Next one is going to be in two weeks, October 9th. And we're going to, Dr. Kentaro Onishi is going to present a medial knee case. And then the one after that will be October 23rd, where Dr. Ryan Kruse will present a plantar hindfoot case. So we're just going to roll along with these case series. The cases have been in discussions and presentations have been impressive so far. And I'm pretty sure that we're going to see another impressive case today from Dr. Adam Porcho. Dr. Porcho comes to us from Seattle in the Swedish hospital system. I don't think there's probably any residents on right now. But if you're watching this in the future, careful if you apply to fellowship, because you might be required to get up and watch this at 530 in the morning. Anyway, I've gotten to know Adam pretty well. And the majority of Adam's practice is either diagnostic or interventional ultrasound. I can speak firsthand that Adam is impressive with both of these skills. We collaborate on a number of cases together. So with no further ado, I'm going to turn this over to Adam. All right, I'm going to share my screen here. And I continue, yes. There we go. All right, let me know if you guys can see all of that. Looks good. All right, hopefully. Can you guys see that? Somebody confirm. All right, good. All right. Great. This is a much younger me, probably like six years ago before I grayed out and lost my hair. But anyway, so we're here to talk about lateral elbow. Full disclosement, Derek. Anyway, so yeah, we didn't win that grant. But this is kind of how this year feels so far. I don't know what else can happen besides hurricanes and the forest fires. But yeah, it's a little bit about me, Michigan State grad, undergrad and medical school. And then I did my fellowship with Jay at Mayo Clinic a number of years ago. Anyway, special thanks to Selen, Jay Smith for training me, and then Doug for setting this up. I probably should have put Derek on here, but I didn't have a picture of him. Anyway, so lateral elbow, we're going to talk about the elbow, which is a very important skill anyway. So lateral, I'm going to kind of go over the scanning protocol first, and then we'll dive into a case. Same way I teach my fellows, basically, we'll go over the protocol, and then we'll go over a report and what that might look like. So this is a standard AOM protocol for this. The ones you have to hit are on the top here, and the advanced ones that you sometimes hit are kind of on the bottom here. Anyway, let's get this party started. For those of you who remember what this is, we're probably aging ourselves. For all the young fellows and residents on this, probably means nothing to you. Anyway, so patient positioning. I typically position the patient seated with a couple of pillows under their elbow. This allows me to point at things. Usually I use the cursor, but for this, you wouldn't see the cursor on here. But it allows me to point things out and explain things to the patient as I'm going. I find this very effective. It saves time at the end of the exam because I'm explaining things as I'm going. And I think that patients really like to see the pathology as you go, too. Anyway, so let's talk about the tendinous anatomy first. So you really have a tendinous complex here. You have four tendons coming together. The most anterior one, extensor carpi radialis longus, followed by the extensor carpi radialis brevis, your extensor digitorum commonus, and then your extensor carpi ulnaris. Commonly accepted in the literature, and in my experience, the ECRB is the most affected tendon out of these with pathology. And it also has the most varied insertion point. I find sometimes it blends in with the EDC. Sometimes it has its own facet. I'll show a couple of examples of that here. And so your first view, they say kind of the home base for this is the long axis view of the ski jump view from the side. You can see a great view of the common extensor tendon complex, rate of collateral ligament, the anterior ligament, anterior recess, all in one view. And then you're going to do a sweep from distal to proximal. And I'm actually slightly varying the distal into my transducer to keep all of the tendons in view. And I'll show you what that looks like in individually isolating the tendons as well. So I'm looking for radial collateral ligament tears, effusions, I'm taking a look at the joint if there's any arthritis, and then also looking at the tendinous structure here. And so now we get to our short axis view. We turn 90 degrees to that level. And at the top here, you see the four tendons. And then I want you to pay attention to where the ECRB ends up here. This one actually has a separate facet for it. And you can see how that has like a varied insertion point. And so once you start paying attention to how these tendons come together, you can be very specific about which tendons being affected, which in my opinion, probably affects your treatment. And you can be very specific what you're treating, whether you're putting orthobiologics in there or using ultrasonic tenotomy or doing various other techniques. I think it's really important to know what tendon you're actually treating. And then you can possibly design better braces and taping techniques for these. So these are the individual tendons together. Hopefully you guys can see the top one here. The first tendon we're gonna do