All right, let's go ahead and get started. If you see your colleagues come in, just push them forward, because these screens are smaller, so it may be difficult to see some of the nuanced imaging with ultrasound. So my name is Yusuf Saeed, I'm an assistant professor at the Uniformed Services University in both PM&R and family medicine. I am also the director of surgery for the VA in Texas Coastal Bend. I don't have any pertinent disclosures, this is just an educational talk. I will just state that my work, I do do this work in my practice, and so I am clinically based. So when it comes to posterior thigh pathology, so pain in the butt, what we're talking about is primarily hip pathology, but as you all know or may not know, when people present with painful posterior thigh complaints, you can also have referred pain from lots of various anatomic issues, and whether it's facet joint arthropathy, spondyloarthropathy that you see with ankylosing spondylitis, you can also have degenerative disc disease. So I'm just going to go over some of those referred pain in the lumbar spine before we head down and discuss the posterior thigh. So the facet joints, they're made up of two articulations. As you know, you have multiple facet joints that go up and down your cervical, thoracic, and lumbar spine. They consist of the inferior articulating process and the superior articulating process. When they come together, they form an apophysial joint, a joint that's full of synovial fluid, just like the knee joint is, and they can also have capsular tears, just like you would see in a severe injury to the knee. So when you have capsular disease, once the capsule is ruptured and torn, inflammatory mediators enter those joints, and that's how you develop degenerative joint disease, and that's the case with every joint in the body, usually. So you can have impactful joint disease from repetitive trauma. You can have one event that tears the capsule and creates trauma. I see tippitus, spear combat controllers, green berets, army rangers in my practice, and so my patient population is the 30- to 50-year-olds that all present with low back pain because it's facet joint-mediated back pain. So a couple of things that I want to point out when it relates to the facet joints. This is the referral pattern, and so people don't realize this. The referred pattern of facet joint disease is posterior thigh, anterior thigh. It can radiate down the leg at times, and so being a very good clinician helps you to identify the pathology that many of these etiologies cross together and mingle. Some people have complex disease where it's not just one issue, right? Many times people have degenerative disc disease as well as facet joint arthropathy, and it's very difficult to treat those patients. So you use a stepwise approach and try to address each issue, and then finally you can restore some functionality, and we're going to talk about some of the evidence behind these interventions in a few minutes. So the facet joint is innervated by the medial branch nerve. So each nerve root supplies the joint from a superior medial branch and an inferior medial branch nerve, and so when we address facet joint pain, what we're trying to do is isolate the joint. So as an interventionalist, I have to intervene at two levels for me to affect one joint. Does that make sense? And oftentimes, as we all know, the most common site of facet joint disease is between the L3 facet joints to S1, and so again, remember those referral patterns that I just talked about. So there are many ways to evaluate the facet joints and determine if the facet joint is really the issue when it comes to these facet joint arthritis and facet joint pain, facet joint-mediated pain. The easiest way that I do it clinically, you know, you can do several maneuvers. It's a very easy maneuver. It's not just palpation. All you have to do is extend the back and rotate, do a lateral rotation. What you're doing is you're loading that joint, and so when you load the joint, people always complain of pain, right? Oh, that hurts me, that hurts me, but you tell the patient, take one finger and point to where your pain is, and generally, when they're extended and rotated, they'll take their finger and they'll point to either the L4, 5, or 5S1 joints. Sometimes they will point lower, and that may be SI joint-mediated as well, and we're going to talk about that. So the one-finger trick is probably the best clinical pearl I can give you today. One other thing I want to mention as it relates to facet joints and medial branches, the way that you're able to diagnose facet joint medial branch issues is by simply doing a medial branch block. So the way that it's done from the academic literature, this isn't from, you know, people in practice and communities, is that the transverse process, as you can see in this, the medial branch nerve lives on the L of the transverse process, okay? So the medial branch nerve, when it comes off the nerve root, it goes over the transverse process and then the inferior articular process below it. So we know that the medial branch nerve lives in 94% of patients at that level. We take a needle and we simply just go right to where that medial branch nerve lives and put 0.2 to 0.3 cc's of whatever anesthetic of choice you'd like, bupivacaine, lidocaine, et cetera, et cetera. And we check the patients afterwards. And so in order for you to qualify for facet joint radiofrequency ablation or a denervation of that medial branch nerve, you have to have pain relief from the medial branch block. What happens in community practice is not the way it's described in the academic literature. The way that we should be doing that is we bring the patients in, we do our procedure, we evaluate them, of course, prior to the procedure and confirm that our suspicion is facet joint mediated back pain. And then after the procedure, we reassess them. Unfortunately, that doesn't happen in most cases. And so that brings our sensitivity and specificity of the medial branch block down. What I do with my patients is I do the block, they come off the table, and then I facet joint load them again. I ask them to do the things that normally cause their pain. Does their pain occur when they squat? Does it occur when they're in that rotation or extension? And when I have a block that is completely diagnostic, i.e., I have taken care of 100% of their pain, they have no more back pain, that's very conclusive that their primary pathology is facet joint mediated and they're good candidates for radiofrequency ablation. So the other etiology that we have to consider when it comes to spine disorders is the discs. So obviously, you know, I've given lots of low back talks within ACOM. You're free to watch those as webinars. The discs, as we age, become less hydrated, and as they become more and more dehydrated, they're prone to tears in both the annulus and the nucleus pulposus will herniate out. That herniation can cause radicular symptoms, which may match the posterior thigh pain, or patients can have discogenic pain just from simply the tear. We know that when the annulus tears, the body tries to recover