All right, so good morning, everybody. Happy Friday. Welcome back for this week's AMSSM Sports Ultrasound case series. It's been a little bit of a break just because of the holidays, almost a month since our last presentation. So it's good to be back finally, and good to have some more talks to close out this section of the staff presentations for the series. We'll talk about kind of the setup for the next portion of the talk here at the end, but today I'm super excited to have Dr. Ryan Hubbard here presenting today. Ryan's a really close friend of mine. I've known him for quite a long time. He and I trained together out at Mayo in Minnesota, and then he did his sports medicine fellowship at the Andrews Institute down in Gulf Breeze, Florida, and he's now currently at Anderson Orthopedics out in the DC area, where he is a sports medicine doc out there. So I'm super excited. Ryan's brilliant. He and I do a lot of teaching together. He's excellent with ultrasound, so really excited to have him. And with that, Ryan, I'll let you just take over. Great, thank you, Dr. Cruz. Flattering as always. Let me see. I'm going to have to pull this down. Can you guys see my screen there? Yep, that's perfect. All right, perfect. Great, so really excited to be here. I appreciate you guys having me. Dr. Cruz, thank you for that introduction. This is going to be a part of the case series that you guys have been doing for the year. We're going to look at the onoculotor ligament today, particularly of the elbow and a tear in that. Again, as Dr. Cruz said, I'm a sports medicine and non-operative orthopedic physician out in Northern Virginia, DC area, at the Anderson Orthopedic Clinic. And then no disclosures here. Real brief, went to college at Davidson, played football there back when they were still wearing oversized jerseys, as you can see. Did med school at Georgetown here in DC, actually, then trained at the Mayo Clinic with Dr. Cruz, as he mentioned, and then did fellowship down at the Andrews Institute with some phenomenal people down there and got the base of my training at Mayo, which is wonderful, and then musculoskeletal ultrasound, and then really got to build upon that at Andrews. And I want to thank initially everybody that has been involved in my training, which is basically anybody that's ever published a video or a talk or anything on musculoskeletal, anything, is a part of me being successful, and I'm very appreciative. And then want to special thanks to the people down at Andrews who some of these videos and pictures are from, particularly Dr. Brett Kendall, who was instrumental in a lot of my development and I get to where I am right now. So let's get into it. Objectives, as you guys have seen before, we're gonna review a complete diagnostic ultrasound protocol for the medial elbow examination. We'll discuss normal, somewhat briefly and quickly, structures to look at to do a complete exam, and then also specifically discuss some pathology at UCL. And then lastly, we'll review a complete diagnostic ultrasound report for the medial elbow. We'll talk about that a little bit later on. Let's get into the case. So 27-year-old professional baseball pitcher with insidious onset of medial elbow pain, really kind of progressing over about a month, month and a half or so, and then got acutely worse after a game where he actually had to leave the game and stop throwing. This point is a couple of weeks out from that happening, came to see us, had some mild pain at rest, a sharp pain with throwing, particularly throwing hard, which he was really unable to do. And then did complain of some paresthesias in the kind of the ulnar distribution that were intermittent and not consistent. On exam, slight tinnitus palpation of the medial precondyle, pain with valgus stress in the medial elbow, positive milking maneuver, and we'll talk about this a little bit later as well as being important. And then no really appreciable laxity or gapping from the contralateral side on exam at least. And then strength was well-preserved for flexing extension of the wrist. X-rays, unremarkable, the elbow, no osteophytes, nothing really significant abnormal here, no calcifications, look like an attendant or anything like that, nothing really exciting. So let's discuss real brief, complete diagnostic ultrasound protocol. These are really kind of check boxes you need to do for every diagnostic exam to make sure that you, one, cover everything and don't miss anything. And two, something we don't talk about, I don't think enough, particularly once you get out in practice. Also important from a billing standpoint, if you're gonna build a diagnostic exam, you have to make sure that you cover all the structures. For the medial elbow, it's actually a fairly short list typically. Wanna look at the common flexor perineum, tendon and muscles. Wanna look at the humeronal joint, look at the ulnar nerve, particularly with