All right, good morning, everybody. And as usual, happy Friday. Thanks for joining us today for this week's AMS Sports Ultrasound Case Series. Today, we're super fortunate to have Dr. Adam Smarsky here, giving us a talk on the ulnar nerve at the elbow, specifically some ulnar nerve instability at the elbow. Adam is originally from out East, from Pennsylvania, originally stayed out in the state, did his PNR residency out at Pitt, and then was at the Naval Academy for quite some time until he decided to come to the state of Iowa over here. So he's out in Dubuque right now at the Medical Associates Group out there. Adam's a good friend of mine. He and I have taught quite a few things together. He's quite great at ultrasound, and so we're fortunate to have him here for this talk. So with that, I will give it to you, Adam. All right, thanks Ryan for the great introduction. I wanted to thank you to AMSSM for inviting me today to speak as part of the sports ultrasound case series presentation. I've had some recent changes in affiliations as Ryan has mentioned as I've transitioned out of active duty in the Navy out of Naval service this summer after 15 years and my role at the Naval Academy there in Annapolis and joined the civilian world back here in the great Midwest with Ryan here in Iowa and Dubuque, Iowa and very proud to be part of such great organizations here locally. Today I'll be speaking on ulnar nerve instability. I have no disclosures for today's talk from an outline perspective. Our talk here today begins with a clinical case presentation of medial elbow pain followed by an in-depth look at musculoskeletal ultrasound of the elbow and wrapping up with review of documentation to communicate with our colleagues once the ultrasound exam is complete. Objectives for today's discussion are listed here. Give you a moment just to skim those before we move forward with our case. Our case today is a 20-year-old right-hand dominant male quarterback with right elbow pain. You know for quite some time he had mentioned aching in his medial elbow for approximately you know one to two years. He marked it around 18 months, however increasing discomfort over the past three months. Potentially that exacerbation event was during a tackle in a pre-season game where he may have had some trauma to the inside of his elbow or maybe a little bit of a stretch of his elbow there or a little bit of a force at that medial elbow but not anything like really like pertinent that stuck out. What started to stick out is that previously there's a mild annoyance intermittently throughout the year during peaks of training or competition and strength and conditioning with the very rare distal symptoms. However more noticeable recently during strength and conditioning sessions with provocation with resistance on chest and thigh workouts and also with direct pressure during biceps workouts for example if he was leaning on a preacher bench. Items that cause him to speak up the most is that he reports an occasional sharp pain at the medial elbow that would radiate distally into the medial forearm and into his hand. At that time he felt like that symptom or sensation almost gave him some pain-related weakness and he was concerned about his control of and or dropping weights in the room. He has some sensitivity to touch or pressure like we mentioned leaning on the elbow he noted a little bit during class or when he leaned on the inside of his console on the car. He also was starting to bother him as well is that he was starting to get some nighttime symptoms that were affecting his sleep and he has a pretty regimented routine when it comes to those things and how it impacts his like daily activities. So if he was laying on his back or if he had rolled over on his right side he was becoming very sensitive and he was developing numbness and tingling that was awakening him in the middle of the night. From an exam standpoint full manual muscle testing, full strength, he had great light touch and impact sensation. A little bit of a tennels at his medial elbow. Structurally his arm felt stable. No reproduction of his symptoms with wrist flexion. We also checked a little bit more proximal on his neck to ensure that he wasn't having any radiating symptoms more centrally. His symptoms of course like we mentioned were worse with repetitive and weighted activities so we asked him to perform some dynamic testing there in clinic which included sets of push-ups. Unfortunately when you're dealing with people who are very fit the set of push-ups to get the symptoms isn't 5 or 10. It happens to be slightly larger than 5 or 10 which can take some time. While I feel like the benefit of this dynamic testing is we're trying to like mimic as much the symptoms or the situations in which he was able to provoke his symptoms that led him to come in today. While I feel like it can hold my own for an old man in the gym I likely can't produce that same force or effort that he produces during strength and conditioning sessions. So we tried our best to recreate these uh recreate those provocative positions or motions that causes symptoms. In this dynamic testing is what we came up with to kind of over over to over perform over the manual muscle testing simply in like a static position. So during push-ups you know eventually or at times he would develop palpable mechanical symptoms at his medial elbow. However again not with every rep and and when he did get those symptoms those are the symptoms that he was correlating with at times with a little bit more resistance or if it happened enough or sometimes just a randomly like some of those symptoms would eventually lead to distal symptoms down his medial arm. And so what else what also was interesting or what he was able to what he was also very