So I'll let Ryan and Doug moderate any questions because for some reason my chat box isn't popping up, but so as Ryan mentioned, so our goals here are going to be a little bit different than the typical stuff we've done before and so we're not going to try to go through all the pathology and everything from that regard. We're really going to just try to do like a practical case and focus on maybe a few relevant things from that individual case, but really try to put it in the context of how you're going to approach this in the clinic. So start with the referral and then how do you set up your protocol, what I do for my protocol for this particular problem, and then particularly in how do you then convey that information to your colleagues? And so how do you actually write the report? I think this is one of the hardest things for people to do when they move from getting good at scanning and then recognizing pathology and then you have to describe what you're seeing and that's often the hardest thing to do. And so I think that's what we really want to try to accomplish with some of these talks is sort of helping everybody along that pathway. And the other thing to say too is there's probably more than one right way to do this. So people may have different scanning protocols that they use. That's fine and share those. I think we can all learn together with this. There's probably different ways that people do imaging reports and so you all see that when you get different radiology reports back from your own clinic. And so this is the way I do it. It's not necessarily the way you have to do it and we can maybe have some good discussion whenever people are seeing things that they do differently. So today there's a few disclosures from my end, nothing really relevant to our talk today. So we talked about our learning objectives. So we'll hop into the case. So this is kind of how I walk through a case that comes into my clinic. So step one is going to be finding out what are they here for? And so usually we'll look for an indication. Hopefully the referring provider put in a good indication on the referral and in this one I see I have a 35 year old female. She has acute on chronic atraumatic right shoulder pain. She was seen by one of our orthopedic PAs. X-rays were performed and there was a calcification note on the x-ray. And so she was sending for an ultrasound to evaluate the rotator cuff as well as the presumed symptomatic calcification. So step two is going to be review available imaging. And so this is a really important step and sometimes people get really excited to go do the ultrasound and see the patient. And this is a step that can get missed at times. And it should never get missed. It's really important. Doug brought this up last time, but if you have radiographs, get them, review them. And if there's other imaging, look at it too, because it can really save you a ton of time on the front end if you go in with your eyes open by what's already been done. So in this case, we have shoulder x-rays. We already knew that. That was part of the referral. And we can see indeed there is a calcification. And so you can start to get information and start to develop your differential diagnosis based on these radiographs. We can see this somewhat amorphous larger calcification, likely in the supraspinatus here. We know it's in the rotator cuff based on the positioning. And so this is an AP view. We can see greater tuberosity. It's going to be here. Other things that we're going to look for, you know, certainly the location of this. We're going to use all the different views, but we get a somewhat of a sense that this is more anterior versus posterior just on the radiograph. So that helps whenever you're going in to do your ultrasound. You can also look for other things, right? So we know there's not any significant degenerative disease of the joint here. And then we also know, and this is one of the more important things just to recognize, is, you know, where this calcification lies. Is it in the rotator cuff or the bursa? So sometimes we'll see this that's sitting down here. And we know just based on the radiograph that this is already erupted into the bursa and is now you know in that space because the cuff is going to insert here, you know, not down here. So those are all really helpful things to get. That you get a lot of information just off one picture. Just a companion case here. This is a pet peeve of mine, but we'll get these not infrequently. This was just a couple weeks ago. We got asked to do a diagnostic ultrasound or evaluate for rotator cuff tear. What do you think the answer was, right? It's, you know, if the rotator cuff needs to live in this space here, you know, there's not any space here for it to live. And so this is the same as getting, you know, an x-ray of the knee with grade 40A and then, you know, ordering an MRI for a meniscal tear, right? It's just a waste of time. And this is another example of something that you might see. And again, it's quite common these things come in. This was an elderly patient. Couldn't raise their arm up well. It hurt. Yeah, I mean we already know what's going on here. This person has rotator cuff arthropathy. They've got all this sclerosis. They've got lack of distance between the head of the humerus and the acromion. They've got degenerative changes. And so advanced imaging in these cases, you know, often is not required. All right, so we looked at our imaging. We looked at our referral and now we need to figure out what's our scanning protocol going to be. And so I have a few different scanning protocols depending on what the clinical question is. And so I encourage