But for our last lecture of the morning, we have Dr. Matt Gotland, which a lot of you I'm sure recognize that last name, and this is the son of Dr. Gotland. Unfortunately, he is actually at an orthopedic conference right now, so he's unable to join us live. So his lecture is recorded, and he won't be able to answer any questions, but if you have questions that you would like to submit, you can email those to me or Betsy, and we'll be happy to get those to Dr. Gotland, and you will get a response back within a week. So I think most people have Betsy's email just from registering for the conference. Mine's pretty easy. It's Jenny, J-E-N-N-Y, A-O-C-P-M-N-R, or I'm sorry, A-O-C-P-M-R at gmail.com. So you can email me your questions if you have questions as well. I'll have Rebecca put that email in the chat for the virtual attendees. But Dr. Gotland is actually, he's an MD. He went to medical school at the Stony Brook School of Medicine, and then he completed his orthopedic surgery residency training at NYU Langone Orthopedic Hospital, and that's also where he developed an interest in sports medicine. And he was the recipient of the 2019 Herodicus Award for Best Resident Paper at the AOSSM Annual Meeting. And in his final year of residency, he was selected as the Executive Chief Resident. And he's currently a sports medicine fellow at Lenox Hill Hospital, which is in New York City. So please join me in welcoming Dr. Gotland. Hi, everyone. My name is Matt Gotland, and I'm a sports medicine orthopedic surgery fellow in New York City. And I have the distinct pleasure to speak to you all about the operative management of common shoulder conditions in the active adult. Unfortunately, I have no disclosures, but maybe one day I will. My goal today is to go over the who, what, when, where, why, and hows of shoulder surgery, focusing on some of the most common pathologies we see in our active adult population. We will discuss impingement syndrome, rotator cuff disease, AC joint injuries, shoulder instability, slab lesions, adhesive capsulitis, and finally, arthritis. For each of these conditions, we want to know who will benefit from surgery, and how we identify the ideal surgical candidate, what are our surgical options, when is the ideal time to pull the trigger and operate, where are these procedures being performed, which for these topics will all be outpatient ambulatory cases, what is our rationale for operative intervention, and lastly, I'll go over some of the latest surgical techniques. First, we'll talk about impingement syndrome. Described by Neer in 1972, he described impingement syndrome as a ridge of proliferative spurs on the undersurface of the anterior process of the acromion, apparently caused by repeated impingement of the rotator cuff and the humeral head, with traction of the coracochromal ligament. This is the most common shoulder issue we see in the office, making up for almost 50% of the patients presenting with shoulder pain. These patients typically have preserved strength and range of motion, however, they have pain with overhead movements and a positive Neer and Hawkins test. We know that this condition leads to a spectrum of disease, starting with the mechanical impingement of the rotator cuff on the anterior structures of the shoulder, which then leads to subacromial bursitis, and then repetitive microtrauma can eventually lead to partial and full-thickness rotator cuff tears. Similar to the mechanical extrinsic compression is the idea of intrinsic degeneration of the rotator cuff tendons. Highlighted in the intrinsic theory is the combination of oxidative stress and suboptimal cuff vascularity that leads to a diseased rotator cuff. An anatomical consideration to consider is the type of morphology of the acromion. Sigliani described three types of acromions where type 1 is flat, type 2 is curved, and type 3 is hooked. The morphology can be routinely assessed on a scapular-wide view of plane radiographs. As you can see, the space available for the rotator cuff is decreased in patients with type 3 and type 2 acromions compared to those with type 1 acromions. We know that patients with subacromial impingement do very well with non-operative treatment, with prospective studies suggesting about 80% of patients can avoid surgery when implementing an exercise program with or without subacromial injections. Surgery for impingement syndrome is a widely debated area. There are multiple randomized controlled trials that state that surgery does not add any benefit to conservative management. They state that the placebo effect from surgery and the prolonged rest in PT were the reasons why surgery worked. However, the conclusion that surgery is ineffective is not that simple, as other studies reported good outcomes after arthroscopic subacromial decompression and better long-term outcomes when compared to people who only had conservative treatment. Many studies that encourage the use of exercise and PT for impingement don't offer a solution to those patients who fail conservative management. So who are the patients that could benefit from surgical intervention? We believe that patients who have clear impingement syndrome with positive physical exam findings and MRI findings suggestive of impingement, such as subacromial spurs or bursitis, young patients who have concomitant rotator cuff pathology, and those with type 3 acromions because they have an anatomic variant that can be surgically addressed. The procedure we can offer these patients is an arthroscopic subacromial decompression. This involves a brisectomy with or without an acromioplasty. In terms of timing, we generally consider surgery in patients who have failed four to six months of non-operative treatment. This timeline