aware of is that he's able to manage this discomfort with body weight activity. So he's able to adjust his hand or elbow positioning or perhaps more of it was amount of elbow flexion and extension. However this of course becomes more challenging with weight training uh there's only so much limitations of how much of that hand elbow position and how much you can like avoid or adjust your elbow flexion and extension. And and he notes uh you know multiple times during uh his initial presentation and throughout the workup that again the thing that brought him in the most was his the stress associated with he didn't want to be in the gym and all of a sudden have that strong sensation that happens uh and end up losing control of the weights and having a having further injury uh in the training in the in the conditioning room. From an imaging standpoint um it was largely unremarkable he had x-rays before he came to us as well as an MRI and also actually had an on energy nerve conduction study performed as well that was fairly unremarkable. Uh and at this time uh he got referred over to us to try out some diagnostic ultrasound which is a new skill set that we've that we've brought to the area. Um from a from an elbow x-ray standpoint so fairly unremarkable playing films that you can see here and as I mentioned the patient actually came to me with his x-rays already completed. However if the patient is organic to me I would typically augment my musculoskeletal ultrasound evaluation with x-rays as well. I think there is often benefit to these films to evaluate for bony abnormality especially in areas that may be more challenging to view with an ultrasound even if you are an expert level of diagnostic ultrasound. I think also other things to kind of keep in mind from the aspect of medicine you know in x-rays in a sports clinic are often fairly readily accessible just down the hallway. It's usually like pretty accessible as far as like not having to wait or make an appointment. They're low cost they often you know the important stuff here like they they typically do not require prior authorization to obtain those images in a traumatic situation or an acute painful situation and distal dens especially have relatively low rash exposure. Prior to reviewing the pathology for this case I'll just take a moment to review key structures that will be evaluated and we we base this on the MSSM scanning protocol that you can find online. This slide itself here starting with the posterior elbow will review the triceps and also key key areas on the olecranon. Medial elbow wise taking a look at the common flexor pronator the UCL as well as in a dynamic evaluation situation on the joint and then getting into the heart of it at the ulnar nerve. When possible you know I always advocate for a dynamic evaluation. I think that you heard me mention it from like a physical exam standpoint and from an ultrasound standpoint I think this is you know it might be preaching to the choir but I think this is a huge strength of musculoskeletal ultrasound to be able to functionally evaluate the area of interest in comparison to other imaging modalities. So I try to use this benefit, use this to my benefit as much as possible. In regards to the ulnar nerve I also want to make a quick advocate, be an advocate to say that I think that in addition to the detailed evaluation here at the area of concern at the ulnar nerve at the medial elbow I would also argue for evaluation of the entire length of the nerve from the upper arm approximately through down through the wrist through the elbow down to the wrist as well. I think this gives us a better idea and evaluation of the nerve pathology and health as a whole. I'm going to get a little bit out of the soapbox here for just a moment. I think when we talk about patient positioning I think this is helpful to get the patient in the ideal position for yourself so it's obviously important for the examiner to prevent painful positions for you to struggle bent over for long periods of time or have a hard time locating the target on the patient. However you know whether I'm giving talks at a conference or talks like this or in clinic teaching residents fellows etc. You know I always harp on the importance of positioning. I think most folks go to you know with what I'm talking about is in reference to positioning for us as the provider. However really what I'm talking about as well is it's important to maximize this time in positioning for the patient as well. So I'll always place the ultrasound in a place where I can view it and it's convenient for me but also so that the patient can view it. I think that you know while I think it's a great opportunity for musculoskeletal ultrasound for a point of care imaging modality to be able to educate the patient as well and it's probably clear that I'm and a lot of the folks on that that are watching this today you know love the skill of musculoskeletal ultrasound excited to perform these examinations. But I'll tell you the athletes and patients I perform the examination on are always very interested as well. Our patients and athletes are well tuned with their body and they're eager to see what's going on. That's oftentimes why they request imaging, why they want to see an MRI and I think that being able to evaluate to show them this evaluation live is a huge benefit here and so I want to make sure they're always able to view everything and so I'll like make sure I orient them to the screen just like I would during a talk and point out pathology, key anatomy, etc. Although often sometimes I don't always need to help my help they don't need my help to figure out the pathology or at least find out that something doesn't look right and it doesn't always require a doctor to do that when when