is pretty strong

Emergency orthopedic surgery

Peter just had a patient go through this, the clavicle and mediastinum separated This is not common, but can be very problematic
This patient had a high fall (maybe off a horse), but what surprised Peter was the patient said, “ Look, I just saw two surgeons at HSS and they said I need to have surgery right away ”
This turned out to be one of those things in orthopedics that needs immediate surgery
Alton drew a lordotic view basically of the manubrium sternum (see the figure below) Our breastplate is 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
This is not common, but can be very problematic
Our breastplate is 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
We can feel those sternoclavicular joints

Figure 20. Lordotic view of the manubrium sternum. Sketched by Alton Barron

You can see it’s even worse than the shoulder; it’s a very shallow joint
So if you take a hard blow laterally (a common injury) Cocky players get slammed up against a glass The football players, the quarterbacks that get tackled by these 300 pounders, and their shoulders are wedged together like that It just so happens that the injury that Quinn Ewers (the quarterback for UT) suffered when he 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 such as Peter was talking about, the mechanics can be that It happens a little more commonly in kids, but if the fall is just right and the mechanic’s just right, it will open this up, tear everything and then, displace it behind the manubrium And that’s where a major vein lives (red and blue circles at the top of the drawing above), and that can be hugely life-threatening We have to be careful with those
This one, where it subluxes out the front are also a 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 Alton has had to go in and reconstruct these, where he takes a tendon from the forearm and makes a figure of eight across the front to basically rebuild those ligaments to hold it back in place This is stronger than doing an anchor or something like that
Cocky players get slammed up against a glass
The football players, the quarterbacks that get tackled by these 300 pounders, and their shoulders are wedged together like that
It just so happens that the injury that Quinn Ewers (the quarterback for UT) suffered when he 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 such as Peter was talking about, the mechanics can be that
It happens a little more commonly in kids, but if the fall is just right and the mechanic’s just right, it will open this up, tear everything and then, displace it behind the manubrium And that’s where a major vein lives (red and blue circles at the top of the drawing above), and that can be hugely life-threatening We have to be careful with those
He’s now back
So he obviously didn’t have this full dislocation
But that’s what can happen, in weird circumstances such as Peter was talking about, the mechanics can be that
And that’s where a major vein lives (red and blue circles at the top of the drawing above), and that can be hugely life-threatening
We have to be careful with those
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
Alton has had to go in and reconstruct these, where he takes a tendon from the forearm and makes a figure of eight across the front to basically rebuild those ligaments to hold it back in place This is stronger than doing an anchor or something like that
This is stronger than doing an anchor or something like that

What is it about the insult laterally that will determine a separation at the medial end (sternoclavicular joints) versus the lateral end (acromial end)?

These are two weak points at each end of the clavicle
It more frequently happens at the acromial end, but that’s usually a top down impact That’s usually pitching forward and landing
But what happens more commonly than the SC joint (the sternoclavicular joint) is just a clavicle fracture (these are ubiquitous) And that just fractures somewhere over there We fix them some and we don’t fix others (those heal) But this weird little joint is very important Damage here is not common, but it’s not rare
That’s usually pitching forward and landing
And that just fractures somewhere over there
We fix them some and we don’t fix others (those heal)
But this weird little joint is very important
Damage here is not common, but it’s not rare

Total shoulder replacement [1:55:45]

A lot of people are pretty familiar with the total knee replacement, a total hip replacement
For Peter, the hip replacement has been one of the modern marvels of orthopedic surgery in the last 30 years When he thinks back to when he was in medical school, a shoulder replacement was a brutal procedure Today they are outpatient (unless you have comorbidities)
Alton points out, “ 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 Pain is the primary indication
Alton sees patients all the time who have the ugliest x-rays you’ve ever seen, but they have no pain and they can do whatever they want to do So they’re fine Occasionally, they’ll say, “ Hey, I’m going on a trip, where I want to be able to play golf for 2-3 weeks with my family. Can you give me a cortisone shot ” They get the shot and they rock on They get 3-4 months of relief and keep on going
It’s only the very active people who need to be able to do certain things, and age is not a factor
Alton’s oldest patient who he did shoulder replacements on (quite a long time ago), she was 97 and she was spry and healthy She walked the streets of Manhattan up and down, and she actually was still working at 97 She was the oldest and longest standing employee of a famous place After he did her surgery (back to back), he’d see her on the street, walking down 57th Street, and she’d say, “ Hey doc, I’m doing great ” It totally changed her life, because she couldn’t use her arms and they were hurting so much So age is not a factor
When he thinks back to when he was in medical school, a shoulder replacement was a brutal procedure
Today they are outpatient (unless you have comorbidities)
Usually because of pain
Pain is the primary indication
So they’re fine
Occasionally, they’ll say, “ Hey, I’m going on a trip, where I want to be able to play golf for 2-3 weeks with my family. Can you give me a cortisone shot ” They get the shot and they rock on They get 3-4 months of relief and keep on going
They get the shot and they rock on
They get 3-4 months of relief and keep on going
She walked the streets of Manhattan up and down, and she actually was still working at 97
She was the oldest and longest standing employee of a famous place
After he did her surgery (back to back), he’d see her on the street, walking down 57th Street, and she’d say, “ Hey doc, I’m doing great ”
It totally changed her life, because she couldn’t use her arms and they were hurting so much
So age is not a factor

What caused so much degeneration in her?

Some people just get it
It doesn’t have to be constant subluxations
One of Alton’s attendings when he was in med school residence said, “ Yeah, it’s like a paint job. You can have a paint job that’s a Mercedes or you can have a paint job that’s a Ford Pinto .” It’s the quality of the paint you’re born with That’s the main source of garden-variety osteoarthritis of the shoulder
And then, there are the athletes who are separate categories based on wear and tear
It’s the quality of the paint you’re born with
That’s the main source of garden-variety osteoarthritis of the shoulder

What is the youngest person Alton has done a shoulder replacement on?

Almost 55
He saw a 48-year old guy about 15 years ago who was booked for a replacement Alton told him he was too young for him to operate on and he should at least give him a shot He also recommends a scope clean out The data is not great, but anecdotally patients have about a 50% chance of getting better These patients have arthritis, but they don’t have instability Cleaning them out will buy them some more time It’s a minimal operation, no recovery If people have bilateral osteoarthritis, they don’t need both sides done and are happy with one good side About 15 years later, the guy came back and his shoulder motion was fine His x-rays had not advanced He came back for something else
Another of Alton’s patients was a very athletic woman who was still sailing in regattas at age 75 She was still going racing all the time, pulling lanyards, etc. She complained that she couldn’t do it anymore and wanted to keep doing it Alton replaced both of her shoulders about 4 months apart She gave up sailing for a year but is now back at it
Alton told him he was too young for him to operate on and he should at least give him a shot
He also recommends a scope clean out The data is not great, but anecdotally patients have about a 50% chance of getting better
These patients have arthritis, but they don’t have instability
Cleaning them out will buy them some more time It’s a minimal operation, no recovery If people have bilateral osteoarthritis, they don’t need both sides done and are happy with one good side
About 15 years later, the guy came back and his shoulder motion was fine His x-rays had not advanced He came back for something else
The data is not great, but anecdotally patients have about a 50% chance of getting better
It’s a minimal operation, no recovery
If people have bilateral osteoarthritis, they don’t need both sides done and are happy with one good side
His x-rays had not advanced
He came back for something else
She was still going racing all the time, pulling lanyards, etc.
She complained that she couldn’t do it anymore and wanted to keep doing it
Alton replaced both of her shoulders about 4 months apart
She gave up sailing for a year but is now back at it

Anatomy of a shoulder replacement

There are 2 pieces to it‒ the humeral side and the glenoid side
Alton draws what an arthritic shoulder looks like in the little picture labeled part A in the figure below

Figure 21. An arthritic shoulder (A) and shoulder replacement surgery (B). Sketched by Alton Barron

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 are 2 reasons patients come in
1 – Dysfunction, because they can’t do what they desperately want to do, whether it’s recreational or work sometimes
2 – Pain
Either one of those is a solid indication, when the radiographic findings are there
We do these through a very small 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 the humeral head off (to the right of the diagonal black line) You have a window there, you have retractors in, and you use an oscillating saw and just take that arthritic head off and all the bone spurs Then with that space that that creates, you use another retractor, push the head, 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 socket (drawn in blue in part B of the figure above) This is ultra high molecular weight polyethylene (very durable) It’s the same thing on the tibial plateau
We use these little pegs by drilling holes, put in a little cement, and it’s a perfect new Teflon surface for the cobalt/ chromium (or whatever alloy it is) humeral head The pegs are draw in black in part B of the figure above The metal humeral head is shaded green to the right of the black diagonal line in part B of the figure The bone has a central core and you clean that out (shaded in green to the left of the black diagonal line in part B of the figure) And this is press fit We don’t cement these anymore, unless people have really bad bone or it’s a revision We just press fit it into that cancellous bone and it’s super solid The rotator cuff is still intact on top (the black line above part B of the figure), you’re working around that
Reattach the subscapularis
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
You have a window there, you have retractors in, and you use an oscillating saw and just take that arthritic head off and all the bone spurs
Then with that space that that creates, you use another retractor, push the head, 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 socket (drawn in blue in part B of the figure above) This is ultra high molecular weight polyethylene (very durable) It’s the same thing on the tibial plateau
This is ultra high molecular weight polyethylene (very durable)
It’s the same thing on the tibial plateau
The pegs are draw in black in part B of the figure above
The metal humeral head is shaded green to the right of the black diagonal line in part B of the figure
The bone has a central core and you clean that out (shaded in green to the left of the black diagonal line in part B of the figure)
And this is press fit We don’t cement these anymore, unless people have really bad bone or it’s a revision We just press fit it into that cancellous bone and it’s super solid
The rotator cuff is still intact on top (the black line above part B of the figure), you’re working around that
We don’t cement these anymore, unless people have really bad bone or it’s a revision
We just press fit it into that cancellous bone and it’s super solid

If you’re going to transect the subscapularis, what is the least traumatic place to do it?