that fibrous tissue by bringing new vessels to the tear to try to heal that disc. Unfortunately, as we age, that pathway is very elusive in many of our patients that go on to chronic disc-related pain. And so what we do is we can do procedures into the disc to try to denervate them. We can try to wash out the discs and remove some of the inflammation with an epidural injection. But most oftentimes, if it's disc-related pain, and they have a herniation or even without a herniation, those patients are not very receptive to interventional treatment. They may have to go to fusion surgery if their pain causes them to be non-functional. Okay? So as you know, the discs take multiple forces in lots of different ways, which predisposes it to disc herniation the older we get. So this is the dermatomal referral pattern. I know there's some young clinicians in the room, so I always like to cover some of the basic clinical material first. So one thing you should know when it comes to disc herniations, always do a pain and temperature, right? A pinprick across the dermatomes. That will help you isolate the nerve root that you suspect the lesion is in. So a patient with degenerative disc disease, with a disc herniation, and with the herniation is to the side and compressing the nerve root, you should simply break, you can break your tongue depressor and use it as sharp. Now remember, when you're doing your pain sensitivity scale, the dull side is not sensitive. It's only the sharp side. So the dull side is only a distractor, right? It's always the sharp side. You want them to feel pain, okay? When it comes to physical exam now, now we're talking about posterior thigh. So we've left the lumbar spine. Now let's talk about the posterior hip. I like to talk about landmarks when I teach residents and fellows. And so when you palpate somebody's iliac crest, right, the very top of the hips, that is the L4-5 level. Usually the dimples in the posterior thigh, that is the posterior superior iliac spine. And so those are your major landmarks. When patients have pain and you've now facet loaded them, you're going to do some testing on the SI joints. If you palpate the posterior superior iliac spine and the pain is above the PSIS, you should consider facet joint pain. If you palpate the PSIS and the pain is below the PSIS, it may mean SI joint issues. And we're going to talk about SI joint. There's been some confusion in lots of the literature as it relates to SI joint dysfunction. Typically you see SI joint dysfunction from ankylosing spondyloarthropathies, but you also see it in plain run-of-the-mill degenerative joint disease. And we're going to talk about why that is. So here are your SI joint assessment techniques. On the top right is sacral compression. So what you're trying to do is grab the wings of the iliac crest and compress them in an oblique fashion to allow you to compress the sacrum and the iliac bones together. And if that reproduces pain below the PSIS, then that's a positive test. So remember, the pain has to be reproduced at the site of the anatomic deficiency that you feel you're evaluating. Many people perform a Faber's test and they don't really know how to perform the Patrick's or the Faber's test. So I'll quickly just teach you how to do that. You'd cross the foot over the contralateral knee. You want to stabilize the hip. So on the contralateral hip that is not flexed, you push down on the hip so it doesn't roll up when you're pushing down on the knee. So again, what you're trying to do is force closure in the SI joint. And so a positive test, many patients will say, oh, that hurts when you do that. Where does it hurt you? Does it hurt you below the PSIS or above the PSIS? Remember, it's only a positive test if they reproduce the pain either ipsilateral or contralateral. The other issue that I just want to briefly mention on the Faber's test, it also evaluates hip pathology. And the way that it evaluates hip pathology is when you're performing that Faber's test and the leg is crossed, if the patient has pain on the anterior thigh, what have you done? You've externally rotated the hip out. What you've forced into compression is the femoral head into the acetabulum. And so when you externally rotate, you're turning that femoral head into the acetabulum, which can generate pain. But the pain is in the front of the hip. Then you should start considering anterior hip pathology. Get an x-ray. See if there's a cam deformity. Then you can go on. And if the pain continues on and on, consider MRI for possible labral tear. All right. So this is just an outline of the SI joint provocation testing. You can look those up. They're freely available on Google. I won't go through them today because we have a lot to talk about. So now let's get to some of the academic science on SI joint disorders. So the SI joint is a really stable platform. It only has two degrees of motion in three planes, though. And because it has lots of motion in lots of different planes, it predisposes it to injury. So the platform itself can take the longitudinal force across the spine. It can also take the torsional force, the force across the body when you twist in other directions. It's unique because it's limited, but it's also very complex. And there's no muscles that actually impart movement to the SI joint. It doesn't have an origin or insertion that allows you to ambulate, for instance. But if you consider some of the torsional forces on a solid bony pelvis during gait, we can talk about that. When your left leg is in swing, in the swing phase of your gait, your hamstring tendons, so the semimembranosus and the semitendinosus, will draw the ischium forward. The left hemipelvis rotates clockwise. The right leg extension now while you're in gait, the iliofemoral ligament draws the anterior ilium forward, and the hemipelvis rotates in the other direction. So what does that do? Well, when it comes to sacral insufficiency fractures, our colleagues in radiology have mapped out the transmission of forces, and guess where they are? At the SI joint. This study was done as a nuclear study out of Mayo Clinic, and they solved the finite element of the sacral endpoints with this modeling. And so now when you consider that, that stress relief really requires a dynamic joint complex. And it's really made unique by all of the ligamentous insertions around it posteriorly, and it has a formed closure anteriorly. So that formed closure anteriorly is both made up by the bones of the ischial bones and the abdominal wall musculature. Let's see what that looks like. And so that's primarily what it looks like. If you look at that, that's a sagittal view of the sacrum and the iliac bones. Here's how you get that formed closure, and then the soft tissue helps to force it closed. So this is what it looks like. It's a wedge in two planes primarily. And so this is an oblique MRI to really show you what that looks like in imaging. So, you can imagine as those forces are translated from the lower extremity and from the lumbar spine across that joint, and it's feeling forces in different directions, it's very easy for that joint to become dysfunctional