So, first, sorry for the delay, and thanks, Mr. Shaheeda, for reminding us, I was just thinking of that 30-minute break, but we should be on time. I am Sajjad Savol, everybody calls me Saj, I'm more local here at the University of Pennsylvania. I direct the Occupational Medicine Residency Program there, and also a clinician. You are in session 315, Diagnostic and Management Pearls for the Shoulder, and also part two, a smaller part of this lecture will be for the wrist and hand. So, it's the format is more like meet the professor or ask the professor, so we will have a resident, actually from my program here at Penn, Occupational Medicine Resident, they will come and present a case, and then we'll be asking the professor on how their approach will be. And our speaker, Dr. Alexis Tengen, he is the current Division Director of Sports and Exercise Medicine, and an Assistant Professor of Rehabilitation Medicine and Family and Community Medicine at Thomas Jefferson University, and his role as the Division Director, Dr. Tengen oversees the advancement of the division's clinical, educational, research, and community service initiatives. He has a particular clinical interest in running and exercise medicine, and has served on the U.S. track and field sports, I think he has been to Columbia as a team physician, and here at Penn as the Penn Relays, which is a big event every year, he's the team physician. He's a native of Beaumont, Texas, he received his BA in Molecular Biology from Princeton, and then his medical degree from Emory, he then came to Penn, surgical residency, PM&R residency, we kept him here for a while, but recently he transferred over to Jefferson in a much bigger role. He teaches Occupational Medicine Residence, in addition to other residencies, and is a regular speaker for our residence, and without further ado, well, I will have Dr. Huang first, our resident, Ziyun Huang, will present the case, thanks. Good morning. So this morning's talk will be about shoulder, and a little bit about the form and wrist as well. These are your learning objectives, regards to looking at the diagnosis of rotator cuff pathologies, and the role of imaging, ultrasound, and the idiosyncrasies regarding shoulder diagnosis and rotator cuff pathology. So I have the privilege of presenting the case, which is a 40-year-old male construction worker who presented to the office with a complaint that he, Doc, I got an MRI that says I have a rotator cuff tear, which is a great start upon taking a history in physical. He gives a history of a four-month history of left shoulder pain without any recalled specific trauma or unusual activity. Prior to that, he states he was in his usual state of health. He has continued to work, but states he's had some limitations in that work because of his pain. He is left-hand dominant, and he reports his pain to be over the lateral aspect of the left shoulder. He says that the pain worsens with overhead activities. He notes no neck symptoms, no numbness or paresthesia. He was prescribed two months of physical therapy by his primary provider, but without significant benefit, and he's not had any medications or injections. On exam, his general demeanor and description was pretty unremarkable. The look at the shoulder did not identify any specific abnormalities on general inspection. On range of motion, he did have limitation in forward flexion to 110 degrees on the left, and it also produced pain. With abduction of the left shoulder, he was also limited to approximately 110 degrees. With external rotation, he had full range of motion without pain. On internal rotation, he was limited to being able to reach L1 on the left with some pain. His motor exam was notable for a little bit of weakness noticeable on abduction on the left. Otherwise, internal and external rotation had full strength, but with pain. Palpation did not elicit any specific point tenderness, and on special tests, it was notable that his Hawkins impingement test on the left was positive, and the empty can test was a little bit about four minus out of five on the left with pain. Otherwise, his drop arm test, speeds test, O'Brien's, and the shear test were negative. So I'll turn it over now to Dr. Tinker. All right, thanks, and sorry, I had to get some water. I'm going to be doing a little bit of talking, so I want to stay hydrated. So thanks, everybody, for just the opportunity to speak with you. And so what we're going to do today, we're going to have basically two subjects. We're going to talk about the shoulder and about the wrist and the hand. And when I was asked to give a presentation, one of the requests was to talk a little bit about the application of ultrasound in musculoskeletal medicine, sports medicine, so we'll touch on that a little bit in this case. And then when we get to the wrist and the hand, we'll just talk about some very important principles to think about with