On the tendon, where it inserts on the bone

We leave a sleeve, so we can suture tendon to tendon
But then, we also put this heavy suture into bone

So you’ve got bone reinforcement and you’ve got tendon to tendon healing

By doing that, you also maintain the normal length

The biggest thing this person is missing is a labrum

Yes, and they don’t really need it

What stabilizes the joint?

The fact that it’s arthritic, it’s already stabilized itself Unless it’s a weird dislocating joint, which is a different entity (that you have to address that differently) For the garden variety one, they’ve already stiffened up
Unless it’s a weird dislocating joint, which is a different entity (that you have to address that differently)
For the garden variety one, they’ve already stiffened up

So what does their capsule look like when you go in, typically?

It’s super thick
We resect some of it

In a good case, what is the limitation on this person, a year out from surgery?

Really nothing except heavy weights Alton doesn’t want people doing bench press or Iron Cross type things
They can throw a ball and play catch with their grandkids, for sure They can play tennis and golf They can shoot basketball They can swim, that’s a big one what people love Later in life, it’s such good general action exercise
Alton doesn’t want people doing bench press or Iron Cross type things
They can play tennis and golf
They can shoot basketball
They can swim, that’s a big one what people love Later in life, it’s such good general action exercise
Later in life, it’s such good general action exercise

Is this another one of those game changing operations?

It’s different than the hips and the knees, they allow people to live in the world again
Alton won’t do them if he knows he can manage them and kick the can down the road and just inject them once a year with cortisone
He wants them to be dragging that arm in and saying, “Y ou’ve got to do it now. I’m not getting enough relief from the cortisone. ”

The elbow: anatomy, pain points, common injuries, treatments, and more [2:05:30]

Anatomy

Figure 22. Anatomy of the elbow. Image credit: Adapted from Wikipedia and Learn Muscles

The humerus bone is the arm bone is coming down You see it’s a super weird undulating structure there, which makes it intrinsically quite stable So different from the shoulder
You see it’s a super weird undulating structure there, which makes it intrinsically quite stable
So different from the shoulder
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
We have the ulna, which is the fixed straight bone of the forearm
What’s cool about the elbow is the tendons that go down to the forearm and to the hand originate above the joint Juxta-articular, close to the joint but above it And then, the ones that go from the shoulder and arm down attach below the joint
In tennis elbow a tear occurs on the radial collateral ligaments On the inside of the elbow, where our funny bone nerve is The funny bone nerve is the ulnar nerve
Overlying that is the muscles, the flexor pronator muscles , that helps bend the elbow and pronate the forearm And those can tear right in this region (marked with a star in the figure above) That’s actually where we get golfer’s elbow (medial epicondylitis) On, the lateral side, which is the tennis elbow (lateral epicondylitis)
Another common tendon injury occur to the biceps tendon
The 4th (less common), is shown in the lateral where the triceps comes down and attaches to the tip of our elbow
We talked about the bursa before, and there is a bursa that lives over the tip of our elbow And we can get the big golf ball size filling of fluid ( olecranon bursitis )
This is beyond what we’re talking about today, to go into the fractures, but any parts of these can be broken
Juxta-articular, close to the joint but above it
And then, the ones that go from the shoulder and arm down attach below the joint
On the inside of the elbow, where our funny bone nerve is
The funny bone nerve is the ulnar nerve
And those can tear right in this region (marked with a star in the figure above)
That’s actually where we get golfer’s elbow (medial epicondylitis)
On, the lateral side, which is the tennis elbow (lateral epicondylitis)
And we can get the big golf ball size filling of fluid ( olecranon bursitis )

“ The elbow is a very finicky joint. You can see it’s stable, because of those undulating surfaces. But because they’re undulating, there’s less wiggle room. ”‒ Alton Barron

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.
There is a very thick ligament on the inside of the elbow, that is the Tommy John ligament It’s not really Tommy John but he’ll clarify that in a minute That’s the the ulnar collateral ligament , and that’s the one that’s torn in throwing athletes It can be career ending, except now because of the reconstructive surgery, it’s generally not
It’s not really Tommy John but he’ll clarify that in a minute
That’s the the ulnar collateral ligament , and that’s the one that’s torn in throwing athletes It can be career ending, except now because of the reconstructive surgery, it’s generally not
It can be career ending, except now because of the reconstructive surgery, it’s generally not

Why do tennis players get inflammation in the lateral epicondyle , whereas golfers get inflammation in the medial tendon ?

Of course, people who have never played tennis or golf often get these things 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 back hands 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 Alton treats a lot of people age 40-60 And now that’s creeping up to the 70’s Now in competitive tennis players, he’s 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 they are hit using their pronators so much more than they used to, and that’s a reason why it is stimulated more
Of course, people who have never played tennis or golf often get these things
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 back hands 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
Alton treats a lot of people age 40-60 And now that’s creeping up to the 70’s
Now in competitive tennis players, he’s 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 they are hit using their pronators so much more than they used to, and that’s a reason why it is stimulated more
Use patterns are significant for that
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
And now that’s creeping up to the 70’s
And the reason is because everybody is trying to hit massive top spin
And they are hit using their pronators so much more than they used to, and that’s a reason why it is stimulated more
Historically, even golfers were getting it
Alton don’t know why, because you’re not supposed to be overhitting 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 jolt, again, the eccentric load on these tendons, which our tendons don’t like
But now he’s seeing, because golfers are hitting so much harder, they’re hitting bigger clubs (especially drivers and such) and they’re getting more left leading arm lateral epicondylitis
This causes damage on the leading arm when they’re just trying to hit harder and farther

First line treatment

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 NSAIDs by mouth
Rarely does he use physical therapy for these formally, because it’s just not much to do
Sometimes they’re very painful Some people wake up in the morning, they can’t even straighten their elbow out The elbow is spongy and really inflamed He doesn’t splint those but has them stretch More often, because they can’t use their arm, he will go ahead and give them a half dose of cortisone just to cool everything down
Some people wake up in the morning, they can’t even straighten their elbow out
The elbow is spongy and really inflamed He doesn’t splint those but has them stretch More often, because they can’t use their arm, he will go ahead and give them a half dose of cortisone just to cool everything down
He doesn’t splint those but has them stretch
More often, because they can’t use their arm, he will go ahead and give them a half dose of cortisone just to cool everything down

Peter’s experience with elbow pain

Peter remembers Alton injected him 4-5 years ago when he was in the transition of really learning how to control his scapula and had overcooked doing too many pullups The pullup pain was translating into tennis elbow, which surprised him It was a stubborn pain He went to see Alton after 6 months of pain, but that 1 injection cooled it off It never hurt again because he had already fixed the underlying movement pattern
The pullup pain was translating into tennis elbow, which surprised him
It was a stubborn pain
He went to see Alton after 6 months of pain, but that 1 injection cooled it off
It never hurt again because he had already fixed the underlying movement pattern

Is this a common scenario?

Yes, it’s common and this is one reason why Alton doesn’t operate right away
He operates on 20% at the most

Most people get better after a cortisone shot and correcting the underlying movement pattern

What are the indications for operating on the lateral versus the medial side?

The indications are the same‒ failing conservative treatment A lot of stretching and strengthening
A lot of people get these
In Peter’s case, it was mechanics and overdoing
A lot of stretching and strengthening

Many people get these because they’re getting back into something that they haven’t done in a long time and they overdo it

It can be weightlifting or something more mundane like lifting your luggage around on a 2 week vacation

The theme is conditioning, if people don’t have grip strength and are weak

Strengthening is a critical component
Alton has a device he has patents squeeze, and if they can squeeze that without a little pain, he has them do that first Often it will cure it But if they can’t squeeze it without undue pain, he gives them a little dose of cortisone
If it’s chronic, like Peter’s was, then there’s not that much to do Peter is fit, he’s got great tone and full motion So he only needed a little booster dose of cortisone to knock it out
We think sometimes just sticking the needle in a few times kind of stimulates a healing response (we haven’t ever done the study to prove it) Peter has seen a lot of anecdotal stuff around dry needling Just increasing the influx of inflammatory cells and getting macrophages to come and clean it up
Often it will cure it
But if they can’t squeeze it without undue pain, he gives them a little dose of cortisone
Peter is fit, he’s got great tone and full motion
So he only needed a little booster dose of cortisone to knock it out
Peter has seen a lot of anecdotal stuff around dry needling
Just increasing the influx of inflammatory cells and getting macrophages to come and clean it up

Outside of fractures, how often does Alton see acute injuries to the elbow, that ultimately are surgical cases?

Antecedent elbow pain or forearm pain is common in middle age in a very active/ fit person They don’t know what did it but they ruptured their distal biceps and they get a Popeye muscle (see the figure below)
The bicep is the primary supinator of the forearm and a secondary elbow flexor
They don’t know what did it but they ruptured their distal biceps and they get a Popeye muscle (see the figure below)

Figure 23. Anatomy of the elbow and distal biceps tendon. Image Credit: Riley Williams, MD

So when people 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.
In the exam, patients will come in and they won’t be in pain but will have a deformity Alton will pronate them to wrap that tendon kind of around the radius, and then have them pull up, like they’re doing a pronated curl‒ and they scream You get it just isolated And then, you test their supination, and they didn’t know that they didn’t have any supination strength Then you’d test their other side and they can lift you off the table
Alton will pronate them to wrap that tendon kind of around the radius, and then have them pull up, like they’re doing a pronated curl‒ and they scream You get it just isolated
And then, you test their supination, and they didn’t know that they didn’t have any supination strength
Then you’d test their other side and they can lift you off the table
You get it just isolated

When you surgically repair that, are you reattaching the tendon?

