Revolutionizing Shoulder Surgery with Dr. Patrick Denard

Get ready for a deep dive into the cutting-edge world of shoulder surgery with none other than Dr. Patrick Denard, one of the top shoulder surgeons in the U.S., on the latest episode of Sports Doc Talk. Hosts Will Sanchez and Dr. Grant Garcia bring the energy as they uncover what it takes to perform over 7,000 shoulder surgeries, the importance of surgical nutrition, and game-changing techniques for rotator cuff repair and shoulder instability.

Dr. Denard breaks down the evolution of augmentation in rotator cuff repairs, why some shoulders just won’t heal, and his expertise in the revolutionary Remplissage procedure to prevent shoulder re-dislocations—because if there’s one thing athletes and active individuals fear, it’s an unstable shoulder holding them back.

But this episode isn’t just about surgery—it’s about maximizing recovery and outcomes. Dr. Denard shares his science-backed approach to surgical nutrition, explaining why pre-loading with protein, vitamin D, and leucine can make or break post-op success. This episode will change the way patients—and even surgeons—think about recovery.

Tune in for a high-energy conversation, expert insights, and a look into the future of shoulder surgery, from biologics to advanced implants. Whether you're an athlete, a patient, or just fascinated by sports medicine, this is a must-listen!

🩺 Available on Spotify, YouTube, and LinkedIn. Don’t miss out—your shoulders will thank you.

Chapters:

00:00 – Intro & Recovery Shop Shoutout

03:00 – Meet Dr. Patrick Denard: 7,000+ Shoulder Surgeries

05:30 – Small-Town Roots to National Impact

08:00 – Building a High-Volume, 100% Shoulder Practice

10:30 – How Efficiency and Systems Drive Elite Outcomes

13:00 – Training Fellows, Running Research, and Leading Innovation

15:50 – Shoulder Surgery Trends & Rotator Cuff Repair

17:30 – What Is Augmentation? When Should You Do It?

21:00 – The Realities of Healing: Age, Activity Level & Outcomes

24:00 – Nutrition, Biologics, and the 300% Healing Risk Factor

27:30 – The Trilogy of Demise: Bone, Strength & Attitude

29:00 – Shoulder Instability: Why Remplissage Matters

33:00 – Avoiding Re-Dislocations & Surgical Failures

36:30 – Teaching Better Techniques Through Simplicity

38:00 – The Mental Toll of Repeat Injuries on Athletes

41:30 – Wrestling, Rugby & High-Risk Populations

43:00 – Prehab, Mindset, and Optimizing Recovery

45:00 – Creatine, Leucine & Evidence-Based Supplements

48:00 – Study Data: 2-Year Outcomes with Amino Acids

51:00 – Top Supplement Strategy Before & After Surgery

54:30 – Choosing Between PRP, BMAC, or Nutrition First

57:00 – The Future of Shoulder Care: Data, AI & Surgical Systems

59:00 – Closing Thoughts

Episode Transcript

(00:16):
Welcome to Sports dot Talk Will Sanchez, along with our
orthopedic surgeon and sports medicine specialist, Doctor
Grant Garcia. Doctor Garcia, I'm I, I started
this conversation before we hit record.
I'm going to have to take the AIfunction away from you because
you're getting out of hand with your backgrounds.

(00:37):
I don't know what's going to happen next show.
But you have no idea you're. Having too much fun, man.
How? How are you, man?
What's going on? I'm good, I'm things are good.
Got vacation, recovering from time zone changes and I'm really
excited for our our guests tonight.
We're not going to give away toomuch of the spoils.
That's supposed to be a shoulderabove me and that's some
nutritional stuff. I go backwards this way, so I

(00:59):
don't want to give away too much.
We'll get into it in a second, but I'm really excited for this
guest. This is going to be We're trying
not to nerd out too much with our shoulder talk.
Oh God, please. You know we're going to get
nerded out. You know you love it.
Let's give a shout out to the good folks at the Recovery Shop.
Let everybody know why you love utilize the Recovery Shop.
Yeah, so big thanks to our sponsors, you know, the recovery

(01:22):
shops really great. And actually, you know, our our
guest uses the recovery shop tooand, and actually sells some of
the stuff on there we can talk about as well, which is great.
So the recovery shop for me, forsurgeons, it gives the surgeons
the ability to get some patience.
These aftermarket things that they want, they want a little
bit extra, you know, how do I get better recovery with, you
know, complete surgery nutrition?
How do I get better machine options?

(01:43):
They have those on there, nice machines, you name it, different
products that are not available through the standard insurance
processes. And my patients have been so
enthusiastic and I had multiple patients today talk about the
post op recovery stuff they wereable to do with something like
the recovery shop. They were just really happy
about it. It's a win, win for everybody.
So reach out to [e-mail].

(02:04):
You know, again, this is the, there's no cut from us for
sponsoring you and sending you there.
But the key here is really to make sure that your patients get
what they need and that the surgeons feel like they can give
their patients everything that ask for it.
So. Yeah, and it's not just the
doctor saying it is the patient as well as someone that's
recovered from the torn Achillesand utilizing that nice machine.

(02:25):
It not only made my life better,but my wife's better.
I've, I've, I've told everybody that the fact that I did not
have to bother my wife to go getme ice every 40 minutes as I
iced on and iced off really saved our relationship.
So if you can't utilize recovery, me too.
It, it, it will save your marriage.

(02:46):
So it's one of the great things.Listen, I'm excited about our
guest today recognized as one ofthe top shoulder surgeons in the
United States, co-author of two books.
I don't know how he does it. I'm going to bring them on
because my first question is, Doctor Denard, thank you for
being here. But how the hell have you done
over 7000 shoulder surgeries? Where is the time?

(03:10):
Do you do anything else besides stay in the operating room?
How is this possible? Thanks for the introduction.
Yeah, efficiency, man. You know, I just, I'm an
efficiency monster and just try to prioritize.
It's all about time management. A lot of people think I don't
have a life actually, but I mean, I just got back from

(03:30):
multiplications. I spend tons of time with my
kids, tons of time with my kids and, you know, relationships, so
and do other things. So yeah, this is what it's just
that's what. It is.
There's no rumors that you have an operating room in in your
house and you just that's how you save time.
You just go. You go to the room next door and
start surgery. I do do 2 rooms, yeah.
Back and forth, back and forth. Yeah, yeah.