assessment of the flexion and extension views for subluxing of the ulnar nerve. And then obviously the ulnar collateral ligament, including dynamic stress views, which typically I would say if there's a significant clinical context or even a not significant clinical context to add the stress views. There's some other structures that are optional. These are kind of a combination of Jacobson protocol and then also MSSM. You can look at the posterior medial impingement with snapping triceps, medial cutaneous nerve of the forearm, which I don't do a whole bunch. And then really, really anything that's otherwise clinically relevant. So you'll have a suspicion on your exam what's going on. And I get sent people to scan for questions of lumps and bumps, or it hurts right in this area. What is that? Those kinds of things. And you can add that stuff in after you've looked at all the basic structures and the required structures. A quick comment on kind of progression and how to scan and kind of what to scan. I tend to reserve the things that I think are gonna be abnormal for last. If you started doing scanning, you realize that once you start scanning stuff and you find pathology, you tend to fixate on that and spend a bunch of time getting a bunch of pictures and different views and really evaluating that pathology really well. And sometimes you can forget to do stuff. I've had a couple of times where I've been scanning, saw something really interesting and ran out of the room to grab my attending. And he asked me about the other structures and had missed one or two things because I was so excited about the pathology. So I tend to, in my practice, at least leave the things that I think are gonna be abnormal for last. We'll kind of talk about that a little more. So if you've ever looked at any anatomy, anything for the medial elbow, you've probably seen this picture. So I won't belabor this. UCL comes in three bundles. As you all know, the major stabilizer for valvular stress in the medial side is the anterior bundle. So hopefully you can see my cursor here. That's split into both an anterior and posterior bundle, which can tear differentially in this area. There's a posterior bundle back here and then a transverse bundle. Posterior bundle, I've looked at a couple of times, I've seen some pathology in. Haven't seen a ton of pathology in the transverse bundle personally, but I'm sure that it's probably seen me. Importantly, the UCL anterior band runs in the obviously medial pecondyle and attaches down to sublimic tubercle. Positioning. I think this is probably one of the more important aspects of starting out and doing diagnostic ultrasound, getting somebody in the right position and making sure they're in a good position for both you to scan the structures and for you to be comfortable while you're scanning is of the paramount of importance. And so taking some time to make sure that the patient is comfortable and you're comfortable and you can access the structures and everything you need to see at the beginning is really gonna save you a lot of time, energy and effort while you're scanning. And even more importantly, doing procedures. Positioning is one of those things that will really have you developing carpal tunnel and shoulder problems and elbow problems trying to access things if the patient's not in the right position. And all this is about body habitus and your room setup and your machine and that kind of thing. So take a little bit of time at the beginning to make sure that you can access everything quickly and easily. I tend to start in this exam usually with the common flexor tendon. I usually scan the common flexor tendon in about 30 degrees of flexion of the elbow. I tend to be able to find it the best in that degree. I usually next go to the UCL. You can just anchor the proximal to the probe at the medial pecondyle and translate the distal on the probe kind of posteriorly or laterally to get to the UCL as we'll see a picture of that here in a second. And then I lastly typically do the ulnar nerve which I then keep the anchored up proximal to the probe at the medial pecondyle and translate posteriorly to the olecranon. And you can see the ulnar nerve there in the reticulum of the groove. I also look at the humeral joint when I look at the UCL, which we'll see. So that's my typical scanning protocol. Common flexor, pronator tendon, UCL and then ulnar nerve. But as I said earlier, I typically leave what I think is gonna be pathologic for last. So here we'll go to common flexor tendon and then look at the ulnar nerve and then leave the UCL and a humeral joint for last. So let's get into the exam. So common flexor, pronator tendon and muscles initially. So you see a picture up here on the left, common flexor tendon. Usually I like to anchor at the medial pecondyle and this picture you'll see over here and then really orient the probe a little bit towards the wrist. Common