Biceps Pain and Surgical Options in Overhead Athletes with Brandon Erickson - Episode 25

Anterior shoulder pain is common in overhead athletes and baseball players. This pain often comes from the biceps, but may not be the root of the issue.

In this episode, I talk with Dr. Brandon Erickson about the role of the biceps, it’s contribution to shoulder pain, SLAP tears, and biceps tendodesis surgery.

Full show notes: https://mikereinold.com/biceps-pain-and-surgical-options-in-overhead-athletes-with-brandon-erickson

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Transcript

0:31

On this episode of the sports physical therapy podcast, I'm joined by Dr. Brandon Erickson. Dr. Erickson is an orthopedic surgeon at Rodman orthopedics in New York and a team physician for the Philadelphia Phillies. Dr. Erickson has an impressive amount of research publications related to baseball injuries. And this episode, we're going to focus on the biceps and overhead athletes. We talked about anterior shoulder pain, slap lesions and biceps tenodesis surgery and baseball players.

Mike: 1:08

Hey, Dr. Erickson. Thanks so much for joining us on the podcast today and taking time outta your really busy schedule to share some of your knowledge today. Welcome to the podcast.

Brandon: 1:17

I'm Mike, I appreciate you having me on. Always good to catch up with a friend and, uh, talk a little bit about the biceps

Mike: 1:22

I, I love it. We're always, we're so excited to talk about the pie but, um, sincerely, um, what you've done in your career so far, uh, you know, the last five, 10 years or so with. With the amount of publications and research that yourself and all your colleagues have done and, and just pumping out great stuff. It seems like something every month. Uh, it's really impressive. Uh, I don't know how you do it, but I am super thankful that people like you do this sort of stuff. Um, I, before we get into it, I mean, how do you do it right? How do, I mean, you're, you're a busy orthopedic surgeon and you're just pumping out so much stuff. I mean, do you just have an amazing team with.

Brandon: 2:01

It's, yeah, honestly, it's a lot to do with the team and, you know, similar to a lot of orthopedists and, you know, physical therapist, trainers, everybody that's, you know, listened to, this was probably part of a team sport at some point. You know, when you get along in your career, having a good team is, is the best thing you can ask for. And I've been very fortunate, um, when I was a resident out at Rush, um, got involved with, uh, a guy by the name of Dr. Anthony Romeo, um, who's been a great mentor to me and is. Help guide me through a lot of things, um, during this, during this process. And, you know, I also got linked up with a guy by the name of Peter Chalmers, who was actually a couple years ahead of me in residency. He was, uh, one of my good friends, um, and who was probably the smartest person that I've ever met and, um, is just a wizard with statistics and things. And so he and I, you know, have done a lot of papers together because I have no problem going through data and writing papers. And he's really great at analyzing data and kind of getting to. Answer to questions that sometimes people who are really good at statistics have a hard time getting at. He gets the clinical relevance cuz he's a shoulder noble surgeon. So we've really just been very fortunate. And also, I gotta tell you the help that Major League Baseball has given us between John D'Angelo, Kevin Ma, their entire research team over the years to, you know, go through the Hits database and kind of mine the Hits database and give us some data that's in a concise and understandable fashion has just been outstanding.

Mike: 3:17

Yeah. Yeah. And it, and it seems like it's getting better and better, right? Like as, as you know, we, you know, obviously we started with some broad stroke type research, but now, like we're, we're getting specific with things and that's gonna help us answer a lot of questions. And, you know, the. The data's just gonna grow over time. So, um, you know, it's exciting that you and, and all your colleagues do it and man, you, it's such a great group of people coming outta rush there in Chicago and, and all the great doctors there. Um, you guys really are amazing. So, uh, again, appreciate all that you do for us.

Brandon: 3:49

I mean, it's, it's, it's kind of a two-way street, right? Cuz we couldn't do what we do without the help of all the athletic trainers in baseball. Right. I can. Mind the data, unless somebody puts that data in and takes the time to make sure that the input's good. No, I mean, seriously, you know, we go, we always say it, and I know it's kind of, you know, we, we say it, we joke about it, but we say garbage in, garbage out, right? So if you put, you know, you don't put good data in. We can't get good data out. You know, the, the trainers at the major league and minor league baseball level do such an outstanding job putting data in. That's useful for us. Then on the back end, that, that's really what's. Fueled all the publications that we've had and what's gonna, to your point of getting better over time, what's gonna make us better as we expand the Hits database over the next couple years?

Mike: 4:26

Right, right. And, and no, I'm already seeing it too. Just like yourself, like as a surgeon, I'm sure you know, you're amazing. I'm fortunate to not have had you be my surgeon. So, uh, I, I, I, I haven't, I, I haven't experienced that, but, but in terms of just like, like, you know, seeing you speak at conferences and stuff like that, you can see that all that research, all that stuff that you've published, it comes across even in things like that biomechanical talk that you did at Chris Ahmad's course in New York. Um, right. I mean, it wasn't a biome. Talk, it was like a clinical implications of injuries in biomechanics. I mean, you, you can't put together a talk like that if you don't have the understanding of the injuries that you guys do. So, um, you know, again, just, just really, really awesome stuff to see coming out from you guys.

Brandon: 5:08

I appreciate that.