from left to right. Here's the ECU. And so you can individualize these tendons. And they both have a different varying appearance, kind of a shallower facet for the ECU. The EDC is kind of your ski jump view. We'll see that in the second one here. And you can individually isolate these though. And then here's your ERCB. And this patient actually blends in with the EDC. And then here's our ECU. Notice the, or I'm sorry, ECRL. And so the ECRL has the muscle belly that is the closest to the lateral, kind of has the most proximal muscle belly. So note that that has actually inserts on the supracondylar ridge. So common findings, tendinopathy. I'll just show you guys a picture of that really quick. I threw some pathology in here along with my case. Hypochondrogenity, where you're gonna get some darkening of the tendon. Partial thickness tearing after treating thousands and thousands of tendons at this point. I'm convinced that most of these probably have a partial tear hidden in them. And you'll see this when you inject any type of lidocaine or saline into them. It'll actually open up these tears. And I think that's kind of how mostly start, these micro tears, and then they change from type one collagen to type three, which is less able to withstand a tensile load. And then the tendon continues to fail along those lines. You know, oftentimes too, with the lateral, or the common extensor tendon complex, I find the radiocollateral ligaments almost always involved with it. Sometimes the annular ligament. Again, most common is the ETRB. Check for dynamic instability. We'll go over that later in this lecture. And then looking at the posterior neurostasis nerve, other reasons why you might have lateral elbow pain. So think of it kind of as tendon failures, kind of the way I think of it. So this is a 38 year old male. By the way, this is my elbow from two and a half years ago. This is a tendon tear. So mine was about 90% torn along with my radiocollateral ligament. And so I did a combination of ultrasonic tenotomy and leukocyte-rich PRP. And you can see how this tendon heals from the initial one at the top to my six week, and then down to my 12 week healing over time. I can tell you that for you, those of us who haven't had PRP in a tendon, it's extremely painful. That was pretty miserable for about a week after I did this. And then I think I taught a course with Doug the same week, I was right before AMSSM. Calcium hydroxyapatite in the elbow. I've seen this in just about any tendon in the human body. Most common is the shoulder. And so this particular patient, this onset of this was very quick over a course of two to three days, this was a hairdresser. And we were able to flush that out and get her back to work. So I include the distal biceps tendon. This is not part of the original protocol, but it is a tendon that's in this area that I find gets overlooked for lateral elbow pain. I've seen people come in for a lateral epicondylitis or a tennis elbow evaluation, and it ends up being the distal biceps tendon. So this is the pronator window. And so you're gonna start in line with the humerus and you're gonna slide until you see the artery. And so once this loops around, I'll hit the other video here and we'll see that go. So here we go. So this is what it looks like when you're doing it live. And as soon as you see the artery, you're gonna start seeing the tendon deep to it. And then you can do dynamic pronation supination to take a better look at that tendon. So what might tendinopathy look like in this? This is an example of distal biceps tendinopathy. Now there's probably again, a partial tear in there. You can see the hyperemia in this. Now, not all machines are gonna be able to isolate this hyperemia because the artery is right above it. So you'll get a lot of noise from that. This is a normal, on the right of the screen here is the contralateral side for comparison. Oops, skipped one. Sorry guys. Go back, go back. Oh, maybe it'll go back. Oh yeah, sorry. I got two keyboards here, sorry. There we go. And so this is a distal biceps partial rupture. This was treated with some Leukocyte-rich PRP, the short head of the biceps torn distally here. There's a 12 week and a one year follow-up. He came back for his other elbow. Anyway, this was a guy using steroids partially tore his tendon. And so now let's talk about the lateral collateral ligament complex. So we're gonna talk about the annular ligament, the radial collateral ligament and the lateral onoclateral ligament. And just note the angle of that lateral onoclateral ligament. Once you get that in your head, that's kind of the key to finding it heading down to the supinator tubercle. So first we'll talk about the radial collateral ligament. Typically I find that torn in the long axis view here, although you can confirm that in a short action. So I'll show you an example of that. And then the annular ligament, I like to test dynamically. And you can see that here, that this one's clearly intact. But this is the motion for it. You put it in short axis to the tendon, which is gonna put you long axis to the annular ligament. And then you can do dynamic motion of it. This is one that I just saw two days ago. This was a hyperextension injury. And clearly this annular ligament is torn. This patient also had a torn lateral onoclateral ligament and it needs some stabilization or they're gonna get