Yeah, it’s like a tendonisis
After surgery, many patients say they feel stronger than before the injury But they probably had a partial tear for a long time They were working around, they were little decondition in 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
But they probably had a partial tear for a long time
They were working around, they were little decondition in 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

How Tommy John surgery revolutionized Major League Baseball [2:17:15]

This is a tear on the medial side from the ligament being subjected to super physiologic torques Think high-level throwers who are throwing 90+ mph
When the medial collateral ligament (aka ulnar collateral ligament) is subjected to such traction forces, it will rupture (see the figure below)
Think high-level throwers who are throwing 90+ mph

Figure 24. The Ulnar collateral ligament (aka medial collateral ligament) . Image credit: Performance Health Academy

And the way they keep from rupturing, in general, is by steady long-term fitness Flexor pronator fitness, that’s 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 super physiologic loads
When it ruptures‒ instantaneously, they lose 10 miles per hour on their fast ball They can still throw, but it just immediately downgrades their ability to throw
Flexor pronator fitness, that’s shoulder strengthening, biceps, triceps, and so forth
They can still throw, but it just immediately downgrades their ability to throw

Most of us can’t throw a ball 50 mph. Does this mean I would go from 50 to 40? Would I notice a difference?

This is a common fallacy
You would notice it
If we’re playing catch, we don’t need the ligament

This is really an operation only for the most elite throwers

What was done on Tommy John was not the same operation It was the same ligament, but it was totally different now It’s good to refer to it as that The guy who invented it was brilliant
Some parents will bring their kids in asking for this surgery, who say, “ We know our kid has this great potential ” but their kid has no problem Because so many people have had partial tears (like the biceps), and once they have a reconstruction, they can throw 5-7 mph faster News of that travels through the chat rooms and lore, prompting parents to bring their kids in
It was the same ligament, but it was totally different now
It’s good to refer to it as that
The guy who invented it was brilliant
Because so many people have had partial tears (like the biceps), and once they have a reconstruction, they can throw 5-7 mph faster
News of that travels through the chat rooms and lore, prompting parents to bring their kids in

What type of injury will damage the triceps tendon to the point where it’s coming off the olecranon ?

Figure 25. Anatomy of the triceps tendon and olecranon . Image credit: Sports Injury Clinic

Eccentric loading They almost always tear falling, skiing, when someone is trying to stop themselves from smashing their face Alton sees them every winter
They almost always tear falling, skiing, when someone is trying to stop themselves from smashing their face
Alton sees them every winter

How clean a break is it?

It varies
If someone has a chronic condition and has bone spurs in there, it will pull off part of the bone spur and everything
It’s usually pretty clean

“ But man, the triceps is a huge muscle ”‒ Alton Barron

The triceps is bigger than the biceps
And so the injury here is really disabling People can even pus up out of chairs
You have to fix these injuries
They’re not ruptured in sedentary, low-functioning people
They rupture in active people
People can even pus up out of chairs

Elbow exam:

Discussion about the elbow + elbow exam:

History of hand surgery and the most significant advancements [2:22:15]

Peter points out that he didn’t do a rotation in orthopedics or plastics, so this is like a black box to him
It’s a highly specialized field Anybody who wants to operate on the hand has to complete both the orthopedics program or plastics program and then go on to a dedicated fellowship
Anybody who wants to operate on the hand has to complete both the orthopedics program or plastics program and then go on to a dedicated fellowship

What do we know today about the hand, in terms of repair or injury that wasn’t known when Alton finished his residency?

In the 50s-60s microvascular techniques were developed That was the holy grail of so much in the hand
Prior to this if you had a laceration or war injury, there really wasn’t much you could do for those injuries (especially nerve and blood vessel related) These were not reconstructible, and you would do a lot of amputations
J. William Littler , who was one of 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 luminaries in the field developed these techniques that brought us where we are today
The most significant advancement, since Alton graduated and went into private practice, has been the the complete hand transplantation It involves general surgeons, it involves hand surgeons, it involves a huge team to be able to do that And the results are mixed As recently as 5 years ago, only a few had been done Only in the last several years have these teams been built up at larger institutions to be able to handle this Even then, it’s fraught with peril You have to have a patient in perfect physiology as any comorbidities greatly decrease the likelihood of success And it requires a huge investment for the patients themselves A bilateral hand amputee is usually the one that can qualify for this surgery (as opposed to a single hand amputee), and they have to meet all the physiologic parameters
The hand transplantation is joined at the midpoint of the wrist At the distal forearm where you’re beyond that transition zone and can link up tendon to tendon The nerves need to be linked as well
You have to HLA match these things because they’re all cadaveric
The only other thing that’s changed a lot, that relates so much to the hand, 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
That was the holy grail of so much in the hand
These were not reconstructible, and you would do a lot of amputations
And that’s how he and other luminaries in the field developed these techniques that brought us where we are today
It involves general surgeons, it involves hand surgeons, it involves a huge team to be able to do that
And the results are mixed
As recently as 5 years ago, only a few had been done
Only in the last several years have these teams been built up at larger institutions to be able to handle this Even then, it’s fraught with peril You have to have a patient in perfect physiology as any comorbidities greatly decrease the likelihood of success And it requires a huge investment for the patients themselves
A bilateral hand amputee is usually the one that can qualify for this surgery (as opposed to a single hand amputee), and they have to meet all the physiologic parameters
Even then, it’s fraught with peril
You have to have a patient in perfect physiology as any comorbidities greatly decrease the likelihood of success
And it requires a huge investment for the patients themselves
At the distal forearm where you’re beyond that transition zone and can link up tendon to tendon
The nerves need to be linked as well

“ These electrical prosthesis now that are linked to the brain, it’s cool ”‒ Alton Barron

Are there injuries in the forearm 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
It’s really more the elbow more than anything because most of these injuries, the patients can still control their shoulder, can position the arm somewhere
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 are many limitations just trying to get through an average day
To be able to flex the elbow for instance, or extend the elbow or flex the wrist
There are many limitations just trying to get through an average day

What fraction of those injuries that require surgical intervention are the result of an acute trauma versus chronic injury (wear and tear)?

It varies depending on where you are
Alton took trauma calls for a couple of decades, but not any more
He sees cold trauma that still needs surgery, but it’s not acute It’s subacute and it needs to be fixed in a delayed fashion
If you are in a practice such as a county hospital where there’s trauma coming in (whether it’s hunters, highways, etc.), then a much higher percentage of your day and your week is spent repairing acute, traumatic, often polytrauma injuries
Alton is in a mature metropolitan type practice where it’s more in the area of 50/50 There’s plenty of arthritic conditions, of wear and tear conditions (gym work, or getting back into various forms of exercise, or the weekend warrior phenomenon) And those are not dramatic traumatic injuries And then there are the people that are falling off the scooters and water skiing and dislocating their shoulders, all that spectrum But the actual acute… something as mundane as cutting avocados, he sees tons of nerve injuries and tendon injuries in the palm
It’s subacute and it needs to be fixed in a delayed fashion
There’s plenty of arthritic conditions, of wear and tear conditions (gym work, or getting back into various forms of exercise, or the weekend warrior phenomenon) And those are not dramatic traumatic injuries
And then there are the people that are falling off the scooters and water skiing and dislocating their shoulders, all that spectrum
But the actual acute… something as mundane as cutting avocados, he sees tons of nerve injuries and tendon injuries in the palm
And those are not dramatic traumatic injuries

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

Peter’s takeaway: 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. The hand is really complex.

The hand: anatomy, common injuries, and surgeries of the hand and wrist [2:29:30]

Anatomy of the hand

There are 3 bones in each finger (except for the thumb, which has 2), so 12+2 = 14 bones
Then you have the next layer, which are the metacarpals , 5 of those
And then the carpal bones in the wrist are 8 small bones They are are called coalitions where they’re fused together Alton had a resident that used to make fun of hand surgeons who would say, “ Never operate on a bone you can swallow ” He was just, in a fun way, piling the fine smaller, caliber things that we’re dealing with in the hand and wrist region
The wrist owns the one bone that is the hardest to heal in the body, the scaphoid bone (see the figure below) “ 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 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 retrogrades So if you crack that bone in the middle (at baseline), it has very little blood supply, and you probably disrupt it This one generally takes 10-12 weeks to heal (compared to 6 weeks for the average bone)
They are are called coalitions where they’re fused together
Alton had a resident that used to make fun of hand surgeons who would say, “ Never operate on a bone you can swallow ”
He was just, in a fun way, piling the fine smaller, caliber things that we’re dealing with in the hand and wrist region
“ 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 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 retrogrades So if you crack that bone in the middle (at baseline), it has very little blood supply, and you probably disrupt it This one generally takes 10-12 weeks to heal (compared to 6 weeks for the average bone)
It goes in retrogrades
So if you crack that bone in the middle (at baseline), it has very little blood supply, and you probably disrupt it
This one generally takes 10-12 weeks to heal (compared to 6 weeks for the average bone)

Figure 26. The scaphoid bone highlighted in red. Image credit: Wikipedia

What’s the common injury that breaks the scaphoid?

A hard fall with just the right position of the wrist, where it’s leveraging on that A directed wrist extension force
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
A directed wrist extension force

Does a patient with a broken scaphoid typically present with a lot of pain?

No, often they know they injured their wrist and they’ll get some swelling there, but it’s not that bad Often in young athletes that are used to pain, they just shake it off
There’s no great distortion of the wrist when you fracture your distal radius , it just swells up and looks like a dinner fork
Often in young athletes that are used to pain, they just shake it off

Figure 27. Location of the radius and X-ray of a distal radius fracture . Image source: Wikipedia

Often athletes with a fractured scaphoid bone come in at 6 weeks because they can’t lift weights, they can’t shuck somebody on the offensive line, etc.

Is the scaphoid fracture the one that’s really easy to miss on an X-ray? Would a MRI or CT scan be the imaging of choice?

