<p begin="00:00:03.998" end="00:00:06.040" tts:origin="0% 0%">- My name's Dr. Steven Sampson.</p>
<p begin="00:00:06.040" end="00:00:08.986" tts:origin="0% 0%">I practice in Los Angeles, California.</p>
<p begin="00:00:08.986" end="00:00:11.910" tts:origin="0% 0%">My specialty is physical<br />medicine and rehabilitation,</p>
<p begin="00:00:11.910" end="00:00:13.977" tts:origin="0% 0%">also known as physiatry.</p>
<p begin="00:00:13.977" end="00:00:15.955">My practice focuses primarily on</p>
<p begin="00:00:15.955" end="00:00:20.122">non-surgical orthopedics and<br />musculoskeletal medicine.</p>
<p begin="00:00:23.640" end="00:00:24.919">I was initially motivated</p>
<p begin="00:00:24.919" end="00:00:27.399">to incorporate ultrasound into my practice</p>
<p begin="00:00:27.399" end="00:00:29.490">because I've always been intrigued</p>
<p begin="00:00:29.490" end="00:00:33.210">by cutting edge treatments and<br />developments in technology,</p>
<p begin="00:00:33.210" end="00:00:35.600">and trying to offer that to my patients.</p>
<p begin="00:00:35.600" end="00:00:38.308">And I'm aware of the treatments</p>
<p begin="00:00:38.308" end="00:00:40.617">that are commonly performed in Europe</p>
<p begin="00:00:40.617" end="00:00:42.620">and it was surprising to me that</p>
<p begin="00:00:42.620" end="00:00:45.120">some of the ultrasound<br />treatments aren't quite as common</p>
<p begin="00:00:45.120" end="00:00:48.082">in the U.S. when patients<br />initially have injuries.</p>
<p begin="00:00:48.082" end="00:00:51.761">And so I began to investigate<br />different equipment</p>
<p begin="00:00:51.761" end="00:00:53.790">and technology and<br />realized that I could be</p>
<p begin="00:00:53.790" end="00:00:57.039">providing this care and quality diagnostic</p>
<p begin="00:00:57.039" end="00:01:01.206">and therapeutic interventions<br />to my patients here.</p>
<p begin="00:01:04.496" end="00:01:07.822">Ultrasound's opened up many<br />doors for me and my patients</p>
<p begin="00:01:07.822" end="00:01:11.112">to do many treatments that we<br />never conceived previously.</p>
<p begin="00:01:11.112" end="00:01:13.040">Basically, by looking into the body,</p>
<p begin="00:01:13.040" end="00:01:16.766">we can see within a millimeter<br />exactly our target area.</p>
<p begin="00:01:16.766" end="00:01:19.311">So we are able to both<br />increase our ability</p>
<p begin="00:01:19.311" end="00:01:23.394">for diagnostic purposes<br />as well as interventions.</p>
<p begin="00:01:26.727" end="00:01:28.727">I think the most important thing</p>
<p begin="00:01:28.727" end="00:01:31.205">is to like almost get your feet wet.</p>
<p begin="00:01:31.205" end="00:01:34.593">Really grab onto a<br />probe and start scanning</p>
<p begin="00:01:34.593" end="00:01:38.020">and you'll really see once<br />you can look into the body</p>
<p begin="00:01:38.020" end="00:01:40.076">and see inside the body,</p>
<p begin="00:01:40.076" end="00:01:42.836">as you're doing different treatments,</p>
<p begin="00:01:42.836" end="00:01:44.841">it really enhances your practice.</p>
<p begin="00:01:44.841" end="00:01:47.635">So, I'd suggest considering taking a</p>
<p begin="00:01:47.635" end="00:01:49.933">musculoskeletal ultrasound<br />training seminar,</p>
<p begin="00:01:49.933" end="00:01:51.473">even if it's for a day,</p>
<p begin="00:01:51.473" end="00:01:54.979">just to interact and<br />see how easy it can be</p>
<p begin="00:01:54.979" end="00:01:58.230">once you learn the basic<br />anatomy structures and scanning</p>
<p begin="00:01:58.230" end="00:02:02.397">just to begin and integrate<br />it into your practice.</p>
<p begin="00:02:06.296" end="00:02:08.384">What's really exciting about ultrasound</p>