all of you to have at least a scanning protocol in your head, if not written out, and how you're going to approach some of these problems. And so for the shoulder, oftentimes we're doing a you know, a complete exam of the shoulder region. That's really the rule here. There may be times whenever people have very specific questions, you know, say there was an MRI that was already performed and now there's a specific question about a dynamic process or something like that. Then in those cases, I will do limited exams just trying to answer those questions. But by and large, we're typically doing what would fit for a complete exam of the shoulder region. Now a complete exam of the shoulder region doesn't necessarily cover every possible structure in the shoulder region either. And so you can see that this is kind of my standard required images and this fits the bill for a complete exam of the shoulder. But then there's a handful of other things that I may or may not do depending on the clinical scenario. So, you know, everybody that comes in with shoulder pain is not necessarily getting a detailed evaluation of their pec tendon. You know, I may not be doing a sternoclavicular joint eval and everybody who comes in with, you know, with typical shoulder pain where I want to look at the rotator cuff, you know, certainly not imaging the lat and everybody. But these do come into play for certain scenarios. So what we're going to go through is basically these images here and we're just going to go through one by one and how I would document these. And so there's different ways to do this, but typically I would say I mean when I first started all of my studies had like 10,000 pictures associated with them and that's difficult to actually go back through and navigate those images and it makes the people managing your PAC system upset when you're dumping over that much. So I think being efficient in the number of images that you're saving is probably a good idea and that's something that I've tried to work on over the years and it gets hard to do but I think having some good representative images and probably not more than you need is something that I found helpful. And so I always start at the biceps tendon. I have the patient lying down on their back, usually head of the bed up a little bit. Their palm is going to be supinated and we want to orient off the bicipital groove. And so in this case we can see the biceps tendon sitting here within the groove. I usually like to have an image somewhat like this that delineates the bony morphology. So here it's pretty clear where we're at and then here's the biceps tendon, which looks pretty normal. No sheath effusion. For the purpose of this I have labeled everything up just so people can see. I typically wouldn't label everything to this degree on my images. And so the labels down here are the ones that I would have and then I may put some annotations and arrows on important findings. Otherwise, you know all this stuff you see up here probably wouldn't come through on the images. I usually will then follow the biceps up a little higher and get a view towards the intra-articular portion of the biceps as well. And so usually if everything's normal, I get two short axis views, one in the groove and one up at the rotator interval. Here we can see the subscap and the supraspinatus and we're already starting to see some interesting stuff over here. And so my pearl here would be to not get too excited. We already know this is going to be the area that we're going to want to look at. So I usually save that for last so that I make sure I get through all the rest of my imaging. I do my same protocol every time so I don't forget to do something and get all excited about the pathology that I'm seeing. Next we'll move to a long axis view. You should always try to get orthogonal views of all your structures. You can take this long axis view if it's normal, you know, wherever you want. This one's a little bit higher right as it comes out of the intra-articular portion. You can certainly get one down at the muscle tendon junction as well as you want. You know, you can take a couple but I think if there's nothing really suspected, one normal view here I think is reasonable. So after the biceps, I then move to the subscapularis tendon. So the patient's going to be an external rotation at this point. I usually like to use the coracoid as a nice bony landmark to orient and if that can be included in the image, I think that's helpful. One, in case you forget to label here, then it's quite clear which directionality you're looking at. And it also ends up putting you pretty much in line with the long axis of the subscapularis tendon. And so we can see lesser tuberosity here, subscaps inserting, coming down to the myotendinous junction. So again, normal appearance of the subscap. If the patient had some mechanical symptoms that you were concerned about, potential biceps instability, then this may be a time to do an assessment of biceps stability, looking for any subluxation or dislocation through or above the subscap as well as potential for subcoracoid impingement. If there was a clinical suspicion of those diagnoses. And then we'll get a short axis view again of the subscap. So trying to label superior, inferior, I think is helpful here. So just for orientation purposes. And again, we can see subscap short axis on the lesser tuberosity. So that was normal. Just include two normal images and then we move on. From the subscap, I'll move up to the AC joint. And so this is a pretty normal looking AC joint, which is fairly uncommon in my practice. You see a lot of abnormalities at the AC joint, oftentimes which are