All right, good morning everyone, welcome to another Friday morning AMSSN Sports Ultrasound Case Series. Today's case is going to be the last of the fellows session for the 2022-2023 year. We'll be back in a couple of weeks starting the attending series again. Today we have three fellows from Stanford, Dr. Montanino, Dr. Chu, and Dr. Ramirez who will be presenting on tarsal tunnel syndrome. Dr. Chu completed medical school at Brown University, residency training in physical medicine and rehab at Northwestern University, Shirley Ryan Ability Lab. Dr. Chu is, as I said, a sports medicine fellow and will be starting a sports medicine position at Kaiser Permanente in Orange County this fall. Dr. Montanino attended Washington University for Pima Residency, currently a Stanford sports fellow also. After a fellowship, Dr. Montanino will be returning to Tulane University as an assistant professor and Dr. Ramirez is also a sports medicine fellow at Stanford. Dr. Ramirez completed pediatrics residency in medical school at the University of California, San Francisco. And Dr. Ramirez will be turning there after fellowship as an assistant professor in the Division of Pediatric Orthopedics. I will stop sharing my screen and you are welcome to start. That looks great. Great. Thank you so much for the introduction. My name is June Chu and along with my colleagues, Dr. Jamie Montanino and Dr. Faustine Ramirez, we're the Stanford sports medicine fellows for this year. We will talk about the sonographic evaluation of the tarsal tunnel. So many thanks to Dr. Michael Fredrickson, our fellowship director, and Dr. Jeremy Stanek, one of our attendings that we work with very closely. They served as really invaluable mentors throughout the process of putting together this presentation. So for the outline for today's talk, we'll start off with a case, then we'll review pertinent and anatomical structures, then we will go through the ultrasound protocol and dive into details of the diagnostic scanning. Then we'll draft a sample ultrasound report and conclude with an injection setup, an injection of the tarsal tunnel. So starting off with a case, this is a case of a 27-year-old female runner with history of tarsal tunnel syndrome that she had surgically released two years ago, presenting with recurrence of pain at the bottom of her right foot. She described this pain as tingling and burning, whereas with running, it occurs at night when she's trying to sleep. No weakness in lower extremities or no radiating low back pain. She described this pain as being similar to the pain that she had in the past, which had completely resolved after the surgical release of the tarsal tunnel that was performed two years ago. On exam, she has paste plainness and she had reproducible pain with tunnels or percussion at the tarsal tunnel. She had decreased sensation over the distal plantar aspect of her foot. She had a negative calcaneal squeeze test and a positive triple compression test. And the triple compression test, as visualized on the right, is when you maximally invert and plantar flex the foot with compression at the tarsal tunnel. And this has about 86% sensitivity and 100% specificity for tarsal tunnel. And the compression is to be held for 30 seconds. So reviewing the anatomy of the medial ankle, the anatomical structures we'll cover include the tarsal tunnel, branches of the tibial nerve, which we'll dive into more detail in the later slides, the subtalar joint, the posterior tibialis tendon, and their insertions. So including the navicular tuberosity, medial cuneiform, the plantar surface of the second and through the fourth metatarsal. So the borders or the anatomy of the tarsal tunnel borders the bony floor include the medial tibia, talus, and the calcaneus. And then the top is covered by flexor retinaculum of the ankle. And that connects the medial malleolus with the medial tubercle of the calcaneus. The structures inside the tarsal tunnel, going from anterior to posterior, a common mnemonic that we learn is Tom, Dick, and very nervous Harry. So post-tip tendon, flexor digitorum, longest tendon. The neurovascular bundle, which is between the FDL and FHL, include the posterior tibial artery, two or more posterior tibial veins, which we'll see on ultrasound. And then the tibial nerve, which runs deep to the artery and vein. And there can be anatomical variances of how the neurovascular bundle arrangement. And finally, the flexor hallus is longest tendon. The branches of the tibial nerve, the terminal branches include the medial plantar nerve, lateral plantar nerve, the inferior calcaneal nerve or Baxter's nerve. It is typically the first branch of the lateral plantar nerve, but there can be a lot of anatomical variances. It can sometimes branch off the tibial nerve. And there's a medial calcaneal nerve. Also branching point can be variable, but it's proximal to the tarsal tunnel. Just making a note that neuroanatomy can really vary from individual to individual. So bifurcation into terminal branches is variable, which is where ultrasound can be really helpful. So bifurcation usually happens at the beginning of tarsal tunnel. About 90% of the medial and the lateral plantar nerve division occurs at the level of flexor retinaculum, but much less commonly, about less than 10%, it can occur proximal to the