pretty bad arthritis in the elbow. The radial collateral ligament of the elbow is important. This is a great study done by John Jacobson, I believe 2013, it might've been 2014, but anyway, studies up there. The bottom 54% of your slope here is ligament. And so note when you're doing procedures on the lateral elbow, that you probably shouldn't be using ultrasonic tenotomy in the ligament. Although I don't know if that's something people do or not, but try to keep it into what you're actually trying to treat unless you're trying to treat the ligament, probably should try to stay above that line when you're treating it. And so here's an example of isolated radial collateral ligament tear. This short axis view is at the bottom there on the left. And then this is 12 weeks after treatment showing interval healing of the ligament. Lateral ulnar collateral ligament, you're gonna start long axis on the joint like the picture on the upper right there. And then you're gonna rotate clockwise in this case, counterclockwise if it was the opposite elbow to get the lateral ulnar collateral ligament in view down to the supinator tubercle. So let that play one more time here so make sure everyone gets that. Okay, still hanging in there? All right, so we're gonna talk about the nerves because now we get into the more esoteric stuff that people don't think about. And I see a lot of nerve injuries in the lateral elbow. So start with the radial nerve. The radial nerve passes from cranial caudally between the long head and medial head of the triceps and then close to the humerus. And it's gonna pierce the lateral septum. Now this is the most common area for impingement after the spiral groove. With a type of fracture called the Holstein-Lewis fracture which is a humerus fracture with entrapment of the radial nerve. Average, there's a couple of studies out there showing the average size 7.9 millimeters squared. It goes round over round. So just note the size can change. And then immediately it's gonna split here into the posterior cutaneous nerve of the forearm which is then splits again anyway on that video up there. Again, common injuries, saturnite palsy, crutches, entrapment, septum. And so next one, posterior rossius nerve. I don't know why that's playing ahead of time. This is in my opinion, one of the hardest nerves in the body to scan. I always know when my fellows are ready to graduate when they can actually scan this in a 10 second sweep consistently. It does a 180 degree flip around the forearm going through the supinator muscle. You're gonna look for a leash of Henry which is a branch of the recurrent radial artery going over the top of the nerve. And then the tendinous edge of the ECRB, the supinator. There's a couple of areas where this gets entrapped, the arcadia ferox. And then of course, commonly referred for tennis elbow evaluation. So we're gonna see that sweep here at the top in its entirety going through the supinator and then it's gonna pop up in its entirety going through the supinator and then it's gonna pop out distally. I've seen a lot of issues with this nerve in various forms. And then this is a little bit closer look of it changing. Notice it normally flattens a little bit. So normally always looks a little bit big here. And I think that's probably subclinical dynamic impingement and I'll show you that in a second here. So looking at this dynamically, I think is really important. So you'll see this nerve here, if you keep your eye on the nerve on the right here, this one's gonna be dynamically impinged in supination. Now, I see a lot of this and I think people get subclinical impingement of this, just my own anecdotal experience, because you'll see what happens in long access to the nerve. So this is a person that was complaining about pain with doing biceps curls and doing full supination curls. The fix was to get him an ergonomic keyboard and to have him stop doing full supination curls. So you can see how that nerve gets tethered in range of supination. I was thinking about going to the next slide. I can tell, there we go. Okay, so talking about Leish of Henry, this is an example of that. There's a recurrent radial artery going over the top of the nerve. So you can see the nerve breaking off from the radial nerve, the PIN and heading underneath the artery, which is going over the top of it, just proximal to the arcade of Frosch. This is what that looks like in long access. Notice how the artery indents the nerve. And so I find these also can lead to a worsening of the dynamic impingement I just showed you. Okay, and then a couple other interesting things. Here's PIN entrapped by ganglion. Obviously, when you see a mass, you do your usual things of throwing the Doppler on it. Is it a pseudoaneurysm? Is it compressible? This ended up being a PIN or a radiocapitellar ganglion that was impinging on the nerve. And so obviously, this guy's joint is the issue. There we go. Distal PIN entrapment. If you watch this, this is our sweep here. Looks pretty good coming into the tunnel and into the supinator. And as it comes out, you'll notice vesicular heterogeneity. Here's a closer look at that at the end. So some distal entrapment. Next one. Here's a PIN that was cut during a surgical repair. The one on the right is going from distal to proximal. This is going proximal to distal. You can see I lose the nerve through the incision