Mike: 5:09

Yeah. So, uh, so one of the ones I wanted to talk about, there's a million things that you and I can talk about, and we could, you and I could have a weekly podcast on baseball injuries I bet. But, um, one thing that I know that you have some experience with, and I know Dr. Romeo obviously is, is some experience here is the biceps and baseball players. Right. And biceps tenodesis in particular, but you recently published a paper in O J S M that was a nice, like, uh, update, right? Like a follow up to, uh, an article that you guys published a few years ago about the outcomes of biceps tenodesis and baseball players. So, um, I thought we would kind of frame today's chat about that. Um, and, you know, before we get into the specifics, let's, let's talk biceps in general. You know, for me as a athletic trainer or physical therapist that works with a lot of baseball players, anterior shoulder pain and, and just generic anterior shoulder pain is so common, right? It's, it's, it's, you know, and everybody always says, you know, why is my shoulder hurt? And I'm always like, well, it's. you throw a ball for a living. Right. I'm, I don't have a better answer, but, um, they have anterior shoulder pain. The diagnosis of biceps tendonitis or pain, or whatever it may be, is, is just so frequent that we see that. Why do you think pitchers have so much anterior shoulder pain?

Brandon: 6:25

Let me put a question to you first on that. What does the bicep. what does it do? Right? What does this thing do that causes us so much problem? I mean, I don't, I don't know that we fully understand what the biceps does yet, right? If you look at some of the EMG studies that are out there, you know it, it may not be super active during the baseball throw, but if you look at some of the biomechanical work, maybe it does act as a humal head depressor. I, I think that we're still figuring out what the biceps does, and so to your point of, you know, why do these guys wind up? You know, bicep symptoms, listen, when you put the shoulder in a position that most people don't, and when you put as much torque and stress in the shoulder, as these guys do and they throw, there's gonna be some parts of the shoulder that are gonna see more stress than they were made to see. Right? And so, From a biceps tendon perspective, listen, we all know our basic anatomy, the biceps tendon generally comes off of the superior labrum. The superior labin baseball players oftentimes develops a small tarrant, whether or not that's from a peel back mechanism or for attraction mechanism. When guys are throwing, usually there's some amount of adaptive or pathologic changes that the superior labrum sees. And in turn the biceps tendencies. Because if you disrupt the attachment point of something, obviously then that structure's gonna see some extra stress too. So when we think. The biceps tendon in these guys, guys that wind up developing adaptive or pathologic, superior labral changes oftentimes over time will then develop some bicep symptoms, because initially, usually the biceps is not involved. But once the superior label starts to get disrupted, once they start to throw at that over time, then the biceps tendon may start to move in a way that it wasn't meant to move in and starts to become inflamed and.

Mike: 8:04

Right. That, and that makes sense to me. So, yeah, this is like a chicken or the egg question, but so you're saying that as the slap progresses, right, and that that lesion becomes bigger or whatever, more, more pathological over. Time, then you start to see more bicep symptoms. Is that right? Is that what you're saying?

Brandon: 8:22

That's, that's kind of my personal view on this. And, and again, let me, let me put the disclaimer out there that this is the, this is the Brandon Erickson thought on the biceps, right. Because we don't know the answer to this, so I don't wanna tell that this is right or wrong, but, but for me personally, you know, I, I do think a lot of the bicep stuff starts at the attachment point. And, and we can discuss, you know, listen, the biceps tend in, there's certainly an interarticular portion. There's a portion that goes in the biceps tunnel that, you know, Steve O'Brien and, and Sam Taylor have done a lot of great work on it of hss. Um, That also can be a, a cause of pain as well. But for me, I think all of that stems from the superior label issue or a biceps attachment point issue, you know, biceps tearing aside. Um, I think that, I think that that oftentimes stems from a superior label problem.

Mike: 9:03

That's, that's, that's interesting. And have you ever thought of it this way too? You know, with, with the amount of like glenoid, glenoid, uh, uh, retro torsion that we see, right. Um, I, there's some correlations between, you know, torsion and, you know, slap pathology in there. But it makes sense that that would also probably torque the biceps differently. Right. It's almost like the force lever gets changed with different amounts of, of, uh, torsion. So it, it's, it's like, you know, why are some guys more susceptible to it? Others is, is, you know, perhaps that, that part of it. Do you think that people that have more retroversion and retro torsion of their humorous, do you think that is, is something that, that plays into this as.

Brandon: 9:40

Hundred percent. And so we, you know, we know that when people are born, they have a lot of retroversion to their humorous. And then as they get older that. Actually starts to antivert, so the retroversion goes away. But in guys who throw when they're young, they halt that process of de rotation. So they maintain all of that retroversion a little bit more. So guys who are usually throwers earlier wind up maintaining that retroversion. Guys who start picking up pitching a little bit later usually are a little bit more introverted or less retroverted. So if you think about the position of the biceps and the bicipital group, if you think about the humal head as it change, From being very retroverted to being less retroverted. You're right, the bi room in these guys sits in a very different spot based on probably when they started throwing in some other, um, some other anatomic factors that come into play. So a hundred percent I agree with you. So if you think about the more retroverted somebody's arm is versus a electro retroverted arm, the biceps tend sits in a very different spot. So is the length tension relationship on the biceps different based on the amount of retroversion it might be? We haven't looked at that yet, but that's a, that's a good clinical question that we can probably.

