I'm Madair Call. We'll be performing a live ultrasound evaluation of the lateral knee. This video is not meant to be a comprehensive review of this topic. Rather, our objective is to cover the core competencies as outlined in the AMSSM Recommended Sports Ultrasound Curriculum for Sports Medicine Fellowships. For our medial evaluation of the knee, we'll ask our patient to get into a slight externally rotated position of the hip to allow for access to the medial knee structures. We'll begin at the adductor tubercle at the femur, which lies right here, and this is the origin of our medial collateral ligament. So we'll follow that medial collateral ligament down, distally, and it'll cross over the joint space, and then we'll continue to follow it down. It actually moves quite far distal, and it's still here. We'll follow all the way down to its insertion on the tibia, so it's a quite long structure. As we get down towards the distal insertion, we'll begin to see some hypoechoic structures that sit in this position here, and this is gonna be the PES tendons. And so at this level, because they're coming in oblique, oftentimes they're anisotropic, which is why they'll look a bit hypoechoic. Typically, you may be able to get one of them in view, which we can see this has a hypoechoic appearance, and then this one, again, is hypoechoic, and it's because of the different angles the tendons are coming in. So between the medial quadriligament and the PES tendons will be the space for the PES anserine bursa. And so in this patient, there's no fluid here, so this is just a potential space right where the arrow is, right at this location here. So that's where you would see fluid if there were a fluid within that PES bursa. We can also evaluate these tendons for tendinopathy, which you can see. You can rotate into a long axis view. So if we rotate here on those PES tendons, we'll begin to see a long axis view of the tendon as it comes through. So these tendons will be somewhat variable, and they will often begin to blend together the farther distal towards their insertion site. So you may or may not be able to identify each individual tendon. If you want to, certainly you can come back in the short axis view. You can follow any of these tendons back posteriorly into the posterior aspect of the knee. We can look at those with the posterior evaluation. So you can do that if clinically indicated. Otherwise, if there's only pain anteriorly, visualize them at this location and looking for any pes anterine bursitis. So we'll come back up approximately. We'll pass over the inferior geniculate artery, which we can see sitting right here, beating. You can put the Doppler on just to evaluate that. And then as we come back up towards the joint line, we'll be able to appreciate the two layers of the medial quadriligament in a bit more detail. And so there is a superficial layer that's gonna come over top of the joint here, and then there'll be a deeper layer that will be intimately connected with the meniscus itself. So that'll be the femoral meniscal and meniscal tibial components of the medial quadriligament. And at this location at the joint line, we can also evaluate for any irregularity, any osteophytes associated with arthritis. And then we can look at the fibrocartilaginous meniscus, which sits right here. So we do not get complete evaluation of the meniscus. We can't see all the way into the joint, but you can see a large portion of it. So you can just extend posteriorly, anteriorly along the meniscus, looking for any hypoechoic clefts, any associated perimeniscal cysts that may be in the area in the setting of a meniscal tear. When evaluating the medial quadriligament, you can also perform a dynamic evaluation as well to put stress across this portion of the knee. This often requires a slightly different positioning, but you can even provide a little bit of stress right here. So we can see we're able to provide some stress across the area, and we'll see some motion here at the ligament, and it looks quite taut. In certain cases, you may need to actually pick up the leg and let that rest on your hip to provide a little bit better evaluation here. But oftentimes, this will provide enough to be able to see some motion there, particularly in the acute setting. So here we can see a very stable medial quadriligament. So after we evaluate the medial quadriligament, the last thing we'll look at will be the medial patellofemoral ligament. And so for that, we'll turn into a transverse view, and we wanna visualize the patella, which sits here on our left. Here's our femur, and so if we remember back where we were at with the MCL, so there's our MCL, and that's the adductor tubercle. So we wanna rotate off the adductor tubercle towards the patella, and that's where our medial patellofemoral ligament is gonna lie. And so this structure is just simply a thickening of the medial patella retinoculum. So oftentimes, it's not as distinct as one may wish, but we can see here this thickening component of the retinoculum that runs over, again, towards that adductor tubercle. Here you can apply a dynamic stress on the patella, and you can try to glide that over to see if there's any motion within that area, sometimes bringing the patient into a little bit more extension can make that a little easier for us as we look for any evidence of injury of that area. Just of note, this is the joint recess here, so you may see fluid from the joint extending up into this medial aspect of the knee as well. So just recognize, again, that's patella, and this would be knee joint deep to the area of the medial patellofemoral ligament. And that will complete our medial evaluation of the knee.

2nd Edition, CASE 26

2nd Edition

Knee

ultrasound evaluation

medial knee

ligament stability

tendinopathy

meniscus tears