Latest / The Ask Mike Reinold Show / The New Tommy John: The Rise of the Internal Brace - #AMR386

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The New Tommy John: The Rise of the Internal Brace - #AMR386 · The Ask Mike Reinold Show

• 0:50
  SPEAKER_00: On this episode of the Ask Mike Rhinald Show, we talk about the new internal brace procedure for Tommy John surgery.
• 0:58
  SPEAKER_00: The Ask Mike Rhinald Show.
• 1:03
  SPEAKER_00: Helping people feel better, move better, and perform better.
• 1:16
  SPEAKER_00: Before we get to the podcast, I wanted to make sure you knew about my free online course on the introduction to performance therapy and training.
• 1:24
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• 1:29
  SPEAKER_00: Head to micrennold.com/slash performance.
• 1:32
  SPEAKER_00: Sign up today.
• 1:46
  SPEAKER_00: Submit the form and really ask us anything: sports medicine, PT, career advice, performance, anything you want to talk about, we are here for you.
• 1:55
  SPEAKER_00: Let's see, who do we have today?
• 1:56
  SPEAKER_00: We have Lenny McCrino, Dave Tilley, Brenda Gates, Dewesh Podell, and Anthony Vedetto all here for your listening pleasure today.
• 2:05
  SPEAKER_00: No students, we're kind of playing with some new formats that we're messing with with the podcast.
• 2:09
  SPEAKER_00: So, Len, I don't know, do you have any opening statements since you don't have the students to announce?
• 2:13
  SPEAKER_00: No, I usually write the students down and it's blank.
• 2:15
  SPEAKER_00: So I guess I was waiting for a magical like a ride.
• 2:21
  SPEAKER_04: You have a scratch pad there on your desk?
• 2:23
  SPEAKER_04: We have like a whole we have a whole PT department of students now, so uh I have to keep track of each one, like gremlins.
• 2:29
  SPEAKER_00: Yeah.
• 2:30
  SPEAKER_00: All right.
• 2:30
  SPEAKER_00: So first what question from today.
• 2:33
  SPEAKER_00: I'll be happy to read it.
• 2:34
  SPEAKER_00: So let's see.
• 2:35
  SPEAKER_00: Chris from Tampa.
• 2:36
  SPEAKER_00: We're seeing way more repairs with internal brace lately rather than the standard Tommy John.
• 2:43
  SPEAKER_00: Surgeons are clearing them to throw much earlier, and frankly, it scares me.
• 2:47
  SPEAKER_00: Are we rushing these guys back too fast?
• 2:50
  SPEAKER_00: What are the red flags you look for in these accelerated UCL protocols that differ from the traditional reconstruction we've done for decades?
• 2:58
  SPEAKER_00: Uh, good crush question, Chris.
• 3:01
  SPEAKER_00: I mean, you know, it's funny, like you could tell you've done this for a while just by reading your question, right?
• 3:06
  SPEAKER_00: You know, the traditional reconstruction we've done for decades, I kind of kind of read into it.
• 3:10
  SPEAKER_00: So we have this new internal brace.
• 3:13
  SPEAKER_00: Let's start with this.
• 3:14
  SPEAKER_00: I'll kind of like lead some questions here.
• 3:17
  SPEAKER_00: Um, what do you think in the last year in your guys' caseloads?
• 3:21
  SPEAKER_00: I know Anthony and Lenny at least, myself, you know, I'm not sure Brendan, how many you have over at your place, but um how how many internal braces are we seeing and not reconstructions?
• 3:32
  SPEAKER_00: What do you think?
• 3:33
  SPEAKER_00: What's the percentage you think?
• 3:34
  SPEAKER_00: What do you think, Anthony?
• 3:35
  SPEAKER_02: I feel like it's half for me.
• 3:37
  SPEAKER_02: I'm seeing it so much more of internal braces, especially um kind of in the college level.
• 3:43
  SPEAKER_02: It's just like it's it's so much more prominent than what I've been seeing in the past in terms of the reconstruction versus the hybrid.
• 3:48
  SPEAKER_02: So that's just me personally.
• 3:49
  SPEAKER_02: I don't know, Len, is that similar for you?
• 3:51
  SPEAKER_04: Yeah, I think it was a little less for me.