tarsal tunnel. So reviewing some innervations of these terminal branches, the medial plantar nerve, the motor innervations include the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, and the first lumbrical. The sensory innervation is much like the medial nerve for the hand. It's medial half of the sole, including the plantar aspect of the first toe to the medial half of the fourth toe. So it splits the fourth toe, just like the medial and ulnar nerve of the hand. The medial calcaneal nerve is a sensory nerve, and it supplies the sensory information to the inferior and medial aspect of the heel. The lateral plantar nerve motor innervations include the abductor digiti minimi via the inferior calcaneal branch, adductor hallucis, flexor digiti minimi brevis, quadratus planti, the inner ossei, and second through fourth lumbricals. It carries sensory information from the lateral third of the sole. The inferior calcaneal nerve, or the Baxter's nerve, the motor innervation includes abductor digiti minimi and sensory information of the long plantar ligament, calcaneal periosteum, and it does not carry any cutaneous sensory information. I'll pass it on to Dr. Montanino. We felt it was important to discuss a little bit the anatomy as well as the pathophysiology for Tarsal Tunnel Syndrome, so that drives our protocol that we'll discuss today. The pathophysiology for Tarsal Tunnel Syndrome is very frequently multifactorial, with traumatic causes such as ankle sprains or fractures being more common than atraumatic, but atraumatic causes do include inflammation such as arthritis or space-occupying lesions such as from ganglion cysts, bone spurs, tumors, as well as from tenosynovitis of tendons, hypertrophied abductor hallucis muscle, as well as tendinopathy at the knot of Henry, which we will review later. Risk factors being repetitive stress such as with running or other high-impact activities, a pes planus or hindfoot valgus, as well as with overpronation during stance phase and excessive body weight. The mechanism is thought to be either or a combination of stretching of the nerve versus dynamic compression of the nerve by the abductor hallucis brevis when the foot is in that excessive pronation. It is important to note that the inferior calcaneal nerve or Baxter's nerve can be entrapped medially, but then again it innervates structures of the inferior and lateral portion of the heel. So let's get into our medial ankle ultrasound protocol for this case. The protocol should include the tarsal tunnel and its structures, again our Tom, Dick and Very Nervous Harry structures, being the posterior tibialis tendon, FDL tendon, the tibial artery vein and nerve, the FHL tendon, as well as the flexor retinaculum, and then we will follow the medial and lateral plantar nerve branches and review the subtalar joint. The optional structures that we decided to add today for this case include the medial calcaneal nerve, the knot of Henry, AH muscle, the inferior calcaneal nerve, and then as well as a distal portion of the medial plantar nerve. So at this point, we're going to switch over to looking at our scanning images. And so for all of these pictures, we'll have an image of the ultrasound as well as a diagram in the bottom left demonstrating the relevant anatomy and where our transducer is positioned. So the black box and some of the slides that will be a yellow box demonstrates where our transducer is positioned, because the photo was not always easy to see exactly where the transducer was as you're holding it. So in this image, starting out at the proximal tarsal tunnel, we have our orientation here, the right of the screen is anterior and the left of the screen is posterior. And in the diagram in the bottom left, we have a medial view of the ankle with the abductor hallucis has been partially removed to depict the tibial nerve branches and other relevant anatomy in the tarsal tunnel. So here we're located at the more proximal aspect of the tarsal tunnel, and we see some of the important structures here. So we see the flexor retinaculum at the top, and we see the flexor digitorum longus as well as the flexor hallucis longus. Those tenants are indicated in the image. And here we're starting to see the very early bifurcation of the tibial nerve into the medial plantar nerve and the lateral plantar nerve. And those two branches are just starting to separate, and those are located under the vessels here. And as Dr. Chu went over, it's important to note that this bifurcation is really variable depending on the patient. And in the majority of patients, it's going to occur at the level of the flexor retinaculum. But in about less than 10%, it actually occurs proximal to the flexor retinaculum. So really important to scan proximally and distally to identify where it bifurcates. And in this patient specifically, we were pretty proximal in the tarsal tunnel, and it was already starting to bifurcate. And so if we went more proximally, we would see that tibial nerve, but we would be more proximal to the flexor retinaculum at that point. So we started in the tarsal tunnel here. And if we go just a little bit more distally here in our next slide, a little bit more distal in the tarsal tunnel, we see the lateral plantar nerve and the medial plantar nerve bifurcating further. So in this view, again, anterior