can vary from surgeon to surgeon, but a prolonged period of non-operative treatment is fine as long as there is no cuff pathology in a younger patient. A reason to operate sooner would be a young patient, someone less than 40 years old, or a patient who has a high-grade partial rotator cuff tear, as these are likely to progress. The reason we operate on these patients is to debride the inflamed bursal tissue, resect the acromial spurs, and remove hypertrophied or frayed coracoacromial ligament. Now I'll show you some pictures from an arthroscopic subacromial decompression. The picture on the left is a normal subacromial space. On the bottom of the picture is a rotator cuff, and above is the acromion. There is adequate space between the rotator cuff and the subacromial space. The picture on the right shows a subacromial spur that is causing significant narrowing of the space between the rotator cuff and the acromion. This is a before and after picture during an arthroscopic acromioplasty, where we take a burr and shave down the spur, which increases the space available for the rotator cuff. Next we'll segue to rotator cuff tears. We know from many epidemiologic studies that rotator cuff tears are very common. About 30% of patients over 60 have full thickness rotator cuff tears, and that percent increased to 65% in patients older than 70. Rotator cuff disorders make up for over 4 million visits a year, and we perform over 700,000 rotator cuff surgeries a year. Patients typically present with pain, specifically nighttime pain, and pain with overhead activities, as well as weakness. Weakness can be subtle side to side differences in strength, or it can be full blown pseudoparalysis, like pictured here. One of the issues with rotator cuff tears is that we don't fully understand the natural history of these tears. How is it that some patients have tremendous pain while others do not? Also, patients are able to maintain their function while others cannot. And as we start to see these younger patients with incidental findings on MRI scan, how do we predict which tears will progress and which ones will not? If we knew these answers, we could have a better understanding of who needs treatment and who doesn't. Why do some rotator cuff tears hurt? Well, we think it is due to the bursal inflammation, synovitis, intra-articular pathology, such as the biceps tendon, and subacromial pathology and friction associated with the proximal humerus as it migrates superiorly. We also need to understand what is limiting the patient's function. We have all seen patients with small rotator cuff tears and horrible pain, and conversely, we have seen patients with massive rotator cuff tears and limited pain. Pain seems to be a major driving factor in patient's function, and we can mitigate pain and then function may return. Some patients are able to use compensatory muscle function to lift their arm while others cannot. And location, instead of the size of the tear, is an important factor in whether function is compromised. We know that if we lose the anterior and posterior force couples, function is severely compromised. We know that not every patient with a rotator cuff tear needs surgery, and there are plenty of patients with rotator cuff tears that don't need treatment at all. Identifying those patients who need treatment is important. Some things to consider when evaluating a patient with a rotator cuff tear are age, severity level, pain level, and current function. Whether the tear is acute or chronic, and then some things specific to the tear, such as whether it's a partial or full thickness tear, the size of the tear, the retraction of the tear, and also the muscle atrophy. Rotator cuff tears are not only tendon issues, but are a muscle issue. When the tendon tears, this leads to muscle fatty degeneration. We know that the more fatty infiltration there is in the muscle belly of the rotator cuff tear, specifically greater than Goutelier stage 2, the more likely the repair will fail. Another easy way to determine the fatty atrophy is the tangent sign. On the sagittal T1 MRI image, draw a line from the superior border of the coracoid to the superior border of the scapular spine. If the muscle belly is below this level, there is a high likelihood of failure at the repair. This is a busy slide, but this is the treatment algorithm for patients with rotator cuff tears. In general, if the patient is young and highly functional with an acute tear, there is good evidence to support early operative repair within three months of injury, and we know these patients do very well. Unfortunately, the vast majority of tears we treat are chronic in nature. Aside from the medium-sized tear involving more than one tendon, we typically elect to proceed with the course of conservative treatment. We know that conservative treatment works well. This prospective study looked at 39 patients with full thickness rotator cuff tears who underwent a supervised rehab program. Within three months, 75% had a successful outcome and did not elect to have surgery. Of these patients, almost 90% of them maintained success at two years. This is another study looking at the effectiveness of physical therapy on patients with full thickness rotator cuff tears, and they also found a 75% success rate, which has been pretty consistent in the literature. So our job is to try to identify patients who fall into the 25% category, who fail non-operative treatment, and see if we can use that information to guide early management. One of the biggest predictors of success of non-operative treatment is whether the patient feels that non-operative treatment will be successful and whether they buy into the process. So who is most likely to benefit from rotator cuff