• 3:53
  SPEAKER_04: I was my my gut said like 30%, something like that, you know.
• 3:57
  SPEAKER_04: I have I have a couple right now that are isolated, but the majority are hybrids for me.
• 4:01
  SPEAKER_04: Yeah, in my head.
• 4:03
  SPEAKER_00: I I feel like on my end, they are, you know, the reconstructions went to internal braces for a hot second, but then hybrids took over.
• 4:11
  SPEAKER_00: So a reconstruction with an internal brace, and now I kind of feel like they're scaling back again, and we're starting to see more internal braces and less hybrids again.
• 4:20
  SPEAKER_00: So it's you know, but I I would say the traditional Tommy John reconstruction's gone, right?
• 4:25
  SPEAKER_00: Like it's either an internal brace or it's a Tommy John reconstruction with an internal brace or a hybrid, right?
• 4:31
  SPEAKER_00: Anybody disagree?
• 4:33
  SPEAKER_00: I agree with that.
• 4:34
  SPEAKER_00: Yeah, I agree.
• 4:34
  SPEAKER_00: Yeah, yeah.
• 4:35
  SPEAKER_00: And it's just all internal brace right now.
• 4:37
  SPEAKER_00: No way, really.
• 4:38
  SPEAKER_00: It's just all internal brace.
• 4:39
  SPEAKER_00: Yeah.
• 4:39
  SPEAKER_00: So, you know, it's funny.
• 4:40
  SPEAKER_00: I mean, so what what was our first internal brace, you think?
• 4:43
  SPEAKER_00: Like 2013-ish?
• 4:44
  SPEAKER_00: Is that what it was when when Dr.
• 4:45
  SPEAKER_00: Dugas down in Birmingham started doing uh internal braces lunch?
• 4:49
  SPEAKER_00: Probably around the yeah, 2012-ish, 20.
• 4:52
  SPEAKER_00: Yeah.
• 4:53
  SPEAKER_04: It's funny.
• 4:53
  SPEAKER_04: I were were you scared?
• 4:56
  SPEAKER_04: Uh yeah.
• 4:57
  SPEAKER_04: You know, it all happened by accident.
• 4:59
  SPEAKER_04: Like the the it was a Troy pitcher who uh just pitched earlier than he was supposed to and did well.
• 5:05
  SPEAKER_04: So I think we were like, oh, they can handle it.
• 5:09
  SPEAKER_04: Troy University.
• 5:10
  SPEAKER_04: Jugas is a team doctor for Troy.
• 5:12
  SPEAKER_04: And the kid just kind of violated all you know the restrictions.
• 5:16
  SPEAKER_00: If that's the methodology, then we I think we need to have a kid like that violate a traditional Tommy Johnson.
• 5:23
  SPEAKER_04: By the Shellbound paper in 90.
• 5:24
  SPEAKER_04: Like it was just like they all vital violated the precautions and then they did well.
• 5:28
  SPEAKER_04: So yeah.
• 5:29
  SPEAKER_00: I I just remember because the doctors are like super gung-ho about this at the beginning.
• 5:33
  SPEAKER_00: I think we're starting to get them to scale back a little bit here, but they're just they're super gung-ho that they can go super fast, you know, like get back a lot faster.
• 5:40
  SPEAKER_00: And we were just like, oh man, like this this seems too fast for us.
• 5:45
  SPEAKER_00: Like, you know, like, you know, I don't know.
• 5:47
  SPEAKER_00: What what were your initial thoughts, Len?
• 5:49
  SPEAKER_00: And then as you went through the first people, like what do you think?
• 5:52
  SPEAKER_00: Like, did you scared?
• 5:54
  SPEAKER_04: Uh yeah, yes.
• 5:55
  SPEAKER_04: Um, I'm not scared anymore, but initially in my head, you're putting a tissue in that's not the patient's own tissue.
• 6:02
  SPEAKER_04: And so I thought it would take longer for that to kind of incorporate um, you know, almost like an allograph, but even like not.
• 6:08
  SPEAKER_04: It's not even like tissue, it's just like material.
• 6:11
  SPEAKER_04: Um so in my head, I'm like, wow, we're getting these kids to throw earlier with tissue that's not theirs.
