Good morning, everybody and happy Friday and welcome to this week's AMS and sports ultrasound case series, we are back on our rotation of phenomenal fellows giving present presentations now and then that will be the case for the next five to six months or so. So, today we are really fortunate lucky for the second, I guess I got second presentation in a row we've got more Stanford folks here so we've got camera faucet and cool bar and Jessica Sal from Stanford they're the current sports medicine fellows out there, and they're going to be talking today, a bit of a different case which actually I'm really excited about this because I think a lot of us see this and there's some, you know, really good literature on this and be interested to hear their, their take on this but they're gonna be talking about the sonographic evaluation of medial tibial stress syndrome. So with that, I'll let you guys take over screen sharing and and get going. Sounds great. All right, can you see our presentation Okay, yeah, we can looks great. All right. So yes, thanks for the introduction, Dr. Cruz. My name is Annie or Ann Kuwabara, and I'll be presenting first. So we have no disclosures, and I'm just going to give some background about bone stress injuries. So bone stress injuries are overuse injuries due to an imbalance of excessive bone damage and inadequate repair. They're often commonly seen in runners and military recruits, but also among new athletes. People have recently started more intensive physical activity. And bone stress injuries account for 10% of all sports-related injuries and have an incidence of about 20% in college runners. And early identification is critical for preventing progression to higher-grade bone stress injuries requiring longer times, ultimately out of practice and competition. And there's a continuum of bone stress injuries varying from bony edema to full fracture. And as these injuries progress along the continuum, it takes longer and longer to recover. And there's also different classes of anatomical locations, low, medium, and high. And this is based on the bone blood supply and loading forces to the bone. And risk factors for bone stress injuries can roughly be divided into four categories based on intrinsic or extrinsic factors to the athlete, as well as non-modifiable and modifiable factors. So just to briefly go over some of the factors, demographics can include females are at higher risk, as well as being Caucasian ethnicity and having a history of stress fractures, and having a history of stress fractures predissociated to more stress fractures. And genetic predisposition, including people who have maybe genetic polymorphisms at placement higher risk of developing osteoporosis. And pes cavus or pes planus is an important risk factor because a more rigid foot makes more forces distributed to the tibia, for example. And some modifiable intrinsic risk factors include relative energy deficiency syndrome, low energy availability, plus or minus disordered eating, hypothalamic amenorrhea, osteoporosis, calcium and vitamin D deficiency, having a low BMI, poor or improper biomechanics or strength and balance, and certain medications like contraceptives, corticosteroids like prednisone, substance abuse, including tobacco and alcohol. And extrinsic non-modifiable risk factors. So similar to being a new athlete and getting into more intensive activity during the preseason, people are often ramping up at a rapid pace. And extrinsic modifiable factors are training variables. So trying to ramp up the volume in a more progressive way. And then people are at higher risk training on a non-compliant or uneven surface. And equipment variables like having an older non-supportive shoe wear and sports that gravitate towards leanness are also at higher risk such as track and field, cross country, and gymnastics. And in the figure on the right hand, it just demonstrates that these risk factors all play together to increase or decrease your susceptibility to both stress injury during training. And for diagnosis, MRI is currently the gold standard. So our own Dr. Fredrickson came up with the MRI grading scale that goes from 0 to 4. And 0 is normal. Grade 1 is periosteal edema only. Grade 2 is edema seen on T2 imaging. Grade 3 is edema seen on both T1 and T2 imaging. And grade 4 is severe edema in multiple areas and includes full cortical fracture. And where does ultrasound come into all of this? So ultrasound can be used. And some benefits are specifically you're able to perform a dynamic exam so the athlete can tell you exactly where their pain is. So you can know palpate over that area. It's also low cost compared to the other modalities and can be done point of care at the bedside and doesn't cause any radiation like CT or bone scan and is less compromised by patient movement, metal artifact, or claustrophobia. And these are some things that Dr. Sao will go into a little bit later. But similar to MRI, ultrasound can show findings of bone stress injury including periosteal thickening, soft tissue edema, increased vascularity, bone callus, and cortical fracture. However, it can't assess structures deeper to the bone such as the specific bone neuroedema seen in grade 2 and grade 3 MRI bone stress injuries. So now moving on to our case. Our case is an 18-year-old female collegiate cross-country runner who presents with one month of right shin pain described as a sharp, deep ache. And she does not have pain at rest, only when running and occasionally when walking. She has increased her volume of activity lately as she was in the preseason. And her risk factors include that she had a right metatarsal stress injury one and a half years ago that has since healed. She's also had irregular periods over the last few months. She denies any weight changes and follows a regular diet. She's not on any medications except for