<p begin="00:02:08.384" end="00:02:11.153">is that we're able to<br />interact with the patient.</p>
<p begin="00:02:11.153" end="00:02:14.013">It's a very hands on<br />interaction with the patient</p>
<p begin="00:02:14.013" end="00:02:16.397">where we can ask them where their pain is,</p>
<p begin="00:02:16.397" end="00:02:18.618">place the probe directly over that area</p>
<p begin="00:02:18.618" end="00:02:22.201">and determine whether<br />it's relevant or not.</p>
<p begin="00:02:24.772" end="00:02:27.489">I found that by using<br />ultrasound with my patients</p>
<p begin="00:02:27.489" end="00:02:30.664">it creates a connection<br />in education with them</p>
<p begin="00:02:30.664" end="00:02:32.414">that I haven't really seen before.</p>
<p begin="00:02:32.414" end="00:02:35.679">After doing my comprehensive<br />hands on physical exam,</p>
<p begin="00:02:35.679" end="00:02:38.775">a lot of times if they need<br />a diagnostic ultrasound</p>
<p begin="00:02:38.775" end="00:02:40.361">for further clarification,</p>
<p begin="00:02:40.361" end="00:02:41.808">we'll do the study.</p>
<p begin="00:02:41.808" end="00:02:46.336">And the patient is able to<br />look at the screen with me</p>
<p begin="00:02:46.336" end="00:02:48.126">and get educated on the structures</p>
<p begin="00:02:48.126" end="00:02:49.443">for example, their shoulder,</p>
<p begin="00:02:49.443" end="00:02:51.598">and determine exactly what the problem is.</p>
<p begin="00:02:51.598" end="00:02:54.039">By identifying the specific problem</p>
<p begin="00:02:54.039" end="00:02:56.536">and explaining them all<br />the comprehensive options,</p>
<p begin="00:02:56.536" end="00:02:58.289">they're able to make an educated choice</p>
<p begin="00:02:58.289" end="00:02:59.510">about what's the best treatment</p>
<p begin="00:02:59.510" end="00:03:01.097">for them and their philosophy.</p>
<p begin="00:03:01.097" end="00:03:03.446">For some patients it's<br />a cortisone injection,</p>
<p begin="00:03:03.446" end="00:03:06.349">some it may be physical<br />therapy versus acupuncture</p>
<p begin="00:03:06.349" end="00:03:10.695">versus medications versus<br />therapeutic yoga treatment.</p>
<p begin="00:03:10.695" end="00:03:13.668">There are many options for problems</p>
<p begin="00:03:13.668" end="00:03:17.418">depending on their issue<br />on their philosophy.</p>
<p begin="00:03:20.399" end="00:03:22.706">It's really helped increase<br />referrals from both</p>
<p begin="00:03:22.706" end="00:03:26.600">primary care, orthopedists,<br />and then most importantly,</p>
<p begin="00:03:26.600" end="00:03:29.933">from our patients that are so satisfied.</p>
<p begin="00:03:32.214" end="00:03:34.440">I did a demo of a couple<br />of different machines</p>
<p begin="00:03:34.440" end="00:03:36.613">and I was really happy<br />with the Sonosite machine</p>
<p begin="00:03:36.613" end="00:03:39.331">because it was very easy to use.</p>
<p begin="00:03:39.331" end="00:03:42.225">I have very basic needs<br />from my ultrasound machine</p>
<p begin="00:03:42.225" end="00:03:44.650">specifically for musculoskeletal use</p>
<p begin="00:03:44.650" end="00:03:47.737">and I found that the machine<br />was very compact, portable,</p>
<p begin="00:03:47.737" end="00:03:50.255">and most importantly the<br />price was very competitive</p>
<p begin="00:03:50.255" end="00:03:53.658">when it compared to the other systems.</p>
<p begin="00:03:53.658" end="00:03:54.727">But for the most part,</p>
<p begin="00:03:54.727" end="00:03:56.619">I just felt very comfortable<br />with it and ease of use</p>
<p begin="00:03:56.619" end="00:03:59.369">and I've been very happy with it.</p>