A MRI is used to detect occult hidden fractures
The scaphoid is not big enough for a CT
We can see edema
Peter has seen a number of people who had this issue and it’s been long enough that they don’t necessarily tie the problem back to the fall

The evolution of treatment for these patients

Historically, we treated all of these non-operatively
Then there was an Australian fellow named Herbert who came up with a really ingenious screw that had two sets of threads on it and they were a 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 (called the Herbert screw) And that was a game changer for us, especially for treating athletes
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 (called the Herbert screw)
And that was a game changer for us, especially for treating athletes

Where do you access this bone operatively?

There are different schools of thought
When Alton was coming out of training, everybody made a full incision to expose everything (on the underside of the thumb near the base of the thumb and wrist ) And you had jigs that you can put those screws down
Alton does almost all of his via a small, percutaneous incision, and he’ll go either retrograde often or antegrade (working from the top side of the thumb at the base) 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 hand drill to drill out that and then put the screw down over the wire It’s really great because patients hardly feel that they’ve had any surgery They heal very quickly, faster This allows you to start movement earlier so that when it is healed, you already have your movement back so you’re not stiff and needing to do a lot of physical therapy
And you had jigs that you can put those screws down
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 hand drill to drill out that and then put the screw down over the wire
It’s really great because patients hardly feel that they’ve had any surgery
They heal very quickly, faster
This allows you to start movement earlier so that when it is healed, you already have your movement back so you’re not stiff and needing to do a lot of physical therapy

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 We put them in a splint As long as you mobilize the wrist (even if the thumb and fingers are free), these will heal
Athletes often get a screw because they just can get back faster, even with protection
We put them in a splint
As long as you mobilize the wrist (even if the thumb and fingers are free), these will heal

What is the time course for recovery?

Let’s say you go and get the MRI to confirm the fracture right away and have surgery the next day You’ll be back catching a ball in 6 weeks
As long as it’s not contact, the surgeon can operate in a week It’s really fast, a game changer now
You’ll be back catching a ball in 6 weeks
It’s really fast, a game changer now

What is the safest wrist position?

Peter notes, “ You 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 two 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 .””

A neutral position in terms of the carpus, some wrist extension

Too much flexion or too much extension increases the pressure on the median nerve and the carpal tunnel (see the figure of nerves in the arm below)
So people can get acute carpal tunnel syndrome (especially with some extra swelling from the injury) That can be quite substantial in those more extreme positions
So a neutral position is best for function in terms of 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
On occasion if Alton has to immobilize a musician for example, he will immobilize them in the position they need to play their instrument Everybody’s different It’s an important consideration
That can be quite substantial in those more extreme positions
Everybody’s different
It’s an important consideration

What do we need to understand about the anatomy of the radial bone, the ulna bone, and these 2 big nerves (the median nerve and ulnar nerve)?

The median nerve and ulnar nerve are shown in the figure below The ulnar nerve runs on the pinky side
The ulnar nerve runs on the pinky side

Figure 28. A. Nerves of the left arm and the B. ulnar nerve . Image credit: Wikipedia

The 3rd nerve which completes the hand is the radial nerve That’s profusely sensory, but it is important and provides sensory input on the back side of the hand and thumb
Both the ulnar and radial nerve are at risk for lacerations They’re at risk even when you distort the anatomy through a fracture
That’s profusely sensory, but it is important and provides sensory input on the back side of the hand and thumb
They’re at risk even when you distort the anatomy through a fracture

What is the approximate size of the median nerve?

Peter remembers it was bigger than he expected and about 3-4 mm wide by 2 mm deep
It’s an oval shape and it varies, but it is even bigger than this A smaller petite person would have one about that size Alton has seen them as large as almost 12 cm wide and 4-5 mm thick in a large hand
Peter remarks, “ I guess speaks to the innovation of this unbelievable part of our body that occupies so much of our homunculus ”
Meaningful hand use is so important for cognitive development and wellbeing Over 60% of our higher cortical neurons are devoted just to our hand through the homunculus The sensory homunculus (shown below) has big ears, big eyes, but huge hands and then a tiny shriveled up torso
A smaller petite person would have one about that size
Alton has seen them as large as almost 12 cm wide and 4-5 mm thick in a large hand
Over 60% of our higher cortical neurons are devoted just to our hand through the homunculus
The sensory homunculus (shown below) has big ears, big eyes, but huge hands and then a tiny shriveled up torso

Figure 29. Sensory homunculus . Image credit: Wikipedia

“ We need to keep using our hands to keep our minds vital in whatever form we’re doing ”‒ Alton Barron

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 Not typing nor texting
But handwriting still does stimulate our brain It’s an art form even though it doesn’t feel like it for many of us Alton recalls a study done a long time ago at Virginia (or maybe Indiana), and they looked at kids who were asked to hand write versus type the answers to essay questions The kids who were handwriting used longer sentences, bigger words, more ideas, and produced it faster than the kids who were typing There was way more cortical activity with handwriting
And it doesn’t stimulate our cortex very much at all
Not typing nor texting
It’s an art form even though it doesn’t feel like it for many of us
Alton recalls a study done a long time ago at Virginia (or maybe Indiana), and they looked at kids who were asked to hand write versus type the answers to essay questions The kids who were handwriting used longer sentences, bigger words, more ideas, and produced it faster than the kids who were typing There was way more cortical activity with handwriting
The kids who were handwriting used longer sentences, bigger words, more ideas, and produced it faster than the kids who were typing
There was way more cortical activity with handwriting

There are 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

Carpal tunnel syndrome [2:40:00]

If you took a cross-section through the hand the carpal tunnel is created by a Roman arch of bones (shown in the figure below)
We have a tie bar across the top, which is a very thick transverse carpal ligament and it holds that together That creates a U-shaped inverted parabola tunnel through which the 9 flexor tendons and the median nerve pass and occasionally, a medium sized artery
That creates a U-shaped inverted parabola tunnel through which the 9 flexor tendons and the median nerve pass and occasionally, a medium sized artery

Figure 30. The carpal tunnel . Image credit: Wikipedia

There are 9 flexor tendons

Figure 31. Flexor tendons . Image credit: OrthoInfo

There are 2 flexor tendons in each finger (shown above) and 1 in the thumb (9 total)
If we look at our palm up, the median nerve is running down almost the center of the wrist and it is vulnerable to compression So that if we then flex our wrist down, those flexor tendons are trying to bow string down, they will press that median nerve up against that rigid transverse carpal ligament Swelling (edema) can compress that nerve as well (a problem with rheumatoid arthritis) The tendons aren’t really vulnerable in that way, but the nerve is very vulnerable to compression, and that’s why it’s such a ubiquitous problem
So that if we then flex our wrist down, those flexor tendons are trying to bow string down, they will press that median nerve up against that rigid transverse carpal ligament
Swelling (edema) can compress that nerve as well (a problem with rheumatoid arthritis)
The tendons aren’t really vulnerable in that way, but the nerve is very vulnerable to compression, and that’s why it’s such a ubiquitous problem

Which functions are controlled by the median nerve versus the ulnar nerve?

People often come to Alton thinking they have carpal tunnel syndrome (because it’s so ubiquitous)
Carpal tunnel syndrome 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
However, if you have an arthritic process, without having as much numbness and tingling, you can have isolated atrophy of the muscles You have atrophy of the thumb muscles It can be very gradual It occurs from the encroachment on that nerve of bone spurs that grow through he arthritic process
Rarely in a younger person, Alton 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 without any numbness and tingling But they will have isolated atrophy, and that needs to be addressed surgically
Which is the palm side of the thumb, index, middle, and usually half of the ring finger
You have atrophy of the thumb muscles It can be very gradual It occurs from the encroachment on that nerve of bone spurs that grow through he arthritic process
It can be very gradual
It occurs from the encroachment on that nerve of bone spurs that grow through he arthritic process
They’ll have a weird compression of just that without any numbness and tingling
But they will have isolated atrophy, and that needs to be addressed surgically

People who often get carpal tunnel syndrome

Pregnant women often have carpal tunnel in the 3rd trimester simply due to swelling and fluid imbalances
People can get carpal tunnel if they’re always pressing down and putting extra pressure on that area It’s a dynamic situation 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. Weightlifters can get it, depending on the style of what they’re doing
It’s a dynamic situation
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.
Weightlifters can get it, depending on the style of what they’re doing

“ Generally speaking, most people don’t get carpal tunnel just from typing ”‒ Alton Barron

There was a massive class action lawsuit against IBM many years ago, and they lost the case because there was no data to suggest that it was caused by just using a keyboard
However, if you already have it, typing will absolutely exacerbate it That’s why ergonomics are so important, how you’re sitting
During COVID, everybody went back home and worked from home and worked at random places (the kitchen table, with their laptop in bed) Alton saw a lot more of both wrist tendonitis and carpal tunnel syndrome after that That doesn’t affect the ulnar nerve, it involves the median nerve
That’s why ergonomics are so important, how you’re sitting
Alton saw a lot more of both wrist tendonitis and carpal tunnel syndrome after that
That doesn’t affect the ulnar nerve, it involves the median nerve

The ulnar nerve

While our opposable thumb is critically important, that’s governed mostly by the median nerve
The ulnar nerve is so important because it supplies almost all the rest of the small muscles (intrinsic muscles) of the hand These allow us to spread our fingers apart, pull our fingers together, do these weird funky positions that we do Like the intrinsic plus position, that is almost all ulnar nerve
The intrinsic flexors are ulnar
The extrinsics are split between the median (more approximately in the forearm)
From an evolutionary perspective, the hand is a pretty primitive structure Except for the opposable thumb
Our foot is fantastically adapted and modified over evolution to walk When we stood up, our food completely changed
Our brains grew when we started using our hands and making tools That’s when our heads enlarged
These allow us to spread our fingers apart, pull our fingers together, do these weird funky positions that we do
Like the intrinsic plus position, that is almost all ulnar nerve
Except for the opposable thumb
When we stood up, our food completely changed
That’s when our heads enlarged