flexor tendon is a short tendon and attaches right at the medial pecondyle and then gets into the muscle mass pretty quickly here. Catch a peak of the UCL down here. This is obviously medial pecondyle humerus then attaching down to the humeral joint here. And then this is again, I typically also do a picture of the tendon and still a long axis and then a video where I sweep medial and lateral, look at the tendon. Of course, sorry. Of course my videos are not gonna play today, it's typical. Let's see if this'll do it. Perfect. So this is just sweeping lateral to distal. You see the tendon coming in here and it attaches medial pecondyle and then going away. And I just wanna see the full extent of the tendon when I do this. You can do a power doppel in this area to look for acramia or any tendon tears. Let's go back. Next, I go into short axis on the tendon and look at it at the medial pecondyle as well. And I just take a video and save that, which is also not gonna work for me, sorry. So you'll see here right at the top medial pecondyle coming off tendon and muscle belly comes in. You can see the muscle belly really well in short axis. And you can see any tears or any pathology in that area. And I usually save those and comment on those in my report. Next, it looks a little over game, but next we go to the, like I said, going to the ulnar nerve assessment. Medial pecondyle here, ulnar nerve just sitting right in the retrocondylar groove here. And I take a still picture here at the medial pecondyle right in the retrocondylar groove. Again, looking for any swelling pathology. You can put doppler on here and look for any hyperemia. And then I do a still picture also typically at the two heads of the SCU under the arcuate ligament or osteoarthritis. Arcuate ligament or Osborne's ligament, whichever you prefer. And then I tend to also do a video, two videos. One, transversing the actual cubital tunnel. I'm going to assume that's just not going to play for me. Go ahead and pull this up. Cubital tunnel. So I'll start at the medial pecondyle and rotate the probe or translate the probe distally looking all the way down into the cubital tunnel with the two heads of the SCU. You'll see here, those of the SCU I'm actually coming distal to proximal on this. I'm going to play this again. So medial pecondyle, two heads of the SCU coming there and then medial pecondyle, median nerve right here in the middle. And just again, looking for any choke points or abnormalities during that course. I want to make sure that I evaluated completely. Sorry for the back and forth here. And then lastly, I'm going to play this next video without jumping back and forth. The last is the ulnar nerve subluxation. I find this to be a little bit tough. Sometimes one of the harder things to learn how to do really easily. It takes a lot of practice. I tend to anchor the probe again at the medial pecondyle and then passively flex and extend the elbow. I usually get a good amount of gel for this and I will try to a little bit float the probe towards the olecranon. And then you're looking for the ulnar nerve here to sublux or perch or even dislocate over the medial pecondyle here. And again, this is one of those things that you just have to practice a good bit and try to get some good pictures of. Let's see if we can head back. So let's get into some pathology. And so we're going to be talking about the ulnar collateral ligament obviously here in this case. I actually like to, for this one, I'm going to start with the normal contralateral sciences of the patient's actual left elbow. And I was always taught when I started learning ultrasound and still find it true to me today that the best way to know pathology is to know what's normal. And so if you scan enough things that are normal, it may seem unexciting at the time, but the more things you see that are normal, you can very much pick out what's abnormal and you might not know what it is, but you know that it's not supposed to be there or that it's not supposed to look like that. And so here is less, starting at also the medial pecondyle, typically the deep 50 to 30% of the common flexor area tends to be the UCL. You see it coming off here and very nice homogeneous architecture attaching down to the subline tubercle here. Again, humeral ulnar joint here in the middle. And then with these, you do a valgus stress maneuvers, a lot of conversation kind of with what's the most appropriate way to do this. And it's really just about your personal preference for how to do your valgus stress. Again, positioning is a paramount importance when doing this, and it's another thing that's a little bit difficult to learn and get comfortable with, but I tell people, one, to do a couple things, at least how I do it. When I do my milking maneuver, I'll see what degree of flexion they tend to have the most pain in, and I have good success with going to that degree when I do my