<p begin="00:04:03.193" end="00:04:06.050">Perhaps, two of the<br />most talked about topics</p>
<p begin="00:04:06.050" end="00:04:07.637">in orthopedics and sports medicine</p>
<p begin="00:04:07.637" end="00:04:11.804">at conferences and various<br />areas is orthobiologics,</p>
<p begin="00:04:12.956" end="00:04:14.848">which is basically a broad field</p>
<p begin="00:04:14.848" end="00:04:17.004">that describes cutting edge technology</p>
<p begin="00:04:17.004" end="00:04:20.233">maximizing the body's natural<br />ability to heal itself.</p>
<p begin="00:04:20.233" end="00:04:24.400">Including stem cells, platelets,<br />and various growth factors.</p>
<p begin="00:04:25.388" end="00:04:30.217">And the second hot topic is<br />musculoskeletal ultrasound.</p>
<p begin="00:04:30.217" end="00:04:32.936">And so, being able to<br />provide some of these</p>
<p begin="00:04:32.936" end="00:04:34.520">biologic type treatments,</p>
<p begin="00:04:34.520" end="00:04:37.248">we need a means to<br />administer them accurately.</p>
<p begin="00:04:37.248" end="00:04:40.665">So ultrasound allows us<br />to inject the patient's</p>
<p begin="00:04:40.665" end="00:04:43.130">own growth factors,<br />platelets or stem cells,</p>
<p begin="00:04:43.130" end="00:04:45.452">within a millimeter of the target injury</p>
<p begin="00:04:45.452" end="00:04:49.619">to give the patient the<br />best opportunity to recover.</p>

<p begin="00:00:07.432" end="00:00:09.095" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.095" end="00:00:11.235" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.235" end="00:00:13.676" style="s2">is used to perform an<br />ultrasound examination</p>
<p begin="00:00:13.676" end="00:00:15.475" style="s2">of the biceps tendon.</p>
<p begin="00:00:15.475" end="00:00:17.318" style="s2">The patient is in a sitting position</p>
<p begin="00:00:17.318" end="00:00:20.061" style="s2">with the hand placed palm up on the knee.</p>
<p begin="00:00:20.061" end="00:00:22.230" style="s2">The transducer is placed transversely</p>
<p begin="00:00:22.230" end="00:00:23.766" style="s2">over the head of the humerus</p>
<p begin="00:00:23.766" end="00:00:28.067" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:28.067" end="00:00:29.698" style="s2">The deltoid muscle is seen as</p>
<p begin="00:00:29.698" end="00:00:32.001" style="s2">the most superficial structure.</p>
<p begin="00:00:32.001" end="00:00:35.322" style="s2">The bright hyperechoic greater<br />and lesser tuberosities</p>
<p begin="00:00:35.322" end="00:00:38.758" style="s2">of the humerus surround the<br />oval-shaped biceps tendon.</p>
<p begin="00:00:38.758" end="00:00:40.408" style="s2">The transverse humeral ligament,</p>
<p begin="00:00:40.408" end="00:00:42.151" style="s2">which covers the biceps tendon,</p>
<p begin="00:00:42.151" end="00:00:44.621" style="s2">can be seen as a thin, bright line.</p>
<p begin="00:00:44.621" end="00:00:48.055" style="s2">The biceps tendon is seen<br />in the bicipital groove</p>
<p begin="00:00:48.055" end="00:00:51.014" style="s2">and can appear artificially bright or dark</p>
<p begin="00:00:51.014" end="00:00:53.628" style="s2">due to anisotropy, which<br />occurs if the transducer</p>
<p begin="00:00:53.628" end="00:00:55.700" style="s2">is rocked over the tendon.</p>
<p begin="00:00:55.700" end="00:00:57.933" style="s2">The transducer should<br />be moved down the arm</p>
<p begin="00:00:57.933" end="00:01:01.182" style="s2">to evaluate the tendon to<br />its musculotendinous junction</p>
<p begin="00:01:01.182" end="00:01:04.277" style="s2">and the insertion of the<br />pectoralis major tendon.</p>