Other common injuries of the hand and forearm [2:47:15]

There are 3 categories of common hand injuries

1 – Acute traumatic events (usually fractures, sometimes dislocations)
2 – Wear and tear injuries (begin in middle age and go on into older age)
3 – Degenerative arthritic types of problems This will vary among individuals based on genetics and lifestyle
This will vary among individuals based on genetics and lifestyle

Fractures

The most common by far is the distal radius fracture (the big bone of the radius near the wrist)
Now, the the forearm is super cool (shown in the figure below)

Figure 32. Bones of the forearm, the radius and ulna. Image credit: Mayo Clinic

We already talked about the elbow, 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 That’s a straight bone and that goes down and it forms the bump here that we see on the back of our wrist
The radius is a curved, arching bone The radius is flared and provides the biggest structure at the wrist level, but it’s much smaller at the elbow level It rotates around through a fixed ulna (the ulna never moves rotationally) a So any disruption of that can dramatically alter our ability to hold a bowl of soup or to pronate and type and write And that can be disrupted in many ways
It’s super common to fall and have a bending moment on the radius that fractures and displaces it Alton sees this commonly in kids who fall off jungle gyms They’ll have both a forearm fracture and a mid forearm fracture, and that’s just another bending moment That can very much disrupt the function there
At any different point along the forearm (depending on the mechanism), these bones can break
And if they’re displaced, we have to often fix them (except in very young kids)
That’s a straight bone and that goes down and it forms the bump here that we see on the back of our wrist
The radius is flared and provides the biggest structure at the wrist level, but it’s much smaller at the elbow level
It rotates around through a fixed ulna (the ulna never moves rotationally) a
So any disruption of that can dramatically alter our ability to hold a bowl of soup or to pronate and type and write
And that can be disrupted in many ways
Alton sees this commonly in kids who fall off jungle gyms They’ll have both a forearm fracture and a mid forearm fracture, and that’s just another bending moment
That can very much disrupt the function there
They’ll have both a forearm fracture and a mid forearm fracture, and that’s just another bending moment

Nursemaid’s elbow

A nursemaid’s elbow occurs when a parent grabs a kid by the arm to yank them across the road
This is a subluxation of that round radial head at the elbow
Alton had the interesting and formative experience to create one in his first daughter He remembers spinning her around, she was giggling and so forth Then he felt just the tiniest little weird movement in her elbow, it kind of threw her hand He saw her face start to scrunch up and set her down Then he just had this vision, he knew what it was He quickly did the reduction maneuver so fast that she hadn’t even started crying, and then it just immediately stopped hurting
He remembers spinning her around, she was giggling and so forth
Then he felt just the tiniest little weird movement in her elbow, it kind of threw her hand
He saw her face start to scrunch up and set her down
Then he just had this vision, he knew what it was
He quickly did the reduction maneuver so fast that she hadn’t even started crying, and then it just immediately stopped hurting
When you pronate, it will cause that radial head just to slip out (pop up) a little bit
So the easy maneuver is you supinate (twist the forearm towards the core so the palm faces up) and flex the elbow up with a little pressure (bend at the elbow to bring the hand up to the chest) This is the most stable position of that bone And it will pop right back in every time
If it stays out and you sit in an emergency room for 6-8 hours, then it’s harder to get back in You’ll often have to do it under anesthesia
Peter has seen a lot of radial fractures in friends and kids and it really seems like one of those awful luck things If you fall out of a tree, slip on ice, etc.
Then the older we get, if we have a little osteopenia or osteoporosis , then it takes less and less force to fracture those bones
This is the most stable position of that bone
And it will pop right back in every time
You’ll often have to do it under anesthesia
If you fall out of a tree, slip on ice, etc.

Does the ulna ever break on its own?

The most common cause is a direct blow
For example in football, it can be a weight falling
It can be a door smashing into you, that’s called a nightstick fracture Named for the billy clubs in the UK where it would strike you when you had was up and it cracks the ulna That’s the most common
Often it is fractured in association with the distal radius The styloid part can come off, it’s attached to a ligament or it can just both snap same time, and that complicates the treatment
Then the other common one is really more of an elbow fracture, it’s the ulna (the olecranon) That’s when you fall on your elbow The only other way you can pull that bone off is if you fall really hard, say snow skiing With the eccentric load, that triceps pulls it right off Alton loves that Peter educates so many people about eccentric loading because it’s more injurious in a way
Named for the billy clubs in the UK where it would strike you when you had was up and it cracks the ulna
That’s the most common
The styloid part can come off, it’s attached to a ligament or it can just both snap same time, and that complicates the treatment
That’s when you fall on your elbow
The only other way you can pull that bone off is if you fall really hard, say snow skiing
With the eccentric load, that triceps pulls it right off
Alton loves that Peter educates so many people about eccentric loading because it’s more injurious in a way

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

Overuse patterns are more tendonitis
There are subtle differences between tendonitis and tenosynovitis
Tendonitis is just inflammation in the tendon If the tendon is 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 envelope the tendon This is a constant rubbing and further degeneration of that You get chronic pain You can inject it with cortisone, but ultimately they can rupture depending on how much force they’re being subjected to and for how long it’s been there
Tenosynovitis is a subset of that where we have these effectively watertight tubes, on our flexor tendons (the synovium ) Our body produces a little bit of lubricating fluid to keep the tendons gliding smoothly in there It can get inflamed from overuse and the tendon becomes trapped in there and it really hurts It can limit mobility and can even cause the tendon to lock down sometimes He often cures this with a cortisone shot, rest, or both A subset of them ultimately require surgery (which is very minor)
This is important for 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
If the tendon is 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 envelope the tendon
This is a constant rubbing and further degeneration of that
You get chronic pain
You can inject it with cortisone, but ultimately they can rupture depending on how much force they’re being subjected to and for how long it’s been there
Our body produces a little bit of lubricating fluid to keep the tendons gliding smoothly in there
It can get inflamed from overuse and the tendon becomes trapped in there and it really hurts
It can limit mobility and can even cause the tendon to lock down sometimes
He often cures this with a cortisone shot, rest, or both
A subset of them ultimately require surgery (which is very minor)
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

Grip strength [2:55:15]

Peter is obsessed with grip strength and about a year ago he started experimenting with training the way rock climbers do, where you’re only using finger strength What blew him away was how much weaker he felt all the way through his lats when he would restrict the amount of fingers he used to do a pull-up It took him a while to work up to 10, 4-finger pull-ups (a couple months) Then he moved to 3-finger pull-ups, and that was an order of magnitude harder
What blew him away was how much weaker he felt all the way through his lats when he would restrict the amount of fingers he used to do a pull-up
It took him a while to work up to 10, 4-finger pull-ups (a couple months) Then he moved to 3-finger pull-ups, and that was an order of magnitude harder
Then he moved to 3-finger pull-ups, and that was an order of magnitude harder

Why is it when I use only 3 fingers that all of my strength fades away?

Alton has a couple of theories
1 – It could be that your brain is holding you back For example, this applies to the weakness you feel and detect asymmetrically in a rotator cuff If you have a small partial thickness rotator cuff tear (tiny and mechanically not relevant), yet you can be quite weak Your brain is so smart, it knows it doesn’t want to overstress that area Alton’s 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 one. So I’m going to relax everything. I’m not going to give you what you need because they may rupture .”
What’s ironic is that the ulnar nerve is much more important for grip strength This innervates only 2 fingers‒ the pinky and ring finger
For example, this applies to the weakness you feel and detect asymmetrically in a rotator cuff
If you have a small partial thickness rotator cuff tear (tiny and mechanically not relevant), yet you can be quite weak
Your brain is so smart, it knows it doesn’t want to overstress that area
Alton’s 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 one. So I’m going to relax everything. I’m not going to give you what you need because they may rupture .”
This innervates only 2 fingers‒ the pinky and ring finger
Let’s say you have an ulnar nerve that’s completely in and a median nerve that’s out, you’re going to be pretty strong still
Whereas if you have an ulnar nerve out and a median nerve that’s still in, you’re going to be much weaker The middle finger, forefinger and thumb are under the median nerve distribution
The middle finger, forefinger and thumb are under the median nerve distribution

Peter’s takeaway :

The pinky and ring finger matter more to grip strength than middle finger, fore finger, thumb
You can engage your forearms much more with your pinky and ring finger
He is endlessly fascinated by what our hands are capable of It’s such a force multiplier for our species It’s an unbelievable asset in our ability to carry things Michael Easter has written about this in his book The Comfort Crisis , which introduced us all to rucking Other animals (domesticated) can carry a lot on their back, but we can carry our body weight in our hands Alton adds, “ 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 .”
It’s such a force multiplier for our species
It’s an unbelievable asset in our ability to carry things Michael Easter has written about this in his book The Comfort Crisis , which introduced us all to rucking Other animals (domesticated) can carry a lot on their back, but we can carry our body weight in our hands
Alton adds, “ 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 .”
Michael Easter has written about this in his book The Comfort Crisis , which introduced us all to rucking
Other animals (domesticated) can carry a lot on their back, but we can carry our body weight in our hands

Arthritis in the hands [2:59:30]

There are 2 types
1 – Rheumatoid arthritis An autoimmune form of arthritis It impedes function and physically deforms the fingers in the joints
2 – Common osteoarthritis More of a wear and tear problem It’s doesn’t have an autoimmune component
Currently Alton sees very few rheumatoid arthritis patients because there is so much more medical therapy available for them now The biologics are amazing, an absolute game changes in keeping people normal for a long time
When he started his practice he would operate as often in a patient with rheumatoid arthritis, but now he sees maybe 1 a month that needs surgery It’s pretty rare
An autoimmune form of arthritis
It impedes function and physically deforms the fingers in the joints
More of a wear and tear problem
It’s doesn’t have an autoimmune component
The biologics are amazing, an absolute game changes in keeping people normal for a long time
It’s pretty rare

For Rheumatoid arthritis

Surgery is needed because of functional limitations in the hand This can also occur in the elbow and shoulder
It’s a tendon subluxation, joint deviation that weakens their hand and decreases their ability to remain independent
This can also occur in the elbow and shoulder

For Wear and tear osteoarthritis

This varies among individuals
Some people have really good hands until the very end
Alton compares it to a nice paint job on a car and a cheap one
There’s a big genetic component
He will see some young patients (50 years old) that already have a lot of visible alterations Not affecting function so much as they are getting the knobbiness and inflammation in the joints
Not affecting function so much as they are getting the knobbiness and inflammation in the joints

Arthritis at the base of the thumb

Arthritis at the base of the thumb is ubiquitous, about 50% of all of us will develop this

It’s a biomechanics problem, there are 6 degrees of freedom
It’s this biconcave saddle joint that in order to come back and forth this way (radial and ulnar deviation), then straight up (palmar abduction), and then rotating around and pronating in order to oppose the thumb tip to the fingertips
It’s doing 3 different directional movements and it just wears out
It’s just subjected to so many odd stresses and it’s unstable like the shoulder

In what fraction of those people will osteoarthritis at the base of the thumb pose a functional limitation, more than something that is treatable with some Aleve here and there?