exam, when I'm doing my ultrasound exam, evaluation of valgus stress, and putting in that degree and seeing that the ligament pretty well there with gapping, but really anywhere between 30 and 90 degrees of flexion of the elbow for doing this maneuver is appropriate. I think most people kind of float around the 50 to 70 degrees for comfort and can see it best there. I would tell you, again, go to where either it's easiest for you to see the tendon or the ligament, rather, or the easiest for where the patient has pain at with that degree of flexion. So you see here, we did this maneuver, this valgus stress maneuver. Stress in the ligament here stays tight. You don't see very much gapping, touch of fluid there coming out of the joint space, but no gapping and no significant laxity. Now we go to the contralateral side, and pretty obvious here when we look at the right side, this is the tear in the UCL. You see this loss of the architecture attaching down to the sublime tubercle, mid-substance tear right down into the joint space. It's a little bit hypoechoic and looks a little bit thickened here as well, and that's all very common for pathology when you have tears here and them being swollen. Then when we do the valgus stress, it becomes real apparent here. You see how we do the valgus stress. You see the ulna translating. You see the joint space opening up. You see fluid coming up underneath here and a little bit of air, and that is obviously significantly more lax than the contralateral side and looks very, very different. I'll play that again. You see they're just kind of widening there. When you see one of these for the first time, when I first saw it, it's pretty dramatic, particularly when you can compare to the contralateral side. It's something that you know is abnormal. Again, even if you didn't know what that was, you could tell that wasn't like the other side. Lastly, kind of with this, you want to measure the degree of gapping in that space. This is also one of those things that took me a long time to get to do well, and I'm not even sure if I do it well still. I found personally the best way to do this is to take the sitting clip or take the video of the dynamic stress, and if you have the capabilities on your machine to slide through the video and find where the initial gapping is, so at rest, and then go to the place on the video where it looks like it gaps the most and measure there. I initially tried to do this where I would try to catch a Frieza clip at the maximum capping as I was doing valgus stress, and that's real difficult, I'll be honest. So if you have the capabilities on your machine, I would recommend doing the maneuvering and doing the sitting clip or the video and then scrolling through the video to find the area where it gaps the most. You'll see here at rest, 2.3 millimeters of gapping, and then with stress at maximum point went to 5.2 millimeters. Standards obviously are more than two millimeters of gapping being pathologic or the contralateral side difference of greater than one millimeter. And again, a plug for scanning the contralateral side is obviously some research in younger athletes who are a little more lax. They might have some opening up of greater than two millimeters, but you want to compare to the contralateral side as they have a similar amount of gapping, but no more than one millimeter difference than not pathologic. So this is one of those things you want to measure and it's helpful to know for your report. So lastly, my report here, complete diagnostic scan of the medial elbow. Everybody does this a little bit differently, as I'm sure you guys have heard multiple times here. This is just kind of my version of it, I've stolen stuff from all my preceptors and put together stuff from again, Jacobson, AMSSM, and this is kind of how I do my reports. So I just kind of go through this briefly, complete diagnostic scan of the right medial elbow. Pre-procedure diagnosis, I just put elbow pain, it makes it easier. And then post-ultrasound diagnosis, still elbow pain. And I tend to put my findings at the top of the report and then again at the bottom, just because I find that people either want to read it initially or want to skip to the bottom and a lot of times skip the meat. So I want to put it in both places. But the real substance here is complete tear of the onocollateral ligament at the mid-substance with moderate dynamic instability. I comment on all the structures we looked at, particularly again, the required structures and anything additional that I looked at and just say, you know, what I did and what it looked like, or if it looked normal. So aminopecondyle common flexogen was normal, essentially. Onocollateral ligament, I go into detail here. They're complete tear to the mid-substance, the UCL, with dynamic imaging, valvular stress, there was moderate laxity. And then we talk about the measurements we took with the humeronal