All right, good morning, everybody. Thanks for joining us. We are transitioning back to our faculty presentations starting today and we'll continue through the rest of this year. I've got a couple of housekeeping points I'll make at the end, but in order to be sensitive to our speaker's time, I will introduce him and let him get going because this is gonna be a great talk. And I certainly don't want to rush him. So we've got Dr. Chris Visco with us today. He's gonna be giving a talk on pectoralis major tendon injury. Chris is an Ursula Corning Associate Professor. There's a long list here. The Vice Chair and Residency Program Director and the Sports Medicine Associate Fellowship Director in the Department of Rehabilitation and Regenerative Medicine at the Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital. So I'll let you take it away, Chris. We're really excited to have you and thanks for doing this. Terrific, thank you so much again for inviting. And it's absolutely my pleasure to be here. I'm gonna go ahead and get my case up and get started here. So I was asked to talk on pectoralis tendon injuries. I'm aware that you have a pec muscle injury lecture. There is a bit of overlap between these two, but we'll go through some of this pertaining to, my disclosures, our objectives, pertaining to the sonographic approach of pec major and minor tendons. We'll outline a protocol for a complete exam of the region and we will discuss common pathology and help you recognize common pathology here. So our case before us today is a 35 year old male power lifter. He has a day job too, but on his workout, he got acute pain and a pop in the anterior shoulder while super setting. So he was doing incline bench and he was doing flies. Wanted to get a nice pump there. And on the bench, he felt the pop. So he had initial bruising, an immediate defect, and he had pain, which was sharp and reproduced with any lifting activities, any overhead and anything forward. That was isolated to that shoulder. He immediately stopped and sought care months later. At that point, ecchymosis had resolved and there was a palpable defect at the anterior pectoralis. It was about as obvious as could be, it was tender. Tender both at the anterior humerus and throughout the myotendon and throughout the muscle belly, which was partially retracted and dense and painful. There is full strength throughout myotomes in the upper limb, which is important point to assess. And there's a weakness of the shoulder forward flexion. And there is also weakness in extension from a forward flexed position. So pain was reproduced with resisted shoulder forward flexion and causes exact typical symptoms. So let's get a little bit into the scanning protocol. Somebody comes in with anterior shoulder pain. What do you do from a scanning protocol? Well, you follow the AMSSM scanning protocol. And this includes all the key structures that are important to scan. The biceps subscap, the AC joint, infraspinatus, teres minor, glenohumeral joint, and supraspinatus tendon and muscle. You wanna look at everything in longitudinal and transverse imaging. You wanna get dynamic imaging of anything that's important to get dynamic imaging of and assess the key nerve structures as appropriate, including suprascapular notch or an extended field of view when appropriate. Nowhere on this shoulder protocol is pec major tendon, though you will run into it. And so I'm gonna show you what I mean by that in just a minute. The pec major ends up being an add-on. So with a lot of my scanning protocols, because I spent a lot of time scanning the brachial plexus, I spent a lot of time scanning abdominal wall, anterior hip, I'm adding these protocols onto a standard joint protocol. So I'll typically perform the AMSSM standard protocol for the area, plus I'll add on that particular region for a complete examination. In order to do that, following the complete protocol of the joint, it is possible to do a more limited examination of just the pectoralis. And there I'm sure are circumstances where that's come up both in my clinical practice and will be for you all as well. But for a complete examination, it really requires doing more extensive evaluation. So the plus pectoralis here, adding the pectoralis, means that we need to scan the clavicular head, the sternal head, and I will include the pectoralis minor and evaluation of the coracoid, and optionally the coracobrachialis and short head of the biceps, and I would say optionally nerves as well. We're gonna look at a little bit of these things as I talk about the scanning protocol, and we'll go through some of that typical anatomy, which I wanna get into now. It's important to understand this, that there are two layers to the pectoralis tendon. There's an anterior tendon and a posterior tendon, and you can see that in this bottom left screen here. The anterior tendon, much like a