Cutting Edge Rotator Cuff Repair with Dr. Baker

We’re going to talk today about a cutting edge rotator cuff repair. For those of you guys who don’t know me, I’m Chris Baker. I’m a sports medicine and a shoulder specialist with a Florida Orthopaedic Institute. I’m also on staff at University of South Florida. Here’s my disclosure slide. I work with a Zimmer Biomet as well as rotation medical both for consulting and speaking fees. A little bit about me though, to kind of introduce myself. I’m afforded native. I was born in Miami and raised in Fort Myers. I’ve been in Florida all my life except for my training in orthopedic surgery in which I went to Pittsburgh. I went to University of Florida for both undergraduate and for medical school. So I’m a big fan of the Gators. That’s what I do on Saturdays. I then traveled to residency at the University of Pittsburgh medical center in UPFC in Pittsburgh, Pennsylvania.
I got to work with a lot of great doctors there that take care of the Steelers, the Penguins, the Pittsburgh Panthers, and about the dozen colleges. There are more that are in the Pittsburgh area. After I finished my general orthopedic residency, I then went on to do a fellowship in sports medicine and shoulder reconstruction at the Steadman Hawkins Clinic of the Carolinas. Again, there I got to work with some great doctors who took care of the Colorado Rockies, the Greenville Drive, who are the Boston Red Sox minor league team. And then we got to take care of a lot of the high schools. It was a pretty cool experience there. I actually got to be the team doctor for the Rockies during spring training. So I got a lot of really cool experience with shoulder injuries in that venture research-wise. I, one thing I wanted to single out is a ultrasound.
I’ve done some research in this and training physicians. I’ve also educated doctors nationally on this. The important part for this is really indications. In the state of Florida, we have lots of elderly folks and retirees lots of pokes with pacemakers and a foreign metal bodies. Those patients really have a contraindication to getting an MRI. So ultrasound is a great option for them. A claustrophobia is also a rampant disease in the state of Florida, and that they can’t really sit in MRI for very long. So ultrasound is a way to skip them being stuck in a tube for, you know, up to an hour on end. The other important benefit of the ultrasound is that you get immediate results. So the patient comes into the office, they have a shoulder pain, they leave with an answer, they know whether they have a tear, they know whether they have impingement.
So it’s a good point of service, a type of instrumentation. And it’s also orders of magnitude less than MRI. The ultrasound is gonna run you maybe a hundred, $150, which is MRIs could run from $600 upwards of $2,000. So, ultrasounds pretty important to me. This is my family. My wife, Tori in the center with me. We’ve been together, you know, approaching 20 years now. My son Liam, who’s seven on the right there, my baseball player. And then my daughter Ansley, the little cheetah there on the left. And then obviously Duke is the focus of the family for those guys. But also had an interesting opportunity where I was going to be able to help provide an unfit need in the area with the high schools. I was able to athletic training into the Wesley Chapel High School, Zephyrhills High School, and the Pasco County High School.
And at that time when I came here, there were no shoulder fellowship train guys in the area. So it was particularly appealing to me. Currently I’m a with the Florida Orthopaedic Institute. I’ve been with FOI now for approaching five years. I’m a partner now. I have offices both in Wesley Chapel and on Telecom Parkway in in Tampa, Florida Hospital, Wesley Chapel as well as Florida Hospital Tampa. I have privileges for, so I operate there. And then I operate at our surgery center in Telecom Parkway in Tampa. I’m currently the team physician for the sunlight high school as well as Cambridge Christian and Seffner Christian high schools. I’ve been a team doctor for about five other hospital high schools in town as well as the Tampa Bay Storm. So cutting edge rotator cuff repair. That’s why we’ve come here to talk kind of about the future of rotator cuff and I guess the current and past as well.
With a special emphasis on this rotation medical bioinductive implant. So I want to give a special thanks to the rotation medical staff as well as my staff for putting a beautiful dinner together. And we’ll get into the talk first and foremost. I want to make sure that we understand that rotator cuff repairs are a very successful surgery in orthopedics. If you look at how we define success though, there’s wildly disparaging results here. If you look clinically, when we look at patient satisfaction, either by quality of life scores or if you look by patient function based on ASES scores or emotion or strength or pain. We do very, very well in that when we look at structural healing, either utilizing ultrasound like I was telling you about earlier or MRI, maybe we’re not quite so good as we think when we look at clinical success.