• 6:17
  SPEAKER_04: I'm worried that it's not gonna incorporate into the bone and stabilize appropriately and we're just gonna rip it out.
• 6:23
  SPEAKER_04: Um, and I was like, oh, we're gonna throw it 10 weeks.
• 6:26
  SPEAKER_04: Like we're just like if they're if we should have them like do a slow rehab or a regular rehab for the first four to six weeks, that gives us a month to basically get them ready to throw.
• 6:36
  SPEAKER_04: And it felt like it was quick with healing and strengthening wise, and and you know, I don't think I'm I'm not doing a lot of throwing at 10 weeks, but like 12, 14 weeks, you know, we get an extra few weeks out of it and they seem to hold up.
• 6:49
  SPEAKER_00: I you know, and I it's funny you get, you know, you you said that really well because I think we all shared kind of the same concerns at the beginning with this, and like, man, why are we why are we rushing back to like throw so fast, right?
• 7:01
  SPEAKER_00: Um it to me, like I guess we should probably start with the audience here and just say, you know, what's the difference?
• 7:06
  SPEAKER_00: But you know, traditional Tommy John, like I would say for the longest period of time, we started throwing at week 16.
• 7:12
  SPEAKER_00: Um, and in the past, I know Kevin Wilkins in the 90s tried week 12, week 20, he tried, you know, a bunch of different things, but you know, we settled on week 16, and I think week 16 was really there for a very long time.
• 7:23
  SPEAKER_00: Um, the physicians started to want to slow down a little bit, not really slow down the rehab to in terms of starting to throw, I don't think, but really in terms of the whole general rehab process.
• 7:33
  SPEAKER_00: You know, and to me, I pushed them back to week 20 just because if if you go week 20 and then you do a seventh-month throwing program, which by the way is a very long time, right?
• 7:42
  SPEAKER_00: Like a seven-month throwing program is very long, right?
• 7:46
  SPEAKER_00: So for these people, they they you know, five months and seven months works out pretty good to year.
• 7:50
  SPEAKER_00: So we started doing that.
• 7:52
  SPEAKER_00: Then all of a sudden, as Lenny alluded to, internal braces come out in the doctors at the beginning, right?
• 7:56
  SPEAKER_00: Weren't they saying eight to ten weeks at one point?
• 7:58
  SPEAKER_00: Or they say eight weeks at one point.
• 7:59
  SPEAKER_04: I don't know if I remember eight, but it was definitely ten.
• 8:01
  SPEAKER_04: It was trying to just break the sound barrier of like, all right, we're gonna get you back faster, you know, like let's go.
• 8:07
  SPEAKER_04: And this is this is our selling point, you know, we can get you back faster.
• 8:10
  SPEAKER_04: Crazy.
• 8:11
  SPEAKER_00: So man, ten weeks.
• 8:13
  SPEAKER_00: Wow.
• 8:14
  SPEAKER_00: All right.
• 8:14
  SPEAKER_00: So here's a question for we'll start with Anthony and then you know, Brendan, you know, Len.
• 8:19
  SPEAKER_00: Sorry, Dave.
• 8:20
  SPEAKER_00: Dave's Dave's actually have an internal brace right now.
• 8:23
  SPEAKER_00: Yeah, I mean with gymnasts.
• 8:26
  SPEAKER_00: Yeah.
• 8:26
  SPEAKER_00: Yeah.
• 8:26
  SPEAKER_00: The non-baseball players are actually perfect for this because like a traditional Tommy John is an enormous procedure for them when an internal brace is much better.
• 8:34
  SPEAKER_00: Um, all right, let's so let's go to week 10.
• 8:36
  SPEAKER_00: So your week 10 and an internal brace protocol.
• 8:38
  SPEAKER_00: How many times have you felt the person you're working with was ready to start the rowing?
• 8:42
  SPEAKER_00: What do you think, Anthony?
• 8:44
  SPEAKER_02: Uh never.
• 8:46
  SPEAKER_02: Is that too?
• 8:48
  SPEAKER_02: I mean, it's just it's so soon, right?
• 8:50
  SPEAKER_02: They're wearing the brace for mostly six weeks, right?
• 8:53
  SPEAKER_02: And then we're just gonna give them a month to get strong enough, get in the gym, and then maybe start applying metric progression.