site here. And this guy obviously had other symptoms on physical exam, like the inability to lift his wrist. So, and then you can see long axis on the nerve, a centimeter gap in between where it was cut and had retracted to. Wrong keyboard. Come on. There it goes. And then this is about four days ago. I had this case. It was sent to me for lateral elbow pain. This ended up being a neuroangiofibroma within the brachioradialis. So obviously you can have tumors, all sorts of things. So I was just doing my usual scan of the PIN and saw this lesion here. But after removal last week, it confirmed a neuroangiofibroma. So you can see it's highly vascular. Superficial radionerve. I don't see a ton of problems with this at the elbow. I haven't seen a ton of injuries of this, but needless to say it's there. It's gonna break off from the radial nerve and then travel under the brachioradialis. I see more pathology with this at the wrist where it's around the first dorsal compartment and the SR2 and SR3 branches of it. But needless to say, cover it as part of the elbow protocol. Now we're talking about lateral antebrachial cutaneous nerve. This is the most common nerve taken out on a distal biceps repair or a distal biceps rupture. Now I find the best way, this is a continuation of the musculocutaneous nerve. Best way to find this is find it more proximal in between the biceps and the brachialis. And then it's gonna swoop underneath the biceps tendon, end up underneath the cephalic vein. And you're gonna see that here. So it's at risk in venipunctures and then certainly any type of a biceps tendon distal rupture there. And it spreads out very quickly into its multiple branches for sensation. Last nerve to cover here, the posterior antebrachial cutaneous nerve. Great paper on this by Smith and colleagues at Mayo Clinic. The anatomy on their paper is awesome. So it very quickly breaks off from the radial nerve, just distal to the lateral septum. And you're gonna see that here at the top image. And then it very quickly splits into anterior and posterior divisions. You'll see that here on the video and then I'll sweep back, show that division. And then towards the elbow, it splits again to the nerve to the anconius and then to the epicondyle branch, which is at the most at risk during any type of procedure to the lateral elbow. So just note it usually lies right over the lateral collateral ligament or the lateral extensor complex. And so here's this some stuff from their paper. I encourage you to read that if you want more information on it, but it's a they did a great job of kind of dissecting all this out. So here's our case. So that's our protocol and then I'll go through the case and I'll demonstrate this protocol again and then kind of go over our report. So I had a 32 year old female professional guitar player. She had gradual onset left lateral elbow pain with playing. She had pain rating down the elbow to the wrist, worse with longer periods of playing, unable to play for two days in a row. She rated her playing 5 out of 10 after playing. She had no numbers for tingling. She had no neck pain, no shoulder pain. She had weakness of wrist extension after playing for several hours. She had SAR PCP, she had normal x-rays. She was sent to physical therapy with a presumed diagnosis of lateral epicondylitis or common extensor tendonitis or tendinopathy, whatever you want to call it. As we know it has nothing to do with the lateral epicondyle, but she did therapy for eight weeks, really didn't help. No really significant other past medical history or review of systems. Again, she sent to me for a referral for lateral elbow pain. So she's slightly hypermobile with a recurve bottom. I find people with joint hypermobility have all sorts of weird nerve impingement syndromes. I'm sure other people can confirm that as well and probably leads to her condition here. She's full range of motion, some pain at the end range of supination. She was non tender over her tendinous complex, but kind of tender a little bit more anterior to that and kind of anterolateral elbow. Normal shoulder, neck. She had a painful Kozen's test, but no like a little bit of weakness of wrist extension. So I could see how this would be, people would think this was going to be a tennis elbow, but her tennis elbow stress test negative, hook test negative. Sensation was normal. Pain mildly exacerbated with resistive supination and then she had weakness of wrist extension. I had her go play before she came in so she could be really symptomatic for me. So here's our scan of this one. We start with our our at home base off the lateral elbow and we scan from anterior to poster and again you can learn how to, you can see I'm keeping the tendons long axis to him by slightly rotating the distal end which is to the left of the screen of my transducer to keep a straight long axis view of the fibers so I can best scrutinize them. A short axis view on the bottom here. Note in this case the ECRB actually blends back in with the EDC again. Sometimes it has a separate facet. I see a lot of variation of this and probably leads to why it has so much pathology. Here's our radiocollateral ligament and annual ligament. These both look fine. Here's my dynamic testing for that. So no rotatory instability here. Here's a lateral onocollateral ligament just for completeness. This also looked fine. And then we