Three Boneheads

Labral Tears of the Shoulder... The Three Boneheads Podcast

Episode Title Labral Tears After 40: Why Your MRI Is Lying to You Podcast The Three BoneheadsHoward Luks, MD · Jeffrey Berg, MD · Jonathan Hirsch, MD Episode Summary If you’re over 40 and have shoulder pain, there’s a very good chance your MRI report mentions a labral tear. And there’s an even better chance that tear has nothing to do with your pain. In this episode, three experienced orthopedic surgeons unpack one of the most common—and most misunderstood—MRI findings in adult shoulders: superior labral (SLAP) tears. Drawing on decades of surgical experience, they explain why these findings are often age-appropriate, why MRIs frequently create unnecessary fear, and why surgery is almost never the right answer for adults with non-traumatic labral tears. This is a candid discussion about judgment, restraint, and knowing when not to operate. Key Topics Covered 1. What the Labrum Actually Is * A 360-degree ring of tissue around the shoulder socket * The superior labrum is where the biceps tendon attaches * Age-related changes are extremely common and often mislabeled as “tears” 2. Why MRIs Overcall Labral Tears * Most adults over 40 will have a “SLAP tear” reported on MRI * Radiologists often describe normal age-related changes as pathology * The word tear creates anxiety and drives overtreatment * MRI findings frequently don’t correlate with symptoms 3. MRI Quality Matters More Than You Think * 3-Tesla MRIs are far more accurate than 1.5-Tesla scans for labral pathology * Contrast (arthrograms) improves detection but is invasive and often unnecessary * Fellowship-trained musculoskeletal radiologists provide more reliable reads * Not all MRIs—or interpretations—are created equal 4. When a Labral Tear Actually Matters * Rare in adults without trauma * More relevant after: * Shoulder dislocation or instability * Clear traumatic events * Clicking, catching, or mechanical symptoms alone are not enough to justify surgery 5. Why Labral Repairs in Adults Often Fail * High risk of post-operative stiffness and prolonged pain * Long recoveries with questionable benefit * Literature consistently discourages SLAP repairs in patients over age 40 6. What Surgeons Actually Do If They See a Tear * Most labral findings are ignored during surgery * Minor fraying may be gently debrided (“a haircut”) * If the biceps is truly involved and symptomatic, biceps tenodesis is preferred * True labral repair is exceedingly rare in adults 7. The Real Sources of Shoulder Pain * Subacromial bursitis * Rotator cuff tendinopathy (without a tear) * Age-related tissue changes * Many people improve without ever identifying a single structural cause 8. Why Time and Re-Examination Matter * Shoulder diagnoses often evolve * Multiple visits help clarify what actually provokes pain * Healing, physical therapy, and patience often outperform early surgery * Sometimes the pain resolves—and the “diagnosis” never matters Key Takeaways * A labral tear on MRI in adults over 40 is usually a normal finding * The likelihood that it’s causing your pain is close to zero * The likelihood that you need surgery for it is even closer to zero * MRIs should inform—not replace—clinical judgment * Treat the patient, not the picture Who This Episode Is For * Adults over 40 with shoulder pain * Anyone confused or alarmed by an MRI report * Clinicians navigating imaging-driven anxiety * Patients told they “need surgery” for a labral tear Final Word Sometimes the hardest part of being a surgeon isn’t operating—it’s knowing when restraint, patience, and experience are the better tools. This episode is a reminder that wisdom often means doing less, not more. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit howardluksmd.substack.com/subscribe [https://howardluksmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]

The Rotator Cuff: The Three Boneheads Podcast

Rotator cuff tears. MRIs. Fear. Surgery. Three words that often get tangled together—and usually in the wrong order. In this episode of The Three Boneheads, we unpack why MRI findings often matter far less than people think, how age-related “abnormalities” are frequently normal, and why pain, function, and real-life goals should drive decisions—not radiology reports. Please leave a comment. We need to know your thoughts about these podcasts. We would also like to know which topics interest you. We talk about:• Why many people with massive tears have little pain—and others with tiny ones can’t sleep• How MRIs can sometimes do more harm than good• When surgery truly changes outcomes—and when it doesn’t• Why rotator cuff care should be a conversation, not a knee-jerk reaction• How rehab, load management, and time often outperform the scalpel If you’ve ever been told, “You have a tear—you need surgery,” this episode is for you. Howard, Jeff, and Jon This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit howardluksmd.substack.com/subscribe [https://howardluksmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]