Mike: 10:43

Yeah, it's, it, it's interesting, and I I, whenever we, we have a discussion like this too, when we start talking about retro torsion, um, I always think about like lefties and righties and, and I do think if there's, if there's one critique of most of the research that's published out there on baseball players is that they tend to group everybody together. And I think righties and lefties are different. Right. They're, you know, lefties are supposed to be righties. I still think that, you know for sure, but you know, the injury patterns that we see, the amount of torsion that they see, their range of motion, their total rotational motion side to side is different. Right. And, and they tend to have less lay back and more internal rotation. You know, those types of things that, that, that we see. I, I, I would imagine that you would, would probably start seeing that differently between lefties and righties as well. Have you taken a peek at that even anecdotally, or am I making that.

Brandon: 11:31

No, you're not making it up. And, and we have seen some of that work come out recently looking at different types of version, basic lefties and Right. And the question, you know, it beg. You're right. Lefties are brought up in a righty world. And so a lot of lefties are ambits, right? My, my wife's a lefty, but she, you know, writes lefty, but also can throw righties. So it's, it's a, it's a funny thing for kids who are growing up and then once we realize that, you know, let's say baseball pitchers are lefty, well then that's great, right? Cause we always like baseball pitchers who are lefties. So then you focus a lot of attention on them being elected. So it, it's a good question and I think it's something that is a. Studyable question. So I think we could actually find an answer to the lefty versus right issue. I think to your point, we just have to kind of focus on it a little bit more. Cuz you're right, we generally don't parse out rights and lefties and part of the reason we don't is because there are so many more righties that's to achieve. You know, we, we talk about in studies a lot of times statistical power or what, what is clinically significant. You need a lot of numbers to get that. And sometimes getting the numbers for lefties is a little bit difficult just because there's, they're so outnumbered by rights.

Mike: 12:31

Yeah, we, we, we definitely found that as well. That's part of the problem with that is there's, especially when you start looking at injury rates, cuz there's, there's actually relatively small amount of injuries too, and if you're just following a team or two over the course of a season, so, um, you know, makes sense. Um, so I, I always feel like the junk term of the shoulder, if you have any sort of anterior shoulder pain is they just say biceps tenodesis, uh, or excuse me, tendonitis. I. I, I wonder like how many times do you think it really is the biceps and, and like how often do you actually find that biceps pain happens in, I.

Brandon: 13:05

Yeah. I would tell you that I don't think biceps pain happens in isolation that frequently. Is there something else, either a tight posterior or capsule, is there some partial under surface rotator cuff tearing that's also in there? Probably because there's usually a constellation of things or grouping of things that happen when guys start to have shoulder pain in it. It generally doesn't just localize simply to one specific area in a thrower shoulder. Right. In a in you. Certainly we can isolate things in the shoulder, but in a thrower shoulder when there's so many things that come into play to help them generate the force to throw a pitch, there's a lot of stuff that that has to work in, work, in concert and work together. And so I, I am, I don't usually see just an isolated biceps problem. Now, the problem can sometimes be treated with an isolated biceps ansis because you're taking out the pain generator that's there. But the reason the biceps is a pain generator is probably multifactor.

Mike: 13:58

Right, right. And it makes sense. I mean, I, I, I think it, the more you understand baseball players and the more you work with baseball players, you almost realize that when they have shoulder pain, it's everything, right? It's some anterior micro instability, maybe some, you know, posterior stiffness, some undersurface rotator cuffs, some blade roll, you know, like. You know, posterior superior impingement. There's, there's so many things. It's almost like they all happen together. like almost every time. right? And it's, it's which one's

Brandon: 14:25

no, that's exactly.

Mike: 14:27

right? Like, which one? Which one's the one that's showing itself more, but like, they're all there to an extent.

Brandon: 14:33

Yeah, no, I, I completely agree with that. I think the sad part is I think the more we understand it, you know, the more those of us who work with baseball players, work with baseball players, the more we realize we really don't understand the pitch shoulder very well.

Mike: 14:44

Right. Yeah, no, no doubt. And I, I think a lot of people would be surprised when they see what I do for my rehabilitation for the shoulder. And I say like, well, you don't, I mean, it, it doesn't really matter. Right where we're, we almost do the same thing for every pathology because they're all part of like the same, the, the, the, the same kind of cascade of events that happen that, you know, we, we have a loss of static stability. We have some, some pain and inflammation that are probably having reciprocal inhibition of, of the rotary cuff and their ability to statically, stabilize. I mean, it's the same stuff no matter what the pathology, so, People get caught up on like, oh, is it really the biceps that's causing the pain? And I, I don't, I don't even care anymore. I just, I'm like, yeah, sure. It doesn't matter to me. We're gonna, we're gonna treat what we find anyway, not what we label it.

Brandon: 15:32

correct. Exactly right. A hundred percent agree with that.

Mike: 15:35

Yeah. So I, I mean, to me, I, I think that's what's interesting. And when you start looking at slaps, right? And you start thinking of a slap this way, what is a slap? Right? It's, it's a, it's a, to me it's a loss of a static stabilizer. Right? And, um, I've actually seen, um, there's a point in time in baseball where we could get away with, um, and all the shoulders of all the healthy players like the, The agents don't let us do that as much anymore. But we used to do that, but we, we, we, we, I, I've seen serial m r i testing in players that show slap tears getting bigger year after year. And, you know, it starts 10 to two or whatever, and it starts slowly, slowly extending posterior each year. It goes back an hour or hour and a half. Right. And you kind of start seeing that over time. Um, it makes sense that the biceps pain, you know, is seen with that. But, um, when we're talking slaps in, in your clinical practice alone, uh, uh, how much are you doing slap repairs these days compared to maybe earlier in your practice? Has that evolved for you?