get to the nerves and we got to this poster neurosis nerve and my initial sweep I see this, whoop, you see it? So it gets big there. So she has a leash of Henry and quite a large vesicular change in the size of the poster neurosis nerve here. Here's a here's a zoomed in version of that. Probably the most obvious case I've ever seen of a true leash of Henry syndrome. And then this is what that looks like in long axis. You can see where the nerve is getting compressed down by the recurrent radial artery. And so what do we do with this? We actually blocked it there and got pain relief. But I'll go over the treatment. So here's what my report looked like for this. Obviously took the names and referring provider all that information off of here. And so I tend to do a paragraph form. This is how Jay Smith used to do it. And so I kind of talk about the structures that we look at and I have a template for like a normal elbow and I can remove or add things based off that. And so my report read no abnormality sensor tendon complex, distal biceps tendon, which I didn't include my image of it, but it was normal, or the brachioradialis tendon muscle. There's no joint effusion, visible abnormality of the radiocap teller joint. Obviously you can't see into the joint. So if you thought about seriously about an OCD, there's better imaging than this. Although sometimes you can see it. No lateral collateral ligament injuries. There's no evidence of chronic rotatory instability in Norman Mallee of the radial nerve at the spiral groove, the posterior cutaneous nerve of the forearm, superficial radial nerve. And then basically, we talk about what's abnormal. The recurrent radial artery did traverse superficially to the posterior interosseous nerve. And then I also put, you know, I put the buzzwords in there too, for whatever surgeon or whoever's doing it, because people see that and they're like, well, what's he talking about? Well, if you put Lisa Penry, they go, Oh, I sort of remember that from, you know, medical school, and they can at least look it up. So I put both terminology in there. And then proximal to enter in the radial tunnel arcata ferox, right? So they know where I'm talking about, relatively. And the surgeon I sent this to had me map this out presurgically for him anyway. And so, which we do a lot with our peripheral vascular and our peripheral nerve surgeons here. And then there's focal fascicular enlargement of the posterior interosseous nerve just proximal to the recurrent radial artery, indicating probable entrapment. So I always leave myself an out, right? I don't say, Oh, this is definitely entrapped. I say, Okay, it's probably entrapped here, you know, nerves tend to get large when they get pinched. And, and so it kind of leaves me an out. And then I always I always poke at these when you see them, right? You're like, Hey, is this reproduce your symptoms? Oh, yeah. Okay. Well, then a little bit more information from a from a diagnostic standpoint, about as much as you can get from from doing an ultrasound. So what do we do? I didn't know a diagnostic block at this at the point of entrapment. Her symptoms were 100% relieved following that. And she actually got relief for several days, probably just from the hydro dissection of it. But then her symptoms came back about a week later. And so I referred her to a peripheral neurovascular surgeon, they clipped that little extra piece of artery was completely symptom free by three weeks post and back playing live in a band actually went to see her in a show at one of the places out here anyway. So that that's our lecture. Hopefully, it gives you a little bit more information. A lot of people tend to just think of it at all as common extensor tendon, I can tell you, and anyone in this group can tell you from experience that there's a lot else going on there that we need to understand. It's kind of like when Doug gives his talk on the lateral hip, and I first time I saw it, I was like, Wow, I'm thinking of this wrong. So I think hopefully it gives you some, some insight to that. That's all I got, Doug. So any of us that are on right now who do a lot of ultrasound know that this was just an unbelievable talk on many levels. And so, you know, the level of not only picking apart the common extensor tendon, and its components and variation in pathology and how it relates to the lateral collateral ligament complex, but of course, the differential diagnosis, being one nerve entrapment. It reminds me of a couple things. One is, you know, your talk, Adam reminds me to, you know, each time I scan the posterior interosseous nerve, follow it all the way through the supinator. Sometimes I get a little lazy and, and stop, you know, at the arcade of Frosch and, and, and then we're good. I mean, I'll see it in the supinator, but I don't always follow it through. So that's a good reminder to do that. One of the reasons why we, you know, started this is to have a chance to talk about protocols. And I think Adam, you know, you included everything. I just, when I, just a variation of your protocol, I start with the elbow anteriorly, and I do a short axis at the, you know, the capitellum and trochlea, and then I go long axis to the radiocapitellar and only humeral joints. And then because then I'm also at that same position to do the posterior interosseous, and I go laterally, but obviously you're also