fan, is made up of the clavicular head of the pectoralis major and portions of the sternal head as well. The clavicular head has an attachment onto the clavicle, approximately two thirds to one half of the clavicle, depending on the size of the muscle and the anatomy of the individual. The sternal head has attachment from the manubrium through the sternum, the costochondral cartilage, as well as some of the abdominal fascia. As you can see, much like a fan, these are linearly oriented myotendons from each of these areas in a multi-penate fashion. Moreover, there's very little twisting that's actually happening here, more linearly oriented fibers. And as you can see, the posterior fibers of the lower portion of the sternal head make up the posterior tendon, and the anterior tendon made up of any of the fibers that are originating from this superior portion, including the clavicular head. And here you can see the anatomic separations of the portions of the tendon that can be separated on the clavicular and sternal head. Now, it looks in this image like the sternal head is rotating, but the sternal head derotates if you will, in that abducted position, and sorry, forward flexed position, I should say. So in a forward flexed position, this tendon will essentially straighten out. And that's an important concept because it's the sternal head that's creating extension from a forward flexed position. And that's what you're testing when you're testing that portion of the exam. Note in this image, how close the deltoid is to the clavicular head. It's very easy to mistake the two, but that can be very helpful when you're doing some diagnostic scanning, both when assessing the muscle bulk and for any atrophy, as well as for the actual injuries itself. And deep layers are sometimes helpful to be aware that you can get some attachment down to the abdominal wall as well, and that can be seen at times. In the tendon attachment onto the humerus, there's a substantial and somewhat variable distance of the tendon from the humeral attachment where you have a fused portion of the tendon where the clavicular and sternal heads of the vectorals major are coming together in this fused tendon. Typically that will cover both the biceps tendon long head and short head. And we'll cover at least a portion of the coracobrachialis. So you'll look for the unfused area, if you will, it just a little bit medial to the short head of the biceps femoris, sorry, excuse me, the short of the biceps, or at least at the coracobrachialis, so I misspeak there. So what this looks like in more practical terms on ultrasound here is clavicular, so this is deltoid sitting above the, see if I can get a view here. So we've got deltoid sitting above and the right side of the screen is more medial. It's kind of like gently rocking back and forth here. So we could start to get a sense of what the anatomy is. I'm in an anatomic axial plane with the humerus here, the fused portion of the tendon in this area above the long head of the biceps, which we can see here, and the clavicular head, which we see coming in this region on the superficial most aspect of that tendon. So when we look at these clavicular and sternal insertions, we really need to take multiple views and appreciate how these two separate tendons, clavicular and sternal, become a fused tendon and then ultimately insert onto that humerus, just lateral to that long head of the biceps. So this view is an anatomic axial plane again right here. When we're getting different views in more of an anatomic sagittal plane, which would be a transverse view to the myotendon, we need to assess both the sternal and the clavicular insertions. And the sternal myotendon, which you can see superficial on the screen here, will look like a sort of wavy aponeurosis and have a bit of sort of waviness to the tendon itself, to the aponeurotic portion of the tendon. And then the clavicular head, which is, I'm sorry, this is a sternal head right here. And then the clavicular head coming in on top is going to provide a second layer of the tendon. So here we see one tendon coming in here and another tendon coming here. This is in the transverse view. This is the clavicular portion and the sternal portion. So the exam positioning, the shoulder should be neutral at the side in slight external rotation in a portion of the exam. And then the remaining exam should be done with the shoulder abducted or forward flexed. And it's a little tricky to do in forward flex, so usually flexion and abduction and full external rotation so you can get a full spread of the tendon. And really, as I mentioned, I include a complete shoulder exam with longitudinal and transverse views of the biceps, supraspinatus, infraspinatus, teres minor, and then the AC and GH joint, as well as a dynamic evaluation when necessary. I'm not going to go through those because we're time limited and those