Brandon: 16:39

Yeah, it has. And I, and I would tell you, you know, interestingly, we looked at this, uh, at the, at all the patients who were at Rush. Now this didn't include just baseball players. This is kind of all comers. But what we saw over time was the number of biceps tenodesis were dramatically increasing and the number of superior labor repairs were dramatically decreasing. And we did a similar study looking at the American Board of Orthopedic Surgeon Database. So basically all of us, when we'd start practice, have to, um, upload our, our cases and what we did. To the, um, orthopedic surgery kind of database. And you can kind of look at that and see what, what codes people bill, meaning what surgeries did they do. Um, and similar thing, we saw the trends. The trend was that the number of superior labor repairs was going down. Number of bicep sixteens was going up. So for me personally, I would tell you that's, that's the same in my practice. And a lot of that's based off of some work done by NA preventer years back that showed that people over 35 who have slap repairers don't do as well. People under 35 can do. Ok. So for me to do a slap repair on. they really have to ha and, and by slap PRI mean an isolated SLAP repair with no associated bicep tenodesis. They have to have really isolated superior labral symptoms. And what I mean by that is they really can't have a lot of pain in their front of their shoulder. They really have to have pain with certain overhead shoulder movements and, you know, positive O'Brien's test, things like that. But I don't wanna see any other stuff going on. That to me, screams biceps for me to do an isolated slapper because I worry in those patient. If I do a SLAP repair, even if we do a perfect stop repair, we don't over tighten the capsule that we won't take care of all of their symptoms because they may have other stuff causing the pain.

Mike: 18:08

Right, right. So I, I like that. So the difference is if somebody has, I don't wanna say isolated, but like more of. Like posterior superior pain in the layback position, uh, versus having some of that with anterior shoulder pain. Um, I, I like how you differentiate, you know, between the two different, like a, you know, a slap pain and a biceps pain. And with the those two together, because I definitely see both. Right. And I've, I, I've seen that and I, I do think, uh, I do think the age of the player tends to matter, right? I mean, I'm, I see much, much less like biceps, isolated biceps pain in the younger athlete these days than, than, you know, than, than in the past. But, um, you know, but it, but it's interesting, um, you know, going back to the slaps again for a little bit is, is this one of, is this one of those things that surgically we maybe got a little carried away, maybe. We're repairing it on too many people. Or maybe like, even like putting, you know, four anchors in a, you know, a, uh, small slap tear, right. And anterior verse posterior, like those types of things. Like, like, it, it, our, our slap repairs themselves. The, the problem. Is there a way that we can do them that you think will, will be beneficial or do you just think that they they over tighten the shoulder too much and we probably shouldn't be doing'em that much in baseball.

Brandon: 19:28

No, I, I think that's a good question. And so I, I don't necessarily think you have to abandon them with baseball players, but I do think you're, you're, you hit the nail on the head. So the way slap repairs used to be done, they used to be done with. Anchors that you tied knots on. So there was sometimes a knot stack that could be irritating to the shoulder. I think people tended to get a little bit of capsular tissue in, in addition to the labrum. And what that did was when you grab some capsular in addition to the labrum and then you tack it back down to the glenoid, you wind up tightening the shoulder up. And so what we try to do now, or at least you know what a lot of us would take care of baseball players do, is one would use knotless anchors. Okay? So we don't wanna see any more knots tied cause we don't want the knot stack to be an issue. That's the first thing. Second thing is, We sometimes before would use many anchors. Now we've taken that number of anchor down a little bit. Usually two is about right. Sometimes it needs a third one. It needs what it needs, but you don't wanna, you don't wanna be over aggressive with that. And then the third thing, and this is I think the most critical part of this is, When you're doing your slap repair, you know, a lot of the, a lot of us do these, we use a little spinal needle through kind of a nevi portal in a 20 spot. We kind of, you know, put our, put our sutures through the labrum, but we just grab labral tissue. You do not grab capsule or tissue because if you grab capsule or tissue, you will absolutely over tighten that shoulder. So we are very meticulous at just getting. Labral tissue and even some of us now will start putting the shoulder in the throwing position that abducted externally rotated position before we tighten down the labrum so that you don't risk over tightening them in that particular position.

Mike: 20:54

That's perfect. That's perfect. Right, because it, because that's the reason why, you know, the, the slaps probably didn't do so well, you know, the over tightening of that and then getting back into throwing never went well. Right. We, you know, if, if you just making up numbers, if, if you threw 90 miles per hour, it seems like you, you got back to like, 85 to 88, and it just didn't have the life that it used to have. Right. It was like just missing, missing that last bit of layback that they couldn't, they couldn't get that last bit of motion. Um, and so hearing that from me, from my perspective, uh, everything you just said kind of excited me a little bit. Right. probably because you and I are kind of dorky about this stuff, but it, it, it was exciting because like, uh, to, to me, I'm like, well, well, I mean, again, are we, are we, are we, are we abandoning. too quickly. Now, is there, is there a right person that should still get a slap using this more, more modern approach that doesn't overtighten in everything you just said? Like, is, is, is it still an option for you and your patients?