magnesium and iron supplements. And she does not have any past medical or past surgical history. And moving on to the physical exam, pertinent positives was she does have a BMI on the lower side of 18.2. She also has pes planus bilaterally. And for her right tibia, she had some tenderness to palpation and percussion over the anterior and medial distal aspect of the right tibia. She had pain with a single leg hop test after three hops. And she also had a positive bulk test as seen in the bottom right-hand corner. And for her next steps, we ultimately got an MRI of her tibia. We got leg-length x-rays to assess for any discrepancy. And we also got lab work looking at some of those risk factors including bone health, vitamin D, alkaline phosphatase, endocrine labs including estradiol, FSH, LH-3T3, and some nutritional labs like CBC to assess for anemia, CMP to assess her electrolyte abnormalities in her liver function tests, and ferritin to assess for her iron status. And in regards to her activity level, we placed her out of practice in competition and non-weight-bearing in a short walking boot for two weeks. And what her MRI showed was it did show some focal areas of subcortical bone marrow edema throughout the tibial diathesis around where her skin marker was. And it was present both on T2 and T1 imaging, making this ultimately a grade 3 tibial stress injury. And here's an image of pure MRI images. So the sagittal view is on the left. Axial view is on the right. And now I'll hand it over to Dr. Cameron Fawcett. So good morning. So I'm going to be discussing a proposed ultrasound technique and protocol when you have a suspicion for one of these injuries. I'm going to be discussing how to go about scanning for this regardless of where your concern for the injury is. So it's not specific to the tibia here, but just some things to be thinking about regardless of where throughout the lower extremity or elsewhere that you're worried about with your athletes. So in terms of our equipment, we do really favor a high-frequency linear probe. Oftentimes, these structures that we're going to be trying to visualize with ultrasound are going to be very superficial. So the linear probe is usually your best bet. We do see a fair number of these stress injuries in our rowers as well. They tend to get them on the ribs. That's kind of one of the pathognomonic injuries for rowers. So in a thinner bone, a smaller bone, you could consider using a linear probe. Patient positioning is absolutely key when looking for these injuries. The great thing about ultrasound is that it's dynamic, but perhaps one of the bad things about ultrasound is that it's dynamic. And just as soon as you've got a pretty good image on the screen, your athlete is going to be able to see what's going on with their body. So we're going to be on the screen, your athlete shifts positions and moves, and then you have to kind of start all over again. So getting your patient comfortable and in a place where they can remain still for a while as you're doing the scan is really key. Specifically for the tibia, I like to put them in external rotation or maybe even like a favor or figure four position to kind of get better access to the posterior medial aspect of the tibia. That helps to visualize that a little bit better. And then I really like using a skin marker over the specific area of where they are tender. I can, you can even have them kind of, if you're not concerned about a high grade injury or a high risk location, you can even have them pop up and down on one leg or do something to kind of reproduce their pain so that they can really hone in with preferably just one single finger to point exactly where they're tender. And then you can mark that as a frame of reference. Once you begin scanning, image optimization is really important. As we're going to see, some of this pathology is, can be very subtle. And so making sure that you've done everything to make your images as clear as possible is really important. Again, these structures are usually fairly superficial, so decreasing the depth to maximize the cortex on the screen is important. Adjusting your gain to make the cortex as bright as possible and to make sure that your focal zones are in the appropriate area for the cortex to try and highlight normal from abnormal pathology. This is one of my images. I'm trying to show that it's, you know, perhaps a little bit shaky handed here. That was, but otherwise the cortex is bright. The cortex is in the middle of the screen. I've tried to minimize the dead space here. It's a little bit blurry because I think I was moved as I was trying to take the picture, but otherwise, you know, you're really not seeing a lot of extra tissue or area of the screen. It's really mostly just the cortex. And then in terms of scanning and trying to find normal versus abnormal pathology, I like to start away from the area of maximal tenderness and then to kind of get used to normal anatomy and then slowly scan towards the area where they're hurting. I have to stop and emphasize that going slow is really, really important here. If you're anything like me, I tend to get excited that I might be potentially diagnosing a fracture with ultrasound and I start to feel like this is the culmination of my training and then I just go way too fast and it's harder for me to distinguish normal from abnormal. So I like to start away from abnormal. This is just my own personal preference, but I like to start long access to the cortex of the bone. I feel like that's the best way in order to kind of get the best sense of what's normal, what's abnormal, and so I can start to pick up on any differences in pathology. If and when you do start to see something that is concerning for a stress injury or a stress fracture, make sure that you are close to where their area of tenderness is. It doesn't have to