they see something as we're scanning through that it looks different or abnormal. From a posterior elbow standpoint I typically scan the posterior elbow in this position that I have here on the screen just because you know my focus here on this patient is primarily at the medial elbow and the ulnar nerve and I think this is a good opportunity or good positioning to do this in and so I'll scan the posterior elbow here but there are multiple ways that we can scan the posterior elbow. At times if I want to take a closer look I'll still prefer to keep the patient supine and so I'll have the patient add up their arm across the body to get a better view at times but you also could of course flip the patient over prone and have a flexed elbow hanging over the table. A couple recommendations from tranducer selection you know I feel like also at this slide I want to mention you know from a sports medicine perspective we often find ourselves performing these exams at times outside of working hours right or outside the clinic. When it's during working hours when it's during clinic we often have extra hands, we have students that are with us, trainees, we have a staff, nursing staff, etc. However a lot of times this doesn't happen during that time frame so you know I don't always have that extra hand to help with dynamic testing, saving images, or adjusting the image so I'm also an advocate that if you have an opportunity to to choose ultrasound equipment or be a part of that process that the probe has capabilities of doing things like adjusting depth, storing the images or videos, etc. So essentially then I have use of three hands instead of two and then I also want to mention you know tying in the last two slides that that at that extra hand so somebody that's not there to help you out with maybe dynamic testing or helping with pressure positioning is at is leveraging your scanning surface. For example in this situation we'll talk about how we can use the table as a fulcrum for dynamic testing of the UCL. This picture just a quick anatomical review for visualization of key landmarks for this case including the triceps, olecranon, medial epicondyle, the ulnar nerve, and the flexor carpi ulnaris. I feel like this image from a poster I feel like sometimes it's tough from an anatomic view to get all these structures clear in a picture so that you can see the intimate relationship here from the posterior portion of the elbow and so I really I really like this this image here for teaching purposes. As we discussed positions earlier the elbow multiple opportunities to do so as we progress through the talk we'll be showing a picture of probe positioning and then the applicable ultrasound imaging at these positions. I particularly like this method from a teaching and reference standpoint as it helps us visualize where on the external body we can obtain specific ultrasound imaging and troubleshoot when necessary so as if you're going through scanning on your own and you you see this great ultrasound picture but you're not exactly sure where to put the probe to achieve it I think this helps troubleshoot that opportunity for us. As we transition to reviewing a comprehensive musculoskeletal ultrasound here just to orient we have the pictures of probe positioning on the left and then the corresponding ultrasound on the right. We have the humerus approximately on the left side of the screen here. Key structures here to note are the muscle bellies of the triceps which I've marked with a tm which we can then trace distally to the triceps tendon as we go to the right side of the screen as and trace it distally and through its distal attachment on the lepranon. I tried putting some arrowhead there are some arrowheads here on the screen where you potentially might see some lepranon bursitis if that was an area of concern on the specific patient you know it was not remarkable in this patient but if it was we'd also probably continue to scan more distally and posterior along the lepranon to get better visualization of the entirety of the lepranon bursitis that is of concern. And then also again humerus in the bottom left here approximately and the posterior fat pad marked with stars there without displacement. As we pivot our ultrasound probe 90 degrees to evaluate the posterior joint recess and triceps and short access we are scanning here on the left from proximal to distal on the right. The triceps muscle overlying the lepranon fossa viewed at the top of the screen here with the posterior fat pad underneath. As we move to the right more distally and short access we'll see the trochlea here on the right and the capitellum. I'm sorry the trochlea here on the left and the capitellum here on the right. As the trochlea should have we I guess what I want to point out here too is the reference here I think this is something when we're looking down at the screen too and finding our correct probe position the trochlea pointing these out is helpful because the trochlea we can help identify that we know that the trochlea is more medial and the capitellum is more more lateral. We know that the trochlea has more this like peaked appearance to it versus the capitellum the cap has more of a cap like appearance where it's a little bit more rounded and smooth. I'm not always big on some of these reminder things but I intentionally you know marked TM for this for this evaluation as teaching opportunity as kind of a stretch to have for triceps muscle. And then you can also kind of remember here trochlea is on the medial side of the elbow and we have H down here for humerus. We also want to make sure as we scan dynamically we want to make sure we scan distally all the way through the tendon attachment in the short axis as well as in the long axis. As we transition to the