ultrasound and musculoskeletal medicine. Okay, so we took a look at the case, and there's a couple of things that I want to point out. And first of all, has anyone had a patient come in, well, actually, let me just say this. Is this a chief complaint? Is this a chief complaint? What do you think? All right. All right. So a chief complaint is something that is going on. I have shoulder pain. I have wrist pain. You just saw a lecture on back pain, I have back pain. So this is not a chief complaint, but how many of you have had patients come in, not necessarily with the shoulder, but with other joints, how many of you have had patients come in with a chief complaint of a diagnosis, MRI finding, right? So pretty much all of us, right? And so what I'm going to do a little bit is demystify this idea of imaging, but also how to communicate to the patients, because a lot of times, particularly now with some of our advanced imaging, which we'll talk about, is very sensitive. But sensitivity doesn't necessarily mean specificity in terms of determining what's actually going on, as Dr. Pesky talked about in our last lecture, what's the pain generator. And also, how do we manage the patient? There's a lot of nuance in sports medicine and musculoskeletal medicine in how we manage the patient. With this case, it's a little bit different than Dr. Pesky's, those of you who were in the last lecture that he gave, in that he presented a little bit of a kind of weird off-the-cuff case. No pun intended, this is not off-the-cuff, actually maybe pun intended, I don't know. And it's a very straightforward rotator cuff case. But what we're going to demonstrate, again, is some of those principles of the nuance of imaging, of talking to the patient exam, as well as managing the patient. A couple things I want to point out here, particularly when we're dealing with the side of the pain, and as Saj said in his introduction, I'm PM&R trained, like Dr. Pesky, and we think about function of the patient. We kind of approach them from a holistic standpoint, and I use that principle whether it be someone with degenerative disease, and is overweight, or some of my elite athletes, the same principle. So what I want to point out is that it's on his left side, right? And when we get to the exam, we see that he is left-handed, I think I had it somewhere, yes. So he's left-handed, right? So on his left side. So this is really going to affect his way of living, and he's a construction worker, as we saw. The other important thing with this particular case, again, is neuropathic or neurologic symptoms. A lot of times in the shoulder, as we talked about, we're trying to figure out if it's a neck, if it's referred pain, so that's very important in this particular presentation. It was talked about in the last lecture how the patient often will give you the diagnosis, and we know, I mean, Saj and Dr. Pesky from Penn, so Sir William Osler, a former chief of clinical medicine at Penn centuries ago, said, you probably know this, listen to the patient, he'll tell you the diagnosis. And we spend so much, I spend so much time with my residents, med students, fellows, talking to them about that principle. And so as we listen to him, we can kind of get a sense of maybe what happened, right? And so he didn't have an injury, but we'll talk about some degenerative things, or some overuse things that can be happening. And the last thing I'll say is that this is, I think it's apropos that we've had a back lecture, low back lecture, and a shoulder lecture, because these are two structures in the body that don't lend themselves very well to, like, where does it hurt? Does it hurt? It hurts here, this is the diagnosis. If it hurts on the side of the shoulder, there's so many things it can be. So we're going to talk about how we can work through those things. Okay, so on the exam, some important principles that I want you to get out. First of all, and many of you are familiar with this, but from orthopedic or sports medicine standpoint, this is really how we think about examining the joint. So as you're going through and examining the joint systems, these are the high points that you want to hit. Obviously, their general appearance, and that's actually very important, that's going to tell you a lot, right? You're going to see how distressed are they? How much pain are they having? Is this, you know, how much is affecting them? We talked about neuro, but then again, inspection, range of motion, muscle strength, palpation, special tests. It's generally the flow that we have in a muscle skeletal exam. Some important points here, in range of motion, internal rotation, I like to actually have the patient reach behind their back for that, and it's my way of actually quantifying their internal rotation. So if it's limited, it could be iliac crest, higher up, L1, all the way up to the inferior border of the scapula. So I like to do