• 9:00
  SPEAKER_02: Like, I don't think a month is enough time to do all that stuff.
• 9:04
  SPEAKER_02: Like, and then it's you know, starting with the end in mind, how many of these kids do we need to get back in seven, eight months?
• 9:11
  SPEAKER_02: Like a lot of them are getting injured in the spring.
• 9:14
  SPEAKER_02: Do we need them to be full speed off the mound in November, December?
• 9:18
  SPEAKER_02: No, like we have till the next spring to get them ready to go.
• 9:21
  SPEAKER_02: You know, so I I think situationally it depends, but no, I to answer your question, 10 weeks seems way too early in my head.
• 9:29
  SPEAKER_04: Right.
• 9:29
  SPEAKER_04: And those kids, we we tell them that ahead of time.
• 9:32
  SPEAKER_04: You're not gonna throw it 10 weeks.
• 9:33
  SPEAKER_04: You got hurt in March or April.
• 9:35
  SPEAKER_04: We don't need you to peak in November, December.
• 9:37
  SPEAKER_04: Let's throw it four months, you know, something like that, and go traditional.
• 9:40
  SPEAKER_04: And they all buy in because they they know, they realize.
• 9:42
  SPEAKER_04: Yeah.
• 9:43
  SPEAKER_00: J just be careful, that just might not fit into the surgeon's outcome study that they're trying to publish.
• 9:48
  SPEAKER_00: So I get it.
• 9:49
  SPEAKER_00: That's uh that because sometimes that is part of that process with that.
• 9:52
  SPEAKER_00: So yeah, I mean, I I I completely agree.
• 9:55
  SPEAKER_00: And I actually think 12 weeks is which is, you know, kind of like, you know, 12's, I don't know, probably what we're saying we're we're probably doing the most now.
• 10:03
  SPEAKER_00: You know, somewhere 12 to 16 if we have time.
• 10:05
  SPEAKER_00: I still think they're not ready at 12 weeks.
• 10:07
  SPEAKER_00: And if you think about a Tommy John person right now that's getting an internal brace, it's probably what, like a high school kid, maybe a young college kid.
• 10:14
  SPEAKER_00: And I know, trust me, you could do these on anybody.
• 10:16
  SPEAKER_00: Don't get me wrong.
• 10:17
  SPEAKER_00: That's not my point.
• 10:18
  SPEAKER_00: But you get a lot of high school and college kids here.
• 10:20
  SPEAKER_00: And you know, these kids have never done an arm care program, they're barely worked out in the gym, their mechanics are terrible.
• 10:25
  SPEAKER_00: The first six weeks are damage control, and then all of a sudden you're like, all right, pick up a ball again.
• 10:30
  SPEAKER_00: Like that, it just doesn't make sense.
• 10:32
  SPEAKER_00: I feel like we don't have time to help this kid, right?
• 10:36
  SPEAKER_00: And man, what when we push back from week 16 to week 20 with the traditional Tommy Johns, I actually think the biggest benefit with that was how prepared their bodies were before they started throwing.
• 10:47
  SPEAKER_00: That to me, that's what stood out.
• 10:49
  SPEAKER_00: And I think that's why our players have done so well.
• 10:51
  SPEAKER_00: We we went to week 20 years ago, like before I think everybody else was.
• 10:55
  SPEAKER_00: Um, and it just it just really benefited.
• 10:57
  SPEAKER_00: So you have a kid that's never worked out, not physically completely mature, probably, no arm care program, and you're essentially saying, you know, however you were when you got hurt is what we're gonna get you back to and we're gonna throw again.
• 11:09
  SPEAKER_00: We don't have time to improve you, right?
• 11:13
  SPEAKER_00: So, Brendan, what do you think?
• 11:15
  SPEAKER_03: Yeah, I just wanted to comment.
• 11:16
  SPEAKER_03: I had a uh a kid with an internal brace come in recently, college pitcher, and uh, you know, with this short of a timeline, he missed the first three weeks because he got the surgery in California and then he just didn't come to PT for the first three weeks.
• 11:29
  SPEAKER_03: So with those three weeks, that's kind of significantly pushed us back a little bit.