Most articles would say that we’re about 90% successful, if not better when we do rotator cuff repairs. When you ask the patient. This is Peter Millett, a shoulder surgeon at a Denver who published a study in journal of shoulder and elbow surgery in 2011. He showed improved pain scores, improved function scores, and improve quality of life. 90% improvement. That’s pretty typical in the literature. When you look at structural healing, you need to find success by healing of the rotator cuff. We’re really not that good depending on the type of tear, the patient population and the imaging modality, the healing rate can be anywhere from 20%, which is really, really bad up to 95%, which is really good. When you look at how they function based on healing, did a great job in arthroscopy of 2010 when he basically showed that healing rates can vary in his patient population from up to 60 or 90%, but that those patients who healed did better.
And that’s pretty intuitive. But the way that we’ve looked at this as orthopedic surgeons is we’ve always been looking at this clinical success. So even if it doesn’t heal, we’re happy cause they’ll be happy. But the reality is is that if it doesn’t heal, they’re still not as happy as they could be. So what is our goal? Our Holy grail is to improve healing. Okay. We want this guy to be able to get back in the gym so that he can work his pacemaker out as much as possible. That’s our goal. So when we look at rotator disease in and of itself, and there’s kind of a, an order of, of kind of breakdown of the rotator cuff, we start with tendinosis. So we see this every day. It’s probably the most common thing that I see. It’s starts out as tendonitis. The patient has a little shoulder pain, a little impingement, but at this point we start to see actual loss of quality of the tissue.
So the tissue quality integrity actually goes down. We lose the nice linear fibers. These pointers don’t work on this, but we lose nice linear fibers that we see in normal tendon collagen structure and we see this door disorganized collagen. Same thing you see in tennis elbow, same thing you see in patellar tendonitis. All of those types of things are tendinosis. Tendinosis will typically advance. Unfortunately, it’s one of the most common reasons for full thickness tears is that it precedes a full thickness tear. And the worst part about it is we don’t have a great management strategy for it right now. It’s a cortisone shot and therapy until it tears. That’s really kind of how we treat that or, or recently until recently how we’ve treated that. Partial tears are another really difficult problem for us because small partial thickness tears we tend to think aren’t that important.
There are different types of partial thickness tears, but again, partial thickness tears can progress. And on a on a four-year basis, most people will see increasing pain over time, which will predict that progression from a partial tear to a full tear. Again, repair techniques are very difficult on this. We’ve done partial repairs in the past that has led to stiffness and pain. We’ve done takedowns of the rest of the tendon and do a full repair. Now we’re taking down good tissue that has great integrity and we’re actually making potentially the patient worse. And so what to do with that type of a patient. And then we have the standard full thickness tears, which is what we think about. That’s what we like to operate on. We all feel good that we’re going to get the patient better and we’re taking care of a real problem.
So giving some examples of tendinosis, this is a cartoon and then MRI versions of this, we lose that normal, nice dark linear college and look on an MRI and you can see that on both of these. And what we start to get to see are these areas where the, the tendon is becoming more light. It’s less regularly oriented. And so that’s why you see these abnormal looks to that tendon. When we look at partial tendon tears, there’s three types. There’s the interest substance where the inside of the tendon is actually 10 tearing, but from the outside of the shoulder and the inside of the shoulder, you would never know it on arthroscopy. Then you have the bursal sided tear where the top or superficial portion of the tendon is torn, but from the inside portion of the shoulder would look normal. And then we had the articular sided tears where you’re on the inside of the shoulder and it’s torn.
But from outside it would look normal. And these are just representative MRI shots showing an interest substance, a bursal side, and then an articular sided tear. So those are three different types of partial tears. And then obviously the full thickness tear we know about.
So what are the things that we can do to try to improve healing? I like, I like the lady doing the pose here. So methods to improve healing, there’s mechanical methods to way to truly increase the structural strength of the rotator cuff repair. Biologic methods to improve the healing of the rotator cuff repair. And then we could just bypass the rotator cuff repair all together and go on to other techniques that we can do in those patients that are either like likely not to heal their repair or those patients that are truly just not repairable.