that for my internal rotation. As far as special tests, the important, there's a couple important points. So Hawkins is our impingement test, telling us maybe the rotator cuff is involved, principally the supraspinatus. But this empty can test, it's also known as the Job's test, is very important when I'm examining the shoulder, as well as the drop arm test, because that is going to tell me, that single test is really going to dictate how I'm going to manage the patient. If I encounter significant amount of weakness on the empty can test, and that's the one we're familiar with, with the can down, empty bottle, empty can, thumb down, whatever you want to call it, if there's weakness on that, I'm assuming that there is a problem with the attachment of the rotator cuff to the humerus. And if there's no weakness in that, just pain, I'm fairly convinced that that attachment is intact, and that's going to come into play in terms of how we order tests, how we manage the patient, et cetera. And of course, at this point, I'm not concerned with labral pathology. So approach the patient. We talked a little bit about this, and this is the case for not just the shoulder, but really any joint system. We're not going to read off every one of these. This is to give you the general idea. But again, as you approach the shoulder, approach the joint systems, you want to be thinking about these different aspects. And for this particular patient, again, we're evaluating for trauma, referred pain, and the risk factors for overuse. So he's a construction worker, right? So maybe some repetitive motion. The trauma is very important, because if there is a trauma, then there is a time A, probably, where there is no problem. There is an event, and then a time B in which there's a problem. And so the treatment for that may be more prescriptive, because there was a period of time not too long ago where things were normal. This is opposed to something that's more overused, degenerative, or even an acute trauma that happened a while back. I may not necessarily be as urgent in how I approach the patient, because one day in a case of someone who's had pain for five years, one extra day is much different than someone who had an injury yesterday. So trauma will affect how we approach this. So we talked a little bit about this in our prior lecture on the low back, in terms of how I think about imaging. OK, so this is something I also spend a lot of time talking to my residents, fellows, med students, et cetera, nurses, is imaging. Imaging is a great thing for us, but sometimes the bane of our existence. We started the talk with the patient coming in with the chief complaint of an imaging finding. How many of you have had a patient come in and say, hey, doc, can we just get an MRI just to figure it out? Right. What do you tell them? What's been some of the responses that you had? Yeah, two hands there. Someone just shout out. What have you told them? If it makes you feel better. Yeah, so therapeutic MRI, right? And believe it or not, I'm not going to go too much of a tangent. There are times, and Dr. Peskin may attach, I've actually ordered some therapeutic imaging. And we're going to talk about therapeutic imaging in a second, as it pertains to ultrasound. Because sometimes I can't get the patient to do what I want them to do, which in many cases is physical therapy, without getting the MRI. So we do some gymnastics from an insurance standpoint, get the MRI. It's normal. But then they're able to get past that mental block to do our treatment. But that's very rare. Right. So we think sometimes that the MRI is a magical diagnostic generating machine. Not just a generating machine, but also something, not only is the radiologist going to give us the report, they're also going to tell us what to do and how long it's going to take. And that's not the case. Anytime you order imaging from an orthopedic standpoint, you want to understand clearly what it is you're looking for, and also what you're going to do with that information. The reason why that's important is because also that can be used to educate our patients. So we talked about many of you, if not most of you, rose your hand and said that you've had patients come in and request an MRI. Sometimes it's needed. Many times, if not most times, with a patient saying that, it's not. So how do you speak to the patient? How do you maybe convince them that the MRI is not needed? Well, you put the question back on them often, is what I'll do. I'll say, well, what do you think we're going to find? So let's say someone has six months of shoulder pain, no injury, no red flags, and they say, hey, I want an MRI. So, well, what do you expect to find? They'll say, well, I don't know. You tell me, Doc. Well, I'll tell them. I say, we're probably going to see maybe some partial tearing of rotator cuff, some tendinopathy, tendinitis. And then I throw the question back