• 11:33
  SPEAKER_03: So, how how much do you guys value getting the person into PT, you know, almost immediately?
• 11:39
  SPEAKER_00: That's actually great.
• 11:39
  SPEAKER_00: I I'll start with that just because I have a kid now that had an internal brace that started at week two, and he looks bad, you know.
• 11:46
  SPEAKER_00: Sorry if you're listening.
• 11:47
  SPEAKER_00: So it's not that he looks bad.
• 11:48
  SPEAKER_00: He's he's he's behind where I would like him to be, uh to your point, Brandon.
• 11:52
  SPEAKER_00: Probably five, yeah, exactly.
• 11:54
  SPEAKER_00: Right.
• 11:54
  SPEAKER_00: So his motion was behind, he wasn't moving around.
• 11:56
  SPEAKER_00: He actually has some like ulnar neuropathy, and who knows?
• 11:59
  SPEAKER_00: Maybe that's from sitting in his brace not moving.
• 12:02
  SPEAKER_00: Maybe the brace was too tight on his ulnar nerves.
• 12:04
  SPEAKER_00: Like there's so many reasons other than just like starting the rehab process where you want to go.
• 12:09
  SPEAKER_00: So yeah, I I even started week two, Brendan, and I thought they were too late.
• 12:12
  SPEAKER_00: Um, what do you think, Anthony?
• 12:14
  SPEAKER_02: Yeah, I I have a kid who just came in who was nine days post op and same thing.
• 12:19
  SPEAKER_02: Stiff was in the brace, locked for nine days, and was nervous to move his arm once we took the brace off.
• 12:26
  SPEAKER_02: So, like the importance of getting started in in the first week is I can't, yeah, we can't emphasize that enough.
• 12:32
  SPEAKER_00: Yeah, completely, completely.
• 12:34
  SPEAKER_00: Um, all right, Dave, yeah, sorry, but Dave, what do you think?
• 12:36
  SPEAKER_01: Yeah, I'm I remember overhearing maybe Lenny can correct me, but I think weren't you guys saying too that some of the concern is that the the tape and the repair, like the actual ligament, is like really too strong and it's very, very good.
• 12:46
  SPEAKER_01: And the stress on the other parts around the elbow is what's more concerning is kids are getting forearm flexor issues, kids are getting didn't Lenny, didn't you have somebody with like a bone uh tunnel stress reaction?
• 12:55
  SPEAKER_01: Like is that part of the issue too?
• 12:57
  SPEAKER_04: I I would say so.
• 12:59
  SPEAKER_04: That the material is so strong, and I think the fixation is is so good that um we're seeing more bone stress injuries.
• 13:07
  SPEAKER_04: Um I I've seen a bunch of a couple heterotopic ossifications where you're getting bone like calcification formation that causes elbow stiffness.
• 13:15
  SPEAKER_04: It's not just me.
• 13:16
  SPEAKER_04: I've actually spoke to a baseball player up at Colby College in where is it, Maine?
• 13:21
  SPEAKER_04: They're having the same issue, like motion just doesn't come back.
• 13:23
  SPEAKER_04: And I threw that idea out at them.
• 13:25
  SPEAKER_04: Like it could be this because you work on flexion, they lose extension, you lose work on extension, you lose flexion.
• 13:30
  SPEAKER_04: Um, it just doesn't feel right, but he's throwing and he just he just keeps pushing through it.
• 13:34
  SPEAKER_04: But there's something underlying going on.
• 13:36
  SPEAKER_04: He just had he had a hybrid, if I remember correctly.
• 13:39
  SPEAKER_04: Um, and I just was like, the you gotta look deeper into this because what you guys are missing something, you know.
• 13:44
  SPEAKER_00: So yeah, I was just gonna ask that, Leng, because I was gonna say, I'm not seeing that with internal braces.
• 13:48
  SPEAKER_00: That was that a hybrid?
• 13:49
  SPEAKER_00: Because I feel like the hybrids I'm seeing.
• 13:50
  SPEAKER_00: The hybrids, sorry, yeah, the hybrids, yeah.
• 13:52
  SPEAKER_00: The hybrids are just so tight, you know, especially the surgeons are tightening them up so much.
• 13:56
  SPEAKER_00: It's you know, which is interesting.