and impaired. So, this is what it looks like in terms of the anterior abdominal wall. This is by Willard, and what he wanted to just show anatomically was, well, how does the SI joint work in a clinically meaningful way? And so, this is really how it works. There's really nothing bony in the anterior abdomen that allows that joint to stay rigid. And so, because of that issue in the SI joint, what we've seen in women who are 70 years and 80 years old, they often will present with sacral insufficiency fractures. Those fractures are dynamically caused by their osteoporosis, the osteopenia, but they have those fractures because of the load on the SI joint. And so, that's where I wanted to go with that. Now, when we talk about SI joint injections, there's lots of good ways to do them. There's lots of bad ways to do them. What we found in the interventional spine community is, whether you do it fluoroscopically, whether you do it by ultrasound, it really doesn't matter. We get the same outcomes. The issue is, we have been debating this within our community for probably 10 years, whether a periarticular injection is better than an intraarticular injection. In some cases, people with spondyloarthropathy or very degenerative SI joints, it's very difficult to get into the joint. And so, if you can't get into the joint, what do most clinicians do? They just inject anyway, and that's just the practice. Now, when we compared people that inject intraarticularly versus periarticularly, their outcomes are the same. And so, we have long also debated, is this a neuropathic feature of a bone disease? I.e., is the reason the periarticular injections work just as well as intraarticular, is this a nerve disease? Is this a neuropathy? So, the S1, S2, S3 nerve roots come out of the sacrum. They go around into the pelvis. They send off branches, those sacral nerve roots send off branches that innervate the SI joint. So, when we inject periarticularly, perhaps we are removing the inflammation from the sacral complex nerves that innervate the joint. You can do an injection both diagnostically and therapeutically. And you can do it under fluoroscopy, you can do it under ultrasound guidance. So, ultrasound guidance, you can do right in the office. All you need is a 22-gauge needle, a long needle, maybe even longer needle if the patient's obese. Ultrasound makes it a little bit more difficult when the patient is obese. If you have a lot of sub-Q between the skin and the glute max and glute med, it's gonna be very difficult for you to visualize the needle tip as you go down. And so, in those patients, I would probably recommend fluoroscopy. So, this is what it looks like, though. This is the joint as it comes from medial to lateral. And so, on the medial side, the sacrum is a little bit higher. On the lateral side, it's a little bit lower. And so, under ultrasound guidance, you always really wanna come from the lateral to medial approach. In this instance, that's what I have done with the arrow. The nice thing about ultrasound is, when you're injecting these joints, you can look for periarticular vasculature, which allows you to be more safe when you're injecting. So, as you can see, there's a vessel right in the joint in the approach that I was gonna take. And so, I would stop the procedure at this point because you don't want to inject intravascularly. And that's the advantage of ultrasound over fluoroscopy. And fluoroscopy, you're not really able to see that unless you use contrast, of course. So, now, let's talk about the science, the accuracy. So, the Deleuze and Clouser articles really confirmed, and these were ultrasound-guided procedures, and then we took those patients back and confirmed them under fluoroscopy to ensure that the injectate was where it was supposed to be. So, the accuracy of SI joint injections with ultrasound is very high. Now, when you compare ultrasound to fluoroscopy, there's where a little bit of a difference exists. So, the Gee and Sinegi articles did a comparison by interventional approaches, and fluoroscopy did a little bit better than ultrasound in terms of comparative techniques. The outcomes, though, are the same. And so, that's what I want you to take home. When we talk about functional outcomes, that's really what we're looking for. We're looking for people to go back to work and back to play. And so, the ODIs were the same between both groups, the ultrasound group and the fluoroscopically-guided group. We're gonna move on from the SI joint to the piriformis now. So, the piriformis syndrome was originally described by Yeoman in 1928 as a periarthritis. And the reason it's called a periarthritis is it's pain around the joints, right? And so, it can mimic, and this is the critical issue here, is that it can mimic radicular pain. So, oftentimes on examination, when we're performing some of our provocative maneuvers, and remember, there's not one physical exam that you can do that is sensitive and specific, but when you have a confluence of physical exam findings that are provocative for that one disease, it improves your precision in your examination. So, there's multiple examinations for SI joint as well as for piriformis syndrome. So, the origin of the piriformis muscle is at the sacrum, and it inserts onto the lateral hip. So, it starts here. I'll try to stand in the middle. It starts here, and then it comes out and attaches to the greater trochanter. And as its origination and its insertion onto the hip, when that muscle activates, what it does is it pulls the hip into external rotation. Okay? So, piriformis syndrome as a neuropathic feature or a nerve entrapment feature has been described as well. Oftentimes, there are split piriformis that are just an anatomic variance, but it also causes disabling pain. And so, imagine if your piriformis muscle was split between the sciatic nerve and you activated your hip into external rotation. Well, that muscle is gonna compress the sciatic nerve. That's how you get that neuropathic radicular feeling. And then when you go back into internal rotation, the pain gets a little bit better. So, that's another exam maneuver that you can use as a little bit of a pearl for you. There are secondary disease pathologies that cause piriformis syndrome. The most notorious is wallet neuritis. So, men, if you have a wallet like me, which is very ridiculous, I could be suffering from wallet neuritis. So, I always tell my patients, if they're suffering from piriformis syndrome, take the wallet out of your back pocket, put it in your front pocket, or get rid of all the receipts. So, you know, macrotrauma, wallet neuritis, there's also microtrauma. So, as you go into internal, external rotation repeatedly, we see this in our athletic population, and certainly in our DOD population, especially those tip-of-the-spear operators. Those particular people that have, they're rucking eight miles a day, you know, they're doing squats to stay in shape, et cetera, et cetera. Those are primarily posterior thigh pathology that's secondary to piriformis issues. So, what are the symptoms? It's generally it's buttocks pain. Sometimes you can get pain in the, not just