(03:52):
But in the. Zone.
You stay in the zone, you know, just flowing.
Yeah. I think that's a good point you
bring up because I think the people always say, Patrick, the
same thing with, you know, doingvideos and you do so much on
your social media. You have so many publications,
you're involved with industry. You had you do a really good job
with the shoulder patients. You run your own practice at

(04:12):
Oregon Shoulder Institute. So you know it's a lot of things
you're doing and you have fellows.
Is that correct? So I mean, you know, you're
doing a ton and that's not easy to manage, but the the key year
is efficiency. We can get into this in a whole
nother topic as to how, you know, as a surgeon, you can be
efficient and do so many different things at once.
But I don't want to take away from the all the awesome things

(04:33):
that you have to talk about today.
But we really, really appreciateyou coming on.
I'm really excited for the audience to hear this.
So this will be great. Can you talk to us?
I mean, tell us a little bit about your your background.
I mean, Medford, OR that's awesome.
But like, you're now people flying to see you from Medford,
from all across the United States.
People read your publications. Medford's a, you know, a small

(04:55):
town place in Oregon. Tell us, tell us why, how, how'd
you do it? I mean, that's not I'm a big
city Seattle guy. Like it.
I had some work to do, but it's a different animal than being in
Medford. How'd you do it?
Well, I grew up in a town calledZigzag.
That's where I was born, 500 people at the base of Mount
Hood. And then I moved to the big city
of The Dalles when I was 5 and was raised there at 10 to

(05:17):
10,000. So I'm a small town guy.
I mean like, I don't really likestop lights even.
And neither do I see different. Reasons.
Yeah. I just, you know, that's just
how I was raised. And so when I was looking to
start my practice, I wanted to be in a medium sized town.
I was OK, a medium sized town sothat I could specialize but have

(05:37):
a good quality of life. And, you know, the other stuff
just kind of came after. I mean, I always had kind of an
interest, but to be honest, likeprobably in residency and
fellowships, some for medical school, I was doing some of it
just to kind of get to the next step.
And then when I did fellowship with Steve Burkhardt in San
Antonio, I think that was a big sort of pivot in my life.
And I sort of saw, OK, I can do this and kind of build my thing.

(06:01):
And I just, you know, slowly didit over time.
It's just, I think most people underestimate what they can do
in several years, like the overestimate they can do a year,
but they will underestimate we just with consistency what they
can do over time, you know, and that's really like my secret
power is just time management and consistency.

(06:21):
I'm just relentless about alwaystrying to do the next thing and
trying to build and make it better.
So that's how it's getting whereit's at.
I will tell the audience this. I can tell that Patrick's
incredibly efficient. I will tell you, of all the
people we have emailed for our podcast, the people I have
reached out to, he is by far oneof the fastest e-mail
responders. He is on top of it for how busy

(06:43):
he is. It was so easy to set this up
with you. I mean, that just shows it like,
right, like you're everywhere and you're still available.
And so the ability to do that kind of right.
I mean, the minute we, I reachedout to him, I knew that this was
going to be I could see the breakdown of how he works.
And so it was kind of cool to see that because, you know, I'm
known to try to get my emails done quickly and respond well,

(07:04):
but it's, it's always like pulling teeth sometimes to get
guests on here in terms of getting in touch with them,
setting it up. I think.
So I don't want to go off on tangent here, but thanks for
making it so easy for me becauseit's it's a, it's not so easy,
so I appreciate. You, yeah, thanks.
Why don't we get into this? You know the conversation.
I think you do so many cool shoulder surgeries.

(07:27):
We we just talk about your practice set up like, you know,
fellows and shoulders. And you guys talk.
About it. So I do 100% shoulder.
I've done 100% shoulder since I started practice, probably six
months in a or a year in a practice.
I did 100% shoulder. So I started in 2011, very high
volume practice. I actually, believe it or not, I

(07:49):
only at this point work three days a week.
I work Monday, I operate 2 days.I do Tuesday all day clinic and
I do 3 and I Wednesdays I do 2 rooms.
And then I save the other days for other things like the
nutrition stuff. We'll talk about real estate
investments and working with industry and meetings, right?
And research the way I do that is just, I've just been really,

(08:14):
you know, prioritized trying to make every moment count.
I have 2P as they're great guys,have been with me for 10 years
each. So they funnel a lot of patients
to where when I see patients in clinic, they pretty much have a
problem or need surgery. So I bet I don't see a lot of
non operative stuff. And then, you know, that makes

(08:36):
my clinic like I'm doing what I want to do, right.
It's surgery and or guide peoplewhether or not they need
surgery. And then I have two fellows,
they spend 6 months with me eachand they rotate with two other
guys in my group. So we got to, you know, a busy
group, you know, we also have a research program.
We do quite a bit of research. We usually have a visiting

(08:56):
international research person ortwo who are doing a lot of work.
Did you set that up the fellowship with them, or is that
already established in place? Yeah, I, I started it all.
I started, you know, I started collecting outcomes and then I
got the fellowship and I, I've actually started doing outcomes
and then I got a 5O3 CB, you know, create a nonprofit

(09:19):
foundation so that I could bringin industry funding or grant
funding and had a good relationship with Arts Rex.
You know, I can't ignore that. They really helped me kind of
support my research at the beginning, which was really key
for guy in private practice. And I have two research
coordinators who are full time who collect data.

(09:39):
And I've been doing that just since the get go.
And then we developed the fellowship or started the
fellowship five years ago now, Ithink.
So yeah, it's been a fun ride. Fun.
What's fun is, is the satisfaction of like looking
back and you built it right. Like I had some opportunities at
a couple of different points in my career to go up elsewhere,

(10:00):
you know, and pick up and leave.And it was, you know, you sit
there and go through and you know what, what do you want to
do with your life kind of thing in the middle of your life?
And I think having built it and feel like it's, you know, I have
a lot of autonomy and control over, it's been really
gratifying for me, you know, because then I can start
transitioning into, you know, a really new career would get you

(10:20):
really excited is doing surgery and doing it fast.
And I still love surgery, but what excites me more now is
teaching and research and development and trying to, you
know, move in that next phase, right?
The whole like Arthur Brooks, like strength to strength thing,
right? Like how to transition over your
life. So.
How did you how did you get involved?

(10:42):
What was the passion that you got into when you first got into
this field? Did was it something that as you
studied, you decided to go into specializing in that specific
area or was it a mentor? You know, I'm always curious,
how does this happen? What?
What taught you shoulder only that tells.
You yeah, shoulder, I mean back medicine.

(11:03):
I mean, I knew when I was like 15, I want to go to medicine.
I was going to be a general surgeon because I worked in the
operating room in the Dallas andthey would let me, these guys
would let me like scrub in and hold the camera and and doing
lab collies. And so with them I was like, I'm
going to be a general surgeon. It was so cool.
And then I got to medical schooland just ended up finding that

(11:25):
my personality fit orthopedics more.
It was actually a hand surgeon. I was operating with him and I
was like, this is just, I can see it and I'd like see it get
better. And it was just, I'm a very
concrete thinker. Like if you ask me an analogy,
like I will fail, right, like every time.
But I can think very concretely.So orthopedics fit.

(11:45):
And when it got to orthopedics, just shoulder just seemed to be
the, you know, the field I thought was really growing,
developing the most, you know, really challenging field.
But also I early on I really want to be a specialist.
You know, I just wanted to be like, good at one thing.
So that's how I got to shoulder and yeah.