to them and say, what do you think we're going to do? We're going to do physical therapy. Yes, we're going to do physical therapy. So sometimes patients just don't understand, like they're only thinking one step ahead. And as clinicians, we should be thinking two, three, four steps ahead. So again, thinking about what you're going to do with that information. Now, they may need an MRI, right? And so now you're saying, OK, I'm looking for this specific thing, a complete rotator cuff tear. And then with that, I would consider referring them to surgery or something like that. So you want to not just get imaging, to get imaging is what I wanted to mystify there. OK. And we're mostly familiar with this in terms of our different imaging modalities. We are going to spend a little time on ultrasound. CT, typically in my practice, I'm not seeing it used very often. Often we'll do that in a acute setting, looking at the bony anatomy, or sometimes in preparation for surgery, a surgeon may request it. But typically, it's going to be x-ray, MRI, and ultrasound. Many of you also know the literature on MRIs and, to a certain extent, ultrasound for the low back, for the knee, and of course, for the shoulder, right? There's a high percentage of asymptomatic findings in, a high percentage of findings in asymptomatic individuals. So again, you have a finding of a rotator cuff tear. Does that mean that you're going to do X treatment? You don't know. We have to talk to the patient and examine them, et cetera. And ultrasound, which we'll talk a little bit about, it's a really great modality, but as was mentioned in the previous lecture, it's very operator dependent. So if you're sending a patient for an ultrasound, you wanna make sure that they're going to a place that has expertise in that. And it's a skill that if you have it in your office, you can develop over time. You just stick a probe on a patient for one minute or so, and you can begin to learn a little bit about anatomy. The other thing about the ultrasound is that we kind of joked a little bit earlier about this idea of therapeutic imaging. A therapeutic MRI is very expensive, but a therapeutic ultrasound is not. The cheapest therapeutic ultrasound is the one that you do yourself, right? And I do this all the time with some of my patients. They have pain somewhere. I just throw the ultrasound on for two minutes. I show them, look, this structure, this structure, structure. The reason why patients want imaging, they wanna look at themselves. We're very vain, right? We like to look at ourselves. And so when you show them that image in the office, that could be enough. Now, sometimes if you're not a ultrasonographer or you just don't feel comfortable, what have you, again, sending them for like $100, $200 therapeutic ultrasound that actually can give you very good detail on imaging can be very helpful. So think about that. Think about as a nuanced tool to approach the patient. If they're really, really, really, really, really, really, really pushing for an MRI, you tell them, hey, why don't we get an ultrasound? It's a great study. It gives you a lot of detail. It's dynamic, as we put here, and it can move you around. It can see what hurts and it can be helpful. And also it gives us real information. So that has value there. Okay, we're very familiar with our rotator cuff anatomy. This is gonna give you a sense of what we're looking at as we get into imaging. So 40-year-old male construction worker comes in with a chief complaint. Let's go back one. I think I have this later on in the talk, but I'll just pause here for it. So with this finding, actually, no, I'm gonna do that in a second. I'm thinking two things at once. Okay, so this is ultrasound. This is actually something I did in the office for a patient. He, again, he had that chief complaint of the MRI finding. So I told him, I said, yes, we're gonna look at an MRI, but let me take a look on the ultrasound. So let's just identify some of the important structures. So we see the subacromial bursa, which is green. That is, in terms of nomenclature, ultrasound, we use hyperechoic, hypoechoic, so hyper meaning bright, hypo meaning low signal, or anechoic, or with limited signal there. So we see the hypoechoic area in green. That's a little bit more fluid than we typically see in a bursa, so it just tells us he has a little bit of bursitis and inflammation. And then at our supraspinatus tendon there, the hypoechoic area, we can see that it's, I love this laser pointer, it's very strong. We can see that it attaches there very well at the humerus, but there's places of disruption right here, hypoechoic area, and hypoechoic area here. So the important thing is that it's attaching. And if we, again, go back to our physical exam, he had a little bit of weakness with MDKAN, but the drop arm test was negative. So again, I was thinking that this cuff was gonna be largely intact. And