were done in other lectures. So if you wish to reference a complete shoulder examination pertaining to the actual steps of a sonographic evaluation, then go ahead and watch your other shoulder videos. But where you're going to pick up the biceps, where you're going to pick up the pec major is really when you're scanning the long head of the biceps tendon, longitudinal. So in this, we've got the bicipital groove and a longitudinal view of the biceps tendon. Just superficial to it, right here is where you start to pick up the fused portion of the pectoralis major tendon sitting superficial to that biceps. And you really need at that point to start scanning and sweeping and noting the direction of the fibers because all of the fibers that course in an inferior lateral direction contribute to the anterior tendon layer or the superficial tendon layer. And then the superior lateral directed fibers contribute to the posterior layer. So I'll say that again, if it's going from, if it's in an inferior lateral direction, that means that it's in the anterior tendon layer. That's the clavicular portion and a portion of the sternal head. If the fibers are going in a superior lateral direction, that means that they're coming into the posterior layer, which are just going to be the sternal head. So as you're scanning, you need to start getting to the habit of sweeping quite a bit. Now this is a big, broad muscle and big, broad myotendon. So as you're starting to sweep, you want to sweep, if you're looking at an anatomic axial plane, you want to sweep superiorly and inferiorly and make your way along that myotendon. And so that cephalad-caudal sweep will get you a view of that myotendon in this image that we're looking at, the ultrasound image. We see the clavicular head coming in here and then the sternal head coming in here. You'll also have to rotate slightly to see which fibers are coming in inferior lateral and which fibers are coming in superior lateral to get a sense of the anterior and the posterior. If you're looking in at these fibers in transverse, which is this here, you need to sweep medially laterally. And you get a little bit of a sense here. This is pectoralis minor right here. You get a little bit of a sense. This is the muscle belly. And you can see some of the difference in the contour as some of the deeper portion comes up and the different angled portion of the right side of the screen here is actually superior. So the clavicular head and then the sternal head, which is underneath it, slight difference in the angle of the tendons. Next thing you might want to do is go ahead and turn on Doppler. Doppler can be particularly helpful and especially when you're dealing with hyperemic tissue, acute tears and so forth. But you also might see this. And what we're looking at here is a vessel that in a very sort of circumflex way comes around the humeral head and then has a portion of the vessel which goes just lateral to that biceps tendon. So that's the anterior circumflex humeral artery right there. And not to be confused with hyperemic tissue around that pec major. So keep an eye out for that and don't make a rookie mistake there. A couple of specific pathology considerations here. When you're describing the tearing, most tearing will occur cranial to caudal. So most of the time you're going to see tearing deep in the tendon. Now this makes sense. Most tendons that we see around the body, when they become tendinopathic, they first become tendinopathic on the deep portion. There's a variety of different rationale for why that might be. Mechanical hysteresis, compression of the tendon relative to the shear force and a more longitudinal fiber force that occurs on the more deep portion. Longitudinal fiber force that occurs on the more superficial aspect of tendons. We see this in patellar tendons and quad tendons. In supraspinatus tendons, we see this in tendons all over the body. We see this in pecs. So typically a more common presentation that you might see might be a tendinopathy of the tendon. And you'll see this a bit on the deeper aspect of the tendon first. Perhaps in the fused area, perhaps at the deeper portion. Now, most of the time when you do see, if you do see a tear though, you need to characterize it as by width and by thickness. So thickness is anterior to posterior. Width is cranial to conal. So if there's a tear that occurs on the posterior aspect of the tendon, it was only in the posterior aspect of the tendon for a portion of the tendon. It is partial width, and in this case, partial thickness. If it encompasses the entire posterior tendon, in this case, it's full width and partial thickness. If, as you can see here, it continues and propagates around leaving a portion of the anterior tendon, this would be described as full width, full posterior, and partial anterior thickness tear. And this would be a complete tear, which