Brandon: 22:19

It is and, and I would tell you that an isolated slap for me, again, just the important thing is that they don't have associated bicep symptoms, but I actually don't have a problem in some of these guys if they have a SLAP tear, but they also have bicep symptoms. I'll do both, right? So I'll do a slap repair with a biceps essis because then I've said, okay, at least I've taken care of the pain generator in their shoulder, which seemed to be their biceps based on their clinical exam. And sometimes we'll give, you know, lidocaine shots or steroid shots right into the biceps, tend in cheek to see if that knocks their pain out because. If I give somebody an injection to their biceps, tend in teeth under ultrasound guidance and they get no better from it, well then chances are the pain's not coming from the biceps. But if they get better from that injection, then you, you've gotta think, gosh, that biceps is probably causing some symptoms here. And so if I just fixed the slap, I don't know if those symptoms are gonna get better. So in those people, I have no problem fixing the biceps in a T Visa's fashion, and I do an open Subeck approach. Um, and then also putting, you know, two Knotless anchors in to fix the slap, making sure I don't over attention them.

Mike: 23:20

Yeah. And posterior to where the biceps was, or, or is it just based on the person?

Brandon: 23:26

So it's a, that's a great question. That's, that's a whole other debate. Right. So I generally go posterior to the biceps, but I would tell you, so I had the opportunity a couple years ago to meet a Japanese surgeon named He came out here at Romeo Ahmad's Baseball course. we, we chatted Bunch, and then I was fortunate to go out to one of his courses down. And then we lectured to Bunche he puts his anchors anterior to the biceps, and he swears by it. Not kidding, he swears by it and it, it, it made me nervous because everything you hear here is, oh my God, don't put anchors anterior to the biceps. You're gonna, you're gonna kill this guy's shoulder. So I generally still go, I go posterior to the biceps. I'm not gonna lie to you, and I definitely don't go anterior and posterior. But I will say I had one patient who was a softball player who had a slap tear, and it, it seemed to be a little bit more anterior to me. And I. Two anchors anterior, making sure to respect her sub-label framing, and she did great. Now, I've never done that on a baseball player because it scares the heck outta me,

Mike: 24:18

Right, right, right.

Brandon: 24:19

on my end of wanting a softball player, it worked

Mike: 24:22

Right, right. And, and, but, you know, but that, that's how, that's how things start. I mean, just a few years ago, we would've never even thought about repairing, uh, a, a ucl. Right. And now we're, you know, as we've learned more and we've evolved, we, we've come back to that. So, yeah. You know, uh, maybe we'll come back to the slaps. Right. Like, you know, to me it, it sounds like for the right person at the right time, I mean, I do also think though, the state of baseball, right. Not to get like too deep off, off, off subject, but the state of baseball's evolving. Right. And I, and. I'm making this up. They're completely anecdotal to me, like slap lesions, like they tend to progress over the course of a career. Like we talked about, the serial MRIs that I've seen, like they seem to progress over time. I just feel like baseball players are blowing up at such a younger age with like more traumatic type injuries that, you know, we may not even get to the point where they're having these huge slaps that are problematic in their, you know, like low thirties like we used to. So, um, who knows? I think the whole game is changing, right? The injuries we're seeing, the patterns we're seeing. Different. So, um, who knows? But, uh, I, I don't know. To me, uh, to me, you know, having this as an option is, is still valuable though, right.

Brandon: 25:27

Oh, I totally agree, but you can mark it down. Mike says, number of SLAP carriers are going down starting today, so this is ingrained forever in this podcast.

Mike: 25:36

I, I, I mean, I will say clinically, we, I cannot tell you, like I can count on, you know, single digits, how many postoperative patients we've seen with slap repairs and baseball players. You know, e each year nowadays, and it used to be like one of the most common procedures that we saw. Um, so, you know, it, it's interesting and, and people tend to do well without it, but, um, you know, again, super, super interesting. So, um, let's jump back to the Tesis then. So you started talking about you do biceps tenodesis in these people. Um, how often are you doing a tenodesis in baseball Pitchers nowadays?

Brandon: 26:10

Yeah, so I would tell you the, the thing you have to remember about when we talk about baseball pitcher, shoulder surgery, Those of us that treat these guys have done literally everything else before we operate on their shoulder. So for me to operate on a pitcher shoulder, outside of like, let's say they developed a full thickness rotator cuff tear from a traumatic fall, or they dislocated their shoulder, something like that. So if those traumatic injuries, aside from these kind of wear and tear overuse injuries over. They have had to fail months of physical therapy, injections, steroids, p r p, all kinds of stuff before we, we operate on their shoulder. So I think that's actually part of why we're starting to see maybe some better results for things is we are very selective in who we operate on nowadays.

Mike: 26:54

Right. Right. And it, it, I don't wanna say it's a salvage, but it's almost like that you're, this is the last ditch effort that you're trying to get to with this person.

Brandon: 27:03

Yes, 100%. And, and you, and you counsel them on that. And, and it's not to say that surgeries don't work in these guys, cuz they do, but you really have to make sure that they understand that once we go into your shoulder, it's not gonna be the same. You're not a normal person. You're an an overhead athlete that puts a lot of stress on your shoulder. So I'm gonna fix what's wrong with your shoulder. But what you have to understand also is that some of the changes in their shoulder are adaptive and we don't always know what the adaptive changes. We try to take care of what we think are pathologic, but some of those path, some of those things that we think are pathologic, may actually be adaptive for that guy. So it's very hard to know.