medial elbow again I think these are great pictures. I think that you know from an anatomical review of the medial elbow anatomy we're able to see the common flexor pronator mass as it attaches on the medial epicondyle on the left and then as we kind of remove those those muscles and the tendon here we then can see underneath there and get a view of the ulnar collateral ligament and the fibers that attach here as well. Similar setup here for the medial elbow we have the pro positioning in the bottom left there and the corresponding image that goes along with it. This is a little flipped here from the ultrasound picture on the left versus the ultrasound picture you see on the right. So for orientation we have approximately on the left and distal on the right. We have some arrow signs here to identify the common flexor pronator on tendon attachment. There's a small star there in the middle where approximately where the tendon transitions to the muscle and then we also have arrowheads here to identify the anterior band of the UCL. On the bottom right here distally is also a sublime tubercle on the ulnar distally here. And so a couple things here. I flipped this position, I redid this dynamic testing and I'll play the video here shortly in the training room so that the screen on the bottom left image corresponds with the screen on the right. So now we have, so this is flipped from the last slide, we have the distal now on the left side of the screen and the medial epicondyle approximately on the right. I typically use the patient position with the edge of the table just proximal to the elbow. So if you look at the screen here this brown area of this of the of the transition here would be the edge of the exam table on the upper arm and then as a result I'm able to use that for a fulcrum for dynamic testing of the UCL. And at times after significant injury you know it doesn't take a lot of dynamic testing or pressure. The dynamic testing is simply allowing for gravity to take its effect as you hold the probe here at the UCL and watching the joint gap on the distal part of the arm. As you can see as we go through here as you can see the distal part on the left side of the screen you'll be able to see my attempts at force of up gapping and testing and dynamic testing of that UCL. I'll play it here one or two more times although I know that as we transition here it's being recorded and you could play this as much as you like after we leave. Now we get into the heart of things so we transition to the ulnar nerve reviewing the ulnar nerve and the transverse longitudinal view of the ulnar nerve on the left and the right of the screen respectively. Positive arrow signs in these images as we have arrows and arrowheads to identify the ulnar nerve. Key structures are labeled to include the medial epicondyle, the olecranon, and the head of the flexor carpi ulnaris. I mentioned this briefly earlier and like to revisit now I think that while the scanning objective of the medial elbow in this patient is focused on this specific area I would like to advocate for taking some time to trace out the length of the ulnar nerve from above the medial elbow and the upper arm down distally into the wrist. I don't think that you know from my standpoint that the extra time that this adds is very significant and I think that this gives us a better idea of the clinical picture and health of this nerve. I would argue that for just about every nerve that you scan to take that moment and the opportunity to scan. I think it gives you a better idea of the entire anatomy and physiology and potential pathology that's going on with the patient. This is the key moment, right? So this is what we've been waiting for, the dynamic evaluation of the ulnar nerve. We have a video here that we'll play again in the bottom left here, testing with the pro-positioning arm extended and flexed, transitioning the transverse plane between the olecranon and the medial epicondyle. And then as the patient with and without resistance, and within like I'll typically do with active range of motion and passive range of motion, resistance with and without resistance, flexes the elbow while the examiner observes for ulnar nerve translation, anterior and medial over the medial epicondyle. Now, so some of the pearls here is the observation should be made for additional translation of the medial triceps if the ulnar nerve goes across the medial epicondyle as well, and some pitfalls we mentioned are what we mentioned earlier is that to be aware of an amount of pressure you're applying to the probe on the elbow to avoid any potential false negatives due to probe pressure, which is easier said than done. Some of these folks have pretty prominent medial epicondyles and you're doing some version of a little bit of a gel standoff to make sure that you get enough visualization. And so you have to put a little bit of pressure and then they're moving their elbow and giving you some resistance. And so while it's easier said than done to make sure you don't put too much pressure at the same time you're trying to put enough pressure so you don't lose contact of the elbow. And so just trying to be aware of that and doing the best you can to keep that excessive pressure off there to prevent the nerve from moving. And a couple other items here that I think are key is that when we typically discuss elbow resistance, when we typically test elbow resistance to stress to see if the ulnar nerve subluxes, we talk about testing that resistance in the fully flexed position as the most provocative factor. However, clinically over the years, and in this case as well, we have found that subluxation is not always felt by the patient specifically only in resistance at the fully flexed position. And they can actually feel