in fact, it is, but we see some partial tearing here. What about our MRI, right? So this is supraspinatus. So you can see, again, see that defect that we saw in the ultrasound. And then, but it's a partial tear, right? So if we take the cut, both anterior and posterior here on this coronal view, we can see that there's actually a cut where you can see the entire tendon intact. And I just point out some of the other tendons. This is posterior of the infraspinatus, subscapularis intact, teres minor intact. Okay, and this is our read. So the important thing here is that it's this partial thickness tear and no full thickness tear. Okay, so time for a poll. These are our options. So who among us will have them tough it out? Nobody? Everybody is a very caring, first, do no harm. Well, actually, you know what? The first thing is to make sure that this is not something that is a big problem, right? So we'll talk about a case here in a second that had more of a cute, complete tear. But if we're not seeing any red flags and I have a conversation with a patient and they're like, hey, I just want to get checked out and make sure it's not a big problem. There's nothing wrong with that, right? You talk about the risk and the benefits, it's patient-centered care, it's shared decision-making. And as long as I'm convinced that they're not going to have significant morbidity and mortality and they understand the risk, it's sometimes not a bad option. Okay, so how many of you will send this patient to physical therapy? A good number of you, good. How about injection? We will inject and then consult to our surgical colleagues. Yeah, a couple here. So all the answers here are right, right? So that's testing one-on-one. We're all physicians, so we know how to take tests. So sometimes when we see multiple answers or all above is the answer choice, it can be all of the above. So all of these potentially are appropriate. I would say that the consultation to the orthopedic surgery is probably a little aggressive in this case because the question is what is surgery going to do at this stage without doing physical therapy? But again, all can be potentially reasonable. So again, we talked about this. PT, very important, very, very important. How many of you in the room, when you send your patients to physical therapy, do you direct them to an office or do you, or actually, let me rephrase this. How many of you, when you send patient to physical occupational therapy, do you write, evaluate and treat and just give them a script? Yeah. I mean, so we're giving, there's probably more of you that do that. You're just scared to raise your hand. But it's actually not bad. I mean, you're getting them to the right treatment. I want to take you to the next level. So it's important, first of all, to be specific in your diagnosis to the best of your expertise and ability. You want to direct the therapist. You don't want to just say shoulder pain. You want to say partial tearing of the rotator cuff. Give them some goals, maybe tell them a little bit about the patient, construction worker, needs to try to get back to work in four weeks. So give them some idea of what's going on. Very important here is to direct them to a specific place. 99.9% of all my patients who I send to PT, I'm sending them to a particular office based on geography, insurance, et cetera. Some of them who need a little bit more focused care, I'm actually sending them to a specific physical therapist. I wouldn't necessarily expect you to send to all specific therapists, but it can make a difference where they go. I joke with my primary care colleagues, you know, if you write a prescription for, and it just says hypertension on it, and you send them to the pharmacy, it just says hypertension, and they go, and the pharmacist gives them something, maybe a beta blocker, and they come back to see you, and their blood pressure is not controlled, you wouldn't say they failed antihypertensive, would you? So, how many times does someone go to physical therapy, and they come back, and they've done therapy, and you say, oh, they failed therapy? That's not necessarily the case. Who do they see? Where do they go? What do they do? It's important. And I've seen patients sometimes on the verge of surgery, not less so in the shoulder, but more so in the back, and we've talked about physical therapy, what they did, and I directed them to the right place. They got better without surgery. So, it can make a difference. So, if I want to emphasize one thing with this, really think about directing them to offices that you know that are good, that are reputable, and get to know some of your therapy colleagues. And then injections, so a few of you rose your hand for injections. In these cases, they're pretty much palliative. I always tell my patients, it doesn't change, mainly the long term, really the short term, if they need to get back to work, or if