to the right with our more anterior tendon structures, tibialis posterior, flexor digitorum longus, and the flexor retinaculum at the top there. And then we see our flexor hallucis longus underneath the two branches. So this view demonstrates the more classic appearance of the tarsal tunnel with all of the structures that Dr. Chi went over in her anatomy review. But here we've already seen bifurcation of the tibial nerve into two of its distal branches. So next, after we've identified the medial plantar nerve and the lateral plantar nerve and its bifurcation, we're then going to look for some of the other branches of the tibial nerve after identifying these two main ones. So in this view, we are looking for the medial calcaneal nerve. So note the orientation of the transducers. You can see with the black box in the bottom left corner, we're oriented slightly differently than before, and we're capturing a little bit more of that posterior aspect of the medial ankle. And in this view, we can see the medial plantar nerve most anteriorly, the lateral plantar nerve in the middle there with that classic honeycomb appearance, most hyperechoic structure there. And then more posteriorly, we're seeing the medial calcaneal nerve. And here it is located within the flexor reticulum. So it's important to note that here in this view, the medial calcaneal nerve has actually already branched off of the tibial nerve, which occurs more approximately in the medial aspect of the lower leg. And then it courses posteriorly towards the posterior medial ankle and towards the posterior medial calcaneus. And so this is a really important place to scan when we're concerned about pathology in the medial ankle, because this is a common entrapment site for the medial calcaneal nerve is at the level of the flexor retinaculum, because it kind of courses through that retinaculum to its destination at the medial ankle. So we can see that nerve located here in the retinaculum well. So I like this view because it allows us to see three of these main branches and an important place when we're worried about medial heel and medial ankle pain to try to identify that medial calcaneal nerve, remembering that this is only providing sensory innervation. So there's no motor here and can cause some pain and paresthesias in patients on the medial aspect of the calcaneus. So next, we will try to identify the inferior calcaneal nerve, also referred to as Baxter's nerve, and this nerve has a lot of names. So for consistency, we'll refer to it as inferior calcaneal nerve, but it's called Baxter's nerve commonly as well as sometimes the first branch of the lateral plantar nerve. But as Dr. Chi mentioned, anatomy is variable and it's not always the first branch. So here we see the transducer position with our yellow box in the bottom left diagram. So we're more on the medial aspect, a little bit on the plantar surface here. So we're starting to move more towards the plantar surface of the hind foot. And here, the inferior calcaneal nerve is actually already branched off of the lateral plantar nerve more proximally. So important to scan proximally and distally to identify that branching point because of the anatomic variability between patients. And we are seeing the lateral plantar nerve more anteriorly here, and then a little bit more posteriorly, we see the inferior calcaneal nerve in the fascial plane between the abductor hallucis, which is more superficial, and the quadratus plantae, which is more distal. So this is a really important site to scan when we're worried about medial ankle pain because it is one of the main potential entrapment sites of the inferior calcaneal nerve between that deep fascia of the abductor hallucis and the medial plantar margin of the quadratus plantae. So this is one of the most common entrapment sites of Baxter's nerve, although overall not very common in terms of a condition, but important to scan here when we're worried about medial ankle pain and medial heel pain. So other entrapment sites, although we don't have images of these for this particular case, it's really important to also look for other potential entrapment sites. So one would look a little more proximally adjacent to the fascial edge of a hypertrophied abductor hallucis. So Dr. Montemino mentioned some of the potential risk factors for tarsal tunnel syndrome. And so some patients may have a really hypertrophied abductor hallucis, and that hypertrophied muscle can entrap the inferior calcaneal nerve. Another place to look is to scan a little bit more distally as that nerve is passing along the anterior aspect of the medial calcaneal tuberosity, where patients may have a calcaneal emphesophyte or may have a thickened plantar fascia, and both of those are risk factors that Dr. Montanito mentioned, including plantar fasciitis we often see in association, as well as emphesophytes, as these may also contribute to entrapment of the inferior calcaneal nerve. So these are other sites to evaluate if we were focusing specifically on inferior calcaneal nerve entrapment to identify as potential entrapment sites. So next, as we're scanning the medial ankle, it's important to evaluate other structures beyond the nerves as well, as these may contribute to pathology. So next, we evaluated the posterior tibialis tendon and its insertions