this sensation happen at varying degrees of elbow flexion extension. As a result, I will evaluate the stability of the ulnar nerve throughout this range of motion. And when possible, especially pay attention of the elbow position in which it was felt earlier during our dynamic physical exam to kind of put everything together. If there's a certain degree of elbow flexion extension or a certain amount of resistance or position of resistance that the patient endorses where the symptom happens the most, whether we're able to reproduce that in a dynamic kind of pushups or resistance testing earlier, I'll do that during this portion of the musculoskeletal ultrasound as well. So that's putting that arm through varying degrees, setting it up in varying degrees of flexion extension, and then going through the resistance, not just with the arm, with the elbow completely flexed. And then also, we also need to keep in mind that at times, this subluxation is happening with varying degrees of force in each patient. And this patient, I know that I've talked with a couple of different people about this, and we talked about potential options. Ryan and I have recently talked about this as well, is that how do we kind of identify some of these folks that maybe take a little bit of extra force or do certain positions to get this clinical exam to come forward for us, and then to be able to document it. Especially in this patient who had his most provocative factors while lifting weights, we might not be able to reproduce that force in a clinical setting. And as a result, are we having some folks that we have false negative ultrasound exams because we weren't able to clinically reproduce the symptoms in which they typically feel that ulnar nerve sublux over their medial epicondyle. So here's the video here as we dynamically test the ulnar nerve and able to watch the ulnar nerve slide over the medial epicondyle. I'll play this a couple of times here. And again, I know we won't play it too many times because I know this is being recorded and you can look back at it and slow it down or speed it up and play it as many times as you'd like. But you can see, I mean, you're trying to like put enough pressure on this elbow so you can like find this happening and you're going to slide a little bit as this happens. As you make sure you don't like put too much pressure and try to keep that probe on the elbow. Next transition here is to talk about our ultrasound reports. So now we've done all the hard work. We've identified this instability of the ulnar nerve but here's the key part, right? If we do that and we aren't able to successfully communicate that to the rest of our team, some of the benefit of that is lost. So at the top, of course, like our referring provider, I initially, when completing my ultrasound report templates did not include a location. However, when I started clinically as staff at the Naval Academy, I've seen patients at multiple locations and including the location helped other providers in the treatment plan to know which location the patient is primarily being seen at to arrange follow-up and coordinate care. So when I was at the Naval Academy, I was seeing patients primarily at the Naval Academy but I did go to Walter Reed to do some interventional procedures and see patients there as well. And while they're only 30 some miles away from each other, somehow that's a two-hour commute in DC. So getting confusion where patients are going to the wrong location for follow-up. And it's also challenging sometimes to get on the phone and make an appointment. So if someone's gonna spend some significant time of their day trying to make a follow-up appointment and then once they get to the end of that follow-up appointment tree, they find out that the correct place for follow-up is not at Walter Reed, it's at the Naval Academy. That can cause some frustration and confusion. And so by putting that facility on there, I think that was helpful. If someone had to go to a specialty appointment at Walter Reed, but they were primarily seeing me at the Naval Academy, when that provider was done, they could tell them like, hey, make sure you follow up Dr. Smarsky at the Naval Academy, or here's the treatment plan and make sure you see him there or the opposite if they're being seen at the Naval Academy and it was something that they needed follow-up for when I was at Walter Reed, I felt like that was fairly helpful. So from here on out, I've always included the facility or the location. I think it also gives some context and the people who are reviewing your reports or your images of the setting which the evaluation was performed. It's not always in the clinic, like I said earlier, with a lot of people around and a lot of help. And it also gives us some timing in which the ultrasound was performed. So was it performed on the sidelines? And sometimes when you're traveling with deans, it's done in the airport or the hotel room, et cetera. And so I think that that's kind of helpful to put that on there as well from a facility or a location standpoint. The next couple items are pretty straightforward in indication of right elbow pain, the study complete or limited location of the elbow and then the laterality of right versus left. The comparison imaging is something I would like to comment on a little bit more. I think when we see radiology reports, so I think that a common thing to put here is just what you're comparing it to, right? And then the person reviewing your report can obviously go back and review the report of those images. You could just writing right elbow x-rays dated 17, September, 2021, elbow MRI, 24, September, 2021. However, I typically put my focal interpretation of this area. I do this in my clinical documentation as well, like in