they need to really get into therapy. And in orthopedic surgery, you see here. So, the important point is that there's really no indication to send to surgery if there's nothing for the surgeon to fix. Pain is not an indication for surgery. Pain with a structure, anatomic structure, that correlates to their pain, that can actually be fixed with surgery, is potentially an indication. So, if what's on the imaging doesn't correlate to what's going on, unlikely that surgery is going to fix the problem. Okay, briefly, case two, and this is just to present as a corollary to what we saw previously. So, this is a 68-year-old office custodial worker who I saw about a month ago with left arm pain and weakness. So, she's right-handed. So, again, this is her non-dominant hand. This is going to come into play as we think about treatment. But she had a fall, a trip at work and fell. So, this is an acute case. So, we're thinking a little bit differently in terms of how urgent we may want to be. And she really hasn't had that much treatment. No, it's relatively acute, right? So, it's four months. So, it's not like yesterday. But, you know, again, there was some trauma. Important points here. She has a little bit more decrease in range of motion. Impingement signs are positive. Empty can, three out of five. Drop arm, positive. Okay, so, we're thinking potentially this cuff is not intact. In fact, here we are, the ultrasound in the office. And this is actually prior to the MRI, right? So, this is me, again, listen to the patient. They'll give you the diagnosis. Do a good physical exam. Already knew what I was going to see in the ultrasound. This is just for me to, again, build some rapport with the patient. So, we see here, this is the stump that's still attached to the humerus. But we see this big gap here where normally that supraspinatus is attached. She also has a tear. This is more posteriorly of the infraspinatus. You see that hypoechoic area there where the infraspinatus used to be. And then we come to the MRI. And, of course, we see that supraspinatus tear. So, that area of high signal is some fluid and inflammation. But then again, we see that supraspinatus is detached there. She actually had multiple tears. So, the subscapularis is torn. The infraspinatus is a tear as well. Subscapularis was a partial tear. So, this is intact there. The other part was not. Okay, this is our read. So, full thickness tear, which we saw on the MRI. Time for a poll. So, time heals all wounds. What do you think? Yeah, we're all very compassionate once again. And this is a relatively acute case, so no. How about consult a PT? No? Okay. Injection? No. Consult an orthopedic surgery? Yeah, right. So, really good thinking. Really good thinking. So, we talked about this. So, consult an orthopedic surgery. So, again, consider an acute traumatic cuff tears. In patients that can functionally benefit from surgery, right, so if someone is like a 95-year-old woman, really just needs basic functioning of the shoulder, they may not necessarily need to take on the risk of surgery. So, again, it's not necessarily an absolute indication, more of a relative indication. So, she says, I don't want anyone to cut me for the life of me. So, we have a discussion about risk and benefits of surgery versus non-surgery. Again, if she's an elite athlete, I'd probably say you need to think differently about this. But she's, again, she's right-handed. This is her left shoulder. I said, hey, look, we can get some function back, get some range of motion. What do you think about that? And then after, how many weeks did we do? Four weeks, four weeks, home exercises. She has improvement of her range of motion, improvement of strength, drop heart rate has improved, just with home exercises, right? And she's happy. She's functioning at work. She's getting better. She's functioning at home, right? So, again, this is just to display some of the nuance to the shoulder. Okay, so we'll move on to our next case here. We'll spend just a brief time on it because I'm just gonna be talking about some principles of ultrasound there, and then we'll open up for questions and answers. And so this next set of, you can come up, the next set of lectures, so this was gonna be given by Dr. Saeed, who was not able to attend, and so it's mainly adapted from his slides. Thank you. Hi, everyone. My name's Joshua Stevens. I'm one of the residents with Dr. Saville's University of Pennsylvania Occupational Medicine Residency Program, and Dr. Tingan, I have another case for you here. We're just gonna skip through the new disclosures. Objectives here are to discuss the utility of ultrasound for hand and wrist complaints, review scanning technique and ultrasound anatomy for basic hand and wrist evaluation, and recognize some of the common hand and wrist pathology on ultrasound. So case, and I hope you will agree that the previous two cases were quite common. I mean, it's things that are bread and butter in the clinic, and this one is no different. 