Why Some Surgeries Fail — Even When the Surgery Was Done Right

After more than 30 years in practice, one truth has become impossible to ignore: a technically successful surgery does not always lead to a successful outcome. In this episode, we unpack why “failed surgery” is often the wrong question—and why outcomes are shaped by far more than what happens in the operating room. From biology and inflammation to expectations, secondary gain, recovery, and communication, we explore why surgery should be viewed as an opportunity, not a guarantee. This is a candid, nuanced conversation about what really determines success after surgery—and how both patients and surgeons can do better. What We Cover in This Episode * When technical success ≠ patient success * How decades of surgical experience change how you view outcomes * Why many “failed surgeries” begin before the first incision * The role of: * inflammation * metabolic health * diabetes and insulin resistance * smoking, sleep, and stress * Why expectations matter as much as anatomy * How pain perception and the nervous system influence recovery * The difference between fixing structure and restoring function * Why recovery—not surgery—is where outcomes are decided * The uncomfortable truth about post-op instructions: * When patients don’t follow them * and when the instructions themselves are the problem * How prolonged inflammation can derail an otherwise good repair * Why timing matters—too early vs too late * Why surgery rarely addresses just one problem * Reframing “failure” as insight, not blame Key Takeaways * Surgery is one moment in a long biological process * Outcomes are multifactorial, not binary * Biology, expectations, preparation, and recovery all matter * Surgery creates an opportunity, not a guarantee * Better outcomes start with better conversations—before surgery This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit howardluksmd.substack.com/subscribe [https://howardluksmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]

Meniscus Tears: Podcast Episode 9

Meniscus tears are among the most common reasons people walk into an orthopedic office, and also among the most misunderstood. The word tear carries a psychological weight that often sends people straight to panic mode—and straight to a surgeon—before anyone has examined them, before we know if the tear even matters, and before they understand that many tears have nothing to do with their pain. In this episode, the three of us walk through what meniscus tears really mean, what they don’t mean, and why the overwhelming majority of these findings do not require surgery. We also get into the nuance that rarely shows up in MRI reports or quick clinic visits: degenerative tears that coexist with arthritis, meniscus findings in people with no symptoms at all, and the small subset of tears that actually compromise knee function—like bucket-handle or true radial tears. We talk about why so many people are told they “need surgery” based on imaging alone, why that approach fails patients, and how good clinical evaluation changes everything. And toward the end, we cover biologics like PRP, where they fit, and where they absolutely do not. If you or someone you know has been given an MRI report with the word "meniscus tear" highlighted, this conversation will help you understand what matters, what doesn’t, and how to make decisions that align with your symptoms. Not with fear, quick assumptions, or rushed recommendations. Key Topics Covered * Why “meniscus tear” is one of the most misleading diagnoses in orthopedicsMost tears seen on MRI—especially in people over 40—are age-related changes, not injuries and not sources of pain. * Degenerative vs. traumatic tearsHow to tell them apart clinically, why degenerative tears rarely require surgery, and why symptoms—not MRI findings—should guide decisions. * MRI pitfallsWhy imaging often overcalls pathology, why radiology language can scare patients unnecessarily, and how to interpret findings in the right clinical context. * When a meniscus tear actually mattersThe small subset that truly cause mechanical dysfunction, including: * Bucket-handle tears with loss of extension * True radial/root tears that destabilize the meniscus * Acute traumatic tears in younger athletesEverything else is typically non-operative. * Pain generators that mimic meniscus tearsIncluding early arthritis, synovitis, patellofemoral overload, and deconditioning. * Non-operative managementActivity modification, loading strategies, strengthening, neuromuscular work, and time—plus why most patients improve without surgery. * PRP and other biologicsWhere they fit, where they don’t, and what current evidence actually supports. * When surgery is reasonableClear criteria: loss of extension, true locking, mechanical block, or failure of adequate conservative care in clearly defined traumatic tears—not degenerative fraying. Takeaways * The presence of a tear on MRI does not mean it’s causing pain. * Most degenerative tears behave like wrinkles—common, expected, and not surgically correctable. * Good clinical evaluation matters far more than imaging. * Surgery is for mechanical problems, not MRI findings. * The right rehab plan resolves symptoms for most people. -Howard, Jeff, and Jon This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit howardluksmd.substack.com/subscribe [https://howardluksmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]

Episode 8: What We Would Tell Our 25 Year Old Selves About Building A Sustainable Career As A Surgeon.