the posterior thigh, but it will radiate down the leg. How do you differentiate between radiculopathy and just piriformis syndrome? The way to do it is do a straight leg raise. Usually the pain does not go down past the knee. It will stop above the knee if it's piriformis syndrome. So, just a little clinical parole there. And obviously, for all your patients, you should be evaluating their gait, make sure their stance phase is normal, make sure they don't have a Trendelenburg to the opposite side, check their leg length. Oftentimes, if the sacrum has a pelvic tilt to it, it can destabilize the forces across the joint. So, the examination. The examination is fairly simple. There's tenderness with palpation. I usually take my thumb and I compress it at the origin and insertion right in the middle of the piriformis muscle, because what I'm trying to do is replicate the symptoms. And so, the other ways to do that is, are these next slides. You do the straight leg raise or the LeSage maneuver. You do a Freiberg's provocative test where you're taking the foot on the ipsilateral side that you're having pain in. And what you're trying to do is take that leg and make sure the hips are stabilized. I hope everybody can see me. And then you're forcing that knee to the contralateral side. And so, what that does is, it compresses the piriformis muscle against the sciatic nerve. And if they say, oh, that hurts, where does it hurt at? It hurts right in my butt. That's the provocative test. All right. And the release test is when you just compress the piriformis muscle itself. All right. So, when we look at the literature and we compare ultrasound to fluoroscopic guided procedures, fortunately, what we found in this particular case, which is true in most soft tissue cases, is that ultrasound performs better than fluoroscopy. And so, guess how I do my procedures. I don't use fluoroscopy anymore because it's not really sensitive or specific for piriformis syndrome. You know, you're maybe injecting the glute medius because you're not deep enough, or maybe you've gone too deep and passed the piriformis tendon sheath. The other reason to use ultrasound over fluoroscopy is, now, the literature shows us that there is toxicity both to the tenosite and the chondrocyte from our injectate. And so, we have to be very careful and conservative and make sure that when we're delivering our injectate, we're delivering it external to the tendon sheath so that we don't cause tendon rupture. So, only 30% of fluoroscopically guided injections were accurate in the piriformis tendon sheath, versus 95% using ultrasound. So, how do you do it? You need a curvilinear probe, you need a spinal needle, you need some lidocaine, bupivacaine, if you like, for anesthetic, and then you need some steroid. I tend to use triamcinolone for my injections. I use 40 milligrams of triamcinolone. I feel like in my soft tissue injections, tendon sheath injections, the triamcinolone, the particulate steroid, actually does better for my patients. The nice thing about piriformis syndrome, you can not use triamcinolone, you can not use the steroid, just to do a diagnostic block of the tendon sheath and see if their pain goes away. That's the advantage of doing these procedures, is you know right away, right after that patient gets off the table, and you deliver just a small amount of lidocaine, so you've only done a tendon sheath injection at the level of the piriformis muscle, you haven't worked up the lumbar spine, and it helps your diagnostic acumen and be able to treat these patients better. Now, if under ultrasound, you observe that split tear, there is nothing that an injection that is gonna help that. That patient will be back in your office in a few months with repeat pain, because it's an anatomic deficiency. So this is what it looks like under ultrasound. For those of you in the back, you may wanna come to the front, because some of these slides are hard to see, because we're talking about ultrasound radiology images. So the way that I start my injection technique, first I look for the PSIS, that's my landmark, it's the bony structure, very high, and then I'll scan down the hip until I see the sciatic notch. Once I see the sciatic notch, and I see the sciatic nerve, those are the white arrows, then I've identified where the piriformis muscle originates. That is not where I inject, or else the patients won't be able to walk when they leave your office. And so, sometimes that does happen. So sometimes the injectate will leak towards the sciatic nerve, and they'll be numb down the leg for about six hours until the injectate wears off. So just make sure they have a driver if you're injecting their right leg. Again, the advantage of ultrasound to fluoroscopy is you can see the vascular bundles, so it allows your approach to be much safer than any other approach. Because I turn the vascular feature on with ultrasound, every time I do an injection, I know that I'm not doing an intravascular injection. So I've shown you the glute max is above the piriformis muscle. You can see how the piriformis muscle curves out from the sacrum as it moves towards the greater trochanter here. Those are the white arrows. And again, on that top figure on the top right, that is the sciatic nerve, so you want to avoid that. And now I've moved laterally, and so you can see how far out I am on the hip, sorry about that, on the hip with the transducer. When I'm injecting, I generally, you can see the needle path. I'm going from, I'm going on this, if you look at this screen, I'm going from lateral to medial, okay? Sciatic nerve is over here, piriformis muscle, and it opens wide as it has that tendinous insertion into the greater troch, and there's the ilium. And you can see here, this fluid is actually the hypoechoic fluid that I've just injected to surround the tendon sheath. So that hypoechoic simply means dark in ultrasound terms. Hyperechoic is bright in ultrasound terms, okay? And you can see the glute max and meat are just above it superficially. So, again, critical structure to watch out for is the sciatic nerve. Quadratus femoris is just deep to the sciatic nerve. Piriformis muscle originates right at the level of the sciatic nerve and moves laterally in its insertion. So now I want to show you a medial to lateral approach. Here's my needle. Here's the tip of the needle. Again, here's the sciatic nerve that you want to be careful of. Remember that sacrum is a little bit higher than on the ilium side. And I've delivered my injectate around the tendon sheath. You never want to inject the tendon itself. So here you can see the fluid both surrounding the piriformis muscle laterally and superiorly superficially as well. Can we play this video, please? So this is what it looks like in real time. So I am doing that lateral to medial approach. Can you play it one more time? My needle tip is right at the tendon sheath. The piriformis muscle is hypoechoic at that point. And then I can deliver my injectate directly into the tendon sheath. Very easy to do, takes about a minute. So the treatments for piriformis syndrome. Obviously you can do a steroid injection. For our