asymptomatic for folks. But the things we're going to look at here, we're going to look at the bony margins. So we're going to see, you know, is there any irregularity, spurring? Are we seeing fragmentation? You know, suggestive of distal clitoral osteolysis. We want to look at the capsule. Do we see distension? Do we see any free fluid? Typically, we'll put the Doppler on to see if there's any Doppler flow around the capsule as well. And then we'll often get a orthogonal view here as well. And this is the view that we'll often use for injections. And so this is just showing kind of the actually inside of the AC joint. So this is anterior to posterior shooting right down between acromion and clavicle. And here we can see, you know, very calm AC joint. There's no free fluid, no capsular distension. Capsule looks good. No evidence of prior trauma. And so this is an area where I typically will like to include a little information in my report, given how common abnormal findings are here. I usually will make some comment if the patient had pain with you know, transducer pressure there. If they have significant abnormalities, we might do some dynamic testing just to confirm stability and such. But luckily in this case, things look pretty normal. So we were able to move on. At this point in my protocol, I'll have the patient lie on their side. So they usually roll up away from me and then that gives good access to the posterior musculature. So at this part, really what I'm looking at is doing a muscle eval. And so I like to get a nice view of the infraspinatus and teres minor muscle bellies with the deltoid then overlying the back. And so here we're really looking at both the size and the echogenicity to characterize any evidence of fatty infiltration or atrophy of the muscles. And so the teres minor can serve as a control muscle when it's normal in comparing echogenicity with the infraspinatus. Or it's not uncommon to note isolated teres minor fatty infiltration and potentially atrophy as well, perhaps from a subclinical quadrilateral space syndrome. So just a few points on muscle evaluation of the cuff. The orthopedic surgeons often like to use this as a reason not to get ultrasound. And despite there being multiple publications, even on their own journals, a lot of times they continue to propagate this information. And so, you know, depending on the patient, if you have a patient that images very sub-optimally, they're obese with diabetes and otherwise, who are probably not good surgical candidates anyways, but MRI may hold some advantage in those cases. But by and large, evaluation of fatty infiltration of the muscles is not overly challenging. And this is kind of the grading scale that's typically been reported and used. And so you can use both echogenicity and architecture, simply being able to discern the intramuscular tendon and the pinnate pattern is pretty easy. And so you can see if we go back, you know, we can clearly see intramuscular tendon here. We can clearly see the pinnate pattern. And here the infraspinatus just starts to get whitewashed. And so it becomes hyperechoic. You start to lose the ability to distinguish that central tendon. And then you can see the difference between the muscles surrounding it. So typically using a grade 0, 1, or 2 provides good information and is actually relatively straightforward. And the literature shown has pretty good reliability. So after I do my muscle evaluation, then I will get a view of the teres minor. It's pretty rare to have isolated teres minor issues, but you will see things here from time to time. I've had some interesting cases of, you know, isolated calcific tendinopathy of the teres minor. So you should, you know, be comfortable imaging this tendon separate. This is a hard tendon to image and I see a lot of people will struggle and actually end up getting a view of the inferior infraspinatus instead of actually the teres minor itself. And so the way that I will find this is I will start in this view here of my short axis and I will follow this out laterally towards its insertion. And then once I get towards the insertion, then I will rotate my transducer to get this long axis view. And you can see the the teres minor is a little bit shorter, stouter, smaller tendon through here. This is what it should look like. It looks quite different than the infraspinatus tendon and its insertion is quite separate. So using that trick in short axis and then rotating will help you be able to identify this well. From there, then we'll slide superior and then visualize the infraspinatus. And so I usually like to have a view of the muscle with the central tendon. Again, you can see the nice pinnate structure of the muscle here coming down onto the central tendon of the infraspinatus. Again, this helps you in making that call for any fatty infiltration. And then we'll follow this out a bit towards the insertion on the greater tuberosity. At this point, posteriorly, I'm still predominantly looking at the muscle. I will get a view of the tendon here, but this is not my infraspinatus tendon evaluation. And so the infraspinatus and the supraspinatus really should be thought of as one tendon. It's the continuity of the rotator cuff at that point. So I like to evaluate that really starting at the front at the rotator interval and working back and considering it as one structure as opposed to trying to piecemeal it together with a separate view of the infraspinatus here and then moving towards the supra. So I'll get a view here, but I'm not going to get too excited and if I start to see stuff, I'm going to characterize it later. So from there, I'm going to come back and get a view