repair surgery? Young, highly active patients with acute rotator cuff tears. Age is also not just a number. I put 65 on the slide because most of the literature uses 60 or 65 as the cutoff. However, a 70-year-old that plays golf and tennis should be treated based on their physiologic age and not their chronological age. Patients who have weakness as their predominant symptom rather than pain typically do better with early operative intervention because pain can easily be treated with medication and injections. But if the force couples are disrupted, surgical fixation is the best way to restore them. In terms of partial thickness tears, we tend to be more aggressive with bursal-sided tears as we know these don't do as well with conservative management. And lastly, the muscle needs to be viable. So if a muscle has atrophy, we know that the repair will likely fail. If the tear is repairable, the pendulum is almost completely swung to arthroscopic rotator cuff repair. However, there are a few surgeons out there that are still doing mini open repairs. The surgical options for an irreparable tear deserves an entire lecture. However, the three main options are the new subacromial balloon, which I'll show a little later, a superior capsule reconstruction, or a reverse total shoulder replacement. The reason we fix rotator cuffs are to restore the force couples, which helps to improve function, reduce pain by improving joint mechanics and limiting subacromial friction, and limit tear progression and reduce the risk for arthritis, secondary to humeral head, superior migration. Timing is still controversial. However, most will agree that acute tears in young patients should not be treated conservatively and should be treated with immediate surgery as the literature has shown that conservative treatment does not lead to good outcomes. For all other people, it is typically recommended to pursue operative intervention if a patient still has symptoms after three to six months of non-operative treatment. As most studies have shown that people are going to first improve with conservative management within the first three months. So if they don't do so after three months, they'll likely not improve and should be indicated for surgery. So let's see how we're going to deal with these tears. So this is an arthroscopic picture within the glenohumeral joint. The humeral head is on the right and the rotator cuff is on the upper left. You see here how the rotator cuff is inserting nicely on the humeral head. This is what a rotator cuff tear looks like. The picture on the left is from within the joint and the picture on the right is from within the subacromial space. You clearly see the hole in the tendon and the retraction from the humeral head indicating a rotator cuff tear. The way we fix these is from viewing from the subacromial space. We typically make three or four quarter inch portals where we insert our arthroscopic instruments. We mobilize the tear, clean up the frayed edges, and then place bone anchors in the greater tuberosity. These bone anchors have sutures in them, and then they are passed through the rotator cuff tendon and then either tied in place or dunked into another anchor that compresses the rotator cuff to the anatomic footprint on the greater tuberosity. For tears that are irreparable, this new subacromial balloon has been used to depress the humeral head and provides a cushion within the subacromial space. This procedure is very simple and takes about 20 minutes. Patients can perform accelerated rehab and make early clinical improvements. In this procedure, we clean up the subacromial space and shave down any bone spurs and then insert this balloon and fill it up with saline. This implant dissolves over a few months, but the idea is that it creates a pseudocapsule in the subacromial space that keeps the head from migrating superiorly. Another novel procedure for irreparable rotator cuff tears is a superior capsular reconstruction. Here we are placing a piece of tissue, either an allograft or an autograft, and connecting it to the greater tuberosity into the glenoid. This also provides a superior spacer to prevent superior migration of the humeral head. Lastly, in older patients with irreparable tears, we can do a reverse total shoulder replacement. By reversing the ball and socket, we move the center of rotation medial and distal, therefore giving the deltoid a mechanical advantage, allowing it to perform forward elevation just like the supraspinatus. Our next topic will be AC joint injuries. AC joint injuries are colloquially called shoulder separations. These injuries typically occur in contact athletes as the mechanism of injury is a direct blow to the shoulder. However, you can see these in people who fall off their bikes or even play in recreational leagues. An AC joint separation is by definition an injury to the acromioclavicular ligaments as well as the coracoclavicular ligaments. The AC ligaments are most important for horizontal stability, while the CC ligaments are most important for vertical stability. Patients typically present with a bump over their AC joint, which is usually tendon palpation, and x-rays are often, sorry, x-rays often demonstrate an elevation of the discoclavicle in relationship to the acromion. The Rockwell classification is actually one of the only useful classification systems in sports medicine that helps us identify the injured structure, allows us to easily communicate and actually helps dictate management. Type one injuries are sprains to the AC ligaments without injury to the CC ligaments. These are stable, don't present with deformity and have normal x-rays. Type two injuries are complete injuries to the AC ligaments and sprains of the CC