joint, 2.3 to 5.2, producing 2.9 millimeters of gapping, consistent with excessive laxity. Humeronal joint overall was normal, no significant cortical irregularity or anything other than that. In the ulnar nerve, we looked at that, no significant subluxation or dislocation out of the retricular groove. And I have an additional finding section at the bottom, and that's mostly for, again, when I get sent people who want me to look at something specific that's not in the protocol, I just leave that section in. It's an easy place to add in extra stuff that you looked at that wasn't a typical stuff you look at in that region. And then my impression, complete tear to the onocollateral ligament at the mid-substance with moderate dynamic instability. And that's how I do my reports. So finishing up here, keys to success, positioning, positioning, positioning. Again, I would spend some time really trying to figure out with the patient and with yourself what's the best location to put them in, what's the best orientation for the elbow. Again, that'll save you a bunch of time in the future. Also, with this, you know, have a protocol. Like, again, I tend to scan normal first in my life, but just be consistent. The best way to not miss things is to do the same thing in the same order kind of consistently. So I would develop your own protocol and it'll tend to make sense to you kind of what to do and how to progress through the structures and just be consistent with that. And then, of course, scan the contralateral side. If indicated, I tend to scan it, particularly when I see pathology such as UCL tears, it gives you a good reference point for, again, what it should look like and then what the contralateral side looks like. Even if it doesn't gap as much, even, you know, a little bit more gapping or if it looks different, you can call that and tell that it's not supposed to be there. References real quick. And then those are my two children who keep me on my toes. And that's my daughter actually hanging from a pull-up bar. I guess I've gotten that question before. She's not actually standing on his head with one hand, but just a pull-up bar. And then lastly, I can take any questions and I really appreciate you guys having me. All right. Thanks, Ryan. As is always the case with your talks, that was, you know, exceptionally well done and very thorough. So thanks for doing that. I have a couple points to make, but I do want to ask a question if you're okay with that. You know, in your report, you know, you commented on, you know, whenever mid-substance tear with moderate laxity, are you using specific numbers to determine, I guess, to grade severity of laxity with your dynamic imaging? And like you said, you know, we know greater than two on a single side or greater than one side to side difference is pathologic, but are you, are you grading those and giving them different severities based on your measurements? I'm not typically. I typically am doing it more based on how much I felt like the joint space opened up, you know, some with partial tears, particularly you get a little bit of laxity, obviously. And then with a complete tears, it's fairly moderate. You probably call this severe as well, but I didn't feel like the, the amount of gapping that I measured from my standpoint, for what I seen was, was kind of severe. So I was kind of great at moderate, most of the things I call moderate that gap, unless it's a significant amount of gapping. I'm not familiar with any specific measurements that, that are grading. If you are, I'd be love to hear that actually. But I haven't looked at that, but I'm mostly using like my kind of just stalled if you will. Or no, yeah, that's, that's helpful. I was just, I was just curious. I know some folks, I've seen some folks that will use, you know, if it's, if it's, if it's immediately at two millimeters gapping, you know, calling that mild instability, you add, you know, an additional millimeters with three millimeter that's moderate, so on and so forth. I don't know that there's a bunch of science behind that, but I was just curious what your, what your thoughts were. So just a couple of points that you hit perfectly, you know, the optimal angle for UCL imaging, I think is really important. You know, Dan leaders and Dr. Smith, I put that paper out in 14 or 15, 2014 or 15, I think it was looking at optimal angles, you know, looking at 30 degrees versus 70 and, and 70 tended to have a better sonographic appearance of the ligament and allowed for better conspicuity of the ligament for evaluation. So I think most of us, just like you said, we'll, we'll try and find, you know, their, their angle of, of maximal discomfort, because that's probably when you're stressing the ligament the most. And that tends to be around, you know, that 50 to 70 or 80 degree point. And I certainly tend to go right about 70 degrees. So I agree with you on that. The other point