patients that are refractory to normal care like PT, steroid injection. You can do regenerative medicine techniques by a tenotomy. Oh, sorry, I didn't know what that was, sorry. That's all right. And so you can do regenerative medicine techniques like PRP, bone marrow aspirate. Some people will do some needling, a tenotomy, if it's chronic in nature, to try to restart the healing cascade. You can also, for those patients that have the split piriformis muscle with side nerve compression, then obviously a surgical release may be indicated in those cases. All right. Our last topic today is ischial bursitis. So ischial bursitis was described in many ways, and I kind of showed you what the anatomy looks like here on the left bottom. It's the semimembranosus and semitendinosus, the hamstring tendon, come together to insert on the ischial tubercle here inferiorly. The ischial bursa resides right above it as the glute max and medius are over it superiorly. And so bursa are just simple fluid-filled pockets that allow tendons to slide over each other. You can call something a bursopathy when you have 1 1⁄2 centimeters of fluid within that bursa and you've measured it under ultrasound. The pathology can be multifaceted, though. And so we often see this in our performance athletes, so people that are really activating their hip extensors, running athletes, as well as people that are doing a lot of thigh flexion. So any of your employees that constantly have to go to the ground, pick things up, and lift, their pain in their bottom is right at the very bottom of the bone. You can palpate your own ischial tubercle and you can feel where the hamstring muscle inserts into that ischial tubercle. So how do we determine what is ischial bursitis, what is semimembranosus tendinosis or semitendinosus tendinitis? There's lots of ways to do that and it's primarily, you wanna put the patient into hip flexion and you wanna accurately diagnose where they're having pain. So now they're in thigh flexion, they're on the table, they're turned, and they're in thigh flexion. You know, the hamstring muscles are fairly loose at this point, when the hamstring is the tightest is when it's in extension. You can grab the hamstring muscles when the patient is prone like that and they will jump off the table and they'll say, oh my God, you found it. You can compress the semimembranosus and semitendinosus against the ischial tubercle and also see if their pain is localized there. Easiest way to diagnose it. So when we do the injections, the way that I like to do these injections for people that are refractory to hip stabilization program. So remember, the first thing you should be doing as clinicians is entering your patients into a hip stabilization program. For people that you suspect have tendinopathy or tendinosis or inflammation in the tendons, you should be performing an eccentric strengthening program. So remember, eccentrics is when you both lengthen and you compress the tendon together, right? And so, or concentrically close the tendon. And so, an example of that for rotator cuff issues would be simply carrying a milk jug and doing slow circles with the milk jug and then expanding the circle so you're lengthening the rotator cuff tendons and you're activating the muscles at the same time because you're holding a load and activating the muscles in concentric circles. So those are, eccentrics are the primary tool for functional rehab that our physical therapists can use for problems with tendons, okay? So, if they're refractory to physical therapy, now you wanna try to perform an intervention to try to help your patients, the best way to do it is under ultrasound guidance. The way that I like to perform these procedures is I have the patients with their thighs flexed. What that does is, when the thigh is flexed, it moves the sciatic nerve. So the sciatic nerve is coming down the leg, down the thigh. When I flex the patient, it moves the sciatic nerve about a centimeter laterally out of the path of my needle. And so, that's the way I like to do my procedures. I use, again, a 22-gauge, 3 1⁄2-inch spinal needle because it can be very deep and you don't expect it to be as deep as it is and you just wanna have the ability to go farther under ultrasound if your depth isn't as steep. So, here I am in cross-section and so I'm on cross-section to the hamstring tendon at its insertion. The sciatic nerve is here. My needle approaches here and you can see glute med is just above it and then glute max above it. Okay, so the ischium, that's bone, it's dark. Sound wave doesn't penetrate bone, right? And then there's the skin in blue. And I'm just showing you the differentiation between glute med and glute max. Okay? So, in blue is the insertion of the hamstring tendon right on top, right before. So, this is normal sonoanatomy. This is not pathology. But right at the glute med and the hamstring tendon, that's the ischial bursa. Okay, well, I'll show you some examples of what it looks like when it's pathologic. So, there it is in blue. Okay? So, now I flipped into long axis. So, now I'm scanning across the semimembranosus and semitendinosus tendon. And I wanna show you how these tendons become chronically neovascularized. So, you can see when I turn my power doppler on, you lose the resolution in the ultrasound because you're trying to pick up some of the blood vessels. But within the tendon at the insertion, you can see these new vessels that have been created because the body is trying to heal this. Sometimes that healing goes into chronicity. And when that occurs, the pain just continues. So, you have to do something to restart the healing process. It can be a steroid injection. It can be a regenerative medicine procedure. It could be a tenotomy. Any of those procedures help to restart the healing cascade to allow patients to get better. And so, if any of you have been to any of my other talks, well, sometimes in these patients, if they're acute athletes, what I'll do is I'll take my needle and I'll de-hiss the neovascularization across the tendon. So, I'll take my needle and I'll drag it across the tendon to disrupt this vascularity. And patients get better. You have to be careful with them, though, and not return them to play or to work very quickly because the risk is tendon rupture after you do these types of procedures. Okay, so now, let's go back to the anatomy. As everything in the body, whenever you have an insertion of a tendon into a bone, there's always a facet. So, even in the ischial tubercle, you can see the bone squares off and allow the insertion of the semimembranosus and the semitendinosus into the ischial tubercle. So, again, sciatic nerve here. Make sure if you move that patient into thigh flexion, the nerve moves laterally, one centimeter. Allows you for a safer injection. So, that's what it looks like when you have an ischial bursitis. So, this is a loculated. Actually, Dr. Gandicota published this article. This is a loculated bursa. And you can see how large it is and how painful that would be. Remember, your sciatic nerve is hanging out right here. All that soft tissue is disrupted and compressing the nervous