So we look at mechanical ways that we try to increase repair.We can change our construct, we can use one row, we can use two rows, we can increase the size and strength of our sutures. We can start to add graft either dermal grafts or pericardiums from other human cadavers. Or you can go with xenographs to start using animal type of graft devices. When we look at repair construct, single row versus double row a is depicting a single row repair where we literally have an anchor with one stitch. We tie it down and we call it a day. We wanted to increase our footprint of our healing of the rotator cuff. So what we started to do, the normal rotator cuff has about a 15 millimeter surface area that we were, that that is native. So by doing a double row repair where we do stacked Rosa medial and lateral anchors, we’re hoping to recreate that 15 millimeter footprint and allow more surface area to heal, to increase the chance for it to heal.
Now we’ve gone onto this what’s called a transosseous equivalent where not only are we compressing it at two points, but we’re now going to compress it along the entire length of the, of the suture anchor. The younger guys in my generation are growing up doing it more like this on the right side. The difficulty here is that we’ve increased expense. So we’ve added four anchors now versus two anchors in this particular case. And we haven’t shown clinical significance in a lot of papers. So a lot of these papers that we see, we see that it’s biomechanically stronger, but the patients don’t necessarily do better. So there’s a little bit of a balance of what’s appropriate to do and we need to keep costs as a factor. So allograft augmentation is another way that we can try to increase our ability to heal these rotator cuffs.
Dermal allograft onlay, which is shown here, basically shows a rotator cup that’s been repaired and then on top of that we’ll place a dermal graft so that there’s almost like a soft tissue washer so that the tissue is less likely to pull through that suture because it’ll stop on that graft of, of nice thick dermal tissue and prevent a further propagation of the tear. This can also be done to bridge a defect, so let’s say we’re only able to repair this patient’s tendon about halfway back. Maybe we can actually attach the skin here and then attach that to the edge of the rotator cuff and then bridge that gap. The difficulty here is that this is an extremely technically difficult surgery to do. When I started out doing these, it’d probably take me about three hours to do this through the scope. Most doctors don’t do this through the scope at all.
If they do it, they open the shoulder. I don’t open the shoulder takes me now about an hour and a half to do that type of a procedure. In addition to the normal rotator cuff repair, there’s limited data on its effectiveness, so people can still fail this repair and it’s very costly. These graph tissues are upwards of two and $3,000 for these, these harvest tissues. So we’ll look at a couple of examples of these allograft repairs. The dermal allograft onlay, this is one of my patients where she’s had a very large rotator cuff tear. It’s basically the entirety of the supraspinatus, infraspinatus, and round to the Terry’s minor. So what we do is we mobilize that tissue. We place a medial row set of anchors, we’ll place that down so there’s not tension on that. But now we basically created a single row repair. So that’s the cheapest way in the most old school way to do a repair.
But now what I want to do is I want to augment that. So now this won’t pull out. And I’ll also augment my footprint by using basically a system of pulleys of the sutures that I’ve created. And we’ll take this piece of dermal graft and we’ll actually shuttle that into the shoulder through a little poke hole. So once we shuttle that in, that’s what it will look like. Now this overlays our original rotator cuff repair, we’ll then criss-cross this and turn it into a standard transosseous equivalent repair. So we’ve augmented the repair here at the site that will prevent, pull out from those sutures as a soft tissue washer. And then we’ve extended the healing footprint and the body will actually incorporate into this dermal tissue and then help hopefully become one with that rotator cuff to make a normal, a more normal footprint.
And when they do well, these can do very, very well bridging could graft, bridging a cuff defect is also possible. This is a patient with a very bad rotator cuff tear that even after all of my releases and everything, I can’t get that edge of the tendon back to the normal anatomic footprint. So what it actually do is do what’s called a partial rotator cuff repair, which has been the standard for these types of patients for many years. What we can do now with these dermal grafts is actually extend that footprint with this graft again, so we’ll place our rotator cuff anchors on the on the medial border of the humerus. We’ll then on the outside pass all of our sutures and this is how we can shuttle this in here through this little passport device. We pass all of our sutures on the outside.
We’ll roll it up like a little cigar and we’ll slide it into the shoulder and then once we get into the shoulder, we’ll pull on all those sutures and it’ll help spread it back out like a parachute into the positions that we wanted in. Now this is now bridging that gap. It’s actually being tied directly to the tendon, but then on the outside part of the shoulder and the lateral part of the shoulder, it’s going to be a rotator cuff repaired down to bone on this side. So it’s soft tissue to soft tissue here and soft tissue to bone here as if a normal rotator cuff. Again, not a lot of data on these, a relatively high failure rate in those that are published. But still an option. Now we get into biologic cells. So that was all really augmentation of our repairs mechanically.