<p begin="00:01:04.277" end="00:01:07.211" style="s2">The transducer is returned<br />to the starting position</p>
<p begin="00:01:07.211" end="00:01:10.990" style="s2">at the bicipital groove and<br />rotated 90 degrees clockwise</p>
<p begin="00:01:10.990" end="00:01:14.008" style="s2">to obtain a long axis view of the tendon.</p>
<p begin="00:01:14.008" end="00:01:15.976" style="s2">The fibular tendon should be scanned</p>
<p begin="00:01:15.976" end="00:01:20.143" style="s2">from proximal to distal to<br />the musculotendinous junction.</p>

<p begin="00:00:07.420" end="00:00:08.846" style="s2">- [Voiceover] A linear<br />array transducer with a</p>
<p begin="00:00:08.846" end="00:00:11.191" style="s2">musculoskeletal exam type,</p>
<p begin="00:00:11.191" end="00:00:13.228" style="s2">is used to perform an<br />ultrasound examination</p>
<p begin="00:00:13.228" end="00:00:16.057" style="s2">of the subscapularis tendon.</p>
<p begin="00:00:16.057" end="00:00:17.682" style="s2">The patient is in a sitting position,</p>
<p begin="00:00:17.682" end="00:00:21.380" style="s2">with the patients hand palm<br />up and resting on the knee.</p>
<p begin="00:00:21.380" end="00:00:24.028" style="s2">The examiner is positioned<br />in front of the patient</p>
<p begin="00:00:24.028" end="00:00:26.160" style="s2">and the transducer is placed transversely</p>
<p begin="00:00:26.160" end="00:00:27.938" style="s2">over the head of the humerus,</p>
<p begin="00:00:27.938" end="00:00:29.722" style="s2">with the orientation marker directed</p>
<p begin="00:00:29.722" end="00:00:31.504" style="s2">to the patient's right.</p>
<p begin="00:00:31.504" end="00:00:33.069" style="s2">The deltoid muscle is seen</p>
<p begin="00:00:33.069" end="00:00:34.782" style="s2">as the most superficial structure.</p>
<p begin="00:00:34.782" end="00:00:37.284" style="s2">The bright hyperechoic greater and lesser</p>
<p begin="00:00:37.284" end="00:00:38.948" style="s2">tuberosities of the humerus,</p>
<p begin="00:00:38.948" end="00:00:41.546" style="s2">surround the oval shaped, biceps tendon.</p>
<p begin="00:00:41.546" end="00:00:44.102" style="s2">The arm, is then externally rotated</p>
<p begin="00:00:44.102" end="00:00:47.676" style="s2">to bring the bird's beak<br />shaped subscapularis tendon</p>
<p begin="00:00:47.676" end="00:00:51.843" style="s2">to view, as it inserts<br />into the lesser tuberosity.</p>
<p begin="00:00:57.385" end="00:00:59.975" style="s2">The fibular tendon lies<br />between the superficial</p>
<p begin="00:00:59.975" end="00:01:02.141" style="s2">deltoid muscle and the intense bright</p>
<p begin="00:01:02.141" end="00:01:05.575" style="s2">hyperechoic reflection<br />of the humerus below.</p>
<p begin="00:01:05.575" end="00:01:07.770" style="s2">The subscapularis tendon<br />should be evaluated</p>
<p begin="00:01:07.770" end="00:01:10.180" style="s2">by sweeping the transducer from it's</p>
<p begin="00:01:10.180" end="00:01:12.544" style="s2">proximal musculotendinous insertion,</p>
<p begin="00:01:12.544" end="00:01:15.908" style="s2">on the lesser tuberosity<br />to the inferior portion.</p>
<p begin="00:01:15.908" end="00:01:18.288" style="s2">The examiner can provide<br />gentle resistance against</p>
<p begin="00:01:18.288" end="00:01:20.497" style="s2">the subject's arm during internal rotation</p>
<p begin="00:01:20.497" end="00:01:23.275" style="s2">to highlight subtle pathology.</p>
<p begin="00:01:23.275" end="00:01:26.506" style="s2">The transducer is then<br />rotated 90 degrees clockwise,</p>
<p begin="00:01:26.506" end="00:01:28.721" style="s2">to evaluate the subscapularis tendon</p>
<p begin="00:01:28.721" end="00:01:31.073" style="s2">with a short axis view.</p>