to make, you know, your athlete was a baseball athlete, correct? Yeah, baseball pitcher, we scanned a more number of those than I can count down at Andrews. Yeah, exactly. And so I think it's incredibly important for folks that are starting to do this to scan as many normals as you can with this ligament, you know, in in us who aren't overhead throwing athletes, this ligament, especially distally is fairly wimpy, for lack of better term, small. And I think scanning over and over and knowing what normal really looks like can be helpful, because we'll see these adaptive changes in our overhead throwing athletes, especially baseball athletes, and this ligament can just look absolutely massive, which is normal for them. So I think, I think just scanning over and over and over and over and getting a sense of these different, you know, variants of normal can be helpful in when calling pathology. The next point, this is just a brief point that you made the importance of the protocol, you know, as we all started doing this, we want to jump what we think is the pathologic, you know, region and jump to it, then you see it, then you get excited, and you forget about everything else. And you can miss, miss other pathology by doing that. So you made a really great point about sticking to the protocol. And I honestly tend to do what you do. And, and if I know, or I feel it's the UCL injury, I'll kind of save that towards the end. So I can, you know, focus the majority of my time on that. What else? Oh, just really quickly orientation of the flexor pronator tendons. You know, I think this is just something just to mention and to know, you know, we obviously there's there are there are multiple flexor muscles and tendons that coalesce into a single tendon and kind of knowing the orientation as they insert on the on the medial epicondyle is important. And I like to think about it as like spokes on a wheel, as these tendons come off of the of the medial epicondyle. And you know, we think about the far radial starting with the pronator, and then the far ulnar tendon tends to be the FCU. And just knowing the order of those, I think can be important because you can have preferential tearing or pathology within each of those tendons. And then the last thing that I just wanted to comment on, so a lot of times, you know, folks will have these medial or ulnar forearm paresthesias, and whatnot. And obviously, the biggest nerve in that region is the ulnar nerve. And so we focus on that. But maybe one or two times over the past couple of years, I've been fooled and, and now I've tried to if my clinical suspicion is high enough, just take a quick peek at the antebrachial cutaneous nerve, because that does course, you know, relatively close to that area does, you know, provide sensory innervation to the medial forearm. And so I'll, if I think there's some sort of, you know, neurologic complaint, I'll take a quick peek at that. And, and really just kind of where down to where it branches into anterior and posterior branches. And I'll stop there. But just something to keep in mind, you know, if somebody is complaining of some, some medial or ulnar forearm, paresthesias. And I'll just echo that as well. Sorry to hop in. I agree with that completely. I don't typically look at the medial cutaneous nerve a whole bunch. But it's one of those nerves that you start scanning the medial elbow, and you look for all these big structures that are the obvious ones. And you realize once you, you do learn to find that nerve that you've been looking at a bunch, probably, and just not knowing it, and knowing what it was. And so it's not too difficult to just take a peek at that and look at the course and make sure there's nothing significantly abnormal with it. I haven't seen a ton of abnormalities there, personally, but it's an easy thing to add on there and take a peek at it. It's really a very close in this region. Yeah, yeah, I agree completely. All right. Does anybody have any questions? We're getting right at time here. Let's see if anybody unmutes. Doesn't look like it. All right. Well, if that's the case, then we will wrap this up. Again, Ryan, thanks so much for coming on and giving an excellent talk with a bunch of high yield points that are helpful for all of us. So thanks for doing that. One quick administrative point here. So as always, we're off next week. And then back on the 21st, Dr. Eugene Rowe at Stanford is going to be talking about de Quervain's tena sinovitis. And again, that's on the 21st. Other than that, that's it. Everybody have a great Friday. Great weekend. Anything like it is here. It's ungodly cold. So stay warm. If you're in the D.C. area, be safe. It's been snowing. Thanks again. Thanks a lot, Ryan. Thanks, Ryan.

3rd Edition, CASE 15

3rd Edition

Elbow and Forearm

Ulnar Collateral Ligament

Sports Ultrasound

Baseball Pitcher

Elbow Pain

Diagnostic Examination

Dynamic UCL Stress