of the posterior glenohumeral joint. So here we have the humeral head, the glenoid, the labrum, and again, the musculature over top. We want to look for any effusions, you know, in a sports practice, it's pretty common to see things like Hill Sachs lesions here, you know, regularities, you might see some less or some more subtle irregularities consistent with internal impingement back here where you may be getting some contact in some of your overhead athletes. And so, you know, there's a variety of things that you're going to look for on your usual scanning protocol. If you are looking for effusion and you don't see it here, you may consider moving your transducer just a bit inferior towards the axillary recess where you may see some fluid that has collected at that point. But for our patient here, glenohumeral joint looks pretty good. Then we will slide, just make a slight rotation of our transducer to bring the spinal glenoid notch into view. And so here we just are a little bit back posterior, slight rotation. And now we have the glenoid that we saw before. Here's the labrum again, humeral head. And then now here's our spinal glenoid notch. And so we look for any space occupying lesions in here. As you know, the neurovasculature runs underneath the ligament here. And so particularly labral tears can come back and end up getting a cyst in this region. And that's something that we'll always look for, particularly in our overhead athletes. So after a spinal glenoid notch, then I like to look at the suprascapular notch. And so for this, we simply come up to the spine of the scapula and then we just bring our transducer just over and shoot down through the trap and through the supraspinatus muscle and get this nice contour of the suprascapular notch. This is the same general principles, the spinal glenoid notch. Again, looking for any space occupying lesions here that may be compressing on the nerve. We do also get a long axis view of the supraspinatus muscle here. So you can start your muscle assessment at this time. We'll then turn into the short axis at the same level. So we're still here. We just flip the transducer in short axis. And I prefer the short axis for making my muscle evaluation. And so this is the same as we talked about for the infraspinatus. We want to see that we can appreciate tendon pinnate pattern, and this should completely fill the fossa here between our two bony landmarks. And so this is a normal, healthy appearing supraspinatus. If we start to see atrophy, we'll see that this muscle will decrease in size and will not completely fill the fossa. And again, the same thing with the internal echo texture that we talked about for the posterior muscles. All right, so now at this point, I will have the patient bring their arm back, essentially recreating a modified crass position. I like to do this with the patient side lying. And so now they're going to essentially bring their elbow back into extension at the shoulder. And so gravity is going to keep the elbow down, and so recreating that modified crass position without having to fight and struggle with them in a typical seated position. So the first thing you want to do here, and I always begin my rotator cuff evaluation here in the short axis. I've really come to rely on the short axis as my preferred imaging, and then confirm in the long axis. And so you want to find the biceps tendon, because you need to orient yourself. And so we find the intra-articular portion of the biceps tendon, and this ensures that we're seeing the anterior margin of the supraspinatus. From there, then we will scan posteriorly back through the supraspinatus and then into the infraspinatus. So here, we know we're looking for this calcification. We know it's present because we reviewed the x-rays. And we can see here's the calcification we're seeing already in the posterior supraspinatus. So here, what I'll do is I'll give a location of where this sits. And so we're going to measure back from the biceps, and that way I can tell whoever needs to know that this calcification starts about a centimeter posterior to the biceps. That measurement also lets us know that this is lying within the posterior supraspinatus and extending into the infraspinatus. So then we want to get better measurements, so then I'll continue to optimize my image now for this calcification. So I'll bring my transducer a bit more posterior, still in the short axis. And now we can see that the calcification itself measures just over a centimeter. We can also appreciate that the supraspinatus anteriorly here looks pretty healthy. So we don't see anything that looks concerning for tendinosis or tear. I will put the Doppler on. The Doppler will help us just identifying some of these cases that are in the resorptive phase and may be associated with acute inflammation. Then we'll move to a short axis, or a long axis view rather. Again, we're going to get further measurements, so I like to know how big this calcification is. So now we can see it's about a centimeter by a little over a centimeter by not quite half a centimeter in dimension. So now we have a good dimension of the calcification. Here obviously we would scan the supraspinatus in its entirety, and you may want to document normal image a bit anterior to this. And then you can come back into the infraspinatus as well, just to make sure there's no associated tears or other pathology. We're also noting the subacomial bursa at this level, and so here we really don't see any significant bursal thickening or bursal fluid, which is actually somewhat surprising. Oftentimes in these cases of large calcifications, you will see some associated bursitis, but here