<p begin="00:01:31.073" end="00:01:32.805" style="s2">Note the three distinct tendon bundles</p>
<p begin="00:01:32.805" end="00:01:34.894" style="s2">visible in the transverse axis.</p>
<p begin="00:01:34.894" end="00:01:36.885" style="s2">The deltoid muscle is seen as</p>
<p begin="00:01:36.885" end="00:01:38.492" style="s2">the most superficial structure.</p>
<p begin="00:01:38.492" end="00:01:40.624" style="s2">The bright hyperechoic greater and</p>
<p begin="00:01:40.624" end="00:01:42.874" style="s2">lesser tuberosities of the humerus,</p>
<p begin="00:01:42.874" end="00:01:45.844" style="s2">surround the oval shaped bicep's tendon.</p>
<p begin="00:01:45.844" end="00:01:49.631" style="s2">The subscapularis lies<br />below the deltoid muscle.</p>
<p begin="00:01:49.631" end="00:01:51.746" style="s2">The subscapularis tendon approaches the</p>
<p begin="00:01:51.746" end="00:01:54.546" style="s2">bright hyperechoic coracoid process,</p>
<p begin="00:01:54.546" end="00:01:56.839" style="s2">with internal and external rotation,</p>
<p begin="00:01:56.839" end="00:02:00.839" style="s2">and can be a cause of<br />coracohumeral impingement.</p>

<p begin="00:00:07.103" end="00:00:08.828" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:08.828" end="00:00:11.759" style="s2">with a musculoskeletal exam type is used</p>
<p begin="00:00:11.759" end="00:00:13.738" style="s2">to perform an ultrasound-guided injection</p>
<p begin="00:00:13.738" end="00:00:16.776" style="s2">of the shoulder via a medial approach.</p>
<p begin="00:00:16.776" end="00:00:18.887" style="s2">Alternatively, a curved array transducer</p>
<p begin="00:00:18.887" end="00:00:21.114" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:21.114" end="00:00:23.299" style="s2">can be used in a large patient.</p>
<p begin="00:00:23.299" end="00:00:25.945" style="s2">The patient is in a<br />lateral decubitus position</p>
<p begin="00:00:25.945" end="00:00:27.930" style="s2">with the arm flexed across the body.</p>
<p begin="00:00:27.930" end="00:00:30.634" style="s2">The examiner is positioned<br />behind the patient,</p>
<p begin="00:00:30.634" end="00:00:33.293" style="s2">and the transducer is placed posteriorly</p>
<p begin="00:00:33.293" end="00:00:34.898" style="s2">over the head of the humerus,</p>
<p begin="00:00:34.898" end="00:00:37.985" style="s2">with the orientation marker<br />directed to the patients' right.</p>
<p begin="00:00:37.985" end="00:00:40.210" style="s2">The examination begins by locating</p>
<p begin="00:00:40.210" end="00:00:42.036" style="s2">the glenohumeral joint space,</p>
<p begin="00:00:42.036" end="00:00:43.669" style="s2">which lies below the deep fibers</p>
<p begin="00:00:43.669" end="00:00:46.969" style="s2">of the infraspinatus muscle<br />and the glenoid labrum,</p>
<p begin="00:00:46.969" end="00:00:48.298" style="s2">which appears as a bright,</p>
<p begin="00:00:48.298" end="00:00:51.812" style="s2">hyperechoic region in the<br />mid portion of the image.</p>
<p begin="00:00:51.812" end="00:00:53.408" style="s2">The humeral head can be seen</p>
<p begin="00:00:53.408" end="00:00:55.476" style="s2">on the right of the screen as a rounded,</p>
<p begin="00:00:55.476" end="00:00:57.556" style="s2">bright hyper-reflective image.</p>
<p begin="00:00:57.556" end="00:01:00.535" style="s2">The transducer is<br />adjusted so it is centered</p>
<p begin="00:01:00.535" end="00:01:02.968" style="s2">over the glenohumeral joint line.</p>
<p begin="00:01:02.968" end="00:01:04.721" style="s2">The needle is inserted in the skin,</p>
<p begin="00:01:04.721" end="00:01:07.303" style="s2">just proximal to the transducer.</p>
<p begin="00:01:07.303" end="00:01:08.863" style="s2">The needle is slowly advanced,</p>