distally. So in this patient, there actually was an os navicular. So first, we are showing the insertion of some of the posterior tib fibers on the os navicular. And if we scan just slightly more distally, we see the tendon insertion with some fibers inserting on the os navicular, as well as some tendon fibers inserting on the navicular slightly more distally. So here, there's no pathology relating to the posterior tibialis tendon, but important to evaluate as well. And then if we move in short axis over the posterior tibialis tendon, we can again evaluate the tendon. And we can also evaluate the subtalar joint. So in the bottom left, we see the location of the transducer here located over the subtalar joint. And we can evaluate for any pathology around the posterior tibialis tendon in short axis, as well as the subtalar joint. And then scanning a little bit more towards the plantar surface of the foot, this is another really important site to evaluate where we're looking for potential entrapment sites. So here, we're at the medial plantar nerve at the level of the knot of Henry. So the knot of Henry is the location on the plantar aspect of the hind foot where the flexor digitorum longest tendon crosses over the flexor hallucis longest tendon. And typically, the quadratus plantus lies deep to that. Here, it's more adjacent, depending on the orientation of the probe. And so we can see those two tendons stacked on top of each other here in the ultrasound image. Just to orient ourselves, the orientation is a little bit different now that we are on the plantar surface of the foot. So the right of the screen is medial, and the left of the screen is lateral. And in the diagram in the bottom left, we see that the flexor digitorum brevis and the abductor hallucis, which are the more superficial muscles, have been cut to better demonstrate that knot of Henry, which is a common source of pathology that can cause entrapment of the medial plantar nerve. So here, scanning over this area, we see that medial plantar nerve as the hyperechoic structure in the middle. And it is located and commonly entrapped between the abductor hallucis and the knot of Henry. And sometimes this is referred to as jogger's foot, although trying to be specific and staying away from names like that for diagnoses. And then finally, we can scan a little bit more distally into the midfoot following that medial plantar nerve. So in the bottom left, we see a representation of the midfoot, again, with several structures having been cut off, the plantar fascia, the flexor digitorum brevis, and the abductor hallucis having been partially resected to see that plantar course of the medial plantar nerve. And in our ultrasound image, again, medial to the right, lateral to the left. And we can visualize that medial plantar nerve in the middle of the screen between the abductor hallucis and the flexor digitorum brevis superficial to the quadratus plantae. And so, although beyond the scope of the presentation today, one can also continue scanning the medial plantar nerve distally into the midfoot and the forefoot, as well as the lateral plantar nerve. But given we were focusing on the tarsal tunnel today, we felt like that was beyond the scope of this case. So I will hand it back over to Dr. Montanino. Thank you. Yeah, and I'll just run through our last few slides pretty quickly. So this is our ultrasound report here. So at the top, we'll list our examination, which is of the right medial ankle. The reason for it being right foot pain and paresthesias, we used a high-frequency linear probe. And our findings, we separated by tendons, nerves, and then bones, joints, and other, with tendons being that the tibialis posterior, FDL, and FH tendons all appeared normal with normal fibular pattern without disruption, no intertendinous hyperechoic regions to suggest calcification, and normal appearing insertion of the PT tendon. The AH muscle appeared normal in size, and there was no evidence of tendinopathy or synovitis at the knot of Henry. For the nerves within the tarsal tunnel, there was a pertinent hyperechoic area. With our case of the runner, the hyperechoic area was surrounding the tibial nerve, which could represent scar tissue from either a prior trauma or surgery. But the nerve itself appeared normal in cross-sectional size without focal dilation or loss of its normal structure. And all of the branches of the tibial nerve also appeared normal. We noted that there was an os navicular and that there was no effusion of the subtalar joint. And our impression being that, you know, noting the likely scar tissue surrounding the tibial nerve within the tarsal tunnel. And so quickly wrapping up our case, because electrodiagnostic abnormalities can help guide whether surgical referral is indicated, we did perform electrodiagnostics in this case. Nerve conduction studies of the right foot did demonstrate normal medial and lateral plantar nerve responses, and EMG of the intrinsic muscles, which are innervated by the lateral plantar nerve, were normal. There was no electrodiagnostic signs of a motor radiculopathy. So given that the ultrasound showed the scar tissue, a decision was made to undergo a diagnostic and therapeutic hydrodissection of the tibial nerve within the tarsal tunnel. And this patient had a good outcome. She