(12:08):
And Patrick, I mean, there's a lot of people who think about
this. I mean, you, you, you've been
doing it as a while, but you're not, you know, you're not like
you're not, you haven't done this for 2530 years, right?
And it's a lot of work that you put in.
I mean, to start a fellowship isalready a big deal.
Then to do be able to do a practice setup like you have
then if people flying in for surgery, I mean, that's a lot of

(12:30):
efficiency. Do you, do you, who do you
think? Like, I mean, that's a pretty,
that's a pretty uncommon setup, right?
Someone who's happy as you, who's as busy as you, but also
doing all the stuff. Is it, was there any guidance?
I mean, Burkhart's, we all know Burkhart, right?
He's, you know, one of the world's best shoulder surgeons,
very involved with previous arthrog stuff and doing lots of

(12:52):
sort of design and things like that.
So he had some of that, but was there anybody kind of a template
like in my practice, I'll be honest with you, my practice is
a very big template of coal trained at rush.
It was go, go, go multiple rooms, very efficient cartilage
practice. You know, I do shoulder
surgeries, elbow and knee, but it I that was kind of my kind of
template. Was there any template or you

(13:12):
kind of steered off the course? I mean, you, there's not many
people like you out there, but is there kind of anything you
use as your template? I think that I mean, I Steve was
a really big influence. I mean, the reason I went and
did fellowship with Steve was because he was in private
practice and I wanted to see that ability to do research and
be involved and like, I didn't know it was going to go, it was

(13:34):
going to go, but I thought that was seemed admirable to me.
But I think I kind of take the philosophy of like the tribe of
mentors here and like the thing that I've noticed is that it's
so accessible now, right? You can, you know, Brian Cole is
a guy that, you know, I saw him speak when I was a resident and

(13:54):
I was like, I want to be able topresent like that guy, right?
And or like Tony Romeo is a great presenter.
I want to present like Tony. And then, you know, other people
of like a, you know, like a naval Ravikant, right?
Like Naval Ravikant talks about.I'm a huge fan of his and like
he has no idea who I am, but he's been a big influence in my
life. He talks about things like, you

(14:16):
know, if you're going to, if youwant to be good at something or,
you know, let's take money, you want to make money, you should
not do something that is below that pay grade, right?
So just sort of using your time effectively.
And, and he talks a lot about specialization, right?
Like generalization is, you know, the Renaissance man and in
many ways is kind of gone. You got to be really good at

(14:37):
something, develop a skill. So I just tried to take it all
in, you know, and like, I'm a big reader.
I'm a big podcast guy, you know,I'm listening to stuff all the
time if I'm on the bike and always trying to pick up new
things and just try to, you know, but yeah.
So they said that book of I bet a book of fish, and I know

(14:58):
that's the one different one, the one where it's just like the
one line, you know, it's like the arrow.
You just go one way. There's so many different arrows
going different direction. You just stay super hyper
focused and that's, you know, that sounds a little bit like
this. I remember Josh Dines of her HSS
would kind of get involved with that book and he was like, hey,
you should read this and that I'm not as a vivacious reader as
you, but that one was that one was near and dear to my heart.

(15:20):
But anyhow, I mean, will you talk about?
So I know you do a lot of shoulder surgeries and that's
all great. You know, shoulder surgery is
awesome, but I want to kind of hear more about let's pull up
that rotator cuff slide and I wanna hear more about this
Patrick. I mean, cuz you're like I said,
you're the Jack of all trades. You do research, you do really
high volume surgeries and you doa good job, but you're also

(15:40):
involved in industry. So it's kind of the triple
threat, which is unusual to find.
So I know this is your paper. We could spend 200 hours
reviewing all your papers because you've done so many of
them. But kind of talk to us about
your what, what you're doing forrotator cuff thought process.
And then we can get more into like the augmentation idea.
So people, so listeners can hearthis because they they hear work

(16:01):
took up. But augmentation, they're like,
what the heck are you talking about?
Yeah. I mean, I think it's like, you
know, what we're trying to always do as clinicians is we're
trying to calculate all these things, right and get down to
what is the best for the patient, right?
So, you know, and there's so many variables.
So what we try to do here is give people a framework to think
about when should you augment rotator cuff tears and not

(16:24):
right. So that was kind of the, the,
the big ideas like we have no guidelines.
How do we get there? 25 Will you describe the augment
idea for the for the patients and listeners out?
There, Yeah, yeah, Augment mean right.
So 25% of rotator cuff tears don't heal.
We know that. So the idea is that they need
something else, something like, you know, biology.

(16:46):
We'll talk about nutrition later, which I think is biology.
But right now as clinicians, we've maximized the strength of
the repair of the bio mechanics,right?
So there's certain people that don't heal and they need
something else to to augment. And that augmentation can be
like a graft or tissue that you put on top of the rotator cuff.
That augmentation could be things like putting in, you

(17:09):
know, growth factors, those kinds of things.
Specifically here we're talking about tissue augmentation and we
try to make a recommendation based on looking at patient
factors going into the surgery that you know in advance that
would allow you to A, have a conversation with the patient to
say, hey, you're at higher risk.So now we're going to think

(17:30):
about other things. B be prepared so you can be
efficient when you're going to do it.
See, make the decision ahead of time versus like we're human,
right? We get to the end.
Like do I really want to augmentthis case?
No, I want to get out of here. But if I've made a decision
ahead of time and said that I'm going to augment, that's a big
change. And then I'm in private

(17:51):
practice. Last thing is, you know, I'm in
private practice, so I have to think these things have cost,
right? You mentioned in this
relationship, so I have to know what the insurance is, what the
facility is, where I can go and do the procedure if I think it's
indicated. So that was the idea of this
paper is try to get people a framework.
I think that's important for thelisteners to hear because we

(18:14):
drop all this really cool technology all the time.
But I think Patrick will completely agree.
He's already shaking saying he knows where I'm going with this.
But you know, insurance companies, it's difficult,
right? Again, you get a here's your pot
for the surgery center. And if you start putting more
fancy things, it's like a car, right?
Will you get your upgrades? You want your sunroof, you want
your apple play, you want your souped up engine.

(18:35):
Sooner or later the budget runs out and you can't do the surgery
right. And then the surgery center says
you can't do this. This is too cost and it depends
on the insurance company. So it is it is troubling and
frustrating, right, because if if we didn't have to worry about
that, we could augment everybody.
I mean, honestly, there wasn't come.
Back and say we're not paying for the surgery and you're out
and the patient is out. I've had that happen.

(18:55):
And that that doesn't go very well.
That's not a good conversation. So that's even the like the last
piece of the puzzle when you're augmenting.
What is your sort of, so the idea behind this for will
listen, I don't have any questions, but basically you got
a rotator cuff tear, you fix it,but now you got to add something
extra like you talked about. So you've got biologics, you're
going to add post op surgical nutrition.
We'll get to in a minute. What's kind of your go to?

(19:18):
Like what do you like to do? Does it kind of depend on the
situation? I know again, we're not going to
go into crazy nuances, you know,the subscap, irreparable
subscap, that stuff's important,but really kind of and you're
and most of the time, how often are you adding something else
Interop when you go in there andsee it or you, like you said,
you have that plan ahead of time, you've seen the MRI, like

(19:38):
what factors are you looking at?You got all these things, but is
the MRI the most important for you?
Is it the patient that's most important for you?
Is it just like your gut feeling?
Like how are you doing it? Yeah, I try to look at, I mean,
most of the scoring system the the rotator cuff healing index
was this ROKIE score is based off the MRI, It's based off of
age and the MRI, right, The MRI findings and I think that's the

(20:00):
most objective way. If you look at the time of
surgery, you're probably not as good as you think you are.
And really deciding the exception to that would be like,
I really don't care what it looks like.
If it's revision, I'm going to even if it's small, I'm going
to, I'm going to augment. But you know, to answer your
question. I probably augment about 10% of
my cases. A lot of people think it's a lot

(20:20):
more. I told you 25% don't heal based
on the data and the the fact there though, is that in older
patients who are lower demand, if they get partial healing,
that's, that's, that's probably acceptable.
If I have a 75 year old who has a tear that may have a rodeo 7,
I, I'm probably not going to augment because they're going to

(20:41):
be OK with partial healing. You know, I'm really talking.
We also know some of those patients that you you do the
augment that they don't heal andthey don't have a pain like you
said, the partial healing, they may not even be symptomatic.
Right, not all right, exactly. That's the point.
It's like not all you know, justbecause they don't all heal
still the vast majority of patients do well, right, like
90% of people are going to do well for a rotator cuff repair.