<p begin="00:01:08.863" end="00:01:11.199" style="s2">to lie in-plane to the transducer beam,</p>
<p begin="00:01:11.199" end="00:01:12.479" style="s2">and is seen as a bright,</p>
<p begin="00:01:12.479" end="00:01:14.824" style="s2">hyperechoic linear structure.</p>
<p begin="00:01:14.824" end="00:01:16.443" style="s2">The needle is slowly advanced</p>
<p begin="00:01:16.443" end="00:01:18.387" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:18.387" end="00:01:20.059" style="s2">until the tip is seen to lie</p>
<p begin="00:01:20.059" end="00:01:21.475" style="s2">within the shoulder joint space,</p>
<p begin="00:01:21.475" end="00:01:25.392" style="s2">where an injection, or<br />aspiration, can be done.</p>

<p begin="00:00:07.776" end="00:00:09.436" style="s2">- [Voiceover] A Linear Array Transducer</p>
<p begin="00:00:09.436" end="00:00:11.573" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.573" end="00:00:14.127" style="s2">is used to perform an<br />ultrasound-guided injection</p>
<p begin="00:00:14.127" end="00:00:17.238" style="s2">of the shoulder joint<br />via a lateral approach.</p>
<p begin="00:00:17.238" end="00:00:19.758" style="s2">Alternatively, a Curved Array Transducer</p>
<p begin="00:00:19.758" end="00:00:21.847" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:21.847" end="00:00:24.285" style="s2">can be used in a large patient.</p>
<p begin="00:00:24.285" end="00:00:27.188" style="s2">The patient is in a<br />lateral decubitus position</p>
<p begin="00:00:27.188" end="00:00:29.487" style="s2">with the arm flexed across the body.</p>
<p begin="00:00:29.487" end="00:00:31.902" style="s2">The examiner is positioned<br />behind the patient</p>
<p begin="00:00:31.902" end="00:00:34.421" style="s2">and the transducer is placed posteriorly</p>
<p begin="00:00:34.421" end="00:00:37.277" style="s2">over the head of the humerus<br />with the orientation marker</p>
<p begin="00:00:37.277" end="00:00:39.413" style="s2">directed to the patient's right.</p>
<p begin="00:00:39.413" end="00:00:41.805" style="s2">The examination begins by locating</p>
<p begin="00:00:41.805" end="00:00:44.568" style="s2">the glenohumeral joint<br />space, which lies below</p>
<p begin="00:00:44.568" end="00:00:47.343" style="s2">the deep fibers of the<br />infraspinatus muscle</p>
<p begin="00:00:47.343" end="00:00:49.781" style="s2">and the glenoid labrum,<br />which appears as a bright,</p>
<p begin="00:00:49.781" end="00:00:53.101" style="s2">hyperechoic region in the<br />mid portion of the image.</p>
<p begin="00:00:53.101" end="00:00:55.876" style="s2">The humeral head can be seen<br />on the right of the screen</p>
<p begin="00:00:55.876" end="00:00:58.953" style="s2">as a rounded, bright hyperechoic image.</p>
<p begin="00:00:58.953" end="00:01:01.553" style="s2">The transducer is<br />adjusted so it is centered</p>
<p begin="00:01:01.553" end="00:01:03.992" style="s2">over the glenohumeral joint line.</p>
<p begin="00:01:03.992" end="00:01:05.559" style="s2">The needle is inserted in the skin</p>
<p begin="00:01:05.559" end="00:01:07.533" style="s2">just proximal to the transducer</p>
<p begin="00:01:07.533" end="00:01:10.087" style="s2">on the opposite side of<br />the orientation marker.</p>
<p begin="00:01:10.087" end="00:01:12.606" style="s2">The needle is slowly<br />advanced to lie in plane</p>
<p begin="00:01:12.606" end="00:01:15.126" style="s2">to the transducer beam,<br />and is seen as a bright,</p>
<p begin="00:01:15.126" end="00:01:17.645" style="s2">hyperechoic linear structure.</p>
<p begin="00:01:17.645" end="00:01:19.770" style="s2">The needle is slowly advanced under direct</p>