be perfectly corresponding with your mark, but it should be fairly close. Most of these injuries are fairly focal. If you're far, far away from the mark and you're starting to see something that looks strange, then your degree of your index of suspicion should be lower that perhaps you're not on the right spot and that's not actually the problem what you're seeing. And then once you are over an area that looks suspicious, try and confirm it by looking at it in the opposite axis. So if you're long access to the cortex, swiveling the probe 90 degrees to get into short access to see if you can see a similar pathology or changes in that second access to confirm it. And then this is a tip more for the residents and fellows who might be watching. Once you've got a good picture on the screen, of course, try to save that if you have the capability and then consider making an additional skin mark so you can find it again when you're attending comes back into the room. And then of course, don't forget about the big picture that you might discover other or concurrent pathology that perhaps you weren't initially worried about. Maybe you started thinking that this was a bone stress injury, but you begin to scan and you find something like a hematoma is pictured here or something like a tendinopathy or tendon tear. So just be aware that there are other things other than bone stress injuries, even though that's maybe why you started the ultrasound in the first place. So this is a proposed diagnostic algorithm for how ultrasound can fit in to diagnosing and helping manage these injuries. So currently the kind of gold standard diagnostic algorithm is to get x-rays first, and then if those are negative, then proceed with MRI. So ultrasound isn't always involved in this. One proposed algorithm here is that if your first imaging modality could and perhaps should be ultrasound, if you do see something that is concerning for a high grade injury, and Dr. Stout is going to go over some of those imaging findings. So if you do see something that's high grade, like a fracture line, et cetera, consider getting an MRI. In fact, you should get an MRI to then further characterize the extent of the injury and see truly what it is that you're up against in its totality. If you find ultrasound evidence of a lower grade stress injury, then you probably don't need to go to MRI necessarily. You can probably just make the diagnosis then and there and then begin treatment and then follow them up with serial ultrasounds. So that's just one way that ultrasound can be incorporated into these injuries. And I'll turn it over to Dr. Stout to discuss some of these ultrasound findings. Thanks. Yeah, so I'm Jessica, one of the fellows. So I'm going to be talking about some of the things to look for on ultrasound before we get to our case, so what you might find on ultrasound. So again, kind of as Annie mentioned, it's an ultrasound finding similar to MRI. You're looking for periosteal thickening or elevation. You can see a calcified bone callus or other cortical irregularities or defects, as well as sometimes this more superficial subcutaneous edema. And then using specifically color doppler, we can look for hypervascularity both in sort of the superficial tissues, as well as the periosteum and the bone itself. And I just wanted to note that the expected findings can vary depending on the stage of healing. I don't want to go through this entire table, but just highlight that the findings change based on where you are with the injury, which can actually potentially make ultrasound helpful to track healing. Early stages, you're going to see more of that like hypervascularity. You may see the cortical disruption, the hypo fluid collections, some periosteal elevation edema. And then sort of later on, that's when you start to see callus formation. And you can also see some increased posterior shadowing behind the cortex. And then just, this is some of our kind of internal data, but how good is ultrasound at detecting bony stress injuries? So overall sensitivity of about 80%. Specificity is about 70% when compared to MRI. And then looking at some of the specific markers. So periosteal thickening and subcutaneous edema were the most sensitive for detecting bony stress injury with around 80% sensitivity. And then bony callus, cortical irregularities, as well as periosteal elevation were very specific. So it had specificity basically 85% and greater. So if you see those things, it's definitely indicative of a stress injury. So now we'll kind of go through some of the changes and what you'll see, what they actually look like. Here on the screen is an example of changes that can be seen, particularly in an early stress fracture. So figure A shows some soft tissue edema. It's kind of the curved white arrow. You can also see this hypoechoic periosteal edema with the white arrowhead, but right kind of right above the cortex. And then the bottom figure, figure B just shows an example of a lot of increased vascularity of the periosteum when using color Doppler. And this, I think is a really great image, but these findings are pretty obvious when you look at it. And oftentimes you can have much subtler images. So this is example, this is one of our athletes with a fibular stress injury. And this is, you know, shows a little bit of increased vascularity here, but again, it's pretty quick. I don't know if we can replay. So, you know, it's not quite as obvious compared to the other image. In low grade stress injuries in particular, you may not really even see hypervascularity. You may just see some periosteal hypoecogenicity, cortical thickening. So these are some examples sort of where you can see that sort of hypoechoic space right above the bone. But again, if you're scanning too fast or, you know, not looking closely right over that area, it's pretty easy to miss