had immediately good relief during the anesthetic phase and had lasting relief at the two-year follow-up. And so quickly, injection setup for a tibial nerve injection. The patient is side-lying on their affected side. We use a posterior-to-anterior approach in-plane, usually a 25-gauge needle just for better control around the vascular structures. We view the tarsal tunnel in short axis and prefer a high-frequency linear probe when we're doing the injection, just because it's a smaller footprint and there's not a lot of space between the Achilles tendon and the structures. And a pearl demonstrated in the ultrasound pictures here is scanning proximal to distal and evaluating a safe trajectory to avoid the vasculature. So the top picture is the most proximal picture, and you see you have the best trajectory to block the tibial nerve. Whereas when you go more distal, the vascular structures become more in the way. And as always, but especially with these types of nerve blocks, it's important to keep your needle tip in view at all times. But as you're hydrodissecting and preferably doing these small puffs, you'll have more of an anechoic background to better visualize your needle tip. And then preferred injectate may vary site to site, whether you're using lidocaine or something like the D5. And just a diagnostic block may just include anesthetic, but types of steroid can also be used for more of a therapeutic benefit. All right, thank you so much for that presentation. You guys had some great ultrasound images up there. I just have a couple of things on this area in, you know, scanning the medial ankle. As far as, you know, looking at the medial and inferior calcaneal nerves or Baxter's nerve, you know, I think one thing that you pointed out, and it's something that you really have to think about as you start to scan this area, is as you kind of follow that posterior aspect to the tibial nerve and the lateral pontine nerve, sometimes it can be a little bit confusing. Is this Baxter's nerve? Is this medial calcaneal nerve? And how to identify between these structures? And one thing is, if you just trace whatever you think is a nerve, if it heads up into the subcutaneous space, that can pretty reliably be the medial calcaneal nerve. And if you're tracing something and it doesn't go subcutaneous, then that's not what it's going to be, generally speaking. And that is like a pretty good starting spot of evaluating these areas. I personally, you know, find if I scan this area and I save like a still image of these nerves, it doesn't help me a whole lot when I go back to review in the future. These little nerves, I think are really, they do well with like a sweeping, like a cine clip. And because, you know, these, all these nerves don't necessarily have like a quote unquote abnormal cross-sectional area, it's hard to just look at a still image sometimes and say, oh yeah, that was an abnormal nerve, or oh yeah, this is a normal nerve. And so I think those, those kind of short cine clips of sweeping through a nerve give a really good indication of like, is there a focal area? Is there a compressive, you know, scar band or something like that? Or is this, you know, focally enlarged? And I think, you know, the longitudinal pictures of these nerves are really helpful as well. It can be very challenging because the nerves, they don't go in a straight line. So like if you're going to scan a median nerve, for example, at the wrist, it kind of goes in a straight line. It's pretty easy to get a nice, you know, longitudinal view of that nerve. But in a nerve that is curving a little bit, you can really have to work pretty hard to get a good long view if you're looking for like a focal enlargement or compression of that nerve. As you noted, you know, as you're scanning these nerves within the tarsal tunnel, I think it's really important to combine your clinical history with, you know, what you're scanning. Do they have, you know, medial forefoot symptoms, lateral forefoot symptoms, you know, whole forefoot symptoms? And you mentioned, you know, that you can extend that scan, you know, distal. I've had several patients who have come in for, you know, quote unquote tarsal tunnel syndrome, and they have, you know, focal nerve compression or enlargement or neuroma way down in the forefoot and not up near the ankle. And so I think as we're scanning this area, just be mindful, and you mentioned it, but just for everyone who's, you know, learning this and watching and thinking about scanning this area, be mindful of scanning all the way into the forefoot and tracing those distal medial lateral plantar nerves, because you'll definitely miss pathology if you don't scan that far. I think those are kind of the main things I had on this area. You know, as far as the protocol goes, I do like to get some views of a couple of other things when I'm scanning this area. And so one of them is, you know, the tibiotalar joint, looking for any effusion, you know, that would potentially be causing some space occupying effects. You scan the subtalar joint, which is great. I'll oftentimes scan down into the plantar fascia as well for these kind of medial and forefoot pain areas, because sometimes people can just have a weird pain referral pattern from that. And then as you're scanning the nerves, you know, you got some