We don’t know the exact subset
Many people walk around with osteoarthritis and never have pain They have some stiffness and some deformity
Of the people that present with some pain, about 25% of those potentially are going to need surgery for that at some point This would be around 12.5 % of the overall population
They have some stiffness and some deformity
This would be around 12.5 % of the overall population

“ One fourth of the people that present with pain in the thumb are going to need surgery ”‒ Alton Barron

What is the surgical procedure?

It varies depending on what stage they present at, but it’s some form of reconstruction
Unlike the hips and knees that are so ubiquitous and so wonderful, 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
What we use is basically a reconstruction using your own tissue
Because of the way we evolved, we have so much protective redundancy (this is super cool) We have so many tendons All of the flexor tendons that flex the fingers also flex the wrists and give a strength We have multiple tendons that pull the thumb out They do subtle differences But we use those for tendon grafts
Going back to evolution, hold your hands out and touch the tips of your thumbs and pinky finger There is a big tendon that pops up on the underside of the wrist/ forearm Alton has it on his right arm but not his left, and Peter has huge ones on both sides That’s the palmaris longus Those are hugely developed in quadrupeds, in horses and so forth, a big important muscle But they don’t do anything in us so they are used as a tendon graft all the time We’re evolving, 15% of people don’t have 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
We have so many tendons
All of the flexor tendons that flex the fingers also flex the wrists and give a strength
We have multiple tendons that pull the thumb out They do subtle differences But we use those for tendon grafts
They do subtle differences
But we use those for tendon grafts
There is a big tendon that pops up on the underside of the wrist/ forearm
Alton has it on his right arm but not his left, and Peter has huge ones on both sides
That’s the palmaris longus
Those are hugely developed in quadrupeds, in horses and so forth, a big important muscle
But they don’t do anything in us so they are used as a tendon graft all the time
We’re evolving, 15% of people don’t have this

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

You’re not recreating some artificial joint (at the base of the thumb)
What we’re creating is a pseudoarthrosis We stabilize it, get it stabilized back on top Alton takes a little bit of the bone off to create a space and then he rolls up the rest of that tendon and put it in there as a cushion This relieves the pain and restores function
This operation has a high level of success
We stabilize it, get it stabilized back on top
Alton takes a little bit of the bone off to create a space and then he rolls up the rest of that tendon and put it in there as a cushion
This relieves the pain and restores function

“ I don’t know how I didn’t realize you could make a case that roughly 5-10% of the population will require this at some point in their life .”‒ Peter Attia

This is the single most common, non-traumatic surgical repair of the hand along with a trigger finger

Trigger finger [3:07:45]

Trigger finger is what we were talking about before with inflammation of the tendon sheath Right in the middle of the hand, there’s a series of pulleys
Right in the middle of the hand, there’s a series of pulleys

Figure 33. Anatomy of the middle finger viewed from the side. Sketched by Alton Barron

Take for example the middle finger, it’s the longest There are 4 bones of the finger (see the figure above) The metacarpal and 3 bones of the phalanges The metacarpal is hidden in the hand The flexor tendon is drawn in black, this allows you to do your pull-ups If you had a muscle attached to this and you pulled on it and didn’t have those blue structures (pulleys), 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, you lose the capacity to really curl your fingers tightly The tendon is gliding through the tendon sheath and held closely to finger bones by pulleys The A1 pulley is shown in the figure below
There are 4 bones of the finger (see the figure above) The metacarpal and 3 bones of the phalanges The metacarpal is hidden in the hand
The flexor tendon is drawn in black, this allows you to do your pull-ups
If you had a muscle attached to this and you pulled on it and didn’t have those blue structures (pulleys), 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, you lose the capacity to really curl your fingers tightly
The tendon is gliding through the tendon sheath and held closely to finger bones by pulleys The A1 pulley is shown in the figure below
The metacarpal and 3 bones of the phalanges
The metacarpal is hidden in the hand
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, you lose the capacity to really curl your fingers tightly
The A1 pulley is shown in the figure below

Figure 34. Pathology of a trigger finger. Image credit: OrthoInfo

The pulleys (blue structures on Alton’s drawing) are fibro-osseous tunnels that is very strong (think rock climbing) They can rupture because you’re putting so much force on those in such funky positions and isolating 2 fingers, 1 finger, and so forth Alton sees that a lot in rock climbers
They can rupture because you’re putting so much force on those in such funky positions and isolating 2 fingers, 1 finger, and so forth
Alton sees that a lot in rock climbers

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) and you can get inflamed along that sheath

This particular pulley here is down in the palm (A1), 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, then it just actually catches
We call it a trigger finger because it has a feeling like pulling a trigger on a gun
They’re ubiquitous
And that thickening up of that pulley, then it just actually catches

Treatment

We frequently inject those with cortisone and frequently have to operate If you take someone who presents within say 6 weeks of onset, there’s about a 75% cure rate with 1 or 2 injections
The longer you wait, the more potential damage and more chronic inflammation that ensues
In these types of soft tissue procedures, we don’t keep injecting cortisone because it can lead to soft tissue degradation And ultimately even tendon ruptures (Alton has never seen one, but it can happen)
If you take someone who presents within say 6 weeks of onset, there’s about a 75% cure rate with 1 or 2 injections
And ultimately even tendon ruptures (Alton has never seen one, but it can happen)

What is the rule of thumb for how many times you’ll put in a cortisone shot?

3 in the lifetime of a tendon sheath

Unless it’s very, very broad
Usually, you don’t see someone back 10 years later who needs another injection

Extensor tendons versus flexor tendons

The extrinsic extensor tendon will straighten up the knuckles, but then we look further out and see that tendon stops at the middle knuckle
What pulls the whole finger straight is actually this intrinsic muscle 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 Then it goes all the way on and attaches to the tip It’s a super cool mechanism that through a series of mechanical placements, it’s able to extend (straighten) the finger by contracting But it doesn’t take much to damage that tendon If you take a direct blow to that knuckle and that tendon 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 Boutonnière deformity Then you cannot straighten your finger up because those lateral bands that are used to extend the finger have slipped down and become a flexor
It turns into a lateral band and it travels from the palm side up above the middle knuckle, above that axis of rotation
Then it goes all the way on and attaches to the tip
It’s a super cool mechanism that through a series of mechanical placements, it’s able to extend (straighten) the finger by contracting
But it doesn’t take much to damage that tendon If you take a direct blow to that knuckle and that tendon 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 Boutonnière deformity Then you cannot straighten your finger up because those lateral bands that are used to extend the finger have slipped down and become a flexor
If you take a direct blow to that knuckle and that tendon 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 Boutonnière deformity
Then you cannot straighten your finger up because those lateral bands that are used to extend the finger have slipped down and become a flexor

Emergency surgery in the hand

Peter vaguely remembers one emergency surgery in the hand where that sheath had become infected
Alton notes, “ Yes. It’s one of the few really orthopedic emergencies in the hand, which is tenosynovitis , and then it becomes separative (or infected) with puss in there. I mean, there’s so many nerves in our hand anyway, when you get even a few drops of purulent puss 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… It’s an operative emergency. ”

How does a person get that infection?

It can be an open injury or even a pin prick Sometimes an insect bite or sting If you’re using sports equipment, you can get a little graphite puncture
Alton doesn’t see them as much now because he’s not in the ER
They’re ubiquitous and they come in all the time, year round
Sometimes an insect bite or sting
If you’re using sports equipment, you can get a little graphite puncture

Hand & wrist exam:

Discussion about the hand & wrist + exam:

Nerve pain, numbness, and weakness in the upper limbs [3:14:00]

Parsonage-Turner syndrome

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 scaling muscles and then travels through our armpit and then comes down in through the arm and into the hand
It can be confounding
An example is Parsonage-Turner syndrome (aka brachial neuritis, as in brachial plexus neuritis) It’s uncommon but a fascinating study in that whole process from the neck down It’s an inflammation of those nerves We think it’s probably viral related because there’s usually a viral prodrome associated, but it doesn’t have to be It’s an acute dramatic onset of pain all through here It is a mixed plexopathy can be in multiple different nerves It’s a mixed bag of palsy, weakness, and numbness One of the most common presenting ways is in the long thoracic nerve , which is part of the brachial plexus You get scapular winging where 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 that It presents as a mix, it affects multiple nerves because those nerves are more common up here and then they diverge into the different nerves Alton still remembers trying to learn the brachial plexus in med school and it was brutal because it’s really complicated These are people who show up and you certainly couldn’t attribute what they’re experiencing to any one thing It’s like they would have to have six lesions simultaneously
It’s uncommon but a fascinating study in that whole process from the neck down
It’s an inflammation of those nerves
We think it’s probably viral related because there’s usually a viral prodrome associated, but it doesn’t have to be
It’s an acute dramatic onset of pain all through here
It is a mixed plexopathy can be in multiple different nerves
It’s a mixed bag of palsy, weakness, and numbness
One of the most common presenting ways is in the long thoracic nerve , which is part of the brachial plexus
You get scapular winging where 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 that
It presents as a mix, it affects multiple nerves because those nerves are more common up here and then they diverge into the different nerves Alton still remembers trying to learn the brachial plexus in med school and it was brutal because it’s really complicated
These are people who show up and you certainly couldn’t attribute what they’re experiencing to any one thing It’s like they would have to have six lesions simultaneously
Because the muscle of the shoulder girdle cannot support that
Alton still remembers trying to learn the brachial plexus in med school and it was brutal because it’s really complicated
It’s like they would have to have six lesions simultaneously

Is this self-limiting or do you give these people steroids?