So some mechanical augmentation, biologic, you hear kind of on every street corner right now about PRP and STEM cells. It’s the hot button topic. What is the difficulty with PRP? There are two types of PRP, platelet rich, poor, or excuse me, leukocyte poor and leukocyte rich. Which is better. We don’t know. All the studies are heterogeneous. They combine these things, so it’s very difficult to know. There are variations in the mixes and styles. So one PRP system may give you this, the next PRP may get system may give you this. It’ll have different platelet levels, different factor levels, and you really have limited data on the effectiveness of this. STEM cells are even more difficult. Again, where are you getting the STEM cell from? Are you getting it from marrow, getting it from fat, from autologous, from the patient themselves or using allogeneic or using juvenile rumor or juvenile cord blood?
Again, limited data, not covered by insurances and very expensive to do. So. The bioinductive implant is another biologic way to approach this. And this is where the rotation medical implant comes along. It’s biologic in that it is an absorbable soft tissue scaffold. Your STEM cells will set up in this area, begin to produce Tina sites and actually formed a normal rotator cuff anatomy. Interestingly, on soft tissue microscopy, you’ll actually see tendon to fiber cartilage down to calcified cartilage. And then down to true bone. We don’t see that in normal rotator cuff healing, which is really intriguing about this product. The normal healing, you get tendon scar bone and you never get a normal tendon to bone unit. This has been shown to do that in animal studies and in tissue retrieval studies in humans, you can use it for tendinosis, which we currently don’t have a good treatment option for.
Like we talked about earlier, you can use it for partial tears, which we do have treatment options for, but this gives us a different kind of treatment option. And then you can augment your normal repairs. You can do that same patient where you would do that three-hour graph procedure. And we can do this in five minutes. So that’s the interesting part of this. The rotator cuff repair itself is a made up a xenograph. So it’s a bovine Achilles tendon of a collagen that’s laid on top of the shoulder. There is limited data out there. It is costly, but it’s technically much easier to do. It doesn’t burn any bridges. And the early data is very good in this tip particular patient, again, you can see a pretty bad retracted tear. The tissue quality is very poor. Here we’re going to place our meal row anchors do a standard single equivalent, what I call this, a single equipment repair. I simply bring these stitches down so that there’s not big fat suture not stacks on the shoulder. And then we’ll place this graft on top of it. So this is a deploying device that’ll go in and actually spring that out for me so I don’t have to put a bunch of sutures in, which saves us a lot of time. And then after we’re done, this is lame simply directly on top of it. And this is actual picture from that patient.
So case examples. So, so I think we get the most out of seeing how these patients do. So I can give you all kinds of great ideas, but if we don’t see it in effect, then we don’t know what we’re doing. This is a, JB. He’s a 67-year-old gentleman. He’s known to me for a long time of right sided shoulder pain. He has a history of CLL, so he’s been on a recently got a bone marrow transplant. When I met him, his shoulder pain was pretty significant as x rays were concerning. My concern was that he had a full thickness tear, but because of his hematologic state, he was not a candidate for surgery for several years. So it actually took me probably three years till we got to the point of treating this gentleman. He’s got 10 out of 10 pain.
He’s severely emaciated. He’s broken down immunologically and he’s really a poor candidate for surgery. So after failing all of his nonsteroidals over the counter and time flammatory his, his injectables, his therapy he finally gets off of his immunosuppression for his bone marrow transplant. He’s finally gotten to the point that he wants to do something about this. He’s still his frail. He is still cachectic. He has atrophy globalized about the body upper extremities, but he’s got severe pain over the biceps and lateral cuff. He’s got limited range of motion and significant weakness when we look at his preop x-rays. There’s certainly concerns of reactive changes to lateral tuberosity here. We can see reactive changes here where that rotator cuff belongs. We can see that here that can even look like a small greater tuberosity rupture or avulsion of the rotator cuff.
So he’s definitely got some concerning findings on x-ray. When we look at that same shoulder and MRI. Now we get to see his rotator cuff. What should be a nice robust tendon coming over the top of the shoulder is really just kind of a petered-out kind of degenerative tissue. It doesn’t even really look like rotator cuff at all. And to give you a little bit of an example. This is a sagittal where we can see that torn portion and then the more normal portion, which still isn’t really normal, but it’s better than the other tissue. So we talked about his options. The plan was to go in for at least a debris Mount of the shoulder, possibly a rotator cuff repair. And because of the, his tissue quality potentially on laying this rotation bioinductive implant on top of there.
