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May 03, 2023

The Truth About Shoulder Surgery from New York Mets Chief Orthopedist, Dr Larry Gulotta, MD

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Read the conversation below

Dr. Yoni Rosenblatt: Thank you so much for coming back and joining us at the True Sports PT Podcast. This conversation was an easy one. Dr. Gulotta makes it just easy to shoot the bull, as we say, about shoulder surgery, about being an elite-level athlete, as well as being an elite-level surgeon. And Dr. Gulotta is the head surgeon for the New York Mets, as well as a very well-regarded and research physician up at HSS. I originally met Dr. Gulotta down at MASES, which is just a gathering of the Mid-Atlantic shoulder experts and saw him present very early in the morning, and he was just outstanding, really excited to have him on the pod. You're gonna learn a ton about, really, an eye-opening outlook as to how we operate. And also, Dr. Gulotta's knowledge of the rehab world was also very impressive.

Dr. Yoni Rosenblatt: So, certainly, obviously encourage you to listen and really encourage you to share some feedback here. Tell us what you loved about what Dr. Gulotta said. Tell us what maybe you didn't, what we could do better. We're always looking for feedback so that we can create the absolute best product for you. Along those lines, True Sports is nearly obsessed with providing the best place for a patient to rehab as well as a PT to rehab that patient. So, if you're looking for a rehab or if you're looking to join us as a sports physical therapist, feel free to reach out, truesportspt on Instagram, just shoot us a DM, it's the very best way to get in touch with us. And so, without further ado, here's Dr. Gulotta.

Dr Larry Gulotta: Oh. Yeah. Thanks, Yoni, for having me. It's a real honor and privilege to be here. I don't know, I don't know how far back you wanna go. I grew up a kid in the south suburbs of Chicago. I have the classic orthopedic surgeon story of tearing my ACL as a freshman in high school. At the time, it was put together by an amazing orthopedic surgeon, came back, played the rest of my high school career. The rest, I went to Johns Hopkins and played football there. I don't think that had to do with the ACL or the recovery from that. I think that was probably just of my own athletic ability, pinned me to go to Johns Hopkins as opposed to Notre Dame or something on Saturday afternoons on TV.

Dr. Yoni Rosenblatt: There you go.

Dr Larry Gulotta: But what it did do is it sparked an interest of the fact that this is a really cool combination of a number of my passions, it'd be sports, it'd be science, it'd be the ability to help people and get them back to lead active, healthy lifestyles. And so once I had that injury, I put the blinders on and knew not only did I wanna be a doctor, but I wanted to be an orthopedic doctor, an orthopedic surgeon, a sports doctor. So, did college at Hopkins, played football there, went to med school up in Harvard and then matched in Hospital for Special Surgery for my orthopedic residency, and then stayed there for a sports fellowship. And then when I was finished, I was fortunate enough to travel both in Europe and then go back to Boston for a total of six months, seeing different shoulder surgeons more or less around the world, and getting greatest tips and tricks from each of those.

Dr Larry Gulotta: And then since then, I've been in practice at Hospital for Special Surgery since I'm now the Chief of the Sports Medicine, or the Shoulder and Elbow Division of the Sports Medicine Institute at HSS. And then starting last season I was named the Head Team Orthopedic Surgeon for the Mets. Kind of, I would say stumbled upon it, it's right place, right time, I suppose. They were looking for a doctor to be more present, cover games, go to spring training, things like that, somebody that had particular interest in shoulder and elbow orthopedic care. And so I said I would do it, and now it's just been the one full season last year. We're starting, spring training's done, we're about to start the regular season this Thursday. And it's been an amazing, amazing experience so far. So busy, busy, definitely, two full-time jobs. You have your job, you have the day job as an orthopedic surgeon, I've got my family life, and then also have pretty much a full-time job as a orthopedic baseball doctor.

Dr. Yoni Rosenblatt: It sounds like three full-time jobs.

Dr Larry Gulotta: Yeah.

Dr. Yoni Rosenblatt: But, Jesus, this is why I texted you that your resume is insane. I don't think you stumbled into this, you don't stumble into Harvard. Congratulations on being named the Mets Head Surgeon. That is pretty awesome. Why shoulder though? Why'd you go shoulder?

Dr Larry Gulotta: Yeah. That was essentially right, 'cause I tore up my knee and was interested in knee early on. And then, really what I became interested in during residency and then even in fellowship as well is the fact that the shoulder, there's still a lot of things that we don't know about it. Quite frankly, the knee goes forward, it goes backwards. That's about it. Maybe a twist a little bit depending on who you talk to. But there's a couple of ligaments and a meniscus in there, or two menisci. But there's not a whole lot of complex, I think, biomechanics that are happening with it, versus the shoulder, the degrees of freedom, the amount of muscles that all have to work in a concerted effort to be able to stabilize it, the soft tissue, static constraints are on the shoulder.