24-year-old female presents with four weeks of right hand and wrist pain. She recently started working in a daycare center. There was no injury. Before starting work at the center, she was in her normal state of good health. She has continued to work, but has been somewhat functionally limited by the pain. She is right-handed. The pain is located along the dorsum of the wrist, the base of the thumb, worsens with lifting and other use of the right hand, but no numbness or paresthesias, and she's not really tried any other home treatments or anything to date. Exam, she's neurologically intact, no swelling, bruising, atrophy, full range of motion, full strength. Really only of note is the tenderness, and her Tonell's and Finkelstein's tests are both positive. So with that, I'll turn this over to Dr. Tingen. Thanks, Josh. So what we're gonna do mainly here is just talk a little bit more about ultrasound and its application to musculoskeletal medicine. We'll touch briefly on the end at the case. There's really not that many slides on the case itself. I'll ad lib a little bit about the case. So again, it's an extension, ultrasound's extension of the physical exam, like we talked about with the EMG in the low back lecture. And as we also saw with this most previous case, I already kind of knew what was going on in the shoulder, but it was really just an idea, just helped me to hone a little bit in on the diagnosis. The great thing about it also, no radiation, it's relatively cheap, and it's portable, right? So there's sometimes really small handheld ones you can have and attach to an app on your phone, and early detection of a particular problem, right? So even before they're able to get an MRI or X-ray, sometimes we're out in the field with our sports medicine coverage, we can use ultrasound in that way. Also, again, we talked about diagnosing pathology, but also we can use it for procedures, image guidance, et cetera. And we can also monitor progression with treatment. Oh, there is a video. I didn't know this was a video. So we'll just briefly talk about the hand here. And this is looking at a tendon and cross section. So we can see the drawing here, and then we can see that this is the flexor tendon here. The important thing to note with these, the hand and wrist tendons and cross section, this is what we call short axis, is you'll see the kind of hyperechoic tendon here, and then the hypoechoic area is the tendon sheath. And so often we're looking at that in terms of if there's more fluid or the sheath is bigger or more hypoechoic, we're thinking some inflammation. So tenosynovitis, we'll get into this a little bit later. So what we often will do is put the color, oops, sorry, is put the, sorry, here? Yeah, okay. We'll put the color dopper on, and we can see some motion here. So motion means that there's something moving, obviously, and that often means neovascularization. So when we're looking at tendinopathy, be it in the wrist, the hand, the elbow, Achilles tendon, we're looking for this neovascularization in addition to the more hypoechoic area. And actually, I would say that this is, and again, we see the neovascularization here, but again, there's just a little more hypoechoic here, which is telling me that there's some inflammation. So again, we can make several diagnoses in the hand. So a pulley tear, which is usually I'm gonna be sending to my surgical colleagues. And we see here, this hypoechoic area here is a disruption of that pulley there. And again, this is just, if I'm looking in the office and I see this, I can just send, go ahead and know I'm gonna send it to the surgeon. I may still go ahead and order an MRI, but I'll have an idea of what to tell my surgical colleague. Trigger finger, we see this not uncommonly. Again, do we need ultrasound for this? Not all the time, right? A lot of times this is academic to show the patient because trigger finger is very mechanical. We just see the patient with the finger getting caught. But what we see here is basically an enlargement of the pulley. This is the, in this case, the up top is A1 pulley, A2, sorry, on the bottom is A2 pulley here. And the pathophysiology is that flexor tendon getting caught in that pulley due to inflammation of the tendon and the tendon sheath. So you can see fracture, right? So again, if maybe I'm out covering soccer or something like that and I'm not able to get an X-ray immediately, I can use a portable ultrasound to diagnose a fracture knowing that I gotta get this patient to X-ray soon. Foreign bodies, you can clearly see. So typically they, particularly anything that's metallic will appear kind of hyper-echoic on ultrasound. And the volar wrist. So this is where we're looking at carpal tunnel. So our patient that we, just for our case, she had a positive tunnels at the wrist, so