So we get into a shoulder and we’re in trouble. This, the whole tissue bed is basically just soft tissue. There’s, there’s no structure to the tissue at all. When I do the bone spur resection for a subacromial decompression, I used a shaver and it was just shaving away bone. Like it was nothing like, like a hot knife through butter and even as good tissue, which is this is supposed to be good tissue was really diseased tissue. So rather than taking down tendon here and trying to do a standard traditional to anchor to suture type of repair, what I wanted to try to do is augment the repair. So give him a structure or a lattice with this, this bio inductive implant allow his cells to come in and heal and try to correct the problem that’s been going on. So we do a surgery.
Two weeks later he comes back. The good thing about this is because I didn’t do a rotator cuff repair, a traditional rotator cuff repair, I don’t have to restrict him. So at two weeks we’re already allowing him to do passive range of motion. I don’t want him to do active motion because I don’t want to place extra strain on that healing cuff. But we do passive range of motion right away to prevent a stiffness at seven weeks. He’s doing well. His pain is improving at three months. We’re actually starting to begin resistance exercise, which is pretty routine at that point. He’s got great for elevation, external rotation and at that point we’ll go ahead and do our postop ultrasound at three months. I like to ultrasound these patients and I know I didn’t give you too much of a background on this, but we’re looking for looking at here is the humeral head and this here is the deltoid tuberosity or deltoid fascia.
Everything between that, his rotator cuff, the more oriented and linear it is, the better it is. And so we see a nice full area as opposed to if we’re this, we’re all just a flat area underneath that, that white area, MRIs that we get at six months to follow up on this now are probably a little easier for you to understand. We have this, this pre-op MRI where we see the rotator cuff that looks relatively good tendon here and it’s just crummy there. As we come now we can see the entirety of that tendon is starting to become more dark, more organized, more cellular in nature, more, more more organized. Collagen is being laid down. So that’s a great example of a very, very severe tendinosis from zero to six months postoperatively when we look at a parcel, a sighted tears, this is a 62 year old gentleman who was a work comp patient of mine.
He had a ground low mechanical fall working for ups. He failed conservative measures with work comp and that was then referred to us after getting him with us. He’s got pain 10, a five out of 10. No past medical history is unlike our last patient. A physical exam shows that the skin is intact. He’s tender over the biceps and lateral cuff. He’s got full range of motion but really painful impingement and then weakness on that right side. Having failed preoperative evaluation already. We went ahead and got our x-rays as we typically would. X-Rays look pretty good. There is no major bone spurs, no arthritis. We then go on to get his preoperative MRI and you can see the muscle belly of the supraspinatus. You can see the tendon and then you see the gap between the two. And then you can see here on another section of it, there might be a thin portion of it hanging on right there.
At the time that I saw him, I would’ve bet my house that this was a full thickness tear. This little dark ring I thought originally was the calcified or the cartilage capital humeral head. But we’ll, we’ll see later at the time of surgery that the actually the, the articular side of the tendon is totally intact. So we have the attendant here that is totally normal. It’s the bursal side on top that’s torn and separated. When you see tissue left behind like this, this is a really bad actor as far as surgeries go because generally what we do traditionally is repair that tendon down to bone because tendon attendant doesn’t really heal. It’s, it just doesn’t have any vascularity. So what we normally have to do in this type of patient is we remove this tendon. We then repair this tendon under tension inappropriately and then it fails anyway because it’s under too much attention and it’s poor quality tissue.
So we get into the operating room for this patient. We discussed arthroscopic rotator cuff repair and again because of the quality of the tissue I discussed with them preoperatively about using the bio inductive implant. So at the time of surgery we get into the to the shoulder, the ball and socket joint actually look very good. The rotator cuff looks totally normal from the articular side, so we’re inside the shoulder looking out on the articular side and it looks great. A little bit of tendinosis there, but nothing severe at all. When we get above the shoulder, we get a whole new picture. We can see here that this is the area that was left on the, on the bone here and this is the other end of it that was torn and retracted. So literally it’s just torn directly from here to here at prior to the bio inductive implant option for this type of patient, I don’t know what I would have done.