Dr Larry Gulotta: If any of those things go haywire, the whole system starts to break down. So that to me is very, very intriguing. I thought it was a black box. I thought I could... I thought there was some academic contributions I could make towards it. I'll tell you, I stumbled upon it 'cause I did spend a lot, I still do spend a lot of my career doing also shoulder replacements as well. And the same thing, shoulder replacements when you compare it to hip and knee replacements, it's pretty, pretty new. And all of the things that they figured out for hip and knee replacements years ago are things that we're just now figuring out for shoulder replacements, so it was a wild frontier.

Dr. Yoni Rosenblatt: Yeah, it's come such a long way even since I've been rehabbing. And I always say the shoulder is so fascinating, it's my favorite joint because it's a freaking miracle it ever works. So it's just, it's fascinating, and I gotta do that without a scalpel. I can't imagine with a scalpel. Okay. Tell us, and this is a collection of the world's best sports PTs that are listening to this, what was your welcome to the Major League Baseball moment?


Dr Larry Gulotta: My welcome to Major League Baseball is, and this is pretty public knowledge obviously, is that a few weeks into spring training, our star pitcher breaks a scapula throwing the ball, and it's something that I didn't even really fully appreciate was possible, that you can break your scapula throwing a ball. And right there, it was an understanding that when you're dealing with Major League Baseball players or professional athletes at that level in any sport, you're really dealing with the top 0.00001% of the athletic gene pool there. And one thing that I think these guys have been able to master through the years and been selected out for is their ability to just own their entire kinetic chain. They're able to put every ounce of force that their body's able to generate and translate into a baseball that goes 102 miles an hour, or hitting a ball that goes 450 feet or so. And so such to the point that, to your point, if anything starts to go wrong, they start to have this whole chain reaction.

Dr Larry Gulotta: So, that to me was... And you have to take care of, I think, athletes at that level to see that sort of pathology. And for me, the take-home message for that was, was that as extreme as it was, it was a variation, at least how I've thought about it in my own mind, it's a variation of things we see in a lot of pitchers, like lower level pitchers as well. So what'll happen, as you know, and I'm sure your audience knows as well, is that if your arm's going 102 miles an hour plus or enough with enough forward velocity and torque to be able to generate 102 miles an hour into the baseball, that's gotta stop at some point. You gotta stop it. And so your whole posterior musculature, your posterior cuff, suffers this eccentric injury to it or eccentric load that it sees. And so we'll see a lot of infras made of strains, and then and now we're seeing a lot of latissimus tears and strains as well, which are all deceleration injuries really.

Dr Larry Gulotta: So this guy was, he had a variation, I think, of a deceleration injury. It's just that he tried to avulse his infraspinatus off of the infraspinatus fossa on the body of the scapula. They're interesting thought experiments because if you understand the physiology that's happening, you can understand why these injuries happen, it's just that they happen in an extreme level. And then how you treat them, there's not much by way of a playbook. Sure, there've been other players that have done that before, but you could probably count on both hands, how many that's happened to. So what's the playbook for, return to play for somebody with that type of injury? You don't know. You get together with a bunch of smart people, you try to have some objective-based way to, you're hitting milestones, a range of motion and strength, after you already have evidence that they've healed the initial injury. And you figure it out, you do the best you can.

Dr. Yoni Rosenblatt: Yeah, it's super cool. And it's like I always say, you walk into an evaluation room or into any room in which the patient walks in and you have a list of things that could possibly be wrong. It's just when you deal with athletes like this, that list just has to be larger to try to figure out what could possibly be bothering them. We were talking a little bit earlier before we hit the record button of your take and your outlook on, specifically labral tears and SLAP tears in pitchers. And you opened my eyes as to the way you approach it, 'cause I think it's certainly unique, maybe that's why you're the Mets doctor. But I'm gonna give you a case and you're gonna just hopefully walk us through just the way you think clinically. I think that'll bring a huge amount of value to our audience, and more importantly, to me, so that I could get better today.

Dr. Yoni Rosenblatt: Okay. 20-year-old St. John's College pitcher walks in to your room, anterior shoulder pain, mostly when he drops back towards layback, it's been present for three months. He tried some rehab with his athletic trainer, with a PT, no luck. His velocity has started to tick down as his pain has started to go up. He saw the team physician of St. John's. Hopefully you don't know that guy, or maybe it's you, but let's say you don't know that guy. He put him on a Medrol Dosepak. He injected him two weeks later, no help. Now he's seeing Dr. Larry Gulotta. What does that initial visit look like for you?