my notes when I'm seeing patients. And so, to me, I'm doing this either way when I evaluate the patient. So it's kind of a copy paste for me. If I do this first, I'm gonna end up putting in my note later. And if I do the note first and then see the patient for diagnostic ultrasound, I'm just pulling this forward. But I like to put my focal interpretation of the area or areas of concern along with the date and what image was compared. And so that I have that additional information and people have kind of my interpretation as well. For example, right elbow x-rays dated 17, September, 2021, no focal bony abnormality was noted at the medial epicondyle. I'm not writing my full report as if I was a radiologist for the entire elbow. I'd probably be a little bit more detailed than just that one liner, but just a couple areas of concern and what I think is focal to this specific patient and their injury. And if anybody wanted to review more of the full report that they go back to the radiology report in the computer. Equipment wise, I'll always list the equipment I use, the type of transducer and some information on how the scan was performed. I think one of the things to point out here as small as it might be is, I initially did not have in my report to include the phrase securely uploaded to the patient's electronic medical record. This was actually later recommendation during an IRB process for a research project that is now part of my reports. To be fair though, some of these images are well labeled, have patient's medical identifiers. And so while we know that we're doing everything securely and correctly, I think this helps clarify that we are not carrying around an unsecured thumb drive or uploading people's images to an unsecured device and we're taking good care of patient's medical information. And so I think this makes not only the IRB feel better about what we're doing from an ultrasound perspective or imaging perspective, but also our patients as well. As most of our patients are gonna be reviewing some of these reports as well through their medical records. I almost always provide from a finding standpoint, the abnormal findings in the first bullet, so upfront and keep that separate from the rest of the information that I find normal. And then I lump up the remainder of the normal findings beneath, either in one or multiple bullets, depending on how much the amount of items or areas that we scanned. I also have gone back and forth with how technical of wording I put in these findings section and how, and now tend to lean towards more straightforward language, especially in regards to abnormal findings. I know everybody will probably have a different way to go about this. And I would definitely encourage you to ask as many people as possible or review as many of these presentations as possible for this last part. But no, I initially had only had technical ultrasound terminology in my reports and found that for those not as familiar with ultrasound language, there's potential for wording that is meant as a normal description of say, tendons or nerves to be misconstrued as abnormal. And we don't want things like that to happen from a clinical perspective. And I also, this might be a military term, but I also try to avoid the pitfall of, quote unquote, too long to read and someone doesn't review all my report or they have a hard time finding what the key information is in the report, right? So I try to keep the, especially the impression is clear and succinct as possible and able to be understood by any and all levels of medical staff and patients as well. I never really want anybody to open up a report of mine, whether it's ultrasound or EMG, et cetera, and have a hard time finding the key information or they're able to find it, but then I'm unable to understand the key information. At least for me, my referring providers are typically, you know, other colleagues like orthosurgery or family practice boards, referring providers, but not always is it somebody who is familiar with ultrasound or even familiar or an expert in musculoskeletal medicine. And so I try to keep that information available for them and so that it's very clear what we found. And this is the key part, right? If we do all this great stuff and then I have a hard, we have a hard time communicating back to the referring provider, it loses some of its clinical significance. I include a little bit of an eye chart here. If you're interested, I included some general good reference texts for musculoskeletal ultrasound and some more specific to our topic texts as well. The list here also includes a recently published updated edition of Basics of Musculoskeletal Ultrasound, which had opportunity to offer the chapter on ultrasound evaluations of the peripheral nerves this past summer, which might also be a helpful as a reference guide for you. And then I just need to take a quick moment here. This is a picture of Bancroft Hall. And so I just wanted to, where I spent a lot of quality time, the better part of the last decade in the basement of this building in the Oracle Sports Medicine Clinic. And we'd like to say thank you to my staff and partners and patients there. And of course, here in my current position here in Iowa for assisting in wonderful patient care and tolerating my passion for teaching and ultrasound and taking time out of everyone's day to allow me to give this talk. And then somehow this is not a stock photo. We have a colleague of mine that maybe allegedly climbed to the top of the last building to get a photo of the Blue Angels flying over the flag. And then my last slide is just back to our title slide here. As always, I'm happy to answer questions. I'm fairly readily available to talk medicine or be of assistance if anyone needs anything. And