• 13:58
  SPEAKER_00: They're you know, in the mid-range of motion where they throw, they're actually okay.
• 14:01
  SPEAKER_00: But then even 12 months after the procedure, they feel tight inflection and extension, uh, but they can throw, you know.
• 14:07
  SPEAKER_00: So, you know, I don't think the surgeons care because of that, but like, I don't know, I think it bothers us.
• 14:12
  SPEAKER_00: But um, I don't know.
• 14:13
  SPEAKER_00: So I let's shift gears and talk about like outcomes a little bit here, because I think, you know, the exciting part of this is they're doing great.
• 14:19
  SPEAKER_00: Um, I don't have anything bad to say about internal braces.
• 14:22
  SPEAKER_00: And for years I said it's promising, it's looking good.
• 14:25
  SPEAKER_00: Uh, but at this point, I think we can firmly say that this is a very, very viable procedure.
• 14:30
  SPEAKER_00: It is very effective.
• 14:32
  SPEAKER_00: Uh, recent study by Jeff Dugas and the group out of Birmingham last year showed that the outcomes were excellent, uh, the same as traditional Tommy John.
• 14:40
  SPEAKER_00: Um, and I think what's happening now is the surgeons are doing a better job, like diagnosing the specific type of injury and the right person for these procedures, and they're giving them what they need.
• 14:50
  SPEAKER_00: Um, so the outcomes are great.
• 14:51
  SPEAKER_00: So I have no concerns about this.
• 14:53
  SPEAKER_00: What why don't we end with like the last part of this question and just say, like, all right, in your guys' experiences through this rehab process, we talked about some of the things we find.
• 15:02
  SPEAKER_00: What are some of the red flags?
• 15:03
  SPEAKER_00: That's what kind of Chris asked for, but what are some of the red flags or what are some of the things like the pearls you know that's different with this versus a Tommy John and your experience that you want to share with somebody that maybe hasn't seen a lot of these internal braces?
• 15:15
  SPEAKER_00: Like, you want to start, Len?
• 15:17
  SPEAKER_04: Yeah, I think um getting them in early um and getting that motion right away.
• 15:22
  SPEAKER_04: Um, you know, I think I don't know if if doctors are getting more conservative with these or just in general, but getting them in early, get that motion, get the extension established.
• 15:30
  SPEAKER_04: Um, these things are fixated.
• 15:31
  SPEAKER_04: The docks are not worried about anything.
• 15:33
  SPEAKER_04: Like they get them moving.
• 15:34
  SPEAKER_04: It's not going anywhere.
• 15:36
  SPEAKER_04: But don't be too aggressive because I do see cases where I inherit cases from other people where they start to feel the stiffness in the elbow and the the clinician freaks out and starts really like cranking on the elbow.
• 15:46
  SPEAKER_04: And I think that creates more inflammation and more.
• 15:48
  SPEAKER_04: I think that's probably a couple of reasons why you're seeing uh I'm seeing some heterotopic ossification um in a couple of mine that I've inherited.
• 15:56
  SPEAKER_04: Um so get that motion, especially extension, but don't be too aggressive.
• 16:00
  SPEAKER_04: Um I think just like uh get these kids uh you know, get their strength.
• 16:04
  SPEAKER_04: Like don't just follow the the the 10 week or 12-week protocol.
• 16:08
  SPEAKER_04: They got to be ready to throw because it's just gonna make the rehab process that much easier um when they are, you know, throwing from 90 and beyond, because that's usually where you start to see them breaking down, is they just can't handle those stresses is when they get beyond 90.
• 16:21
  SPEAKER_04: Brandon, what do you think?
• 16:22
  SPEAKER_03: Yeah, I think Glenny said most of the stuff that I was thinking about um getting in early, making sure not to push flexion too much.
• 16:29
  SPEAKER_03: It seems like if uh you know you're really cranking on that flexion early, that kind of gets them irritated and stiff.
• 16:35
  SPEAKER_03: Um and yeah, I think you know, as somebody who probably sees a little bit less of the uh internal braces and Tommy Johns in general, um, you know, I know for me, you know, still ranging them so early at like week six or you know, week eight into that like layback position is a little scary for me.