is full width and full thickness. So being a bit discerning when you're assessing these fibers as to the anterior versus posterior fibers, and again, you can do this by orienting your transducer in a way where you can look at the fibers longitudinally, being a bit discerning on partial thickness or partial width tears becomes important because that could have potential implications for whether something is managed surgically. Accordingly, the tear location does as well. So tears of the muscle origin or muscle belly do not make good operative candidates, but myotendinous, intratendinous or humeral insertion could potentially be repaired depending on how much tendon is there. And then of course, bony avulsions can more easily be fixed. So this is back to our case here. This is a case of a, as you might've guessed, of a complete pectoralis major tear. So this is full width, full thickness tear. What we have here, so we've got deltoid sitting on the top here. We've got pectoralis major, which is contracting here. You can imagine the person's pec popping a little bit here. And we see the pec major tendon with a complete tear with no attachment at all. Now we can see this in longitudinal and we can, you know, in a transverse view, there's no view and there's no visualizing any tendon material in this area. So full width, full thickness tear of the pectoralis major myotendin junction. Sonal palpation over this area correlated with typical symptoms. Here's another, so I, you know, you might not see these all the time and naturally I don't. So I called a couple of friends to say, what are your pectoralis major pathologies look like? And John Finolf was kind enough to send me a couple. So you can see very similar to what we just saw in that last case. Here's a separation of the myotendin. You can see a little bit of a tendon, perhaps a little bit of a tendon remaining there. Deltoid over line, but this is a major rupture. Transverse view. And in a extended field of view, you can get a really good sense about how much this really retracts. So humerus is right here. And these muscular buildups that occur on the more medial side of the muscle retraction can be very painful and very uncomfortable for people. So let me go on to the next pathology or next point here, which is that bench pressing is typically the number one cause of a mechanism of injury of these pec major complete tears. Could you tear the pec minor? Well, this was a neat case. So again, I was calling around saying, what else have folks seen with pec problems? Well, of course, Jeff Strzokowski gave me a nice picture of a pec minor tear, which I thought was kind of interesting coming off the coracoid process over here. Left-sided screen is superior, right-sided screen is inferior. And you can see this bunching up of the pectoralis minor musculature with the neurovascular structures deep to it. Probably more common that you're gonna see in your practice is a little bit of mild tendinopathy. And again, another case, I'm not gonna go through all the pathologies, but I wanna highlight a few things for you so you all can recognize these, is here is the fused area of the pectoralis major tendon, just a small amount of tendinopathy on the insertion of the pectoralis major tendon. What do we see? Well, there's a bit of irregularity, a bit of thickening, and there's a couple punctate echogenic foci in that area. And that correlated to an area on sonocalpation that was tender in transverse. This is the tendon in transverse right here. We can see overlying a portion of the long head of the biceps, the myotendin of the long head of the biceps right here. And again, just a bit of tendinopathy on the deeper portion of the tendon on the more cephalad component. And not severe, mild, but correlated with their typical symptoms with an otherwise pristine shoulder ultrasound and examination. So finally, I just wanna mention a couple optional things here, which would be to spend a little bit of time on the pectoralis minor and identify the medial and lateral pectoral nerves in addition to that. This point is important. The clavicular head is innervated by the lateral pectoral nerve, and the sternocostal head is innervated by the medial pectoral nerve. So the reason this is important is because they have different areas of innervation from the brachial plexus. Lateral pectoral nerve originates from the upper and the middle trunk and comes off the lateral cord. Sternocostal head originates from the lower trunk, comes from the medial cord. They have a lot of overlap from the cervical roots, but the brachial plexus contribution differs quite a bit for the pectoralis major. Pectoralis major is the only muscle in the upper limb that receives innervation from C5 through T1 every level from the brachial plexus. And you'll see, again, if you look at a diagram of the brachial plexus, lateral pectoral nerve, medial pectoral