things actually look relatively calm. So we've got calcification. In terms of describing this or what it is, we know this looks like the typical calcium hydroxyapatite deposition. It really is an amorphous calcification. We always will comment on shadowing because the shadowing is going to help us in determining how hard this calcification is, and we can see differences in shadowing. And so we'll see in this instance here, we see a little edge shadowing coming off, but by and large we can see through the majority of this, which would be pretty typical for some of these softer calcifications, and this is what our case looked like. If we click back, we can actually see through this pretty well. We can still see all the normal bony contours deep. So that helps us when we're trying to determine the consistency of this calcification. The other thing we want to consider is, is it symptomatic? And so one of the main reasons for being symptomatic is going to be either the mass effect, so it's getting in the way. And so we'll get to our dynamic assessment in a second here, but here's some just examples of that. You know, trying to do a dynamic study where we see this large calcification, it's just not moving. This is a different one where we actually see it move just fine, and this was an asymptomatic calcification. The other reason for being symptomatic may be inflammation. So these can resorb, they can then leak into the bursa, and you can get really nasty calcific bursitis associated with these, and that's part of the reason for looking at the bursa as well as the Doppler flow. So here's our, I apologize for the CINI loop is not the highest quality, but here's our lateral impingement testing, and so this is our usual shoulder abduction. We're visualizing the acromion here. Here's our little calcification, and we can see the patient actually clears this pretty well. And we really, we'd like to see maybe a bit more humeral depression, but we really don't see a significant amount of impingement signs that we would normally see. So at that point, what we want to do is look a little bit further medial at the coracochromial ligament. And so we want to visualize the coracoid, you can get a nice view of the CA ligament going towards the acromion here, and then your rotator cuff is going to live underneath this area. So this is a normal view of what it should look like, and this was our patient just at rest. And then we ask her to then bring her arm up into abduction, which was her painful movement, and we could see that the CA ligament actually tense, and so we can see it come up, and we can see the calcification now coming underneath. And so indeed, she does have dynamic impingement, but it was not appreciated at the acromion, but it's a bit more medial at the CA ligament, which is a common area to see this problem. Here's another grainy, slow CINI loop, which I apologize for, but we'll see as we move dynamically. Here's the CA ligament again, this is the coracoid, and we're going to see as she comes into abduction, the rotator cuff is going to come into view with the calcification underneath, and then we'll begin to see some tenting of the CA ligament, which is going to correlate with pain. We can actually see she's trying to rotate her arm a little bit to try to cheat this thing around best that she can, and then we start to see the calcification come in here at the end and tend to ligament. So external impingement, the usual stuff that you guys are used to seeing is going to be these findings out laterally, and so here's the acromion, you know, as this patient brings their arm up into abduction, we're seeing fluid accumulating, so this is essentially fluids getting milked out of the bursa laterally here, so that's a very common finding, and in this we're seeing bunching of the subacromial bursa, so we can see this thickened bursal tissue that's getting actually caught at the acromion and bunching up and resulting in pain. So these are the things that we usually talk about with external impingement, but don't forget to look at the CA ligament, because sometimes this will be the only area that you may find this. So this was a companion case of a young teenage volleyball player who came in with shoulder pain and had, I think, three MRIs, just wasn't getting better, nobody knew what was going on, was unable to play, and her ultrasound was entirely normal except for this, and so we can see, again, here's her CA ligament, as she comes up into her painful overhead position, we can see the tenting of the ligament as well as on the sinew here. What was interesting in this case is I was actually able to completely correct this by simply stabilizing her scapula, and so this was very helpful to show the patient and her mom that all the physical therapy that everyone had been talking about actually could make a difference here, and I think this was really a moment where they bought into the whole idea of doing physical therapy and not being told there's nothing wrong with her shoulder, she should go do physical therapy, but actually showing her there was something wrong with her shoulder, but the fix was not surgery, it actually was physical therapy. So this can be very helpful, but don't forget the CA ligament view. All right, so last thing here, then we'll finish up. So what are we going to say about this? How do we report the findings? And so there's different ways to do this, I encourage everyone to have some sort of template so that you can work from, and so this is the way that I do it, and so some of this stuff is blown into my note automatically, so we use Epic here, and so I have templates set up, and a lot of this stuff is nice for