system peripherally, okay? So, bring your needle in laterally. You can drain this bursa. The patients do great afterwards. So, this is what it looks like when I do my injections. I'm coming from lateral to medial, right? I put that patient in the thigh flexion so that sciatic nerve is moved laterally to the left. Here is the hamstring tendon, the conjoined tendon as it inserts into the ischial tubercle and my needle tip is right at the bursa. So, this is what it looks like in different formats. On MR, this is the same view. And the nice thing about this, if you look at between ultrasound and MR for the soft tissue structures, they're the same, right? You can still make out all of the features that you see under MR. So, remember, ultrasound and MR are equivalent. They're equivalent imaging modalities for things that are external to joints. So, if you wanna look at labral disease, you know, shoulders, hips, the imaging preference is MRI, okay? For soft tissue, if you're looking for soft tissue pathology. Rotator cuff, you can image very well under ultrasound, any of these external hip structures as well. So, this is what it looks like under fluoroscopy. Again, the same issue that you have, you have no idea where that injection is, right? Because you've lost the depth, you can't visualize the needle. You could be injecting into glute max, you could be injecting the hamstring, no idea, okay? All right, so, just again, and just in consideration to safety, it's always better to move that patient into hip flexion because it pulls that sciatic nerve 13 and a half centimeters away from the issue of tuberosity. So, in conclusion, as we know, ultrasound is a fantastic modality. It allows you to both diagnose pathology, it allows you to perform all of your interventions very accurately. You know, ACOM is, what we're hoping to do is to have hands-on workshops so you all can learn the tools in your hands so you can practice what I'm preaching. So you can practice what I'm preaching. But for the feedback, I need all of you to make sure that you write in your comments, we need hands-on courses in ultrasound because that's very important. That's how we get you the education that you need now. And as a section, the Pain and MSK section, who's kind of sponsored these talks, we really also need our membership to join the section and start contributing, asking questions, starting a discourse within the section, and that way we can advocate for better educational material as the years go on for you, okay? I'm happy to take questions. One last thing, don't forget your active resumption of your ADLs, right? You want people to go back to work, go back to play very quickly. So even if you identify the structures that are pathologic, make sure you put them into a rehab program with your physical therapist. If it's tendinopathy and you suspect tendinopathy, make sure you're applying eccentrics to that strengthening program. All right, do you have any questions? Happy to take them. That's it. Can we get the lights on, please? From a practice and legal perspective, for those of us who are interested in MSK medicine, is it reasonable from that kind of medical legal perspective to believe that we could be adequately trained to do these procedures? Has that been studied, in other words, and kind of verified? Excellent question. So I have this discussion many times with many of my colleagues. So remember, we're all licensed to practice medicine, whatever state that we're licensed in. The question is, are you credentialed to do it in your home institution? And some institutions say, yeah, it's okay, as long as you have a record of how many diagnostic exams you've done or interventions that you've performed will credential you based on your caseload. And so my recommendation is, if you start doing them mentored as you're learning, keep a logbook. And so every single one that you do, identifiers, what you did that day, not necessarily patient names, but at least a way to find that record if somebody ever asks. So credentialing is one aspect. Let's say that you have a complication, and that's, from the medical legal side, that's the issue, right? So you have a complication. Have I been certified to do this? So remember, credentialing is one thing. Certification is a whole nother thing. So there are pathways for occupational medicine physicians to be certified now. The Alliance for Physician Certification and Advancement, which is a split off from the American College of Radiology, you have to do 200 diagnostic exams and I think five interventions in order to sit for the RMSK certification. Now, I think that each specialty association nowadays are credentialing or certifying their physicians. So AAPMR has an ultrasound course and they self-certify their specialists within the academy. That is something that we may want to consider as an organization, creating something like that. Great question. I'm a, I wanna, I have a disclaimer. I'm a neurosurgeon with a interest in causation. I have two comments and one question. My first is thank you for a truly exceptional lecture. Thank you. You have. Thank you so much. You have restored my faith in injections of the pelvis in conscience's hands. Two is thank you for pointing out that the sacral examination is not a positive Fortin finger test. And that the essentially six examinations, physical examinations for sacroiliac instability can be found either in the Hoppenfield book or on YouTube. Absolutely. And my third is a question. It gets back to Bradford Hill criteria. And at the end of that paper, Dr. Bradford Hill actually commented on the social responsibility of epidemiologists. And I would like some comments from you on sacroiliac stabilization, the surgical process. Yeah. So from the evidence that I've read about sacroiliac joint stabilization surgery. So when you put a particular type of screws through the sacrum and the iliac bone, is that what you're referring to? Yeah. Those, the outcomes are mixed from what I've read. And so I tend never to send anybody for SI joint fusion I would much rather try lots of other things that may be available before we get to that point. And so, and that's true for many, many forms of surgery. We try in kind of in a stratified way, can we intervene with low risk, then medium risk, then higher risk procedures? So does that answer your question? I'll make a comment again, sorry. On the Hill criteria, the studies on sacroiliac stabilization are almost uniformly performed by industry. And very rarely have a blinded section. So those studies do not meet Hill criteria for evidence. Great, thank you. Hey Yusuf, thank you for the presentation. Sure. Just going back to one of the points that you made when you were talking about disrupting the tendon and the recovery, I was hoping you could just comment a little bit longer or a little bit more on just time you take someone out of doing physical activity those types of things to prevent that type of thing, right? Good question. So I never take anybody away from work unless they're an athlete, right? so their job is to Use muscles and so what I'll try to do is obviously you want to modify the body