Mike: 27:38

Right. Yeah. We used to say that all the time. If, if 80% of baseball players have some sort of slap lesion, I, I think I'd rather be the 80 than the 20. Right? I don't wanna be the guy that doesn't have a SLAP lesion. Maybe you need a SLAP lesion

Brandon: 27:51

exactly right.

Mike: 27:52

I, I, I think, I think that's a good way of saying it too, because I do think when people hear biceps tenodesis, I think there's still some, you know, but, you know, I, I'd call it more confusion than anything else where it's like, oh, is this a good idea? But I think you just frame that really, really well, where you don't necessarily think it's a good idea either. But we're at the point now where we've tried several things. They're not getting better. Let's, let's do this. Right? And, and, and to me, that's when it becomes an.

Brandon: 28:21

Exactly, and, and they've, so they've, they tried, you know, You've done everything and they're still hurting. So now would say, let's call it a very small slap, it's mid biceps. Your slap appears to be more of an adaptive slap. So I don't think fixing the slap is the right move. I think we're just gonna do a bicep. So we go in, we see some partial thickness under surface tearing and the rotative cuff. Cause to your point before of this all being, you know, kind of one constellation of symptoms that just progresses over time, we generally see that. So we don't fix those tears in the, in the rotator cuff. That's a bad idea. Don't. Just gently, Deb, breathe the piece that's torn, leave the rest of it alone. They'll leave well enough alone. That's again, an adaptive change. And then we let the biceps go. And so when we let it go, then it starts to pull back down the arm. Okay? And if somebody was, you know, 80 years old, you can just let that biceps go and let it run free. And that's okay. But in our athletes, we need to reattach that to make sure we give them maximal function of their biceps. And, and the way we reattach it is we do what's called a TSIs, which means basically reattach. The 10 into the bone. And so the way I do it is I use a small uni cortical button that goes within the humus. So you gotta drill a tiny little hole, um, that the button goes in and then it flips against the cortex of the humerus. But you can use an interference screw. You can use a suture anchor. There's no right or wrong way to do it. The important thing when you do it is to set the tension appropriately on the biceps. So you have to remember now you've let it go. So now you have to figure out where does that biceps belong. So you basically wanna reattach the tendon to the. Where it would've naturally sat. And so you have to make sure that when you're doing it, you put the basically muscle 10 injunction of the biceps at the level of the inferior border of your P major, and that generally sets the length tension relationship appropriately so that their biceps will function appropriately.

Mike: 29:56

And how much function do you see out of a biceps after tenodesis, right? Is this, you know, it it, it, do you think that some of the function comes back,

Brandon: 30:05

So I would, I would get you back to what does the biceps do, right? So certainly if it's a humeral head depressor, it's not depressing the humeral head after I cut it, right? Cause it's no

Mike: 30:12

right, right.

Brandon: 30:14

from a supination strength perspective and from an elbow flexion strength, it probably, I, I think it probably still has a role in supination strength. I think that's probably still.

Mike: 30:22

Right? And, and after tenodesis, there's some of that returns.

Brandon: 30:26

I think it does. I mean, personally, I, I don't, I essentially don't do any tenotomies. Even in my older patients, I generally do a tenodesis cuz it only takes about five or six minutes to do it. And I think you restore as much function as you can. Now, is that measurable? Maybe not. But in a pro athlete who, you know, needs every bit of every muscle functioning well for them to be successful, I think you have to do it.

Mike: 30:46

Right. Right. It's worth, it's worth it even if there's a, a partial amount of function restored. That makes sense. Um, so you, you published this paper, OJ s s uh, OJ s m that, um, that, that went over the results in Major League baseball. Tell us a little bit about this. Um, tell us a little bit about the methods. Uh, how many people, what, what were your results, uh, how to biceps, tenodesis procedures perform in baseball?

Brandon: 31:10

Yeah, so we, we initially to point did the study, you know, many years ago in arthroscopy and we saw, you know, not a great return to sport rate for baseball pitchers after we only saw about 17%. Were getting back to play and. That was, you know, kind of early 2010 to 2013. And so we wanted to see, you know, as we've gotten a little better with our indications, as we've gotten better with our techniques, our, our players doing better. So then we kind of did an update recently, um, and we basically looked through the hip database and we found guys that had a biceps TSIs. Um, and now they, we, we allowed them to have other procedures outside of a rotator cuff repair, right? Because if somebody has a rotator cuff repair, that is a, that is a different animal that you, you can't group that in with. that's a big deal. Exactly. So some of the guys had labeled debridement, some of the guys had, uh, rotator cup debridement and that's all. Okay. Um, but we wanted to include everybody that had a tenodesis. So we looked through the database. We got about, uh, 17 or 18 guys that had a tenodesis done, and then we basically looked at their ability to get back to playing both at all, and then at the same level, and then what their performance is like when they got back. And so what we found was, Certainly the majority of these surgeries happened in pitchers, so you know, 80 over 80% of them were pitchers, and then what we found was actually over 80% of these guys got back to pitching. but only 50% got that to pitching at the same or higher level. So much better than our initial study, but still not a great number that you're satisfied with. And so I think we're seeing that the results are moving in the right direction, but I still think we have some things to figure out to get that to be, you know, the over 80% level that we wanna see when we operate on.