We give them steroids and most recover completely
A few have some residual defects long-term

Shoulder pain that originates in the neck

Alton has a tone of patients who present with shoulder pain and they may have a little something on their MRI, but that shoulder pain is actually coming from their neck
He’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
The cool thing diagnostically speaking is an intrinsic shoulder problem (such as a rotator cuff tear, inflammation, bursitis, etc.) usually travels down underneath the pain, underneath the big deltoid muscle , but almost never goes below the elbow
Maybe some ulnar nerve in the little finger, maybe some shoulder pain, maybe some arm pain

If Alton sees pain that’s in the shoulder going below the elbow, he’s thinking maybe neck or maybe something else

Secondarily, if someone complains of numbness here and some numbness on the back of the hand, the radial nerve is rarely involved in association with carpal tunnel or cubital tunnel The patient will say, “ Oh yeah, my neck’s been really stiff ” Just subtle little cues that you can get by speaking with them They could have something 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
Alton doesn’t treat necks other than some initial PT and maybe steroids He refers those out
But many patients will then see a neck surgeon who will say they don’t need surgery and they tell Alton to go ahead and treat He’ll do a carpal tunnel release and their carpal tunnel will go away, but they’ll still have some upper nerve pain
Recently Alton learned from a really smart neck surgeon about compression in the lower level, C7 nerve root Compression here goes deep under the scapula and gives a problem there This was helpful as Alton often sees patients develop scapulothoracic bursitis
You can get scapulothoracic bursitis from lifting weights (especially if you’ve been out of the weight room for a long time, and you go back into it) You can get a lot of upper trapezius , parascapular, 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
The patient will say, “ Oh yeah, my neck’s been really stiff ” Just subtle little cues that you can get by speaking with them
They could have something 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
Just subtle little cues that you can get by speaking with them
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
He refers those out
He’ll do a carpal tunnel release and their carpal tunnel will go away, but they’ll still have some upper nerve pain
Compression here goes deep under the scapula and gives a problem there
This was helpful as Alton often sees patients develop scapulothoracic bursitis
You can get a lot of upper trapezius , parascapular, rhomboid type pain from overuse and those overlap

Example of a complicated patient

The one patient that illustrates how complicated it can be was someone who had a bad shoulder fracture He was treated in the emergency department, put into a sling, but then also maybe told to do pendulum exercises
Well, it was an unstable fracture, very unstable
The weight of the arm is enormous, and all that weight pulling on an unstable fracture, that put tremendous traction on the nerves It ended up killing his ulnar and median nerve
He came and he couldn’t pose his thumb, he couldn’t do anything
All Alton had left to work with was the radial nerve innervate (which are the wrist extensors and the supinators), and he was able to transfer some things and give him back some pretty good function
But it was all just due to traction
He was treated in the emergency department, put into a sling, but then also maybe told to do pendulum exercises
It ended up killing his ulnar and median nerve

How long did it take those nerves to die under traction?

It was super fast
Alton saw him 8 weeks post-op
He said he began to lose hand function within 3 weeks of the fracture
It’s tragic that no one picked up on this

Nerve exam:

Discussion about nerves and nerve pain + the nerve exam:

The Musician Treatment Foundation [3:22:00]

Alton founded the Musician Treatment Foundation about 6 years ago
This is indirectly how Peter met Alton, through a doctor in New York City who got to know Alton through his work taking care of musicians

Alton’s passion for music

When he started his practice in New York City, he was lucky enough to inherit caring for the New York Philharmonic and the Metropolitan Opera Orchestras (mainstays of classical music echelon) That spilled over into Broadway and then jazz musician, rock and roll, and so forth
He’s always loved music and had a passion for it
To be able to take care of musicians is both very stressful initially and incredibly rewarding They’re like athletes, they’re doing this day in and day out It’s their livelihood and if it’s disrupted, then both their mental health and their financial health is greatly jeopardized
For his whole career, Alton has been taking care of freelance musicians (and their significant others) who doesn’t know when your next gig is and can’t afford insurance He was always discounting his cost (sometimes down to nothing)
That spilled over into Broadway and then jazz musician, rock and roll, and so forth
They’re like athletes, they’re doing this day in and day out
It’s their livelihood and if it’s disrupted, then both their mental health and their financial health is greatly jeopardized
He was always discounting his cost (sometimes down to nothing)

“ The costs are absolutely exorbitant for healthcare ”‒ Alton Barron

Waiving his cost is one thing, but he can’t waive the cost of anesthesia or the surgeon center
The average cost for a rotator cuff repair is about $25,000 If you pay out of pocket at a surgery center (which is cheaper than the hospital)
The average income for a fully professional, freelance musician in Austin is about $16,000 a year (pre-COVID)
This was what was going on for years and it was always in my mind, always upsetting Alton
Alton laments that our culture doesn’t support the arts more
If you pay out of pocket at a surgery center (which is cheaper than the hospital)

Patient zero

Alton’s cousin Thor is a mainstay of the Austin music scene, he cut his digital nerve (his finger) He’s a percussionist and now he couldn’t play because such a neuroma had formed and he didn’t have insurance
He called Alton weeks after he had a simple closure done and told him that he couldn’t feel his finger and couldn’t play
He used his air miles to fly to New York and Alton fixed it Alton knew the surgery center and anesthesiologist and called in a favor (they didn’t charge him) Now he’s fine
This was Alton’s patient zero and his aha moment
He has been lucky enough to treat a lot of other musicians
He’s a percussionist and now he couldn’t play because such a neuroma had formed and he didn’t have insurance
Alton knew the surgery center and anesthesiologist and called in a favor (they didn’t charge him)
Now he’s fine

How the nonprofit got started

One day Elvis Costello and Diana Krall were in and he told them he was thinking about doing this officially and asked if they could help in some way (perhaps use their names)
They got IRS nonprofit status in 2017 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 .” They raised about a quarter of a million dollars That was the seed money and people came pouring in
Here in Austin, HAAM (the Health Alliance for Austin Musicians) is a big organization that does so much and for so long, but they don’t provide the actual care They were 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
They raised about a quarter of a million dollars
That was the seed money and people came pouring in
They were 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

The physical demands of playing a violin or the drums

What are the types of injuries that high level musicians come in with?

Musicians are people too, so they do all the stupid things that we all do to injure ourselves (that’s a separate category) They can’t necessarily take the same rest when they’ve injured something They have to be 100%
If you’re a violinist in the Philharmonic, there are 15 other highest level musicians waiting in the ranks for the opportunity to sit in your seat, your chair on the stage
Alton points out one aspect of this, “ 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 .”
They’re not trying to jump higher, hit the ball farther, drive the car faster, all the different ways that athletes are trying to do to maximize their output
They are submaximal athletes, but it’s repetitious
In a standard NFL game, there are about 35 passes
In a typical Mozart violin concerto, it’s 20,000 bow strokes
And they do that repeatedly over and over and over again
A lot of these are very unnatural positions Think about violinists, they need their hands, they’re shoulders, they are abducted, they are externally rotated Their other one is up in the impingement zone They’re living 8 hours a day doing this That is terrible for the shoulder
Think of the drummers High hats and every which way they’re going and going massively for 3 hours straight It’s just uncanny that they even survive
It’s very different from athletes Alton remarks, “ I don’t even know how many passes Tom Brady has thrown in his career, but it’s not that huge of a number ”
They can’t necessarily take the same rest when they’ve injured something
They have to be 100%
Think about violinists, they need their hands, they’re shoulders, they are abducted, they are externally rotated
Their other one is up in the impingement zone
They’re living 8 hours a day doing this
That is terrible for the shoulder
High hats and every which way they’re going and going massively for 3 hours straight
It’s just uncanny that they even survive
Alton remarks, “ I don’t even know how many passes Tom Brady has thrown in his career, but it’s not that huge of a number ”

Work at the Musician Treatment Foundation (MTF)