Dr. Yoni Rosenblatt: Yeah. Now, you mentioned you're hoping it's biceps, long head of the biceps involvement, how do you tease that out?

Dr. Yoni Rosenblatt: You should have been a lawyer.

Dr. Yoni Rosenblatt: Okay. I love where you're going with this rehab. How do you gauge whether they've done rehab properly? What questions are you asking?

Dr. Yoni Rosenblatt: Who the... Who taught you this? Where did you learn that? That's good. Yeah, you're saying the right things, you studied the right stuff before you came on here. That's awesome. Okay. Say they haven't done that, you're gonna make a PT referral. This kid, St. John's pitcher, 20 years old. He's from wherever. How do you find the PT to send them to? Or does that happen?

Dr. Yoni Rosenblatt: Gotcha. One more piece on your evaluation, and that is, you mentioned scapular dyskinesis. I think you said something like an easy fix. Tell me what you're looking for with scapular dyskinesia.

Dr. Yoni Rosenblatt: Mm-hmm.

Dr. Yoni Rosenblatt: Mm-hmm.

Dr. Yoni Rosenblatt: I love that. My very small and humble pushback on that is, this guy has been throwing a baseball for 20 years, it's gonna be a symmetric. So, anything else you're looking for other than a symmetry? Okay.

Dr. Yoni Rosenblatt: Mm-hmm. Mm-hmm. Okay. Okay. Awesome. Okay. This athlete goes to HSS, you know the overhead specialist he's seeing. He comes back six weeks later, he took time off, he picked up that ball, threw again, it hurts at layback. What do you do?

Dr. Yoni Rosenblatt: SLAP tear. Like everyone else.

Dr. Yoni Rosenblatt: Mm-hmm.

Dr. Yoni Rosenblatt: What is that? I love that because it doesn't sound like a measurement. A pinch.

Dr. Yoni Rosenblatt: And you're dead. Right. Layback. Yeah.

Dr. Yoni Rosenblatt: How different is that what you just described, from a softball pitcher who has a torn labrum?

Dr. Yoni Rosenblatt: Okay, awesome. I think... Yeah, no, I think that makes a lot of sense. I'm also gonna rehab them so much differently, I don't care about their layback. I think that changes the whole picture. And that makes sense why you would approach it differently surgically. How about your standard weekend warrior has a SLAP tear, when you say, "Okay, I'm gonna pull a smidge on a pitcher," does that change totally if it's a weekend warrior?

Dr. Yoni Rosenblatt: Mm-hmm.

Dr. Yoni Rosenblatt: Yeah. Yeah.

Dr. Yoni Rosenblatt: I hate that. Yeah. What sucks is when the doc doesn't see that, operates, just put them in a sling for six weeks, I'm dead. We don't have a shot in hell.

Dr. Yoni Rosenblatt: Mm-hmm. Love that. Right, yeah. I think it makes a lot of sense. Remember, if there's a labral tear, they should have more motion. Right. So...

Dr. Yoni Rosenblatt: Mm-hmm. Yeah, that makes sense. Yeah, that makes... That sounds like my offensive lineman, right? And so how are you approaching those? What are you repairing there? 

Dr. Yoni Rosenblatt: I love that intro. [chuckle] Right. Yeah. No, I think that makes a lot of sense. I do think that posterior labral tear to the offensive lineman is the SLAP tear to the pitcher. They all have them. And so it's just a matter of what they're able to get through. But let's not dwell on your football Giants career, let's focus on your Mets career. And so, you do this repair for the St. John's kid. You said there's a little bit of art there. Let me just back up for a second. Why are you hanging out with Japanese doctors? When does that happen?

Dr. Yoni Rosenblatt: How do I get that? Okay. How do I get that invite? To Japan? Yes. Yeah, that's where I wanna go. There we go.

Dr. Yoni Rosenblatt: Well, I am free that weekend, so that's perfect. Did he talk about pitch counts in Japan, that don't exist? Okay. Bring that up next time you see him. Okay. So you repair the St. John's shoulder. How long is this guy in a sling? And...

Dr. Yoni Rosenblatt: Yep, love that. Love VFR. Are you doing BFR... You're doing BFR on his shoulder? Can I put a BFR on a shoulder? Okay. Tell me why. Okay. Okay, cool. Isometrics on that shoulder, when does that start?

Dr. Yoni Rosenblatt: Awesome. Do that with BFR. That seems to make the most sense, do that with BFR and electric stim, if you're talking about waking stuff up. Man, you gotta move back to Baltimore, this is easy. Okay. That's awesome. Then, when is he picking up a baseball?

Dr. Yoni Rosenblatt: Awesome. And what is the number one complication you're worried about post-op?

Dr. Yoni Rosenblatt: Yeah.