I probably would have just taken it all down and repaired this directly down, like I said before, directly to the bone over attention to it and then increased his risk for having a repeat tear. But in this case, all I did was place two simple sutures. Tended the tendon, which then repairs that that repair back down. You can’t even tell it was ever injured. And then again, I simply lay that bio inductive implant directly on top of that, when you talk about cost, everything comes with its costs. The, the bio inductive implant is expensive, but in this particular case it saved four anchors that I’d normally would have put in there. So it was probably cost neutral in all honesty for, for this type of patient. So how is he going to do? So at two weeks we see him back. He’s got three out of 10 pain.
It’s pretty typical. By 10 weeks, he’s got full range of motion, which is atypical. Actually, most patients are still struggling with motion at that point. By four months still pain-free. At six months he’s returned to work with 15-pound weight limit. And at seven months we released him to work with the at MMI with no restrictions. When we look at his postoperative ultrasound, I’ll try to explain this the best I can. Again, we have our humeral head. Here we have the native tissue that was not affected deep here on the articular side. Then we have our suture that we put in. This is actually the, the suture itself from that little side to side suture. The two sutures I put in, everything above there is that bio inductive implant that’s healing. And then this is deltoid fascia on top of it.
So looking at that, if I were to not have that little suture line there, I would read this as a completely normal tendon at three months. It absolutely, or six months. Absolutely beautiful. Absolutely normal. And again, you can see that that same tissue here. So anything above this layer is new tissue. Everything below it is our rotator cuff a tissue. So a great looking ultrasound, very, very happy for that patient. At seven months we went ahead and got an MRI on the, on the house for work comp. Again, this is that preop where the articular side is intact. The bursal side was torn. Now you can see here that we have essentially in a completely normal a tendon footprint and you can just see barely that suture line right there that separates what was the native tissue with what it was, the, the allograft tissue or excuse me, the bio inductive implant tissue above that.So really, really good-looking MRI on this patient to really a, almost a totally normal footprint of the rotator cuff.
And then the last patient just to kind of have completion of this large rotator cuff tear and, and a 59-year-old patient. So this is a lady who also sustaining gravel, ground level mechanical fall, so an acute type injury, a severe pain and came into a hospital or to the office with these types of symptoms. She actually had had a contralateral rotator cuff repair by myself with the dermal allograft augmentation, which is a great case study on this patient. So I’ve done it the old way with, with dermal tissue, with skin tissue and now I’ve done it with the rotation medical tissue as we look on physical exam, again, very tender over the injury site poor range of motion and significant weakness on that side.
When we look at our x-rays, we do see changes here that are concerning. We see changes at the greater tuberosity, changes to the acromion, and then a big type two or three a subacromial spur. All of these findings are concerning for a rotator cuff tear before we’ve even got the MRI. Once we get the ultrasound again, I know I didn’t give you too much of a background in ultrasound, but this is a normal rotator cuff where we see the tuberosity humeral head. And then this is deltoid fascia. Everything between those two segments is normal rotator cuff. So if I take you here after that brief education in rotator cuff or ultrasound, this is the humeral head, this is deltoid fascia. There’s nothing between the two until we hit here. So that’s the torn edge of the rotator cuff. And having seen three ultrasounds, now you guys can probably all identify that that looks good and that looks different.
So that’s kinda how you know that what normal and different are. This is now a 90-degree view of that. So we’ve taken our probe from going this direction. We’d go 90 degrees to it and you can see normal tissue here between this line of the deltoid fascia in this line of the bone. That’s normal between there. As we get to the tear, there’s no space between there because there’s no tissue there, there’s no rotator cuff tear there. So we get in the operating room. This is one of the examples I showed you earlier. We place our medial row anchors and we place this under very little tension so that it won’t pull through. We then do our standard rotator cuff repair and then we put the graft augmentation over top of it. We see her back in a follow-up at two weeks.
She’s still hurting. Pretty typical at two weeks to have pain. Six weeks she’s improving by three months. Her motion is coming around and her pain is coming under control and by six months she has full range of motion, juror contralateral side. Now her contralateral side was repaired a year prior to this. So it’s been a year and a half now for her contralateral side. So again, I, I apologize for making you try to learn how to read ultrasound. But again, this was that torn one. So this is the, the humeral head here, deltoid fascia, that’s the edge of our tendon. Everything between this here and this here is normal rotator cuff ti