ligaments. These have some mild horizontal instability and may present with a small bump on exam and x-rays show less than 25% elevation of the discoclavicle. Type three injuries are complete tears of both the CC and AC ligaments with 25 to 100% displacement of the discoclavicle. Type four injuries are rare and describe an injury that causes posterior displacement of the distal clavicle, and type five injuries are severely displaced and cause skin tenting. Lastly, type six injuries are extremely rare and are inferior dislocations of the distal clavicle. It is universally accepted that type four, five, and six AC joint injuries require surgical intervention because non-operative management has poor outcomes. The type three injuries are controversial. There is a trend towards operative management, especially in the athletic population. However, there's also good data to support initial non-operative management of type three injuries. If we do decide to operate on them, the surgical treatment of choice is a CC ligament reconstruction, which is achieved by multiple different techniques. AC joint hook plates have largely fallen out of favor since they need a second surgery to remove them, but they are an option in difficult cases or in the revision situation. When you have a patient with an operative AC injury, some will argue that more acute fixation makes the surgery easier. However, literature has shown that there's no difference in outcome between delayed or acute reconstruction. We fix some type three and all type four, five, and six injuries in order to improve cosmesis, restore AC joint stability, and some studies report higher functional scores and postoperative pain levels. There are many different techniques we use to reconstruct the CC ligaments, but they all try to achieve the same goal of reducing the CC interval by securing the clavicle to the coracoid with either sutures or allograft. The surgery is usually carried out through a longitudinal incision over the coracoid and clavicle, which are then exposed for preparation. Most techniques utilize allograft to secure the coracoid to the clavicle, attempting to recreate the CC ligaments, and then suture the additional graft over the AC joint to recreate the AC ligaments. This is a postoperative X-ray of a patient who underwent a CC ligament reconstruction for a type five injury. Here you see a nice reduction of the CC interval as well as the AC joint. In this case, suture buttons were used to repair the CC ligaments. The next topic we'll discuss is shoulder instability. The glenohumeral joint is a non-constrained joint that is essentially a round ball on a flat socket. The articular surface of the humeral head is about three times the size of the glenoid, which leads to excellent mobility at the expense of instability. The three major players in glenohumeral stability are the glenohumeral ligaments in labrum, the rotator cuff, and the glenoid and humeral bone stock. The glenohumeral ligaments are essentially capsular thickenings that provide a static restraint at extremes of motion. The glenoid labrum provides a firm attachment for the glenohumeral ligaments and improves glenoid depth, which increases the surface area of contact for the humeral head. The most important aspect of the labrum in preventing anterior instability is the anterior inferior portion, as this provides a strong buttress against anterior dislocation. The rotator cuff is an underappreciated dynamic stabilizer of the glenohumeral joint and achieves this by concavity compression. The cuff compresses the humeral head into the glenoid fossa, which helps to resist sheer force while providing pivot and translation motion to allow full range of motion. Lastly, the glenoid and humeral head bone stock is extremely important for stability, and we know that every millimeter of glenoid bone loss leads to predictable and proportionate instability patterns. We know instability of the shoulder is an issue because it leads to long-term arthritis. About 25% of patients will develop moderate to severe shoulder arthritis 25 years after a shoulder dislocation. Surgical repair of instability hasn't been shown to predispose a patient to degenerative changes, and instability-associated arthropathy is usually well-tolerated and does not necessarily require surgery. Some risk factors for development of arthritis include age over 25 at the time of first dislocation, recurrent instability, high energy sports, and alcohol abuse. Obtaining a thorough history in a shoulder dislocation is critical and affects management. We need to know whether this was their first dislocation or if they had many, how old they were at the time of their first dislocation, and if they were able to perform surgery. How did it happen? What was the position of the arm? Did it need to be reduced in the ER or did it pop in itself? And what is the patient's current activity level? What sports do they play? And what is their desire to get back to that sport? There are a number of physical exam maneuvers to test for instability, but one of our most important jobs is to assess whether the patient has glenohumeral laxity, which is a superphysiologic joint translation versus instability, which is a painful and pathologic increase in glenohumeral translation. The patients who are the best candidates for shoulder stabilization are those with recurrent instability, significant bone loss, and those with multiple risk factors, including contact athletes, age less than 20, male gender, and hyperlaxity. But what do we do with the athlete or the patient who dislocates their shoulder for the first time? These are the questions a physician needs to ask themselves when evaluating a patient with a first-time dislocation. What is the risk