(21:05):
So it's really those new ones. I think you're trying to target
to alter their Natural History because in them healing is not a
lack of healing is not acceptable because they're going
to go on to have, you know, early arthritis, etcetera,
right. Yeah.
And they're. Higher.
Patrick, are you doing any more of like do you do any of the
tendon transfer stuff? Are you mostly cuff
augmentation? I know you do a lot of shoulder

(21:26):
arthroplasty, yeah. I do.
I mean, I do. Thoughts on that stuff?
Yeah, I do 300 arthroplasties a year, right, Because it's all
shoulder and about 300 cuffs andthen the smattering of other
things. So I do it all.
I mean, I do tendon transfers. I do some, you know, cable
reconstructions for irreparable tears do all sorts of, you know,

(21:47):
and really to me, it's about trying to define the, the, the
right patient for right indication rather than
everything being a hammer as a nail, you know?
Do you, what type of are you doing ever biologics for your
rotator cuffs? So you ever add that or what's
your thoughts on that? Yeah, Ioffer all my patients PRP
and we do that in a cash pay model at the surgery center.

(22:09):
I say here the data says supportfor healing it helps with
healing that is it's probably about a 10 to 15% difference.
It's not going to take you from 30% to 90% chance of healing.
I would have it if you want it and you can pay 4th and we low
price point to do that. We also offer B Mac in the same
manner. And B Mac is bone marrow

(22:32):
aspirate. Yeah, just a higher
concentration, growth factors, Idon't like to call it, you know,
stem cells. That probably is misleading.
But you know what, we as far as augmentation though, if I, you
know, if somebody has, you know,maybe a good chance of healing
and they just want to make it a little bit better, PRP is
perfect. But if they have a low chance of

(22:55):
healing without arthritis, that's where I start having a
conversation about augmentation.You know, my, my go to is, is
dermal allografts. I mean, you basically have
xenograft animal, right? You got allograft, which is skin
from humans. And then you have synthetic
patches now emerging in the market.

(23:15):
So I'm doing primarily dermal allograft and a little bit of
synthetic patches in some cases.Yeah, and for people to hear the
the skin's pretty interesting because there's plenty of buyout
studies that show actually the that blood vessels go through
the skin and actually heal it pretty well.
Which is pretty vascinization. Right.
And I don't, I mean, not that wewant to say they fail, but if

(23:36):
you ever take one out, they're actually extremely difficult
because they heal right in. That's kind of socked down.
You. Get a good healing response,
which is impressive so. You're right.
I was going to ask real quick, just the complicated ones where
let's say a patient is older, has an injury, maybe for

(23:58):
whatever reason, they're, they live by themselves.
So they really have to, you know, take care of themselves
and do the shopping. You know, how, how are those
decisions, you know, compared toa normal procedure where you go,
well, this is what I will do forthis patient.
And you have to consider maybe the quality of life that this

(24:18):
person is going through as far as the repair if you can take,
which is impossible to do. You know the insurance aspect of
it, the money aspect, you know just how hard are those
decisions And, and you do you consult with yourself, the team,
how does that work? Yeah.
I mean, there's a lot that goes into that, right?
I mean, you got you might have somebody who actually has a tear

(24:40):
that's kind of borderline, but you might cite say that, you
know, there's 75 or 80 and you might I might do a shoulder
replacement because you know, you want one and done and you
don't want to put them through six months, have it not work
out. Maybe even if it's only one in
three that it's not going to work out, but if it doesn't,
then they have another six months of recovery or plus.

(25:03):
So those are absolutely decisions that, you know, are
factors are going to play. The other one is, you know, I
call it the, you know, the trilogy of demise, right?
It's like poor bone quality, poor strength and poor attitude.
And you know, I can tell within 30 seconds on I'm sure Grant can
as well. You know who's going to do
really well and who's going to do really poorly?

(25:23):
There's like these, they're the far, the far sides, right?
If they have good strength, goodbone, good attitude, you're
like, you know you're going to be great.
Give me more of. Those you've got to read in the
middle, right that you're tryingto like do the best you can, but
you get the people in the end. It's it can be really, really
hard. Yeah.
And that's also real sometimes when you change your method,
right? Like you get patients what like

(25:44):
mid 60s, late 70s and they got apoor attitude.
They've got code biologies on the fence and you just know
there's no way they're going to handle a rotator cuff with
augmentation. It's just reverse, reverse,
reverse because it's just you got to get in the best shot, you
know, and it's just that that's one and done and you can't do
and you do such a good job with your replacements that it's kind
of like the other thing is, you know, the nice thing about

(26:06):
someone like Patrick and I know I'm sure I want to go on the
next topic, but is because because you do every all those
shoulder things, someone doesn'tfeel like they're stuck with it,
right? Like I know a lot of guys in the
area, they do just the cuff stuff or they don't do the
shoulder out the pussy. I do like the whole gamut like
you do so you can offer each step so you don't have to feel
like, OK, he's not giving me thebest option because he doesn't

(26:28):
do it. And I think that's that's a
really important thing. That's where I think the
specialization or the I actuallycall it now, super
specialization. Like a guy like you would be
kind of super specialized. Like just shoulder, just high
level stuff can make a difference to the patient.
That's what patients don't get. You know, you see some of the
shoulder doesn't mean they're doing all the shoulder stuff.
Right. Yeah.

(26:48):
Well, patients still go to people based on proximity and
convenience a lot, right. My busiest year in practice was
COVID because we only had six weeks off here and then I didn't
travel, so and I was just available.
And so people come see me in theoffice and, you know, we didn't
have much of A shutdown. I was, it just really showed me
that I'm like, you know, I'm notthat big a deal to most people

(27:10):
out there. It's just because they can get
an appointment next week. That's how a lot of people make
decisions. And you make that decision with
PT Also, when I, you know, I go,I, well, I'm going to look at a
couple places and if they're comparable, I'm going to the
closest place. Kind of piggyback, you know what
you're talking about. Not saying specifically you

(27:30):
because you have a specialist, but I know when it comes to PT,
you know if it's convenient for me and I could get to it quick,
I'm going to choose something that's close.
Well, we gotta move on. I told you this was to have with
Patrick. I'm gonna be in control of this
situation. Go to that next slide show about
the remples. I wanna talk about the
instability briefly cuz Patrick does more than just this.

(27:53):
And we gotta get to surgical nutrition cuz this is gonna be
to go to the next one. I mean, this is a good one.
We can. Why don't you bring this up
briefly? We'll jump into your nutrition
in a second and then we'll pull up the shoulder stuff.
So kind of go over to your. Thoughts on this we were talking
about, we talked about biology and what's interesting here is
this study recently on Japan, they looked at nutritional risk.