part so that you're not having a load that could cause a A bigger complication than what you intended, right? And so obviously there's a risk to everything that we do Needle tenotomy is one of those procedures that is very low You know, it's at the very bottom of the things that I do first, right? And so physical therapy Steroid injection You know, maybe tenotomy maybe You know needle dehiscence technique what I generally do is I limit that body part for three to six weeks after the procedure and then I have my Physical therapist begin to work with them and start to stabilize that area and see how they do and in a Fashion that's directed by a provider. And so usually that graded recovery Period takes about another six weeks until then until I can return them to full function. Good question very nuanced question Good a lot of great information in a complicated area, obviously With all the ultrasound that you're doing. I've done some reading in the area of the hip bursitis versus sort of the tendinopathy and Some of the literature seems to point to the fact that maybe the tendinopathy Precedes the bursitis. Is that what you're seeing? And then I guess, you know follow up with that I'm a physical therapist. I've seen a number of people So thanks for using the ultrasound who like get the hip injection into the bursa And then they feel better for a while and they get another one and then they come in with what I call a drop leg Syndrome where you literally lift their leg up in the air and they can't hold it as if their glute tendon is just Completely ruptured. Yeah, they usually present with back pain due to their gait But so the interplay between the the tendinopathy and the bursitis, I think is my answer. Yeah, that's a that's a great question You know, I don't know if we've been able to pinpoint that clinically yet, but that is the clinical suspicion that perhaps it's the Tendinopathy that causes the bursopathy Obviously for people that have septic disease if they have an infection that is its own issue, right and so I wouldn't associate a tendinopathy with a Septic bursopathy good question though. Can you make a comment on the SI proloquy therapy versus? Using which is something I'm not sure of efficacy called laser Yeah, not a lot of evidence on on laser for joint disease so far What so prolo I think is a great idea You know if you're using Dextrose as your inject a to so what prolo therapy is for those of you that may not know It's a chemical irritant and the idea is you deliver a chemical irritant to the area to try it up Restart the healing cascade and so we do prolo in lots of different areas For people that have common wrist flank flexor Tendinopathy we're tending not to use steroid anymore because we know that there really isn't a very good tendon sheath Around the common wrist extensors and so for people with common wrist flexor tendon So the term epicondylitis is a misnomer Most academians don't use that term anymore. Just so you know, it's common wrist extensor tendinopathy and common wrist flexor tendinopathy But for so getting back to the prolo therapy, I think prolo is a very good adjuvant to care I the way that I I Practice personally I try steroid first I move on to PRP or some regenerative medicine procedure or Prolo therapy depending on my discussion with the patient what they want, you know what the evidence shows Etc, etc, but great question You have City I've I've never used it. I I've never used it So the extent of laser knowledge that I know is that it can be an activating agent for some of the regenerative medicine procedures and so people that are Doing a lot of advanced regenerative medicine procedures will activate a laser within like the knee joint if they're doing some percutaneous Intervention, but you know, I don't I don't practice it. So I can't really speak to it Use of as usual great presentation. Thank you a comment. The wallet neuropathy is That's a real thing. I asked with everyone. I mean not just right. I also asked about the left Yeah, some people do carry it on. Yeah, so that's true questions the wallet wallet neuropathy The the question was with regards to what amount of Evaluation do you put into leg length discrepancy great issue gate issues and everything when they come with complainings of hip pain and everything So the reason is the first thing I look at is their shoes Yeah They were walk and everything the balance and everything to see where they have the wear and tear That gives you an idea what kind of stature they have and what's their gate and everything? second one is a follow-up question with your prolotherapy versus steroid versus PRP right? I've seen orthos use PRP as the primary one and then going to steroid. So I wanted to see what you're not Yeah, that's a that's a good. That's a so I'll take the second question first. So many of my colleagues and peers and academic organizations are moving towards regenerative medicine first before steroid because of the toxicity to both the tendons the tinocyte and the chondrocyte and so You know, the question is should we all be doing regenerative medicine first, you know I think that's still debated in the literature the issue with regenerative medicine is that we haven't standardized protocol Everyone does everything a little bit differently. Is it leukocyte rich? Is it leukocyte poor? Is it buffered? What's the pH? We we have tried AM SSM has tried to create protocols to help standardize the inject aid But we're just not there yet And so I I tend I'm very conservative in my care And so I tend to use what I know and so steroids is what I know So I use it first if they're refractory to steroids or that the effect isn't durable Then I'll move on to a regenerative medicine technique. Great question. So then What was the first part of your question? Oh, right So before I ever order a leg length imaging I examine the patient, right? and so what I'm looking for is the inspection and so I want to I want to make sure when I Disrobe the patient that you know, they don't have any pelvic tilt, right? And so the way you can characterize that is you feel for those those Physical exam the palpation, you know the PS is The Iliac crests are great landmarks for you to determine if somebody is higher or lower So if I see it and I confirm it by palpation then I order the imaging But I don't order the imaging on every patient that I see Does that make sense? Does that answer your question? Thank you. Okay Any other questions Awesome, I'm just gonna check to see if there's So There were a couple of lots of people asking questions on whether or not we perform ultrasound courses within the organization we're hoping that we're doing gonna be able to do that at the mid-year course or the The biennial course the fall course basically and then hopefully again at a OHC But again, we need feedback from all of you the membership, you know saying that you want it. So You So there was a good question on when do I repeat regenerative medicine procedures and it's an excellent question the literature is also debated on that and It depends on the effect, right? And so if the patients get good effect and what what I call