Dr. Yoni Rosenblatt: Yeah. I think that makes a lot of sense. I see a ton of that. I totally agree with that. Frozen shoulder, makes me nervous, but if you're doing your stuff, you shouldn't see it. Now, what percentage of these athletes get back on the mount, that you've seen?

Dr. Yoni Rosenblatt: Yeah. Do me a favor. Explain to me exactly what a nip tuck is.

Dr. Yoni Rosenblatt: And are you waiting for that to heal up? Is that your sling use?

Dr. Yoni Rosenblatt: Yep. Okay. Now, is there ever any room or thought in your big brain that maybe we start doing tenodesis on this population?

Dr. Yoni Rosenblatt: It's pulling.

Dr. Yoni Rosenblatt: And if they have fraying, say a thrower has fraying of their long head, their labrum's in decent shape. Are you ever doing a tenodesis?

Dr. Yoni Rosenblatt: Yeah.

Dr. Yoni Rosenblatt: Yeah, that's an interesting way of looking at it. The whole picture sounds insanely bleak. Tell me where we go, or what do you wanna research today that's gonna help us in five years, it's gonna help these shoulder patients?

Dr. Yoni Rosenblatt: Yeah. Well, now you're talking about prevention, which is my language. That's awesome. It's interesting with the weighted ball world, those injuries do have an uptick, they just have an uptick mid-season, it's not immediate. And so maybe that supports a little bit of what you're saying, which is to get this increase of range, potentially, speed over the glenohumeral joint, and they just don't know how to control it for any amount of volume. That makes a lot of sense. What about surgically? Do you think we have some type of surgical intervention that's on the horizon that can help these guys?

Dr. Yoni Rosenblatt: Is there a world for biologics here? We didn't even mention those.

Dr. Yoni Rosenblatt: Yeah. Yeah. I think there's a lot to learn that, and how different PRP is from stem cells and a host of things, 'cause SLAP repairs clearly ain't the future. Totally eye-opening. You did share with me one piece that I'd love to share with the audience, your outlook on operating in baseball players on shoulders versus elbows, that phrase that I'm gonna put on the next True Sports T-shirt is what? Says the shoulder surgeon. I love that. I love that. Okay. You have been insanely generous with your time, I'm gonna be very rapid with our lightning round and ask for very quick answers so that we get to know a little bit more about you and about your outlook. Ready? Okay. Best thing about Baltimore, Maryland. And don't say crabs. Good. That's a good freaking answer. Okay. Orthopedically speaking, what have you changed your mind on in the last three years? There you go. What do you wish orthopedic surgeons were better at?

Dr. Yoni Rosenblatt: Yeah. I love that... Who taught you that? It's not 1-0-1 because docs just operate on MRIs too often, so someone was an influence on you, who was that? Obviously. Where's that guy? HSS? Tell Murphy to get that guy to MASES. That would be gold. Yeah. That is... But even just that, not looking at the image before you see them, first of all, that's our world obviously, but not the norm. Okay. Awesome. Next, you could have a beer with one past or present athlete, who is it? I can't believe a Chicago boy didn't say Jordan. So intense, so intense. But Mantle, the guy had a beer or two in his life. Why Mantle?

Dr. Yoni Rosenblatt: Love that. Oh, I love that. Yes, on ESPN Classic. I lived on that stuff. Okay. Awesome. What book changed your life? I love that book. Did you watch the new apocalypse stuff? It's just fascinating to see how well, or not well that jives with Harari's take on Sapiens. So, let me know when you're done watching that. Okay. How many hours a night do you sleep?


Dr. Yoni Rosenblatt: What's keeping you up at night?

Dr. Yoni Rosenblatt: But you recover really well. I've seen you present at like 7:00 in the morning, that's a secret talent of yours. If you tore your... Oh. You can rally. If you tore your rotator cuff, who's fixing it? You can't say Russ Warren. No. No. Who else? Who else? [chuckle] For that very important shoulder. Okay. I love that. Okay. And... Good point. How tight would that shoulder be after that repair? Okay. Now, if you tore your cuff, who is rehabbing it? Oh, I appreciate... And not for the crabs, 'cause I ain't taking you out for crabs. I love... I love... No, lacrosse, dude, lacrosse. Larry, I appreciate your time greatly, you have been awesome, a wealth of knowledge. Tell us, I saw you got some Instagram presence, but where are you active that my audience can interact?


Dr. Yoni Rosenblatt: There's way more information on you on PubMed and that I respect. I love it. Thanks for joining us. Thanks for knowledge. We're gonna do this again, we're gonna talk about cuff pathology, and it's gonna be awesome. And I can't thank you enough for joining us. Alright. We'll talk soon.


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