Mike: 32:44

Right. Right. And you could actually even argue too, that going back to the, the whole concept of this is an advanced injury. Right. And again, not to say the word salvage, cuz I think that's maybe a little aggressive in here. But this is, this is getting towards the end of like options for this person. You could actually argue that those outcomes are fantastic, right? Because if you didn't do this procedure, they had a 0% chance of coming. Right. So it's, it, it, it's, it's, it's not as simple like, does everybody get back? Well, it's like, well, you know, you know, getting that large percentage, 50% of people at the same level, but 80, whatever, what'd you say? 80%. Getting back to, um, um, you know, to, to pitching in general. Uh, I mean, that's, that's fantastic for somebody with an advanced shoulder injury. So, you know, I actually see that as a, as a.

Brandon: 33:30

Yeah. I, I don't think, and I don't think you're wrong to look at it like that, I would tell you like, no, we, as sergeant, I know you guys in the same way, like anytime you operate on somebody, you're treating somebody you want them to do, do great. Right? Because otherwise you'd consider. What you did a failure if you don't get it back. But you're right. I mean, these are guys that have failed everything else, and you had the conversation saying, listen, I'm gonna do my best to get you back. I don't know if you're gonna get back to throwing, but you've tried everything else, you can't get there. So heck, we gotta give it a go.

Mike: 33:55

Right. I love that. So why do you think, why do you think the outcomes changed between those two papers, your original study in arthroscopy 2018, and then your updated one and no J S M? Why do you think the outcomes are so much better?

Brandon: 34:08

I think, you know, I think a couple things. One is I think the indication, so I think. You know, trying a lot of things before we resign somebody to a shoulder surgery. So I think it's a matter of one patient selection. And then two, we changed our implants a little bit over time. We used to use some vigor, tenodesis screws. We used to put the biceps in a different spot for this one, the majority of the biceps for that subpectoral approach that I was telling you about. Um, and they used a lot of the smaller implants, so I don't know if. Necessarily made a difference, but those are the two factors I think probably played into it. So those are the two I think were relevant.

Mike: 34:40

Right. I like that. And I, I, I feel like this episode wouldn't be complete in this topic, wouldn't be complete if we didn't talk about this just for a second here. But, um, I think you've answered it to an extent, but. I think one of the big things people talk about with the biceps, tenodesis and baseball players is that we hate subtraction surgeries. Right? Something that takes something away. The biceps must play a role. We've, we've talked about, we don't completely understand it, and I think that's, that's fair to say. Um, it, it, it must play a role. How much does that. You know, come into your mind when you're trying to make a decision with, should this person get a todi here? It, it, you know, are, are you worried about that? Are you worried about, you know, taking away that, that biceps from the shoulder joint in its potential function in these baseball players?

Brandon: 35:28

Yes. I mean, the short answer is yes, you definitely are. And even though we don't fully understand what it does, yes, I, I am nervous anytime we have to take the biceps out because I don't know if in this particular player that biceps was really doing a lot in the shoulder, or if it was not doing so much, almost think like an appendix. Um, it's hard to know. And so that gets back to the point of, you know, pathologic and adaptive changes and how these. You know, no two baseball pitchers and the same, um, that's the risk you run with doing that.

Mike: 35:56

Right. That makes sense. And, and you know what I mean, for the people out there listening to this, you know, from the, the physical therapy and the athletic training side too. If, if you have somebody that's dealing with this, this is why you send them to somebody like Dr. Erickson or, you know, Dr. Romeo in Chicago, or, or these people that do these procedures more often. Here is, is. Is you can trust that if they've come to the point where they think this is a, a rational idea for this person, you can trust that that judgment, uh, ha has been, has been really put into consideration with all the things we've talked about so far in this episode, right? Is that we've, we've failed a mu bunch of other options. It's, it's the right procedure for the right time. I, that's why you send them to these experts that see these people. What you don't wanna do is have somebody that doesn't treat a lot of baseball players and the, and they say this. A first option. Like, oh, your shoulder hurts for the first time. You've never rehabbed in your life. Let's do a tenodesis. Right? Like, like you, you, you don't want that. You wanna make sure you're, you're going to the right person and that's why you, you gotta get somebody in your local area or, or just get, have your people, you know, get on a plane or get in the car and go see Dr. Erickson. thank you so much for the, for sharing your knowledge with us and all this great stuff in this episode. This was, this was amazing. Um, I think it's a great topic so we can all understand the biceps a little bit better. Um, before I let you go, I love. Five quick questions that we do at the end, really kind of learning a little bit more about you, your growth mindset, stuff like that, but call it the high five at the end. Five quick questions, just five quick answers. First question for you, what are you currently reading or working on for your own professional development? I, I know you're educating all of us, but what are you working on yourself?

Brandon: 37:36

So I'll tell you, I, I always read a Jsm and J s e s, uh, every month. I think they, they put out, you know, a lot of the great research that we have. And so I, I'm pretty diligent about trying to read those, um, read those journal articles, uh, every month from a you. I own furthering like our baseball work that we've been doing. Um, we're kind of looking at pitch counts right now and seeing, you know, what pitch, how pitch counts or, you know, hidden pitches are playing into injuries. So more to come on that.