me, so encounter date comes in automatically, the orders, associated diagnoses, all these stuff get blown in, so I don't have to worry about that, referring provider gets blown in as well, we'll have our indication, I always put the study type, so is it a complete or a limited or a follow-up exam, I recommend putting what ultrasound unit you used as well as which transducers were used during the study, sometimes these are going to be present on your image, and so it may be redundant, so it's up to you to decide how important it is to have those here. We want to have the location, obviously the laterality, I like to put any comparison studies, and so if I looked at any x-rays or MRIs, I'll typically put those on the report here as well. In my finding section, particularly for the shoulder, I have this templated off, so everybody can know exactly what I looked at and what I found, and so we can see the long head of the biceps, I simply say it's intact, it's where it should be, and there's nothing wrong with it, and so I'll put those, some people will just put unremarkable, some people may just not put anything at all, and just report the positive findings, but I do think it's helpful to have at least some running list of what you looked at, so somebody knows both from a billing and coding standpoint, but also the referring provider knows that indeed you did look. If the question, if there's a specific question, right, there's a question, you know, is the biceps unstable, then even if it's completely normal, you definitely should at least at that point say specifically, you know, answer their question and say, you know, the biceps was stable, no evidence of instability, something to that regard. Same thing here, so subscap is intact, normal, AC joint, same thing, looks good, infra, teres, when a humeral joint, we just kind of list them off with sort of the normal language here. Then we get to the supraspinatus, and so say there's an amorphous calcification, I say where it's located, so it's posterior to the biceps, about a centimeter, I say how big it is, let them know that there's minimal posterior acoustic shadowing, again suggesting this is a soft calcification, really not much flow on Doppler, I don't see any associated tears, the muscle looks really good, subacromial bursa actually looks surprisingly normal, and then impingement testing, I talk about tinting of the CA ligament, which resulted in pain, consistent with her pain and consistent with impingement. So in my summary, we have right supraspinatus calcific tendinopathy, I don't bring all the details down into this part, and I just say there's impingement at the CA ligament, and then there was a specific question about an associated rotator cuff tear, and so I will answer that question specifically down here in the summary, that no, there is no evidence of a rotator cuff tear. So that's my report, and that's how I typically will go through a shoulder exam. All right, any questions that folks have about this case or about general approach to reporting or anything else? Hey, Derek, this is Doug Hoffman, that was awesome. I just have one comment and then one question, I just want to emphasize the whole evaluation of muscle and muscle fatty replacement atrophy, because we get those from our surgeons, again, with the misconception that you need an MRI to do that, and then the other comment with that would be that Terry's minor is the most common asymptomatic denervated muscle seen on routine MRI, so just be aware of that. My question is, is it's really common to see fluid within the tendon sheath of the bicep's tendon. Do you want to comment on that, Derek, and how you handle that in your report? Yeah, so that's a good point, and it depends on how much fluid and what the clinical scenario is, but in some regards with these reports, we're reporting what we see, right, and then you have to decide how much extra you want to put into that, and so usually, if there's fluid, I'm going to say there's fluid, I'm going to say how much fluid there is, so is there a small amount of fluid that's just on the underside of the tendon and the dependent portion, then I might add something like physiologic amount of fluid, I will always comment on if there's associated Doppler flow, and if there is any fluid, I will state if it's painful with transducer pressure or sonopalpation, I'll comment on if it's displaceable or compressible, trying to get at is this truly tenosynovitis, is this just a physiologic amount of fluid, or is this a glenohumeral joint effusion, and so that's part of your task here is trying to sort through that the best you can within the confines of an imaging exam, but recognizing, you know, since ultrasound is dynamic, you actually can figure a lot of this stuff out, you know, easier than you can just if you're reading an MRI, you have to just say what you find, but here you can add a few of these different things, but if you do see something, you know, and if I think it's not really applicable, then I may give a little bit of further information, or if I think it's the deal, right, then I'll provide that information as well and say it hurts, there's Doppler flow around it, you know, and then call that out as tenosynovitis. Any other questions anybody have? For those of you still on, just a reminder that this is posted on the AMSSM YouTube website, you know, for anybody to review in the future. I mean, Derek, that was really, really very good, top-notch. Um, so we'll...

3rd Edition, CASE 51

3rd Edition

Shoulder

case-based learning

clinical practice

shoulder pain evaluation

ultrasound imaging

calcific tendinopathy

impingement issues

diagnostic protocol