these. And then in looking at high grade injuries. So this is pretty rare to actually see this, but if you do, obviously it's pretty impressive. So you can see these are examples of high grade cortical disruption. You can see basically the fracture line on ultrasound. And then as Cam mentioned, you know, if you do see this, you know, you probably want to get an MRI just to assess, you know, the extent of the injury and help with prognostication. This is an example here of posterior shadowing. And so this happens, you know, beneath the damaged or healing cortex. On the left you can see there's you know a little bit of callus formation with the arrowhead and then kind of behind it is just darker compared to the rest of the bone. And then an image on the right, it's a little bit more impressive, you can really see the the posterior acoustic shadowing. This one's kind of a cool image because this is a metatarsal and so the roman numerals two and four those are normal metatarsals. And then the one in the middle is the where the injury is so you can see like what a normal one looks like compared to what the injured one looks like. And then sort of as people move along the continuum in terms of healing so that's when you'll start to see callus formation and you'll see kind of resolution of these earlier changes so you'll see less edema, less vascularity. These are all kind of just some typical images showing later findings. The one on the right is I think after about like 80 days you know so basically the athlete has healed. And then again just to highlight that the ability to track these injuries over time I think you know argues for the potential use of ultrasound to kind of monitor and track the healing process. Yeah so now that we've kind of gone through what to look for we'll kind of bring it back to our case and go through go through our actual images. All right so yeah moving on to the case so this is our patient's right tibia. So as you can see there's I'm not sure if you can see my cursor but there's some definitely some edema and I have the normal picture on this slide here so you can see that there's definitely a lot of edema a little bit of cortical irregularity and thickening. But we don't see any break and we do have a video coming up so here is this video. And then here's a video of the normal side on the left. It's a lot more smooth, less irregularity, no edema compared to the other side. And then for her since we got an MRI and she came back a couple weeks later she's in that 10 to 14 day rate so we didn't see significant hypervascularity findings. And then here's some images in short axis. As Dr. Cameron Fawcett mentioned earlier there's it's easy it's definitely easier to see in the long axis versus the short axis view. So this is compared to the left side it looked pretty equivocal to us. Then to wrap things up with the report so examination this is an ultrasound of the patient's right tibia and it was a follow-up on right medial tibial stress syndrome. Our specific findings are periosteal edema, cortical irregularity and thickening, and some callus formation seen over the right tibia at the location of maximal pain without evidence of hypervascularity. No fracture was identified. Our impression was this is a bone stress injury of the right tibia consistent with MRI findings. And to wrap up our case so for her management as a grade three right distal tibia bone stress injury she was placed in a non-weight-bearing short walking boot for two weeks and after she was pain-free with ambulation she came in the clinic and we assessed her and made sure she had no pain with provocative maneuvers on physical exam and then we cleared her to return to run through our ALTER-G progression and because she had oligomenorrhea we also referred her to our nutrition and endocrinology teams to optimize her diet and nutrition and see if she needs any additional supplementation and then because she did have a history of pes planus or flat feet bilaterally we did refer her to get fitted with custom orthotics. And we'd like to acknowledge our Stanford athletes for letting us scan their bone stress injury areas and we'd also like to thank Dr. Isaac Sirup and Dr. Michael Fredrickson for sharing some additional ultrasound images and some of their preliminary data. And here are our references and thank you for your attention we'd like to open the floor to questions now. All right great uh great job guys that was you know very thorough it was a great overview of of ultrasound for these these bony stress injuries um I'll just make excuse me a couple comments um kind of based on my my practice and my experience here but you know I think I think that ultrasound you know for evaluation of bony stress injury is highly valuable you know and especially as a screening tool you know there we can use this in the athletic training room with if any of these athletes you know come in with concerns for stress injuries so I think that's a that's a a significant um utility of of ultrasound for these you know there's there's really good data out there that you know certainly ultrasound is more sensitive than radiographs um and and while MRI continues to be gold standard you know the the sensitivity of ultrasound you know in the 80 percent range or so is certainly nothing um to to discount there you know when I'm when I see these patients and I think this is pretty standard um for for most folks what I what I typically see is that early on um they're going to have periosteal edema or elevation as well as as hyperemia those are usually what I see as the first signs of a bony stress injury and ultrasound um however you know the cortical thickening is also uh something that you're going to see early on I also think that using ultrasound can be helpful to a certain degree um to provide some sort of grading for these injuries you know obviously