Mike: 38:02

I love it. I think that's gonna be, that's gonna be, that's gonna be really important information for us, so. Great. Um, what's one thing that you've recently changed your mind about?

Brandon: 38:13

Oh, good question. Um,

Mike: 38:16

Professionally, I'm not talking about

Brandon: 38:18

Yeah, My, my political, yeah, I gotcha.

Mike: 38:21

exactly.

Brandon: 38:22

I mean, I, I guess I guess, uh, you know, one of the things actually, interestingly, and this is not on the shoulder, but actually on the elbow, so I was talking to Jeff Dugas about the UCL repairs and obviously we're doing a lot more repairs these days and I used to think that, um, when you put these repairs than we, we didn't wanna put them in too tight. But my kind of thought process has changed on that a little bit. George Paleta, you know, is telling me that he puts these things in as tight as he can and they all stretch out. And I've started to do that. And they've all stretched out and done fine. So I, I've changed my thought process on how tight we can put

Mike: 38:51

I like that. That's a good one. That's a good one. I wanna start seeing those with, in the. So we can start seeing how that is, because you guys see'em down the road, right? We're the ones that have to deal with that tightness for several months. But

Brandon: 39:02

to New York, brother. I gotcha.

Mike: 39:05

But, uh, anyway, uh, what, what's your favorite p piece of advice that you give, like residents that are working with you?

Brandon: 39:11

Yeah, I, I would tell them this, you know, as soon as you think you figured it out, you're gonna get humbled. So just make sure that as you go throughout everything and you learn more and more over time, that you understand that. Things constantly evolve what you thought was right one day may not be right the next day. And just to keep honestly learning, to your point of, you know, what are you reading now? You gotta keep reading, you gotta keep learning change. There are stuff out. We have so many great colleagues in this, just pay to what other are doing to make sure you stay on top of your

Mike: 39:41

I love it. I love it. What's coming up next for you? I know spring training's on the horizon. You work with the Phillies, right? So, uh, what else is coming up for you? Anything we're gonna expect to see some publications or anything like that?

Brandon: 39:53

Yeah, I got my, uh, week at spring training coming up, uh, end of March. So that'll be here soon. But no, I think, you know, the, the hidden pitches stuff for me right now is, is something that I find really interesting. And then the other thing, uh, for me is actually, um, grip strength. So I think we're gonna start to, uh, to see some things coming out of guys' grip strength and maybe index and middle finger pincher strength, uh, in relation to injuries. So, so more to come on that soon. We're, we're trying to work on some of that stuff now with the Philly, so we'll see what we can, we can figure.

Mike: 40:20

I like that. I like that. You gotta do that. Perf to performance too, and spin rate and stuff like that. It'd be interesting to see if some of that data

Brandon: 40:27

That's a good que Honestly, I didn't think about doing it from a performer perspective. Cause you know, so that's the difference between our minds, right? My mind is like, how do I keep these guys from getting hurt? Your like, well, how do you do successful?

Mike: 40:38

Right. Right. You know? Yeah. It's, it, it, it's, you know, it's interesting to see. We still don't know. It's funny. We can't, we don't know what impacts spin rate. It's crazy how we have such little information on why people with high spin rate have it. It's amazing. There's tons of, you know, theories, but not a lot of evidence, but, Um, awesome. Well, Dr. Erickson, how can we learn more about you? If people wanna follow up with you, obviously go to PubMed and type in your name, right. But, you know, do you have a, do you have a website or if anybody wants to send you some patients, where would they go?

Brandon: 41:07

Oh yeah. So certainly, you know, anybody can feel free to reach out to me at, at any point. So my email is just my first name.my last name, rothman ortho.com. Um, if you search my name and then Rothman, my, my website will come up. So, pretty easy to find. Um, and then certainly, you know, if, if you have clinical questions, things like that, I mean, I'm happy to give my cell phone out to any of you guys. You know, feel free to just get in touch with Mike and he'd give it to you. I have no problem chatting about questions that come up.

Mike: 41:30

That's awesome. That's impressive too. I mean, you just gave your, your email address to thousands of people. Hopefully that's, that's impressive. I like that. So hope. Hopefully you don't get too many emails, but

Brandon: 41:40

No, it's okay. I, you know, what I found honestly in, in our circles are that, you know, people are pretty respectful that, you know, when things pop up, they have questions I'd somebody they talk to or isn't sure about. So I'm always happy to talk.

Mike: 41:54

Yeah. And, and you know, I, I think that's where social media's helped too. I think it's, you know, people are a little bit friendlier on dms and stuff. You can just ask people some quick questions and I don't think people mind sharing their knowledge. Right. That's, that's why we got into all this stuff is, is to share the things that we've experienced. So, um, you know, so really appreciate you doing that. Today with us on this podcast. Thanks for sharing your experience with this stuff. And, um, heck, we're gonna, we're gonna have to do this again in the future because I feel like we could talk for hours. So, uh, thanks again Dr. Erickson. Really appreciate you having us on the, having w us having you on the show today.

Brandon: 42:25

No, Mike, I appreciate it. Next one's gonna be on weighted balls and lighter balls, and we can argue that

Mike: 42:30

I lo I, I love it. I mean, there's, that, that would be a gr that'd be a great topic. So, uh, thanks again. Uh, really appreciate it.