of recurrent instability? Is surgery necessary to minimize the risk of recurrence? And what kind of surgery will give us the least risk of recurrence? We know that the rate of recurrence is variable and depends on multiple factors. The risk of recurrence is the highest in the first two to five years after the first dislocation, and age and bone loss are the two biggest factors for recurrent instability. There are also good studies to suggest that the risk of recurrence is reduced in this at-risk patient population with surgical repair. The three main surgical procedures that we do for instability are arthroscopic labral repairs, open repair and capsular shifts, and bone block procedures when there is significant glenoid bone loss. Studies have shown that earlier operative intervention is better due to lower recurrence rate after stabilization of a patient with just one prior dislocation compared to many, and also every subsequent dislocation can increase the risk for rotator cuff injury as well as cartilage and bone injury. The rationale for operative intervention is because we know in a young athletic patient cohort, there is a 60 to 80% chance of recurrent dislocation. We operate to reduce this risk. And in the correctly selected patient, we can reduce this risk of recurrence to about 10%. So now let's see how we do this. This is a normal labrum from within the glenohumeral joint. It is confluent to the glenoid articular cartilage and surrounds the entire rim of the glenoid. This is what it looks like when the labrum is torn. Here, you see the labral tissue is no longer connected to the glenoid. Now, this is the end result of a labral repair where suture anchors are placed into the glenoid and then sutures are passed through the labral tissue and then tied, securing it to the glenoid. Some of you may have heard of the Latter Jay procedure, which is transferring the tip of the coracoid to the anterior part of the glenoid in order to restore bone loss. These procedures are often done for glenoid bone loss greater than 20 to 25%, failed arthroscopic procedures or patients with multiple dislocations. The idea behind the Latter Jay is that you are adding bone to the anterior glenoid, using the conjoint tendon as a sling to act as a dynamic stabilizer and using the CA ligament as a ligament as support. The other bone block option in the setting of glenoid bone loss or failed Latter Jay is either distal tibial allograft or iliac crest autograft. We will briefly talk about slap tears. The long head of the biceps tendon inserts on the superior labrum and this attachment site is referred to as the biceps anchor. A slap tear is a superior labral tear from anterior to posterior that affects this biceps anchor. This typically occurs in young overhead athletes and usually presents as an overuse injury, but may also occur in older folks after a fall. These patients usually complain about deep shoulder pain and biceps tendonitis type symptoms. Patients who are candidates for surgery are active adults, overhead athletes, and anyone with refractory pain despite non-operative management. The surgical treatments for a slap tear are slap repair, a biceps tenotomy, or a biceps tenodesis, where you're cutting the biceps and reattaching it to a different location. We are almost always recommending non-surgical treatment for patients. However, patients with continued pain after three to six months of non-operative treatment should be considered for surgery. The reason we operate on these patients is because of pain. These patients rarely have any functional deficits from this pathology. However, this tends to be a nuisance for patients, especially those who do a lot of overhead activities. Let's see how we address these injuries. The orthoscopic picture on the left is what the superior labrum looks like. It is well attached to a superior aspect of the glenoid and attached to the biceps anchor. The picture on the right is what the intraarticular portion of the biceps tendon looks like, which is shiny and tubular without any fraying or injection. These pictures nicely depict what a superior labral tear looks like with clear discontinuity between the superior labrum and the glenoid. If you stick an orthoscopic probe in between the labrum and the glenoid, you see the true instability of these injuries. This patient had their labrum fixed with two suture anchors. So what we do is we place two anchors, one on each side of the biceps tendon, pass it through the superior labrum and anchor it back down to the glenoid. One of the most common complications after a slab repair is stiffness, which occurs in almost 80% of patients, especially ones who are older than four years old. Another option is just to perform a biceps tenotomy, which means simply releasing the biceps at the junction of the biceps and the superior labrum. This relieves the pain generated from the biceps tendon pulling on the superior labral tear. This is typically done for older patients. The more common procedure being done now is a biceps tenodesis, which is cutting the biceps and reinserting it at a different location, all while taking care to maintain the length tension relationship. This can be done arthroscopically or open. The open ones are reinserted under the pectoralis major tendon, where we make a small incision, just distal to the inferior border of the pectoralis major tendon, which is just lateral to the axillary fold. We grab the biceps out of the groove, which is easily accessible through this incision underneath the pectoralis muscle belly. And then we anchor into place within the bicipital groove. This is favored by some over the arthroscopic procedure because it eliminates the possibility of residual pain from within the bicipital