if you're seeing a cortical break that's a grade four injury and um an ultrasound can be can be helpful with that I've I've also seen or found that sometimes looking for periosteal hyperemia can be a little challenging because you know certainly um like Pam mentioned previously if you're moving the transducer at all you're going to get some Doppler artifact and you really have to you know make sure your hand is steady when you're when you're looking for for hyperemia on our machines we've got SMI or superb microvascular imaging which is highly sensitive for slow flow vessels so I've been super happy um using that for detection of of hyperemia because again um it can be fairly uh fairly subtle um I think I think that's all I had um I don't know Doug you want to make some comments I know you've got a couple papers on this yeah um just so just to be clear um is is is I mean that we're all on the same page medial tibial stress syndrome is is simply just a continuum of a stress injury is everybody in agreement to that yes um so one thing so this is a pro you know uh series on ultrasound and protocols and the protocol this would be brief if we're going to be limited to the lower leg so you know we're going to scan the tibia carefully long and short axis we'll probably look at some of the muscle attachments and that's been studied under ultrasound and some debate of what muscle attachments may be contributing to the stress injury if at all um you know so you're going to want to look for other things in part of your protocol but it wouldn't really meet criteria for a complete exam until you have a joint in there I mean there's nerve in there um and so you could scan if you wanted to do a complete protocol you could just scan down to the medial tarsal tunnel and you got everything you need and I do that often with my plantar fascia or achilles protocol when I need joint um just a couple things in in scanning and that is that uh we have nutrient arteries that are often seen in the tibia and so you're going to see a little vascularity um and so it's important to make sure that you're seeing just a single nutrient artery often if you're really sensitive you're going to see the artery and vein go through the cortex and don't mistake that with um you know with an abnormal cortex and almost always you're going to couple some doppler or vascularity with some changes in the periosteum so that's one distinguishing factor um you know I've noticed that hematomas uh in uh because you you had put that up hematomas in the shin area anterior tibial area can be permanent uh so you have permanent in a sense uh thickening or fracturing of the subcutaneous fat so even several years later you can see sonographic abnormalities so that's something to keep in mind that uh those changes may be permanent and then finally I I'm struggling a little bit to understand you know the specificity of this and sensitivity you know there was a study back a few years ago out of the Netherlands showing that periosteal thickening periosteal edema and even doppler activity um was as uh prevalent on the contralateral asymptomatic side or as prevalent uh in in athletes or runners who don't have shin pain um and so yeah I think it can be a marker uh to for further investigation but um in in the tibial area I'm wondering if these ultrafound findings uh you know again um the sensitivity and specificity is is questionable I know you guys are doing some research on this um but I I go back to that study it was in 2017 and and it really showed no change um or differences with symptomatic and asymptomatic sites so I'm sure you guys are aware of that study and I don't know what your experience is because you you see a lot of this yeah so I mean I think so the numbers that we presented um that's kind of obviously uh I mentioned some unpublished data so this was kind of in response to some of the other things that have been published um and so that's been I think this data will be published um in the not too distant future um but just kind of um we were seeing um much higher you know uh sensitivity and specificity in our population um and you know it could be that uh just you know the differences in population versus you know the protocols um but we definitely you know we were scanning sort of both the symptomatic and non-symptomatic um limbs um and then also you know comparing basically those findings so people who had those findings with everyone got MRIs so if you had a diagnosed stress injury on MRI um so we're comparing it to that as opposed to just um like some uh like symptomatic versus non-symptomatic um but like I said the data you know still still unpublished so um I guess still kind of remains to be seen yeah and I uh I mean it's great you guys are doing that because um I think you know this is a very common problem in certain populations and and I like your a logarithm um because I do think there could be there is a role for ultrasound um I'm but I agree that I think MR is really uh the definitive uh imaging test and and and the logarithm for management um and I wonder if you have a 100% normal tibial cortex you know what is the uh the actual incidence that you know there's early stress injury and I think I guess from my perspective that would be the biggest question um is if you have 100% normal ultrasound can you feel assured that uh you don't have an early stress injury because I don't think ultrasound will is is sensitive enough to say okay these findings you know this is definitely a stress injury but maybe then lead you to another imaging test yeah I mean I think we would probably agree with that if you have a high a high enough suspicion you know that a normal ultrasound you would probably still progress then to MRI and it's kind of the middle category where you maybe see something but it's not severe where you can kind of just start treating it