nerve coming off the lateral and medial cords, and of course, all the upstream contributions. Not gonna spend a lot of time on this, but I wanna bring it up because it could potentially become relevant for patients that you're seeing. When you're looking underneath the pec minor, which is what we're looking at here, you'll see lateral and posterior cords that are stacked, medial cord here around the axillary artery. And the lateral cord, you can identify that using an axial oblique plane. You can see the lateral pectoral nerve off the lateral cord between the pec major and the pec minor. And that can be really helpful, especially in traumatic injuries or post-surgical injuries or injuries to the lateral pectoral nerve from catheters or other devices which have been put on the anterior chest wall. That sometimes becomes a relevant issue, especially when you're noticing that someone has pectoralis atrophic changes or pectoralis pain. The lateral pectoral nerve pierces the clavipectoral fascia and then supplies the pec major. And of course, it has a communicating to the pec, to the medial pectoral nerve, which we know, which then supplies the pec minor. The lateral pectoral nerve comes off medially. So it comes off medial to the pec minor. And sometimes we can see a little branch of it coming underneath the pec minor here. The medial pectoral nerve comes off more laterally. And you can identify it coming off the medial cord at times. And again, using an axial oblique approach. When I'm finalizing my report for these things and sort of to kind of like drive this home now, I'm using my shoulder protocol. So coming back to the beginning, we started with the shoulder protocol. We're gonna use a shoulder protocol. I will typically embed this. So my practice might be a little different than others. I embed this within a typical patient note. So I already have elsewhere in my note, the referring provider. I already have a clinical impression elsewhere in my note. And I'm including this in there. So I have my physical exam elsewhere in my note. So you can see it says diagnostic musculoskeletal ultrasound. It says it's a complete shoulder. Indication shoulder pain. I indicate which shoulder, indicate what I'm using, the date. I have this phrase that I use. Multiple longitudinal and transverse images were obtained to the following structures. Key images are saved and annotated. Important to annotate your images accordingly. And then the findings. These structures appear normal. And then if there's abnormality, I'll list it down here. Anything that I do that's more than my standard. So this is my standard plus. Here's pectoralis major. Full width, full thickness tear of the pectoralis major, myotentinous junction. Sonal palpation of this area correlated with typical symptoms. So you can use this area in your findings to put your description of what you see. If there was tendinopathy, I would include a hypoechoic region of irregularity with multiple punctate echogenic foci, thickening and hypoechoic region. That's what I would include in the findings. And I would include my dynamic evaluation. If I'm going to do any plexus or any nerve examination, I will include that here. I will often do that with any anterior chest wall or axillary scanning. I will identify those individual branches and follow them. And then my impression will include a sonographic impression. It will also include a clinical impression if that's not included elsewhere in my note. Full width, full thickness tear of the pectoralis major, myotentinous junction. Clinically, this correlates with a presentation of a complete pectoralis major tear. So that's about that. A little bit of a quick run through peck major with some anatomic and pathologic correlates. And I appreciate all of you sticking with me with that. I have a couple of minutes here if there are any questions. Awesome, thanks, Chris. Does anybody, before I start talking, anybody have any comments or questions for Chris before he has to hop off? Well, just unmute yourself if you do. You know, as expected, Chris, that was excellent. And I really don't have much to say because you really covered everything at an exceptionally high level. So thanks for doing that. Like I said, I thought that was excellent. Just a couple of points, you know, and Chris mentioned this and the importance of a complete examination. And, you know, for the sake of time, you know, this presentation was focused on the peck major and associated structures, but it is important, like Chris mentioned, to, you know, complete your full shoulder examination because it is possible that there are multiple injuries despite the clinical presentation seeming very straightforward. So that's just always something to keep in mind. Chris did a really great job going over the anatomy in this region. He made it seem straightforward because he's an expert in this area, but