going to get components of the joint as well. In my experience, I would imagine yours is the same. Probably the top differential diagnosis in the adult population of lateral elbow pain is osteoarthritis. Yeah, I would agree. So, but anyway, this is, you know, just really got all the components of it. Adam, do you have any pearls from your experience, differentiating, you know, common extensor tendinosis from maybe the posterior cutaneous nerve problems versus posterior interosseous nerve? You know, we're there already. So I think I think a lot of it's just a clinical picture. You know, patients that have a lot of nervy pain tend to have a lot of, you know, sharp, nervy pain. And then I'm never shy about, hey, I'm gonna just drop a little bit of anesthetic in this one area. Let me know if your pain gets better. And I haven't go do the thing that irritates it. And, you know, to kind of lead me down these these directions, like the case I presented is, you know, is this the problem we see changes in nerves all the time, and people have no symptoms there. So, you know, so we block it, and we see if, see if the symptoms go away. And sure enough, if they do, great, then you know, that now we can lead down a treatment avenue, whether that's, you know, doing a hydro dissection, or, you know, or, you know, in her case, I thought, gosh, you know, we'll try one injection, but I have a feeling that this is a, you know, a mechanical problem that I'm not going to fix with a needle. And so, you know, it can be hard to kind of suss that out. And sometimes, as you guys know, you have multiple things going on, you have somebody that's got a nerve problem on top of a tendon problem on top of a joint problem. So then it's like, well, what's driving what? What's the chicken or the egg, you know? And if you think it's the joint, then dunk a needle in the joint, see if the joint, if just taking care of the joint pain would give them enough relief, you know? And it's kind of like unpeeling an onion with a lot of patience, you know, you pick the most obvious thing, unpeel that layer, see what's left. Oh, now this really hurts. Okay. Or they may say, boy, I'm fine. Okay, so we fixed the worst thing. So I think, you know, you play that kind of dance with a lot of patients. And, you know, and usually I'll tell a patient, you know, I'm not, you have multiple things going on here. I think it's possibly this, you know, let's dive down this treatment avenue for a minute. And if we don't get anywhere, or we get, you know, 50% better, and then it's a 50-50 problem, you try to figure it out. So I think that's my biggest pearl is never be afraid. If you have those skills to be able to dunk a needle down and be very specific what you're numbing, you know, numbing one little area can do wonders for helping you figure out what's the pain generator here. Because there's obviously a lot of things that overlap. Yeah, I think that's a great point, Adam. I think a lot of us that, I think one of the more common areas to do ultrasound guided procedures, especially some people getting started with advanced procedures, is the lateral elbow. And I can tell you, I do the same thing. I'm not afraid to put a little anesthetic, even in the common extensor tendon, and to make sure, you know, that is the pain generator. If there's any question or symptoms are atypical. So I think Doug taught me that about the hernias. I'm not afraid to like, and I never thought of it until he gave his lecture. And I'm like, okay, I'll inject starting. So I started injecting hernias, and I'm surprised how many of those are actually symptomatic. You see them all the time. You're like, everyone has one of these. And, you know, and so yeah, I think that that's a, that's something I knew Doug did a long time ago. But yeah. Yeah, so this is a great lecture that we'll have in the archives. And, and, you know, anybody on, and especially in fellowships, encourage people to go back and look at this, because this really, this lecture that Adam gave really incorporates it all, the differential diagnosis, as well as the common extensor pathology. Any other comments from anybody or questions for Adam? This is Maderic. Great job, Adam. Just I'd be interested to get your take and anybody else on the call. So I will see a subset of patients who have calcific tendinopathy, particularly at the ECU. And it was a bit more posterior. And I cringe when I see this, because they just did not seem to do as well as as any other pathology in the common extensor tending complex. And so I'm wondering if other people have noted that as well. You know, both with that location of pathology, and then just, just, you know, more of a prolonged course or difficulty, you know, with them improving with usual measures. Yeah, I would totally, I would totally agree. And then, yeah, I think, I think it has to do with the forces that come across it. It's a little bit more, you know, atypical of a location. But yeah, the calcific tendinopathy that I, as you guys know, I've seen it just about any tendon, the hip, the gluteal tendons, the shoulder, more commonly, I've seen it in the knee, patellar tendons, peroneal tendons, Achilles. So anyway, so difficult problem to treat just in general. Usually, it's your perimenopausal, postmenopausal males, they tend to lay down that calcium and just are turning over calcium so much the third space and in