really nice views of the muscles in the midfoot, but I think scanning the muscles is really helpful for some of these nerve entrapment syndromes, and in particular, scanning, you know, the abductor laterally, looking for any atrophy or fibrofatty infiltration changes, you know, related to Baxter's nerve entrapment. And so just those are kind of the things that I'll add into my protocol if I'm thinking about, you know, a tarsal tunnel type syndrome. I don't know if anyone else has comments. Yeah, I have a couple, just to dovetail a little bit on some of your comments, Brennan. I also start with an anterior ankle talocrural joint for the same reasons. Interestingly, I have found that synovitis of the talocrural joint about half the time is better revealed anteriorly, which obviously would affect medial structures, and half of the time, I actually detect it better medially at the tibial talar joint than I do anteriorly. I also have a straight coronal view as part of my ankle protocol medially, so that would be an important image here. And so on a straight coronal view, I'm going to see the tibial talar joint well, but I'll also see a nice view of the talocalcaneal joint, which we want to see not only for the presence of subtalar pathology, like an effusion, but also a coalition, which is an important cause of tarsal tunnel syndrome. Um, you know, when we do electrodiagnostic studies, you know, we do nerve conduction, and then we also do the EMG portion, and we should think about this with ultrasound. So, for evaluating a nerve for any reason, not only are we evaluating a nerve, but we should evaluate the muscles that the nerve innervates, looking for signs of early fatty replacement or atrophy. You know, my medial tarsal tunnel exam is similar, but also driven by the differential diagnosis. And in my practice, space-occupying lesions are by far the most common, and the most common space-occupying lesions are ganglion cyst. Second probably on that list, two seconds, one would be varicocytes, and then the second would be tenosynovitis of the posterior tibialis tendon. And so, but there are other space-occupying lesions that can occur, and that drives my exam. So, for example, an accessory FDL, it can be a space-occupying lesion. So, it's important to start with each muscle tendon approximately, and in short axis, sweep distally to rule out any abnormalities, whether it's tenosynovitis, whether it's tendinosis or partial tearing with some swelling, or an accessory muscle, or an enlarged flexor as long as muscle. Interesting, I had a patient recently that had some tingling medially, but they also had plantar foot pain, and it was a plantar vein thrombosis, which had propagated into the medial tarsal tunnel veins. If I don't see a space-occupying lesion, but I'm suspicious for varicocytes, I will actually stand the patient up, and I have a great case of someone who we didn't really see this in the lying position, but when they stood up, clearly the varicocytes enlarged and compressed the plantar, medial plantar nerve. And this mentioning, you know, most, in my experience, in most of these is a medial plantar nerve. And when you go back to your images, the medial plantar nerve is more medial within the medial tarsal tunnel, with the lateral plantar nerve being posterior and lateral. And so, the lateral plantar nerve may be more susceptible to external trauma, where the medial plantar nerve, in my experience, is generally involved with a lot of these space-occupying lesions. So, you know, and then finally, the last cause that I see is this, I don't see anything, but clearly they have abnormalities, and oftentimes these patients are diabetic and or, you know, have pest planus. And typically, again, it's going to be the medial plantar nerve. So, I don't know, Ryan and Brennan, in your experience, what's the most common cause of medial tarsal tunnel that you see? For me, it's either ganglion cysts or accessory muscles. Yeah, I would say, for me, ganglion cysts, or I'll often see, like you mentioned, varicosity or, you know, dynamic compressive neuropathy from, you know, the vasculature. I've also seen medial talocalcaneal coalition, which is the second most common type of coalition in the ankle foot, as an important cause. I mean, it's not the most common, but it can often result in medial tarsal tunnel syndrome. Those are all amazing pearls. So, thanks so much. All right, fantastic. Well, thanks again so much, everyone. It was a great fellow series here this year. Just a reminder, we'll be taking a little bit of time off here as we transition to the staff presentations. I'll have to double check, but I think it's going to be at least a handful of weeks before we have another presentation. So, you'll see an email coming out from Andy Meyer in the Thursday e-blast, coming up with dates for resumption of series. But I want to say it is on, gosh, I'm not going to give a date because I don't remember off the top of my head, but it'll be starting up soon again, and that'll continue through the fall, and then we'll have another fellow series again in the spring of, winter spring of 2024. All right. Thanks, everyone.

3rd Edition, CASE 04

3rd Edition

Ankle

tarsal tunnel syndrome

ultrasound imaging

medial ankle

tibial nerve

nerve entrapment

hydrodissection

AMSSN Sports Ultrasound