please don't hesitate to reach out. Thanks again for everybody for joining us and anybody watching this later on. And thanks Dr. Cruz and AMSSM for having me as part of the ultrasound case presentation series. All right, thanks, Adam, that was great, that was well done. I think, you know, very comprehensive approach and, you know, talking about positioning and all of that I think is really important here. I just have a couple of quick points that I'll make and then we can open up to any questions that are out there. You know, I think my protocol here is rather similar to yours. You know, there's a lot of crossover, you know, when we talk about these different types of protocols these different anatomic regions, medial elbow, posterior elbow, lateral elbow, there is certainly crossover. And so, you know, I think my protocol here tends to be a bit of a combination of medial and posterior elbow. Triceps kind of gets lumped in more so in the posterior elbow but I do think it's important and highly relevant for a medial elbow examination in particular when you're talking about mechanical symptoms and snapping at the elbow. I think the other point to make, and I think you made this, you know, it's critical to really try and float your transducer over the medial elbow condyle as you're doing dynamic testing because it can be very easy to, I guess, iatrogenically keep the nerve located as you're holding the transducer on there. So really try and float that to give you your best chance to catch an unstable nerve if you, or if it truly does exist. I think the other point to make here is that if you do see, you know, a snapping or an unstable ulnar nerve, I always try and describe the type of instability that I see, right? And so, you know, some people can have very smooth motion of the nerve as it courses anteriorly over the medial elbow condyle and that's not always, you know, symptomatic for people. Other times you'll see this very dyskinetic snap where it kind of gets hung up on the medial elbow condyle and then will snap over anteriorly in a very obvious manner and often will reproduce symptoms. So I try and comment on that and whether or not the instability of the nerve reproduces the symptoms. And then the last thing just to note here is that, you know, not everything at the medial elbow that snaps is the ulnar nerve. There are other structures in there that can certainly produce these mechanical symptoms and I've been fooled a couple of times. And so, you know, I always keep my differentials broad here. You know, ulnar nerve is probably the most common structure that we see, you know, moving dyskinetically at the medial elbow, but, you know, also keep in mind a snapping triceps. And I have one patient who had both, right? So they had a double snap. So they would come into elbow flexion. They would have one audible snap, which was their ulnar nerve. And as we continued in elbow flexion and had them, or we resisted them with elbow extension, triceps tendon would snap out as well. So certainly keep that in mind. The other things to consider here that can snap the medial elbow, I've seen a couple of cases of an intraarticular loose body that can produce mechanical symptoms. And then even somebody that has a hypertrophied or edematous synovium within the medial elbow, that can also produce mechanical symptoms in the area as well. So I guess point there is that there are multiple things that can snap and it's not always the ulnar nerve. Ryan, when you found that synovial tissue and or that loose body, were those things that were picked up on MRI or arthrogram before? I mentioned that because I've had a case of both of those things that had all this normal imaging and then was fairly clear on ultrasound to identify those things that initially was thought to either be ulnar nerve or a snapping triceps and then ended up being on two occasions a loose body and then at one time an extra piece of tissue, synovial tissue, et cetera, that was causing that sensation. A little bit deeper in the elbow, but it was felt kind of in that medial posterior range as well. Yeah, yeah. So the loose body patient, most of my patients, that's not true. A lot of my patients don't have MRI before I see them in reference to my elbow patients. The loose body patients had radiographs, which were normal. I think these were quite non-ossified chondraloose bodies and they weren't really gonna show up all that well. The snapping synovium patient did have an MRI, not an arthrogram, but just a regular MRI that was read as normal. And I agreed with the read and a lot of times, and you know this as well as I do, with these dynamic mechanical symptoms, MRI is obviously a static image and it's really challenging to catch that and being able to dynamically assess with ultrasound. It looks very obvious on ultrasound because you can obviously move the patient around. So yeah, that was the case with those couple of patients. Anybody else have any questions, comments, concerns? All right. Well, with that, we will call it. Adam, great job. Thanks so much again. I know you're busy out there and so I appreciate you taking the time to chat and educate all of us. So thanks again for doing this. Awesome. Thanks, Ryan. Thanks for having me. Have a good day, everyone. Yep. And just one housekeeping point, everybody. So off next week, back again on October 29th. So Emily Dixon's gonna give a talk on the anterior knee, specifically a case of pre-patellar bursitis. So again, that's 1029 off next week. Everybody have a great Friday, great weekend. And thanks again, Adam. See you guys. See ya.

3rd Edition, CASE 14

3rd Edition

Elbow and Forearm

ulnar nerve instability

musculoskeletal ultrasound

elbow pain

dynamic testing

medical documentation

sports medicine

ultrasound diagnosis