durable effect is about six months of relief If they get six months of relief, then I'll consider repeating it the issue though is every time you go back in and do a tononomy and inject PRP the risk of Risk of rupture increases and so you have to be really careful. So I tend not to inject over and over again, so Any other questions, oh Yes, yeah, so yeah, yeah, I don't have that problem because I'm a federal employee but but yes so cost Reimbursement CMS doesn't reimburse it for it yet Because of all the issues that we've kind of discussed and so it's usually out-of-pocket expense. Yeah Although not a work injury, I was wondering if you would comment a little bit about postpartum hip injury and What the management is for that and how you manage that in the work environment Awesome question as an awesome question so our we have a women's health pelvic rehab division of our VA just for that reason and So as we know when when women go through childbirth that the pelvis expands The ligaments become a little bit looser and so that form and force closure that I just described Becomes much more imparted on the female pelvis and so SI joint dysfunction in terms of the Epidemiology is actually higher in the female patient and we I suspect it's probably because of of childbirth. Excellent question so Pelvic rehab is very important for those patients to try to recover that core and help to stabilize The hip and those structures a little bit better And It would probably be a lifelong journey So good question. Just a quick note for you as a physical therapist We are putting out some pretty good evidence-based Clinical practice guidelines and there's a really nice one in the pelvic health section on Perry Perry pardon pelvic pain Yeah Those patients we see them at least in our veteran our female veterans We see that pain to become More prevalent, you know in their 40s and 50s not, you know When you're young you're able to recover fairly quickly but then you know life takes over and you're not physically active anymore as we all know and And so that ligamentous strain from childbirth May be part of the issue. There are lots of interventions that you can do into the ligaments as well. I didn't go over those There's probably one other pathology that I wanted to talk about I just didn't have time and that's clunial nerve entrapment And so the clunial nerves they come off You know off the sacral nerve roots and they can get you can get a neuropathy from the glute median glute max Where they where they Kind of follow the fascia But that's for another talk very advanced ultrasound imaging to capture the clunial nerve though. You have to be really good Say it again Yeah, so that's a so you can do a diagnostic block so Oftentimes if I'm uncertain of an etiology, I'll do a diagnostic block and see how they do Good so remember when we do a diagnostic block We're checking their function first see, you know What the pathology may be and then we block it and then we want to see how how good they improve And so if they have 80% to 100% improvement Then I may go back and do a therapeutic block sometimes for entrapment neuropathy All's you need to do is hydro dissect and so for my patients with carpal tunnel syndrome, for instance I will simply put normal saline in and shroud the median nerve and see how long it lasts Just with saline and patients get better Yes, Yusuf, would you care to comment on Some findings I've seen on MRI Opterator hernias and the relationship to pain there. I've been a little bit confused about that and its relationship to pain That's a good question. I don't see a lot of that in my in my clinical practice but you know, so Usually that's entrapment of the opterator nerve and so That is very difficult to treat and so pelvic rehab is probably step one for those patients You can you can attempt an opterator nerve block also a very difficult procedure to do so good question And what products you would recommend for regenerative medicine whether it's like umbilical cord stem cells FDA regulation and guidance documents that may have been revised recently in the fall and then also exosomes and then the applications in occupational medicine, so I don't comment on specific manufacturers just because I think that it there's no place for it in academic talks but for For PRP, there's lots of different device makers, right? It's just a centrifuge So if you have a centrifuge you can make you can create PRP yourself in terms of What was the second part of that question? Oh, right, so the FDA so so I'm a federal employee as you know, and so I can't use any products that are not FDA approved and So PRP is autologous. And so because it's autologous I can use it bone marrow Aspirate is autologous. And so I use it. I don't use amnio fix. I don't use any type of amniotic cell lines Because they're not FDA approved Good question, but there are people that do use them Yeah, so obviously you would probably consider regenerative medicine procedures if people have Recalcitrant pain right and so that you haven't been able to improve them through all the conservative approaches Maybe it's time to try try some type of regenerative medicine technique I have a whole lecture that I give on regenerative medicine So I'm happy to do it out. I'll do a webinar or something and I'll cover it. Good question Anything else Trochanteric bursitis. Yeah, so I I Saw that quite a so I see that less and less and the reason is is because I examine patients more and I really find that the trochanteric bursitis is really a glute med tendinosis and so There are a lot of people that will just palpate the outside of the hip and it hurts and they inject it and it gets better Just by like a trigger point injection But the effect is never durable, so then the patients come back every three months and one. Oh, can you inject my hip again? Well, we really haven't figured out what the issue is, right? And so you really want to evaluate the glute med You know make sure that you're rotating the hip make sure you're extending the thigh all those maneuvers to try to elicit pain look under ultrasound and evaluate the glute med as an trochanter at the facet and Then see if you see any tendinopathy, right because you can characterize the glute med tendinopathy very well under ultrasound All right, and then you can also you can also functionally move the patient. That's the advantage for these types of issues oftentimes when I'm Right before I do a piriformis injection, for instance I'll have my transducer before I even have the needle and I've taken the knee and the patient is prone I've taken the knee up and I'm externally Rotating and internally rotating the patient to see if it's entrapping the sciatic nerve To see if it's and this is all passive you can actively ask the patient to do it But usually they're in a lot of a lot of pain too. So it's that's a little bit more difficult. So good question Okay, I think we're at time I feel like maybe we went over

posterior thigh

hip joint

facet joint arthropathy

degenerative disc disease

anatomy

medial branch nerves

radiofrequency ablation

herniation

piriformis syndrome

sciatic nerve

ischial bursitis