• 16:51
  SPEAKER_03: Um but I think we have to make sure, like you said, that we're doing all we can to make sure they are appropriate for uh for throwing, you know, a little bit earlier at that week 12 or week 14.
• 17:00
  SPEAKER_00: Yeah, I agree, Brendan.
• 17:01
  SPEAKER_00: It is scary the first time you do it and you're just like, oh, this is this seems so fast.
• 17:05
  SPEAKER_00: That's the whole point of Chris's question, too.
• 17:06
  SPEAKER_00: I like it.
• 17:07
  SPEAKER_00: So uh Anthony, what do you got?
• 17:09
  SPEAKER_02: Yeah, just to emphasize what I said earlier, like just because they can throw at 10 weeks doesn't mean they should throw at 10 weeks, right?
• 17:15
  SPEAKER_02: So starting with the end of mind is important.
• 17:18
  SPEAKER_02: They have a lot more time than you probably think they do.
• 17:21
  SPEAKER_02: Um and really just take it case by case, because like I said, um, just because the the surgeon says, yeah, throw at 10 weeks, a lot of them probably aren't going to be ready to throw at 10 weeks.
• 17:31
  SPEAKER_02: So um use objective criteria, range of motion, pain-free, right?
• 17:35
  SPEAKER_02: Make sure their strengths adequate, make sure they complete some sort of plyometric progression first.
• 17:39
  SPEAKER_02: So uh yeah, 10 weeks, sure, but like probably not.
• 17:43
  SPEAKER_02: So let's let's wait a little bit longer.
• 17:45
  SPEAKER_00: Yeah, and I think I would just add, you know, there's a there's a different pain characteristic that I think we're seeing with these, especially when we're pushing.
• 17:53
  SPEAKER_00: It seems more flexion, but I'm seeing more extension lately too, where they actually point to like the posterior aspect of their medial epicondyle, which isn't something nobody ever really has pointed with with traditional Tommy John.
• 18:05
  SPEAKER_00: Um that's completely unique for me.
• 18:07
  SPEAKER_00: And just keep in mind that I I've seen, you know, again, like you could throw no problem.
• 18:11
  SPEAKER_00: You can do valgus stress testing, no problem.
• 18:13
  SPEAKER_00: It doesn't hurt.
• 18:14
  SPEAKER_00: But then again, you push into flexion and with you know deep flexion, you get that pain posterior medial.
• 18:20
  SPEAKER_00: Um, remember that that brace is like duct tape, right?
• 18:23
  SPEAKER_00: It's not pliable.
• 18:24
  SPEAKER_00: So, you know, who knows?
• 18:25
  SPEAKER_00: Maybe we're pulling that on a little bit.
• 18:26
  SPEAKER_00: And, you know, I think one of the things we're still trying to learn here is like, is the brace actually what's helping?
• 18:31
  SPEAKER_00: Or is it the fact that the brace holds the the ligament repair together better and allows the ligament to actually repair itself better?
• 18:39
  SPEAKER_00: Maybe it's not the brace a year down the road.
• 18:41
  SPEAKER_00: I don't think we know that definitively.
• 18:43
  SPEAKER_00: So kind of keep that in mind.
• 18:44
  SPEAKER_00: But um, yeah, I mean, to answer all your questions, Chris, this thing is is good.
• 18:48
  SPEAKER_00: We were scared, right?
• 18:50
  SPEAKER_00: And you know, I think Kevin Wilk, we talk about this all the time.
• 18:52
  SPEAKER_00: We've seen a ton of these with Dr.
• 18:53
  SPEAKER_00: Dugas.
• 18:54
  SPEAKER_00: Like we he was scared at the beginning, but you know, they they they're doing great.
• 18:58
  SPEAKER_00: So um I think it's awesome.
• 19:00
  SPEAKER_00: I want to see more and more of these because I'm actually liking them better than the hybrids right now.
• 19:03
  SPEAKER_00: So, you know, hopefully there's more to come.
• 19:05
  SPEAKER_00: So uh great question, Chris.
• 19:07
  SPEAKER_00: Uh, if you have a question like that, head to micronaut.com, click on that podcast link and ask away.
• 19:12
  SPEAKER_00: And be sure to subscribe so you can get notifications for our next episode.
• 19:16
  SPEAKER_00: Thanks so much.