<p begin="00:01:19.770" end="00:01:22.463" style="s2">ultrasound visualization<br />until the tip is seen</p>
<p begin="00:01:22.463" end="00:01:24.599" style="s2">to lie within the shoulder joint space,</p>
<p begin="00:01:24.599" end="00:01:28.349" style="s2">where an injection or<br />aspiration can be done.</p>

<p begin="00:00:07.495" end="00:00:09.368" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.368" end="00:00:11.564" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.564" end="00:00:13.107" style="s2">is used to perform an ultrasound</p>
<p begin="00:00:13.107" end="00:00:16.103" style="s2">examination of the quadriceps tendon.</p>
<p begin="00:00:16.103" end="00:00:18.355" style="s2">The patient is in a supine position</p>
<p begin="00:00:18.355" end="00:00:20.929" style="s2">with the knee flexed 90 degrees.</p>
<p begin="00:00:20.929" end="00:00:24.345" style="s2">The transducer is placed<br />longitudinally just proximal</p>
<p begin="00:00:24.345" end="00:00:26.962" style="s2">to the patella with the<br />orientation marker directed</p>
<p begin="00:00:26.962" end="00:00:28.933" style="s2">to the patient's head.</p>
<p begin="00:00:28.933" end="00:00:32.297" style="s2">The compact fibrillar pattern<br />of the quadriceps tendon</p>
<p begin="00:00:32.297" end="00:00:35.012" style="s2">is seen superficial to the<br />bright hyperechoic signal</p>
<p begin="00:00:35.012" end="00:00:37.124" style="s2">of the distal femur.</p>
<p begin="00:00:37.124" end="00:00:39.177" style="s2">The bright hyperechoic patella is seen</p>
<p begin="00:00:39.177" end="00:00:41.050" style="s2">on the right of the image.</p>
<p begin="00:00:41.050" end="00:00:44.090" style="s2">The suprapatellar fat pad<br />can be seen as a triangular,</p>
<p begin="00:00:44.090" end="00:00:47.089" style="s2">bright hyperechoic<br />structure just superficial</p>
<p begin="00:00:47.089" end="00:00:49.755" style="s2">to the suprapatellar bursa.</p>
<p begin="00:00:49.755" end="00:00:52.983" style="s2">The transducer should be swept<br />from medial to lateral to</p>
<p begin="00:00:52.983" end="00:00:56.314" style="s2">evaluate the entire quadriceps tendon.</p>
<p begin="00:00:56.314" end="00:00:58.883" style="s2">The transducer should<br />then be rotated 90 degrees</p>
<p begin="00:00:58.883" end="00:01:02.627" style="s2">counterclockwise for a short<br />axis view of the tendon.</p>
<p begin="00:01:02.627" end="00:01:05.157" style="s2">The medial and lateral condyles are seen</p>
<p begin="00:01:05.157" end="00:01:07.914" style="s2">as bright hyperechoic lines.</p>
<p begin="00:01:07.914" end="00:01:10.818" style="s2">The cartilage of the knee is<br />seen superficial to the bone</p>
<p begin="00:01:10.818" end="00:01:13.581" style="s2">as a black anechoic line.</p>
<p begin="00:01:13.581" end="00:01:17.041" style="s2">The pancake shaped speckled<br />suprapatellar tendon is seen in</p>
<p begin="00:01:17.041" end="00:01:21.394" style="s2">cross-section anterior to<br />the suprapatellar bursa.</p>
<p begin="00:01:21.394" end="00:01:23.652" style="s2">The transducer should be<br />swept from the patella</p>
<p begin="00:01:23.652" end="00:01:26.636" style="s2">to the musculotendinous<br />insertion of the tendon</p>
<p begin="00:01:26.636" end="00:01:28.969" style="s2">to complete the examination.</p>

<p begin="00:00:07.442" end="00:00:09.161" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.161" end="00:00:11.351" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.351" end="00:00:14.278" style="s2">is used to perform an<br />ultrasound guided injection</p>
<p begin="00:00:14.278" end="00:00:16.258" style="s2">of the pubic symphysis.</p>
<p begin="00:00:16.258" end="00:00:18.665" style="s2">The patient is in a supine position.</p>