(28:14):
And what you see here is that people often underestimate how
good their nutrition is. So first thing you see is that
actually about 50% of people or more have some risk nutritional
deficiency. Interestingly, when they looked
at like all the factors, their nutritional status, if you like,
the odds ratio was higher or more important than their age

(28:35):
and fatty infiltration, which iswhat we talked about the cuff.
So I just think when we're talking about biology, we cannot
not be talking about nutrition as well if we really want to
optimize the patient. And as a surgeons, right, I
mean, you're very nutrition heavy, but there's not, not
everybody's like that, right? So we're like go, go fix, fix,
fix, fix, fix cuff, patch, cuff patch biology, PRP.

(28:58):
And we totally forget about this.
And I've talked about this before, but like, that's why I
like like the recovery shop, butthat's why I like the post
surgical, the pre surgical. Those are very important.
And as surgeons, we're not very good at that.
You are, but not a lot of us are.
But thinking about this stuff. So it's really important.
I think we bring it up. Yeah.

(29:19):
So we'll bring up this. So you do that, you do your,
again, you have your cuff patient population, right?
That's your sort of like, you know, fifties, 70s and you got
your shoulder arthroplasty, you're 67.
Again, this is a generalization.There are people that fit in all
categories, but you got your young athletes right.
And this is actually something that you were known for as well
is your shoulder instability patients.

(29:40):
And this is something I like to specialize in as well with this
sort of stuff. So can you?
I mean, this is a very nice color.
I know you just made it up and it's not from a paper of yours,
but I've definitely, like I toldyou before the audience, I've
seen this plenty of times. It's a really nice thing kind of
just briefly discuss what this is and this, you know, you talk
about a couple of the things here and to talk about rump

(30:00):
massage or whatever else. Yeah.
So when you're looking at peoplewho dislocate their shoulder,
you have to know who they are, like what their risk factors are
for having to repeat dislocations.
Specifically, that's going to beyoung men under the age of 2025,
right? Everybody talks about bone loss
and we talked about how much of the socket or glenoid you've

(30:22):
knocked off because it's like a ball in a golf tee.
Once you knock off some bone, itgets becomes very unstable.
So we talked about do you add bone graft?
The point of this algorithm really is to say there's this
category of people who don't have a lot of bone loss and a
lot of surgeons will still do a bank heart repair.
And my argument is that if you look at isolated bank card

(30:46):
repair and look at the outcomes,they do well for a couple years.
On average, the failure rate's about 8%, but they continue to
dislocate out to two and four years.
So you start approaching a re dislocation rate of about 20%,
which is 8% is not acceptable, but 20% is certainly not
perceptible when you go out midterm for these patients.
So that's where I basically havesaid even with low bone loss,

(31:11):
you know, almost all cases I'm adding a rump massage because if
you look at high risk, you know,that's somebody under the age of
25, you had 25 or you know, 18 year old male, I don't care if
they have a little bone loss, they are very high risk.
They dislocate normal shoulder. They've already shown that.
So we talked about this glenoid tract stuff.
I don't I don't care about the glenoid tract.

(31:31):
I add rump massage and the reason is R.E.M. passage helps
pull the shoulder back biomechanically.
Very clearly it shows a dislocation rate drops our
outcomes 2 years our dislocationrate was 8% with isolated bank
cart, 2% when we had a R.E.M. massage and other studies have
shown that not only that, but you don't have that continued

(31:54):
drop off between two and four years.
It's like the R.E.M. Massages tend to do well mid to
long term. So we really done a lot of rent
massage and it's just become easier with, you know, the
techniques with knotless anchors.
And that's honestly one of the reasons we started doing is this
got easier. I was like, all right.
And then, you know, we looked back and found that it, it, it

(32:15):
got to really make a difference in the outcomes.
And for people listening, I meanthat if you look over here, it's
hard to see though maybe if you're on on your phone to see
the sort of breakdown, but but this less than 15% bone loss is
actually a very common patient population.
I mean, I, I would say in my office, it's probably one of the
most common. Would you agree?
And if you look here more than one, I mean I get a lot of first

(32:38):
time dislocators from some of the sports teams I do, but it's
not frequent that I'm getting a single dislocation patient as
often as I'm getting the multiple dislocation A. 100%,
yeah, I agree with you. By the time they've got to you
or honestly, if they have a single dislocation in there, you
know 1718 they have any health sacs which they should.

(32:59):
I'm going to add R.E.M. Massage most of those patients
because the just the data is so profound the differences.
And it's come. So for the listeners, the R.E.M.
massage, we basically take part of the rotor cuff in the back
and we attach it. Now that sounds kind of morbid,
but I mean, Patrick, what do youthink now with the new
techniques and we'll get into kind of futuristic stuff for

(33:21):
this, the R.E.M. massage, what do you think?
How much longer does the rum massage take you from a surgery
standpoint? 03 to 5 minutes yeah, yeah, it
really doesn't add much with thetechniques we have now and that
used it used to be a big ordeal when I was in fellowship.
It was like a 30 minute thing. It was like, Oh my gosh, we got
to do a massage. It's way easier now just doing
it in through 1 cannula right above, you know, so we can just

(33:44):
link the anchors knotless and and the real quite like why not
right. And you would say why you're
worried about OK time. Well, there's not times gone.
There is cost. OK cost sure, but I'm going to
try to do the right thing. I'd much rather suck up, you
know a few $100 for a couple of anchors then have the patient re

(34:04):
dislocate. We worried about loss of extra
rotation. The data doesn't show that that
bears out. I think that's probably you just
did a study on that. Can you talk about that 'cause
that is the number one thing that shoulder surgeons tell me,
right? I say this word about I love
rampusage. So the idea will is if you
attach the back of the shoulder,there are some older data that
shows maybe you'll lose a littlebit of range of motion.

(34:24):
And obviously people are like, and why would you add it, right.
Like anybody wanting to be a skeptic of this simple
additional surgery is going to bring that up.
So maybe you could bring up thatbrief.
Yeah. We just did a big review, look
at all the world's literature and found that actually when you
compare bank heart and bank heart with renfosage and ladder
shade, there's no difference in loss of extra rotation.
If you think about this, what's going to lower your extra

(34:46):
rotation is tightening anteriorly.
So you're often going to get some slight amount of extra
rotation loss. With a bank car repair.
You tighten the capsule, you have to make it tighter than
what? But the back doesn't actually do
anything. It's not stopping you.
You know, doing work in the backdoesn't stop you from external
rotating, provided you're getting a good view, you're
doing something anatomic, right?It's it's really not going to

(35:07):
limit you. And I think that's important.
What you brought up is, again, you do a lot of teaching.
You and I both work with, we've talked about this, Will doesn't
want to get too excited about internal brace with Arthrex.
But nonetheless, you and I both work with them.
And you know, one of the things that we're trying to do is to
make the surgery easier, right? Because like, no offense, but
you saying 3 to 5 minutes and a random guy that does 2A year is

(35:29):
not going to look at you and go,well, I don't really care.
Three to five. Good job.
Patrick Nard, you do like 100 ofthese.
So we got to find a way to make it more.
You know that's where the futureis, right?
Yeah, it's gotten a lot easier, but we need to keep taking steps
forward to make it even more reproducible.
And I think that's I think that's the right thing about I
think it's nice thing was you talk about you got your time for

(35:49):
the industry. The idea of the industry is that
can we find a way to make it so that that you coming off, you
know, not maybe, you know, no offense, maybe will could do
R.E.M. massage, but so we can have all of us doing maybe who
knows? He's, he can play doctor on TV,
but the the idea of doing havingthese guys that are community
doctors that do a few shoulder surgeries a year, 2030 shoulder

(36:12):
surgery a year, being able to doa run massage to get the patient
because I think that it's hard for.
I probably want you to explain this a bit better, but how much
does it suck to have a Redis location after you just did a
labrum repair I. You know so.
You haven't had it. But I'm just ask.
Me what? Explain the audience?
Yeah, the deal to stop it. What?
So The thing is like, it's the patient, right?