They were flooded with patients initially
There was this backlog of patients who hadn’t played for 6-9 months They were just fallow, they were trying to get odd jobs, they couldn’t take gigs
Alton’s very first patient ( Jennifer Jackson ) is a great singer songwriter in Austin and tours around She had bilateral full thickness rotator cuff tears She had already gone to try to see somebody, and it was going to cost her $10,000 or more She had some very minimal insurance When Alton told her it wasn’t going to cost her anything to fix this, she just started crying
In 5+ years now they’ve provided over $2 million in free care to under and uninsured professional musicians
They’ve probably treated around 50 musicians And that doesn’t include the ones he’s been discounting These are the one s they actually funneled through MTF
They’ve had 100’s of non-operative musicians, it’s mind boggling These are just as bad Often a cortisone shot makes them better
They have an upcoming concert in December with Elvis, Roseanne Cash, John Leventhal, a bunch of great people
Alton has been able to recruit over 60 colleagues who he knows and trusts They have the same ethic, they want to give back They are shoulder, elbow and hand surgeons at the best places around the country
In December they are launching P For M (Physicians for Musicians Network) Up until now, Alton had provided all the care but they they’re going to help provide the care They have 60 surgeons signed on now
Before they were limited because Alton was the only surgeon
Peter notes they need more dollars to help cover the other costs Physicians waive their fee They need to use the nonprofit resources to fun the surgeon centers and anesthesia fees
They’ve been unsuccessful in getting any anesthesiologists who are musicians as well, but are hopeful they will once they get the right momentum
Most surgeons (Alton included) have some participation or partial ownership of a surgery center
His surgery center in Austin costs 1/10 of Medicare
So their biggest cost by far is the anesthesia
They were just fallow, they were trying to get odd jobs, they couldn’t take gigs
She had bilateral full thickness rotator cuff tears
She had already gone to try to see somebody, and it was going to cost her $10,000 or more
She had some very minimal insurance
When Alton told her it wasn’t going to cost her anything to fix this, she just started crying
And that doesn’t include the ones he’s been discounting
These are the one s they actually funneled through MTF
These are just as bad
Often a cortisone shot makes them better
They have the same ethic, they want to give back
They are shoulder, elbow and hand surgeons at the best places around the country
Up until now, Alton had provided all the care but they they’re going to help provide the care
They have 60 surgeons signed on now
Physicians waive their fee
They need to use the nonprofit resources to fun the surgeon centers and anesthesia fees

Alton’s vision for the Musician Treatment Foundation

Peter notes that every year their fundraiser gets bigger and more incredible It’s a huge concert gala
It’s a huge concert gala

What types of fundraising go on outside of that each year?

Alton is kind of a one-man fundraising machine because of all of his generous patients
They are applying for grants and starting to get some
Organizations that provide community grants and so forth 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
It develops relationships that weren’t there before
And it’s all ages

Gratitude and rucking [3:34:15]

Alton practices in 2 cities Monday and Friday he sees patients at his clinic in Austin Tuesday, Wednesday, Thursday, he’s in New York City
Peter is grateful that he’s had the privilege of seeing him in both cities And has sent patients to him in both cities
The gratitude is likewise; Peter mentioned rucking at one of their mini meetings and Alton loves it He’s carrying 35 pounds He does run rucking because he loves running He’s only been rucking for about 3 months, 2-3 times a week, but it’s changed his body He feels lighter, stronger, better It’s been a game changer for him
Monday and Friday he sees patients at his clinic in Austin
Tuesday, Wednesday, Thursday, he’s in New York City
And has sent patients to him in both cities
He’s carrying 35 pounds
He does run rucking because he loves running
He’s only been rucking for about 3 months, 2-3 times a week, but it’s changed his body He feels lighter, stronger, better
It’s been a game changer for him
He feels lighter, stronger, better

Selected Links / Related Material

YOUTUBE VIDEO + CLIPS CREATED FROM THE DISCUSSION WITH ALTON:

Full discussion + individual exams performed on Peter : 232 ‒ Shoulder, elbow, wrist, and hand: diagnosis, treatment, and surgery of the upper extremities
Shoulder exam on Peter : Peter receives a shoulder exam from orthopedic surgeon, Alton Barron, M.D.
Shoulder discussion + shoulder exam : Shoulder: discussion + exam with orthopedic surgeon, Alton Barron, M.D.
Elbow exam on Peter : Peter receives an elbow exam from orthopedic surgeon, Alton Barron, M.D.
Elbow discussion + elbow exam : Elbow: discussion + exam with orthopedic surgeon, Alton Barron, M.D.
Hand & wrist exam on Peter : Peter receives a hand and wrist exam from orthopedic surgeon, Alton Barron, M.D.
Hand & wrist discussion + hand & wrist exam : Hand and wrist: discussion + exam with orthopedic surgeon, Alton Barron, M.D.
Nerve exam on Peter : Peter receives a nerve exam from orthopedic surgeon, Alton Barron, M.D.
Nerve discussion + nerve exam : Nerves: discussion + exam with orthopedic surgeon, Alton Barron, M.D.

The Musician Treatment Foundation : Musician Treatment Foundation (2020) | [3:00, 3:19:45]

Book on diagnosing appendicitis : Cope’s Early Diagnosis of the Acute Abdomen Revised by William Silen (22nd edition 2022) | [59:15]

Comparison of PRP to cortisone to placebo for tennis elbow :

Platelet-rich Plasma or Autologous Blood Do Not Reduce Pain or Improve Function in Patients with Lateral Epicondylitis: A Randomized Controlled Trial | Clinical Orthopaedics and Related Research (L Linnanmaki et al. 2020) | [1:40:00]
Autologous Conditioned Plasma Versus Placebo Injection Therapy in Lateral Epicondylitis of the Elbow: A Double Blind, Randomized Study | Sportverletz Sportschaden (V Schoffl et al. 2017) | [1:40:00]
Autologous blood and platelet‐rich plasma injection therapy for lateral elbow pain | Cochrane Database of Systematic Reviews (TV Karjalainen et al. 2021) | [1:40:00]

A natural history study on asymptomatic rotator cuff tears : Patterns of Tear Progression for Asymptomatic Degenerative Rotator Cuff Tears | Journal of Shoulder and Elbow Surgery (JD Keener et al. 2015) | [1:42:45]

People Mentioned

Dick Asbury (orthopedic innovator) [9:30]
Stephen Snyder (Shoulder Arthroscopic Surgeon) [31:00]
John Elway (former quarterback for Denver Broncos) [37:00]
C. Thorpe Ray (former Professor of Cardiology at Tulane) [1:00:30]
Ken Yamaguchi (Professor of orthopedic surgery at Washington University) [1:33:00]
Tommy John (retired professional baseball pitcher) [1:33:45, 1:40:45, 2:08:30, 2:16:45]
Quinn Ewers (quarterback for the Texas Longhorns, UT) [1:53:30]
J. William Littler (pioneer in hand surgery) [2:22:30]
Michael Easter (author of The Comfort Crisis ) [2:57:15]
Elvis Costello (famous English singer-songwriter and record producer) [3:23:45]
Diana Krall (famous Canadian Jazz pianist and singer) [3:23:45]
Jennifer Jackson (singer song-writer in Austin) [3:28:00]

Alton Barron earned his undergraduate degree in Engineering with honors from the University of Texas at Austin. He earned his medical degree from Tulane University, where he also completed his orthopedic surgery residency. He was awarded fellowships in shoulder surgery at Columbia-Presbyterian Hospital and hand surgery at Roosevelt Hospital.

Dr. Barron is a board certified, fellowship-trained shoulder, elbow, and hand surgeon based in New York City since 1996. He specializes in both routine and complex problems of the upper limb, including all sports injuries, severe arthritis requiring shoulder and elbow arthroplasty, nonunions and malunions of bones, and severe nerve injuries requiring tendon transfers and microsurgery. He is a Clinical Associate Professor of Orthopedic Surgery at NYU Langone Medical Center, and a Senior Attending Physician at the Roosevelt Hand to Shoulder Center at OrthoManhattan. He is Medical Director of Pinnacle Surgery Center in Austin and has clinical practices in both Austin and Manhattan. He is affiliate faculty in the department of Department of Surgery and Perioperative Care at The University of Texas at Austin Dell Medical School.

Dr. Barron has been teaching and conducting research for his entire career and has numerous peer-reviewed journal publications, book chapters, and national presentations. He is a member of multiple professional societies, including the American Academy of Orthopedic Surgeons, American Shoulder and Elbow Surgeons, American Society for Surgery of the Hand, and New York Society for Surgery of the Hand, for which he served as Treasurer (2007-08) and President (2011-2012). Dr. Barron was a Fordham University Team Physician from 2002-2014 and has been a treating doctor for the New York Philharmonic Orchestra and Metropolitan Opera for the past 17 years. He is a consultant for the New Jersey Devils NHL team. He previously held academic teaching positions in Orthopedic Surgery at Columbia College of Physicians and Surgeons from 1998-2014, and the Mt. Sinai Icahn School of Medicine from 2014-2015. He was a Senior Attending Physician in the Department of Orthopedic Surgery at St. Luke’s-Roosevelt Hospital Center from 1999-2015, and a Senior Attending Hand/Upper Extremity Surgeon at the CV Starr Hand Surgery Center at Roosevelt Hospital, the oldest teaching hand service in the country, from 1996 through 2015. He is co-author, with Carrie Barron MD, of The Creativity Cure: How To Build Happiness with Your Own Two Hands published by Scribner in 2012, and has been Chairman of the Board of Trustees at Post University since 2012.

In 2017, Dr. Barron founded the Musician Treatment Foundation . This nonprofit is the first of its kind, in scope and breadth, and is dedicated to the healthcare needs of professional musicians. The MTF mission is to: 1) Provide direct orthopedic shoulder, elbow, and hand surgical and nonsurgical care for the uninsured and underinsured musicians of Austin, New York, and beyond. 2) Educate musicians (both amateur and professional) on preventive medicine techniques that will minimize or avoid musician-specific injuries. 3) Conduct research and gather outcomes data into the unique diagnostic and treatment issues facing all musicians and to disseminate this knowledge throughout the world. 5) Create the first cloud-based platform to allow state of the art remote preoperative, postoperative, and non-operative continuity of care, and to provide real-time consultation and treatment recommendations and referrals worldwide. 6) Build the first physician-surgeon network in the world dedicated to providing the care for needful, injured and ailing musicians. [ altonbarron.com ]

Follow Alton here :

Instagram: @draltonbarron
Facebook: Dr. Alton Barron
Twitter: @altonbarronmd

Follow Musician Treatment Foundation here :

Instagram: @mtfusa
Facebook: Musician Treatment Foundation
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