indicating potentially carpal tunnel. And then we can see the median nerve here as we move along, it's labeled there. We can also, I think he had a slide with that, but I can't remember. He also, but you can also measure the diameter of the median nerve, which can indicate, it's actually very sensitive for carpal tunnel syndrome. Okay, so this is the dorsal wrist. So general principle in ultrasounds, ultrasonography, musculoskeletal ultrasound, is you always wanna have a home base, whatever structure it is. But in the dorsal wrist, it's typically gonna be Lister's tubercle, which is between our second and third compartment. So you see on the bottom right here, the dorsal wrist is divided into our compartments. And essentially, as I go through and I'm scanning the different compartments, I'm looking for tenosynovitis depending, or in making sure the tendon's intact, depending on what I think is potentially going on with the patient. So our first compartment here, which is where we will see one of the conditions that we'll talk about in a second, is our EPB and our APL. So extensor pollicis brevis and abductor pollicis longus. And again, you'll just see pictures here of our compartments. And again, so we've kind of been over most of this. The, you can also look at joints. So this is an examination of the first carpal metacarpals, the CMC joint. This is also very helpful when you're doing CMC injections. So particularly in someone that has a lot of soft tissue for a landmark-guided injection, you can kind of direct that needle directly into that CMC joint. Again, fractures, you can see as well. This is actually, this next slide's a great example of scaphoid fracture. So again, if I'm seeing someone in the office, I'm probably gonna get an x-ray anyway, but this can have some utility out in the field whenever you may not have quick access to radiographs. Again, the carpal tunnel, okay, he did have a slide on that. So just to demonstrate again, carpal tunnel is actually, I'm sorry, ultrasound is actually fairly sensitive for carpal tunnel syndrome. And then this can actually have some value over an MRI because it's cheaper and still very diagnostic. So we'll get back to our case, a daycare worker, probably picking up kids very often. And this is our MSK ultrasound. So again, we'll use our principles we just learned here. There's a short axis, hyperechoic tendons here, your EPL and your APB, I'm sorry, EPB and APL. We see that large hypoechoic area indicating some tenosynovitis. We also see in long axis here, some neovascularization. So we're thinking potentially some tendonitis here. So it's the core veins as our case. And again, something that we see not uncommonly, oops. And so our treatment, we'll just do a quick poll here. So with the core veins, I'm sure you've seen that before. So what do you typically do? Who just lets this thing go? So, usually they come to the office, they want treatment, right? So how about consultation to our hand therapy colleagues? Yeah, so I'll do this often, and particularly if someone really needs to use their hands for work, because you can do home exercises for this, but I definitely want them to get the right education. Injection, yeah, injection I think is very useful. It's not, it's just a rung below, but in orthopedics, there's not many things that are cured by injection. Trigger finger is actually one of them, which we've talked about before. Decore veins is not far behind in terms of actually giving some really good relief. So I have a very low threshold for injecting decore veins, because it really get them better. You can do it landmark guided, but again, as we talked about, you can also do it with ultrasound guidance. Very satisfactory injection to do. And then very, in recalcitrant cases, we're gonna send to orthopedic surgery. It's very rare. I don't think I've really even sent anyone, any of my patients to surgery. So just in quick sum, so this idea of anisotropy. So sometimes when you're looking at a structure, it could look hyper-echoic or hypo-echoic. You really wanna toggle back and forth. It's a dynamic study, and that could make sure you're looking at the right thing. We talked about the fluid and tenosynovitis. You can see foreign bodies. Lister's tubercle is a guide, your guidepost, and the dorsal wrist, but again, the general principle is that anywhere you're doing MSK ultrasound, shoulder, knee, et cetera, you just want to be familiar with your anatomy and your home base, and again, you can have rapid diagnosis of some fractures with ultrasound, and then again, these are the remaining slides from Dr. Saeed. Okay, so we'll open it up for questions here. We have about 10 minutes or so, and we can have some conversation. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Thank you. Thank you.

shoulder

wrist

hand

ultrasound

diagnosing

treating conditions

rotator cuff tears

trigger finger

tenosynovitis