(36:35):
Because it's the Yep, the, the, the surgery that bothers me the
most is instability. Because you have a young
individual who's like their whole life ahead of them.
So they're often and they're playing sports most of the time.
And when they re dislocate, you're just like, oh man.
And you got to talk to the parents and they got to go again
and do something, you know, and they have or, and they, they go

(36:59):
through the psychological response, they dislocate and you
fix them. And then if they dislocate
again, then there's, they're like, they're change for life.
There's actually changes that happen to brain as a result of
this. So it's really, it's really a,
that's the one that keeps me up at night so that the fellows
like they don't get to do anything in the instability
cases, right? They are there to watch those
cases because it's just I feel like the most is on the line in

(37:23):
the in those situations. I've noticed that as I've gotten
more in practice, I do more anchors now, I'm more careful
and I'm adding more rent massages because like you said,
I can't handle like I can barelyhandle a 5% re dislocation rate
in my anterior labor repairs. I mean, I early on in practice

(37:44):
thought I was so good at the anterior labor repairs till I
got a re dislocation, right? Everyone thinks they know what
they're doing, they're straightforward, they're
comfortable cases. Everyone's we're going to flow.
It's like playing the piano, right?
And then you do an awesome killer 4 anchor repair and they
fail and you're like, I don't know what I did wrong, right?
And it's exact same thing and now I'm doing the right massage.
Just makes me feel better. It's just this whole thing about

(38:04):
with your and then your papers. Now I can quote them and say,
you know, there's less. There's no loss of rotation.
And my question, I guess to you is other than, you know, I guess
people can say the costs or challenge.
Why would you? I mean this is going to be like
the LET for the ACL, right The AOL.
You know my question on my patience.
I just saw two. I have four people indicated for
LE TS today. Why would you not do the rental

(38:26):
sock? That's exactly.
Why not, right? Yeah.
Yeah, I want to piggyback on something that that you said and
I know it'll resonate with folkslisting.
I've coached multiple sports, football, baseball, basketball,
and as a parent, as a coach, seeing what that athlete goes

(38:48):
through when they get re injuredwith the same injury they had.
Besides how the parents feel, the re, you know, going through
it all over again mentally for these kids, the trauma, the lack
of confidence, can they do it again?
That whole process is not just starting over, but you're

(39:11):
starting way over. And it's not just recovering
from the injury, but now recovering mentally, depending
on what your lifestyle is spiritually, there's, there's so
much going on and there's so much work that it takes the
community to relift. Most people, other people have

(39:32):
resolved, right? But the majority of the cases
that we've seen with athletes getting hurt, with myself and
other coaches, it's, it's detrimental.
So I can imagine and we don't think about it from your
perspective, right? We think about it as a as a
parent or a patient or coach or something like that, that you're
going through this trauma as well.

(39:53):
And it kind of all makes sense when you're saying if we can do
something to reduce that, why wouldn't we do it?
And it resonates what you guys are talking about.
Yeah, and I think as the audience listening, I mean,
that's who you should be asking a surgeon.
Why are we not? Right?
You told me, I said dislocation.You told me I had a hill sax
lesion. And then you're just going to do
a basic repair of my labor, man,No offense.

(40:14):
A basic repair. It's still complicated, but you
know, like I said, if you start looking in the back of the
shoulder, you make sure you get that posterior sling.
Sometimes those are off, making sure you're adding a massage and
know the order and, and again for the search and listening the
first few times, yeah, it's going to be weird, right?
There's an order to it. At least that's the way I do.
It may be different from you, but you know, there's an order
to it and there's a little bit of an art and three to 5 minutes

(40:35):
is what you'll get down to when you know what you're doing.
But you got to do it. I mean, you just and, and
nowadays, right, it's the one ofthe best arthroscopic procedures
we can do because we can do these Bony procedures through
the scope, but they're major risks.
They're hard, it's really challenging.
And the idea of doing an open latter J is it's, it's got its
own things. But the fact is nowadays we can
get away the rumpusage. It's both spectrums, right?

(40:57):
It's the patients with the less bone loss and even the patients
now with a little bit more bone loss.
We've seen the equivalent results.
And so it's got, it's got such abroad range that it really
should be like a rumpusage. Or do we big enough for ADTA or
a latter J Right. That's really the kind of the
gamma we're at and that in that ladder J DTA group, I feel like
keeps getting pushed bigger and bigger and bigger and the

(41:17):
Rambusage is filling the gap. Would you agree?
Yeah, no, no, I I'm with you. I'm with you.
My only ones are the wrestlers because they just, they're just
crazy. They just put their arms in
their craziest positions. And like those ones, I'll lower
my threshold and I'll do a ladder J.
But that's I had A. Guy I did a ladder J on, he's A.

(41:38):
Motocross. He's gonna stop doing motocross.
Oh man. Yeah, Oh yeah, the wrestlers are
good. Totally.
Agree. I mean I.
Rugby for you? Is rugby the same threshold for
you or? Is it?
I don't have a lot of rugby people.
I mean, Southern Oregon is big in wrestling.
So it's like sports that everybody plays football, you
know, I mean the standard sports, but then like wrestling

(42:00):
is really big in Southern Oregon.
So that's those are my like my high, high, high risk.
Can I follow up on a question there?
Are you seeing any significant injuries when it comes to
wrestling with football players?Usually the season is football
in the fall and then going into winter you go into wrestling.
Are you seeing anything talking to patients say, well my

(42:22):
shoulder was sore while I was playing football and now I got
it aspirated and now you have a bigger injury when it comes to a
wrestler that plays football? You know, I haven't noticed a
ton of that because most of my wrestlers down here are like,
they're like year round wrestlers.
They're seriously. Yeah.
So I haven't noticed that like transition from football to.

(42:43):
We used to see a lot of that back in the Tri-state, New York,
New Jersey, Connecticut, where you had the football players,
the offensive lineman, defensivelineman, linebackers play
football and it goes right into the winter sport for wrestling.
And they would be a lot more wear and tear for these for
these players. So I was just curious to see if
you. Had, you know, this, this, this

(43:04):
data that shows if kids don't get enough rest, they definitely
have a higher rate of injury, especially if they're doing 1
sport all year. I mean, that's, that's another
thing, right? All right.
I don't want to cut off Patrick,but we got to get to his last
piece, which is everyone's trying to figure out why I've
got pills on one side, a spoon and this thing that says
complete surgical. We thought you had issues.