groove. Next, a condition that is extremely common, adhesive capsulitis or frozen shoulder. Frozen shoulder is a fibroblastic proliferation that causes stiffness. Importantly, on physical exam, these patients have almost equivalent restrictions in both active and passive range of motion. Risk factors include diabetes, thyroid, females, and people age 40 to 60 years old. When I see a patient in the office with frozen shoulder, I tell them two things. First, the good news is that you don't need surgery. And second, the bad news is this can take nine to 12 months to resolve. The first line treatment for this condition is aggressive PT, but it could take a long time to resolve. So who would benefit from surgery? Patients with functional limitations despite prolonged PT are considered for surgery. The things we can offer these patients are a manipulation under anesthesia and an arthroscopic capsule release. The million dollar question is when to pull the trigger. Surgeons that tend to be more aggressive will sometimes operate on these patients if they don't progress by three to six months. But more commonly, we'll usually wait up to a year before pulling the trigger. The reason being is that we know most people will resolve. They just need some more time. The reason for surgery is to address the stiffness, not the pain. Intraarticular and subacromial cortisone injections do a good job at eliminating the pain. However, sometimes refractory stiffness can be surgically addressed. We address the stiffness by doing a 360 degree capsular release. You can see in this patient with adhesive capsulitis that their capsule is thickened and hyperemic. We use electrocardiogram devices or arthroscopic biters to release the capsule all around the glenoid. After the surgery, the patients are placed in a sling for comfort, but are encouraged to move their shoulder right away to prevent recurrence. Lastly, I just want to mention a little bit about shoulder arthritis. The most important thing to differentiate is shoulder arthritis in the young person versus arthritis in the older patient. The first challenge with young patients is that the treatment you offer needs to be long lasting and durable. Additionally, these patients have high functional demands and high expectations. One of the biggest inherent challenges is the heterogeneity of the patient population and multiple etiologies that have led to their arthritis. Lastly, there is no consensus on management strategies amongst this group of patients. The patients we consider for surgery are those with end-stage glenohumeral arthritis, pain and stiffness, and those who fail non-operative treatment. When patients fail non-operative treatment, this is the menu of treatment options listed for most joint preserving to full-blown arthroplasty. All the way on the left, we have arthroscopic procedures that primarily address symptom management. Next, we have reparative solutions like microfracture. After that, we have biologic options like osteochondroallografts. If you wanna do a partial biologic reconstruction, you may consider glenoid resurfacing or a rim and run. And lastly, we have arthroplasty, either hemiarthroplasty or total shoulder replacement. We often tell patients with end-stage arthritis that the decision to proceed with surgery is up to them. The surgery is a quality of life surgery. Whenever the patient can no longer deal with their symptoms and have issues with activities of daily living or activities that they enjoy doing, we tell them they're indicated for surgery. In terms of age, there is no cutoff, but we prefer patients to be over 50 just because the longevity of the implant and probable need for revision if done in a very young patient. The reason we operate, especially joint replacements in general, is because joint cartilage is like treads on a tire. Once they wear out, they don't grow back. Once the cartilage is gone, the only option we have to predictably restore function and improve pain is to replace it. So we will focus on shoulder replacement for this portion of the talk. When deciding what kind of shoulder replacement to do, we need to find out if the rotator cuff is intact because that will help dictate treatment. In clinical examination, one hint on the X-ray that the rotator cuff is deficient is superior migration of the humeral head. The picture on the right is an example of superior migration where the head is no longer centered on the glenoid and the acromial humeral interval is decreased. If the rotator cuff is intact, we usually elect to do an anatomic total shoulder replacement in which we replace the humeral head with a sphere and the glenoid with a socket. In the case where the rotator cuff is deficient, we will do what is called a reverse total shoulder replacement where we replace the socket with a sphere and the humeral head with a socket. This changes the center of rotation to give the deltoid the mechanical advantage to lift the arm. I know that was a very broad overview, but the key points are that non-operative treatment is still the first-line treatment for most shoulder conditions that we see in the office. It is important to know who can benefit from surgery, when you should refer for surgical consultation, and what surgical procedures are available. Surgery is not for everyone, so knowing your patient and properly indicating them is extremely important to achieving a good outcome. Thank you for allowing me to participate in this great meeting. Sorry, again, I could not be there in person. If you have any questions, please feel free to email me at any time.

orthopedic sports medicine

shoulder surgery

rotator cuff tears

impingement syndrome

AC joint injuries

shoulder instability

SLAP lesions

frozen shoulder