so we do that oftentimes with our rib fractures and rowers where they may not get confirmatory MRIs but if you see you know something kind of uh some like early changes or mild changes then you just treat them as such yeah have you uh at Stanford um have you tried any type of like prolotherapy on these patients not that I'm aware of now there was an interesting study that came out last year that use ultrasound to to uh guide prolotherapy right to the tibial cortex with and these were with recalcitrant um as you know athletes when shin pain um and that there are some flaws in the study and and and even with the diagnosis um which was mostly clinical but um again it was interesting because in some ways you know I think we think of these as unhealed basically the inability of the bone to repair especially in people with recalcitrant for some reason the bones just not repairing itself um and so if that can be stimulated um so that that was an interesting study of of considering because it's so accessible with ultrasound to be very specific in our injection location there's a oh sorry go ahead Doug I was going to ask you um I mean you see a lot of runners at Iowa do you have anything to add uh with treatment of that or have you done any ultrasound guided procedures on these people yeah so well so first I don't I don't do any prolo here so I certainly haven't done that um there have been a few and not recently but a few that that I've treated with with PRP um again because I don't offer offer prolo and um I don't know they've done fine um now does that have anything to do with the PRP or is that just kind of their natural history and they would have gotten better regardless I don't know um I think you know there's potentially some some role if somebody's struggling to get back um to you know essentially you know augment their healing and get them over the hump but I don't know I'm not I'm not overly convinced um at least at this point that it makes a significant difference you know injecting into that area but again that's that's um just anecdotal evidence in my opinion um so I guess there's one question here quickly um if you guys just want to comment on this you know how do you think image quality on a porn machine versus a cart-based machine especially with doppler affects your decision making yeah I think it's it's similar to what we said before so since ultrasound um is more of a screening tool as opposed to MRI um if you have a strong suspicion even if you're not seeing any clear findings on ultrasound we would still recommend going for the MRI and then alternatively if you do see higher grade features concerning for a fracture we'd also recommend MRI um so just yeah more of a screening tool to help support your clinical suspicion but I mean I do think that certainly on things like say a butterfly um it's going to be pretty challenging to to get like really quality images um you know and otherwise you know the sort of smaller portable ultrasound is probably a little better um but certainly yeah it is definitely more challenging with the the more portable machines yeah so just injuries so just some nuts and bolts of the doppler because it is an important uh point with with these injuries um so you know using a fair amount of gel because this is fairly uh close to the subcutaneous tissue so it won't take much pressure uh to get a false negative with doppler so a fair amount of gel um and then just optimizing the doppler gain um you know with whatever machine you're using by uh you know turning it up getting some of that speckled appearance and then turning it down until that speckled appearance goes away so you know your image of uh the doppler from stefano bianchi's um uh paper back in 2018 on periosteal abnormalities um you know he he's just a master at this and every machine has has a probe that seems to be better at doppler and so i know exactly what probe to use on those images it uh because i have the same machine and and the same um uh sensitivity that that is just better and so maybe you might not have that option with a you know with the portable but on your cart based machines you typically have probes so with a fair amount of copious gel and being sensitive to the gain um you can definitely optimize that which you know seems prudent in this case so this was a really good presentation and a really good it can be really frustrating for clinicians and for patients um to get better yeah great great job guys this is a good topic and great conversation um that you all stimulated afterwards i think yeah we'll see we'll see where in the interest of see where this data what the data looks like um when you guys put that out uh whenever whenever that is and you know seeing down the road if i think my biggest question here is is can ultrasound help with gradation right i mean can there's certain findings that you know we're looking at this year um are there certain sonographic findings that correlate with you know the the classification based on mri so i think that's that's still um to be seen but anyways again great job um great great case great presentation uh thank you guys for getting up ungodly early on the west coast and hopefully you guys can go take a nap or or get some coffee or something um thank you absolutely all right so that's it for today we are off next week and then we'll be back on the 25th uh we've got megan burleson and elizabeth nguyen out of university of washington they're going to be talking about a case of parcel tunnel so again that's on 225 otherwise happy friday again everybody have a good weekend and thank you stanford folks for that talk all right see you guys

3rd Edition, CASE 18

3rd Edition

Foot

medial tibial stress syndrome

ultrasound

bone stress injuries

cross-country runner

tibial stress injury

sonographic evaluation

non-invasive imaging

stress injury detection