(43:24):
OK, I thought. I might, I think ChatGPT I'm
going to blame them. But can we pull up that muscle
loss after surgery? Patrick, So you already told us
how you're the Jack of all trades in the nicest way
possible, but you keep talking about this complete nutrition.
Talk about the important nutrition brief background.
I know we only have about 17 minutes left, so sorry to make

(43:45):
this so much shorter, but will you talk about this and how this
came to be? And now you've got this awesome
thing you work on. And yeah.
Yeah, so I, when I was in high school, I was an athlete and I
started, I was doing supplementsand I started taking creatine
and that time, that was crazy, right?
I was like reading Bill PhillipsBody for Life about HMB and Lucy

(44:05):
and all this stuff and just always had an interest in it.
And I started early my practice,you know, telling patients take
vitamin D, vitamin C, because I would read the articles on it
and like, that's makes a lot of sense and patients liked it.
And then over the last probably five years, I really just saw
the data on protein. And, you know, everybody goes

(44:28):
through this period where they have after they have surgery,
they have muscle loss and you know, you're.
Going to. Disuse and so we're going to go
through this period, you know, whether it's a mobilization from
a sling or you know, a brace forthe knee or a cast.
If you've ever seen me for cast,they come at it and they look,
you know, they look kectic, right?

(44:49):
They look like a skeleton basically.
So concept here is if you can intervene nutritionally, you
from a muscle standpoint, you'renot going to take all that away,
but you can lower the recovery curve, right?
You can make the recovery faster.
And that's the green for people who can't see, is that?
Correct that green nutrition andwhen you're looking from a
muscle perspective, there's a lot of factors, but the biggest

(45:14):
thing is your protein requirement double S after
surgery. Most patients get about 30% of
their protein requirements aftersurgery.
And specifically when you talk about amino acids, the most
important amino acid, there's many that are important, but the
most important amino acid for decreasing muscle loss is
leucine. And you need about 3 grams of

(45:35):
leucine per dose. Most over the counter protein
products that you can get like Costco or whatever, you're going
to get a gram to maybe up to two, but the data on this looks
at 3 grams of leucine per serving.
That's where you really make thebig difference.
So you have to have overall increase protein intake and you
also need to specifically have high amounts of leucine if

(45:56):
you're going to recover faster. And it's not just healthy or
older individuals, older individuals more affected
because you know, our muscle loss occurs with aging, but
there's data showing that young healthy adults, you bed rest
them, they get muscle loss. If you supplement them with
leucine, they get much less muscle loss.

(46:18):
So it's not, you know, it's likeme and you are at risk, right?
It's not just a 65 year old, it's everybody.
It's another one where you'd saywhy not?
So I recommend nutrition for everybody.
Is there a downside? Sorry.
No, there's really, that's the thing.
There's no, there's no downside.I mean, I'm not, I'm not

(46:40):
recommending people are taking anything wild.
You know, it's, it's increased in vitamin DD intake, good for
muscle and bone, increase in their protein intake high and
leucine vitamin C helps with pain, helps with also tendon
healing based on some studies aswell.
Magnesium, you know, they're simple things, but as a society,

(47:02):
we, we eat very, very poorly, right?
And we think we have better, much better nutrition than we
do. So, you know, I've just taken
the opportunity to try to lean into the some of this and try to
help my patients get a little bit better by focusing on this.
I give them a lot of informationabout why nutrition is
important. I do have my own company, you

(47:24):
know, like you, like you mentioned on this, but I Ioffer
all my patients information. So and many of them will just
say, OK, I'm just going to go buy vitamins and get protein.
That's fine, as long as they're doing something that's taking
them forward. You know, and some of them even,
you know, they even say come back and say they, they really
changed their perspective there how they eat in general.

(47:45):
So you maybe make an impact beyond the surgery, you know, so
I think it's, it's been a, it's been a really good thing.
But the data is really clear. You know it's across all
specialties. Show that one well, the next
one, yeah, it's. Not just worth I mean there's,
there's data in colorectal surgery that's got
cardiovascular surgery. This is a study on total knee
arthroplasty supplemented amino acids for four weeks after

(48:08):
surgery. What's interesting about this
study, randomized controlled trial is that patients didn't
use, they did better in other terms this, but this is strength
and what's interesting is those are supplemented.
They did better at 2 years as well.
OK. That was the big difference in
strength. They had earlier outcomes that

(48:28):
were better. But what's interesting about
that is it's not like you're going to what this would say is
it you're not necessarily going to get there eventually
regardless. They would suggest there is a
critical period you have to recover in, in which you're if
you want to get to the ultimate best spot, right.
So I think it's really importantthat we're we're talking to

(48:50):
people about these options so that they can not only recover
faster, but get to the best possible outcome long term as
you're seeing here. So I have a question for you on
this one. So this is a, this is a really
interesting point. I had two patients today brought
this up. I was talking about you and
myself realizing I got injured and had a recovery and realized
I was kind of down still after ayear.

(49:12):
You don't realize people would say like, I would say this first
six week visit, this is like thecritical one, right?
Like you got to see how you're doing.
Like this is how this is true actually for the rest of your
thing and you slack off there. It's kind of those people, you
know, those people come with a stiff shoulder at six weeks.
They're not going to be the sameas your person that comes in
there trying to go crazy and they feel really good already.
You know, they've worked their shoulder a bit more with PT or
whatever. It's different animal than

(49:33):
nutrition. But did they, when did they stop
the supplementation in this? Do you remember?
Was it a roughly a timeline? This was 4 weeks, this was just
four weeks. So they so they gave the
supplement day of surgery four weeks on and again there was
other other things they looked at this, this graph we're
looking at is just strength looking at two years.

(49:53):
But they're the group that supplemented for the four weeks,
did better in the early period by other metrics.
So you would say in this case that basically they, they may
not have seen the strength difference because at 4 weeks
it's hard in general with pain and recovery.
But that basically this is sort of like one of those sneaky
ones, right? Where like you're really going
to notice like you're basically a detriment.
You don't even realize it and you're so down that basically

(50:16):
like you've built this sort of background information,
background strength that's really not going to show itself
until the two year mark, which is fascinating because that's I
haven't seen a slide like that before and looking all nutrition
stuff. So it's really interesting.
To see, Yeah, it's really interesting.
I mean they, you know, in the, there's a question of period.
I mean, some people say, you know, load a couple weeks in
advance, take a couple, you know, two to four weeks after.

(50:37):
There's some data that suggests that the first three months is
critical. But I think the I think the
early period is probably the most critical, I think.
What's your recommended, let's say OK, Patrick or Doctor
Denard, I'm seeing you. You're getting my show surgery.
What should I I, I don't care about.
I don't care about cost. I don't care about stuff.
What's the best thing I should do?
What would you recommend? Yeah.
So I would, I tell patients surgery.

(50:58):
So I usually schedule out a few months, right.
So I usually say see them, I saysurgery starts now, right.
So I want you to start taking vitamin D right away, you know,
which is a month before surgery at least.
But I start if there are three months in advance, I start
taking them nap, taking it now Ihave them load with protein.
Patrick, is that all patients orjust your just your older

(51:20):
patients? Paul, Paul, got it.
OK. I just don't see a downside for
bone and muscle. There's good data for for bone
and muscle for vitamin D. Yeah, sorry about that.
I just curious and no, all good.So then I tell them to load with
protein two weeks in advance of surgery.
So they're basically doubling their protein intake to kind of
load. Up will, are you writing this?
Down? Write this.