The Three Boneheads sit down to answer one question: What would you tell your 25-year-old self about building a career that lasts? The answer isn’t what you’d expect. It’s not about technical skill or case volume. It’s about protecting your humanity while doing hard work for decades. It’s about the sleepless nights that never stop, the weight of worrying about every patient, and learning that you can’t pour out compassion endlessly without refilling yourself. It’s about holding onto your values when the healthcare system shifts around you, learning to listen in a way that makes people feel safe, and understanding that vulnerability isn’t weakness - it’s what keeps you human. It’s about the loneliness of practice and why you need a resource group from day one. It’s about how psychology matters more than you thought - because anxiety and depression magnify pain, and most patients need reassurance they’ll be okay. The complicated cases fade. The titles fade. What sticks are the small moments: a patient dancing because their knee works, someone serving at tennis because you fixed their shoulder, a family who felt heard. A sustainable career isn’t about being invincible. It’s far more than that. Show Notes: This is a podcast episode from “Three Boneheads” - three orthopedic surgeons (Howard Luks, Jeffrey Berg, and Jonathan Hirsch) with 75+ years combined experience discussing what they’d tell their younger selves about building a sustainable career in surgery. Central Theme: Success in orthopedic surgery isn’t about volume, speed, or accolades - it’s about sustainability, maintaining humanity, and protecting what matters while doing hard work for decades. Key Insights from Jeff Berg: Loneliness of Practice * Training is collaborative, but practice is isolating - everything falls on you alone * Early advice: Build a resource group of trusted colleagues immediately * This group becomes essential for support throughout your career Psychology Matters More Than Expected * Initially, I thought orthopedics was “anti-psychology.” * Reality: interpersonal relationships are crucial - doctor-patient, doctor-family dynamics * Anxiety and depression are pain magnifiers - understanding psychology is essential for treating orthopedic patients * Many patients just need reassurance that they’ll be okay Sleepless Nights Never End * Expected during training, but persists throughout the career * Constant worry about patients, questioning decisions, self-blame when outcomes aren’t perfect * Patients don’t realize how much surgeons worry about them The Job is Hard - Don’t Be Hard on Yourself * Bad outcomes happen despite your best efforts * Self-compassion is essential for longevity in the field Key Message from Howard Luks: You Can’t Pour Endlessly Without Refilling * Protect patients, but protect yourself too * Can’t absorb everyone’s fear and expectations without boundaries * Serve patients best when you’re steady, rested, and supported - not carrying the world alone Values Are Your Compass * Hospitals, administrators, chiefs change - your values must stay constant * Hold onto them when efficiency crowds out empathy, when paperwork overwhelms purpose * The healthcare landscape is complex and evolving, but values keep you from losing your way Listen in a Way That Makes People Feel Safe * At 25, you think being a good doctor is about knowing things * What patients remember decades later: whether they felt heard, seen, understood * Listening is the most powerful (and cheapest) intervention - but most straightforward to forget when busy Vulnerability Isn’t Weakness * You’re allowed to be human, say “I don’t know, but I’ll find out,” and ask for help. * Trying to be invulnerable makes you brittle; staying human keeps you flexible and connecte.d Identity Beyond the Job * When you die, no one cares about titles, papers published, or patient volume. * They care about how you made them feel. * Build life outside hospital walls: relationships, interests, physical health, purpose, play. * You’re a person who practices medicine, not just a clinician Burnout is System Failure, Not Personal Weakness * You can love medicine and feel drained by how it’s delivered * Burnout isn’t about resilience - it’s about unreasonable load * Recognize early signs, don’t ignore them out of pride Small Moments Matter Most * Complicated cases fade; even successes fade quickly * What sticks: patients dancing because their knee works, seeing someone serve at tennis, a smile from reassurance * Don’t always need the answer, but always need to be there Purpose Over Prestige * Titles and accolades fade; purpose doesn’t * Never regret doing the right thing, making a patient feel safe, defending a colleague. * Will absolutely regret bending values to fit someone else’s priorities You Get to Write the Story * At 25, the path looks fixed - it’s not * Can pivot, slow down, speed up, redefine success, walk away from what doesn’t align * Meaningful career isn’t found - it’s actively, passionately crafted Final Message: A promising career is built with intention. Patients don’t need a perfect doctor - they need an honest one. The people you help and the values you hold matter far more than accolades. If you take care of yourself along the way, you’ll still love this work decades later. Bottom Line: This is about sustainable humanity in a profession that can hollow you out if you let it. Technical skill matters, but protecting your humanity, building community, setting boundaries, and staying anchored in purpose are what allow you to thrive for 25+ years. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit howardluksmd.substack.com/subscribe [https://howardluksmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_2]