this is a really confusing region. And you can get really tripped up if you don't understand, you know, some of the nuances of the anatomy here. And, you know, just a couple of points, you know, understanding which components makes up the superficial layer, which component of the peck makes up the deep layer and how the orientation of the tendon fibers, how they're not in a single static anatomic plane. I mean, those tendons, I mean, those tendon fibers will twist on themselves. And so Chris, you know, harped on this which is a really good point, making sure you're doing large sweeps throughout this region, because it is a really big tendon. And if you're not doing large sweeps, it may be fairly easy to miss some potentially more subtle pathology. So that's just, that's a really important point is understanding the normal anatomy and some of the nuances here. And then when describing tear types, you know, similar to the rotator cuff and being able to describe partial thickness, full thickness, articular sided, bursal sided, it's also equally as important for the peck tendon. And we think about this, like Chris mentioned, almost in like a zipper mechanism when these things start to tear, you know, going from a cradle to caudal position, deep to superficial, and you can have, you know, full thickness, incomplete, partial thickness, full width. And so understanding, you know, what those terms mean and how you're describing the tears, I think is also really important. It isn't as simple as, you know, rupture versus not. Doug, do you have any comments you'd like to make? Yeah, so anybody who has any experience with ultrasound will realize how difficult sometimes it is to scan the peck major and will also realize how eloquently that Chris presented this. I mean, he made it sound easy. It is anything but easy. Chris, how often do you see peck tears? Well, you know, Doug, not terribly often, which is why I made phone calls when I was given this lecture and I said, you know, and I would say for, this is interesting thing, is that I reached out to probably about eight, 10 people, and I only had like three takers of people that actually had peck tears that they've seen in some reasonable timeframe. And I don't see it that often. I mean, I'll see peck, sometimes I'll get some peck tendinopathy, peck pain, but it's pretty unusual to see a pectoralis major tear. Doesn't happen terribly often. Yeah, and that's, how about you, Ryan, being at a big university? How often do you guys get asked to scan a peck major? I probably, I mean, similar. It's not incredibly often. I probably see, I don't know, two to five per year, and it's usually, almost invariably, you know, one of our football athletes that is doing heavy benching, like Chris mentioned, and they feel a pop and have a very, you know, clinically obvious rupture, and so we're just using ultrasound to help, you know, characterize that tear pattern. Right, and I think that's my point, and my experience is the same, is we're scanning a complex area infrequently, and I think that's sometimes the challenge of the peck major. You know, living in Minnesota, and we have 9,999 lakes, we do see a fair amount of water skiing mechanism injury. I guess, you know, Chris, to you, your anterior, I mean, basically, a full shoulder exam and a peck major, you know, the plus, peck major plus is a very detailed, complete exam. I'll have to admit that when I'm asked to scan a peck major, I don't do a full shoulder exam unless there's something that tells me that I should, but oftentimes, these are younger to, I don't know what we call middle age anymore as I get older, but so my protocol, and it's not right or wrong, just a different approach, is I do an anterior shoulder, and then I add the peck major, and I will add the, basically, the proximal medial humerus, so, you know, going down from the coracoid, the short head of the biceps, the coracobrachialis, musculocutaneous nerve, so I don't do necessarily a full shoulder exam. Ryan, how about you? Do you scan the full shoulder, or do you modify that? I'll still do enough to fulfill requirements for a complete, but I probably don't do every, I don't do everything that I would if this was a non-peck case, and I'll focus this on the anterior shoulder, maybe take a quick look up in kind of supraspinatus region, but I'm probably not looking in-depth at teres or infra or notches or anything like that. Yeah, so just because we're emphasizing protocols here, it's good to just see a range of approaches to this. Again, Chris is an expert in brachial plexus as well, so it's all incorporated, as his report shows, and we're back at the new fellowship years, and so we've emphasized this many times, as Chris pointed out, that it's certainly reasonable and, in fact, encouraged to put in sonopalpatory correlative pain, which he did. Just a couple of quick things on my experience with the pec