the tendons, at least I think that's what's probably happening. But yeah, I think that's really tough to treat. And I also wonder, too, you know, the other thing I look at with the lateral elbow pain is subclinical AIN weakness. And I think we need to be looking a little bit more closely at that ulnar head of the pronator teres and how it compresses the median nerve and the AIN as it, as it crosses. And so I've had remarkably decent luck at actually starting to treat that, as well as treating the lateral elbow, you know, like, so why are we overextending? Because we lose a little bit of our ability to grip. And so I think it's probably has a bigger role in this than we think. So yeah, that is, I agree with Maderic. I think it's, I think it's tougher to treat. I always go, oh, when that, you know, and this is, you know, part of why, you know, being able to isolate specifically what tendon we're treating can affect your treatment, right? So I know up front, if it's if it's in that ECU, I'm going, okay, you're gonna have a prolonged course, it's gonna take me longer to probably get this better than you think, you know, whether we're using a combination of ultrasonic tenotomy on top of, you know, adding a regenerative med procedure in there, and then, you know, teaching them how to tape it for sports. And so I agree, I think, I don't know if anyone else has anything else to add on that. But I think it's a tough condition. So, Adam, it's Jay and Maderic, thanks for the comment. I've not seen the ECU specific calcific tendinosis. But, you know, I've seen the the ECRB. And so the ones that you've seen in the ECU, are they more, are they more linear? Are they kind of globular? Like, you know, we see them in some of the other areas, because I noticed, I mean, as we know, when I see linear calcific deposits, most commonly in the shoulder, although obviously, most of the deposits in the shoulder are globular, you know, or ovoid, but they just, they just tend not to do as well. They're, to my, to me, I think they're just a different beast. I think it's a different problem. And they just don't do as well. So I was just wondering, not having seen the ECU ones, I was wondering, are they tend to be linear? Are they more globular? Yeah, good question, Jay. These ones are, in my experience, and God, I probably have 20 of these cases. They're usually multiple, you know, somewhat punctate, but slightly larger, hard calcifications. And so they're just off of the, you know, just off of the bony insertion site, they're pretty far posterior. And they're, you know, they're, they're really hard. And so I mean, trying to debride them, they're very hard, difficult to get out, not the usual kind of soft, you know, primary calcific tendinopathy, like we'll talk about in some of these other areas. And they're really kind of embedded in the tendon, and usually come in multiples three, four, right along the insertion site. Yeah, you wonder, you wonder with a, again, I have no experience with this, but you wonder whether, you know, assuming that you've done your, you know, diagnostic injection, you know, that's the problem, given, given the wide expanse of the extensor mechanism, particularly posteriorly, you know, we try to, if you're trying to needle them and do the usual thing, you wonder whether a little bit of actually just cutting it might do the trick. With a no core needle, I mean, you know, you're not going to pull the whole ECU tendon off, you know what I mean, you're kind of looking at, so, you know, people talk about doing pretty extensive releases in this area, as we know, for tennis elbow and all sorts of other things, and they get away with it, I think, because this whole complex is really intertwined, you know, and so I think that you just wonder if you go at those calcifications, I guess it might be an area where I might not be too hesitant to be more aggressive, I'm usually very conservative, but I might not be, I might not be so conservative if, if it really is that refractory, again, not having any experience with it. Good point. I would agree, those linear, those linear ones, they, they're always like, when I see them in the shoulder, I'm like, yeah, you know, they're too small, like, really barbitage, and then, you know, 10x, or not 10x, I should, I'm not promoting any brand, but ultrasonic tenotomy, not as effective in the shoulder, in my experience, so, yeah, they're the ones I go, I agree, it's some sort of different beast when it's linear, I've seen both, though, the globular ones, I would agree, typically, I don't know if this year, you're finding them late in the process, where they've already, you know, become solid nuggets, or that's just the way they are, but they're usually harder, and harder to remove, but interesting, yeah, anyway, any other questions anyone else has? Well, everybody have a good Friday, again, Adam, that was a fantastic presentation, and just a reminder, October 9th, we have a medial knee case by Dr. Kentaro Onishi, and all these are recorded, and posted on the AMSSM YouTube site, so, thank you again for getting up early, for those of you on the West Coast, and everybody have a good Friday, and a good weekend.

3rd Edition, CASE 13

3rd Edition

Elbow and Forearm

medical case presentations

knee and hindfoot cases

lateral elbow pain

ultrasound diagnostics

tendon tears

nerve entrapments

calcific tendinopathy