(51:40):
Down. This resonates because we had a
similar conversation with DoctorJazyeri and he was talking about
the preload of the amino. Yeah, yeah, yeah, yeah.
He's a big ass. He's a big.
So a lot of the stuff that we'rehearing this is, this is the,
the way that everything's going and I absolutely love it.
It's just something that everyone should hear about this

(52:02):
supplementation getting ready before surgery and post surgery.
So I, I hope people are just learning a lot.
So I don't mean to to interrupt.Yeah, keep going, Patrick.
Keep. Going prehab?
Well, I'll just finish the protein thing.
So load two weeks in advance. Continue.
I want people to continue for three months afterwards, OK,
They should do a carbohydrate drink the night prior to

(52:24):
surgery. You would never tell an athlete
to run, you know, 1/2 marathon with not eating for 16 hours.
We have patients do that all thetime.
So if you do a carbohydrate drink the night prior, there's
good data that says they have faster recovery.
And then I also think those other vitamin things are
important. You know, the vitamin DI
mentioned, vitamin C very clearly helps decrease pain.
It may help tend to healing, helps collagen production for

(52:47):
wound healing. So all those things are, are,
are really important, but I think you know, it's the, it's
pre hab in general, we're a little bit slow to this
orthopedics, other specialties have looked at this.
But if you combine nutrition andthe psychosocial preparation,
which I try to do as well, if itreally matters and we go back to

(53:07):
that slide we talked about, we talked about augmentation.
But what's funny is when you really look at like the risk
factors that were most important, like nutritional
nutrition was a 300% increase inretail rate.
We're not talking about oh. Yeah, go to the.
Higher risk of re tear, you know, that you see with a large
tear or a 30% higher risk, you're talking 300% increased

(53:32):
risk of re tearing when you havenutritional risk factors, which
is, you know, a high, very high percentage of patients right?
In this one here it's 20% or themoderate risk.
You know, you're talking about really, really big differences
that make an impact on people. So, you know, I would argue if
you're going to spend, you know,500 bucks on PRP, your or you

(53:56):
know, a couple $100 in nutrition, your money's better
spent. If I'm a patient and I have to
pick, I want to do it all. But if I have to pick, my money
is best spent on nutrition basedon the data.
That's an X. That is an absolutely excellent
point because I have probably the same as you, but you know,
you have various options afterwards that people can
choose somewhere beforehand and they always or people come in

(54:19):
the office, they're like, I wantthis or this and I want this and
I don't want, but I don't want to spend on certain stuff.
So that's a really good important point to bring up
because I think it's like when we talk about surgeries, right?
Like this part of the surgery isimportant.
This is the extra credit part, right?
Or we're going to try to do everything for you the same way
post op, right? That people have to make
choices. Some people don't care, they'll
do everything, but that's not the way life is for most of us.

(54:40):
And so as a result, the idea is that the nutrition if you so in
your in your opinion of all the things kind of post and pre op
extra not you know, you do your surgery, your patches, you do
your biologics or you do whatever you want to do you for
you right now, priority is nutrition.
Is that correct? So I actually have now my
instructions prioritize it and I'll say here's like here's tier

(55:01):
one, here's Tier 2, here's Tier 3 or rotator cuff.
Let's say tier one is benzoyl peroxide, right?
Low cost, lower the risk of infection, but that's all
shoulders nutrition and I like cold compression.
OK, My next thing that I say I would do to me that I but I
would add PRP. OK.

(55:23):
And then if somebody really wants to get into it and they
hire in a cash pay situation that I talk about B Mac
augmentation, those kinds of things.
But I think the biggest bang forthe buck on the data is really
those simple big things at the beginning.
Do you, in your opinion, do you think that the bone marrow
aspirant is better than the PRP or is it just that you kind of

(55:47):
the idea is there's obviously more potential mesochymal cells
in the Yeah, I think there's. Potential higher concentration
growth factors, right? I don't, we don't know.
We have three studies. We have one study from Hernigau,
which said we have Brian Cole's study, which, you know, it's
really like you got to dive intothe details to show a big

(56:07):
difference. And then we have the database
study that says there's a lower risk revision.
If people are kind of like, whatdo I do?
I say, well, there's tons of evidence in PRP.
You know, I would probably do that.
But if it's a larger massive tear and they're kind of on the
fence and they're interested in it, then I'm saying, you know,
you're not going to be worse offthe B Mac.

(56:29):
It's you know, they're willing to spend.
I'll I'll do it for him, but PRPlike is a no brainer for me.
Got it. This is awesome.
Well, well, do you have any moreclosing questions as much I told
you I could do Patrick another hour, but.
I think that we're going throughnerded out.
You went full nerd. I got important stuff like I,
you know, the fastest growing sport in the country is

(56:50):
pickleball. What has you know, Doctor Denard
been dealing with and patient like I've got good stuff here.
You got too nerded out, Doctor Denard.
We just. Submitted a paper on pickleball
actually. We.
Didn't even get any nutrition. PRP.
He's got it. Everything.
Yeah, that's funny. Yeah, I know.
Hey, what? What's the future?
For you on this stuff. Future, I mean shoulder

(57:18):
arthroplasty, I'm really interested in getting to an
optimized convertible glenoid. That's like if I had like one
thing that I want to like help develop and you know, and like,
you know, my last like kind of thing in my career, that's what
it would be. I think you're going to see a
lot of you're going to see things like these algorithms
that I took and everybody's justgoing to have little machines

(57:40):
that calculate stuff, right as we have better data, you know,
because it's like it went from like differential diagnosis to
like algorithms to it's going tobe much more sophisticated
individual decision making. I think that is exciting.
I think that is scary, but I think it's exciting because it
kind of raises the bar for everybody or raises the plane,
you know, this playing field, like where everybody can perform

(58:03):
it at a certain level. Because so many questions as,
you know, surgeons will ask, well, what do I do, right?
Because they don't have all thisinformation in their head.
Well, they have experience of the volume either that you.
Have yeah, right, right. But what's scary is limiting our
ability to do things. We talked about insurance early
on and you wonder, OK, are theseguidelines or these, you know,

(58:27):
it's the Gattaca movie, right? The guy who's like, he has the
genetic disease and he he can't perform and of course he
outperforms it. But we might get in situations
where you lose the individual patient.
So I'm a little nervous about that.
I I want to ask you more questions about this, but we are
at one minute and 15 seconds before our timer's up the will.

(58:49):
Do you have anything else? Gattaca Movie We we got a
Gattaca movie reference in we didn't even get to if he's going
to Coachella in 2026, I'm getting my tickets I.
Need another year off Yeah, yeah, I've got.
To go. It's on my list.
They come out May 2nd. Coachella tickets.
So these are our priorities here.

(59:10):
But Doctor Noah, thank you so much for your time.
I know we're wrapping it up here.
Doctor Garcia, say something nice before we say goodbye.
Patrick, awesome. Thank you so much.
Really great having you on. Thanks for showing yourself
anybody listening complete through nutrition is awesome and
you give you heard from the expert right now.
So thank you so much for everything.

(59:31):
Thanks guys, it was very fun. All right.
Thank you.