major. So I find that when I start, I scan short axis down the long head of the biceps tendon and carefully get to the major that traverses over the long head of the biceps tendon and attaches onto the anterolateral humerus, and so that's where I start, because immediately I wanna know if there's a rupture of the tendon, but I find that the short axis view of the pectoralis muscle tendon unit, which is more of a, it's a sagittal oblique view, mostly sagittal, is my key view of scanning medial, lateral, medial, lateral. That's where I can see best, in my opinion, the sternal heads coming in to coalesce to the sternal tendon, as well as the convicular tendon, and then finally joining together, pancaking together to form, in a sense, the conjoined tendon coming in to the humerus. So to me, that's my key, and I confirm that on long axis views, and I also include an extended field of view, as Chris showed, with my protocol. It can be hard to do, and it often takes me several tries, but I find that useful information, particularly to our surgeons, if they're gonna operate, they can wrap their head around an extended field of view where they just can't wrap their head around our short and long axis views. So, and the most common injury is that of a musculotendinous junction injury, and so those short axis views, in my opinion, at least, most accurately reflect whether you have a full width, partial width, or a full thickness, partial thickness tear. So that's just my experience. Yeah, agreed with that, Doug. I couldn't agree more. That's the working image, if you will, that image that medial, lateral sweep is probably working harder than all your others. Yeah, but as you said, pathology, it's a big muscle, and I've seen just a little avulsion of muscle off the clavicle before, and so taking the time to do a full survey of the muscletendinous unit is necessary, as you point out. All right, any other questions? I think there was one in the chat. Oh, Chris, you got to it, thank you. Awesome. All right, well, thanks again, Chris. Like I said, that was phenomenal, as expected, so appreciate you doing that, and always learn something every time you talk, so thanks again. Well, my pleasure, and hope to see you in person soon. Take care. Appreciate it. All right, so that is that. A couple of quick comments in terms of the case series going forward. So like I mentioned before, we have transitioned back to the faculty presentations that'll take us through December 16th, I believe, after which we will then, again, pivot back to our fellows presentation for the second half of the academic year. If any fellowship directors or APDs have any fellows that they think are interested and have the requisite skillset to present, feel free to send me an email. We're gonna start compiling our list of potential takers and speakers in the next week or two, and so feel free to shoot out. I don't know if my email is on here. No, so it's ryan-cruz at uiowa.edu. Yeah, we'll start planning that in the next week or two. The other thing is we are, over the next three, four months, going to be transitioning this over to Brennan Boettcher up at Mayo, so he will be taking over the moderator and coordinator duties for the K-series, which will be great. Brennan's brilliant and will bring a lot of good points to this, so we're excited to have him take the reins at the end of this academic year. So that's all I got. Can I make one quick comment? Yeah, yeah, yeah. So we started this, I don't know, a couple of years ago, and Ryan came in pretty quickly to host this, and basically, I didn't have to do a darn thing. Ryan was absolutely spot-on with organization and vision, and so I need to shout out a big thank you to Ryan. Ryan, I know you're not just signing off today, and we're never gonna see you again, but I gotta send out a big thank you because I can't think of a situation where it couldn't be done any better. You have done a fantastic, and you continue to do a fantastic job, and so I need to thank you for your great work. Well, I appreciate that, and I appreciate you trusting me to take this over because this was your brainchild, right? This was all you, Doug, so I helped out where I could, but this was all you, and this whole K-series started with your vision, so thank you for getting this thing up and running. All right, we will call it there. Thanks, everybody. Appreciate you joining. Have a happy Friday, happy weekend. Stay cool, unless you're Doug, who's in northern Minnesota, who probably needs to stay warm. It's cold up there, and we'll see everybody in two weeks. It'll be Zach Bailowitz who's giving a talk on rectus femoris central tendon injury, so see you guys.

3rd Edition, CASE 09

3rd Edition

Chest

pectoralis major tendon injuries

Dr. Chris Visco

anatomy

ultrasound diagnostic techniques

shoulder scan

injury configurations

medical education

Columbia University