<p begin="00:00:18.665" end="00:00:21.467" style="s2">The transducer is placed longitudinally</p>
<p begin="00:00:21.467" end="00:00:23.198" style="s2">over the pubic prominence</p>
<p begin="00:00:23.198" end="00:00:26.593" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:26.593" end="00:00:28.603" style="s2">The right and left pubic bodies</p>
<p begin="00:00:28.603" end="00:00:32.134" style="s2">are seen as bright,<br />hyperechoic curved structures.</p>
<p begin="00:00:32.134" end="00:00:34.986" style="s2">The pubic symphysis is seen as a darker,</p>
<p begin="00:00:34.986" end="00:00:38.201" style="s2">hypoechoic line between the two bodies.</p>
<p begin="00:00:38.201" end="00:00:41.189" style="s2">The needle is inserted using<br />an out-of-plane technique</p>
<p begin="00:00:41.189" end="00:00:43.676" style="s2">superior to the transducer.</p>
<p begin="00:00:43.676" end="00:00:47.083" style="s2">The needle is advanced until<br />it enters the pubic symphysis</p>
<p begin="00:00:47.083" end="00:00:49.429" style="s2">where the injection can be performed.</p>
<p begin="00:00:49.429" end="00:00:51.588" style="s2">The pubic symphysis should be scanned</p>
<p begin="00:00:51.588" end="00:00:52.929" style="s2">following needle removal</p>
<p begin="00:00:52.929" end="00:00:57.096" style="s2">to ensure there is no bleeding<br />following the procedure.</p>

<p begin="00:00:07.749" end="00:00:09.332" style="s2">- [Voiceover] A curved array transducer</p>
<p begin="00:00:09.332" end="00:00:11.596" style="s2">with a musculoskeletal exam type</p>
<p begin="00:00:11.596" end="00:00:14.226" style="s2">is used to perform an<br />ultrasound guided injection</p>
<p begin="00:00:14.226" end="00:00:16.908" style="s2">of the proximal hamstring muscle.</p>
<p begin="00:00:16.908" end="00:00:19.168" style="s2">The patient is in a prone position</p>
<p begin="00:00:19.168" end="00:00:21.615" style="s2">with the leg slightly abducted.</p>
<p begin="00:00:21.615" end="00:00:23.978" style="s2">The transducer is place transversely</p>
<p begin="00:00:23.978" end="00:00:26.981" style="s2">over the ischial tuberosity<br />with the orientation marker</p>
<p begin="00:00:26.981" end="00:00:31.148" style="s2">directed to the patient's right<br />at a nine o'clock position.</p>
<p begin="00:00:32.248" end="00:00:34.232" style="s2">The ischial tuberosity is seen</p>
<p begin="00:00:34.232" end="00:00:38.015" style="s2">as a bright, hyperechoic,<br />curved structure.</p>
<p begin="00:00:38.015" end="00:00:40.650" style="s2">The hamstring muscle and<br />it's conjoined tendon</p>
<p begin="00:00:40.650" end="00:00:42.860" style="s2">is seen on cross-section<br />in the mid portion</p>
<p begin="00:00:42.860" end="00:00:44.724" style="s2">of the scan field.</p>
<p begin="00:00:44.724" end="00:00:47.306" style="s2">The transducer is translated superiorly</p>
<p begin="00:00:47.306" end="00:00:50.884" style="s2">to see the origin of the<br />muscle in a short access plane.</p>
<p begin="00:00:50.884" end="00:00:54.152" style="s2">The transducer is then<br />rotated 90 degrees clockwise</p>
<p begin="00:00:54.152" end="00:00:57.279" style="s2">with the orientation marker<br />directed at the patient's head</p>
<p begin="00:00:57.279" end="00:01:00.516" style="s2">to obtain a long access view<br />of the hamstring muscle.</p>
<p begin="00:01:00.516" end="00:01:03.236" style="s2">The needle is inserted<br />in a long access approach</p>
<p begin="00:01:03.236" end="00:01:05.895" style="s2">lateral to the transducer.</p>
<p begin="00:01:05.895" end="00:01:08.374" style="s2">The needle is slowly<br />advanced to lie in plane</p>
<p begin="00:01:08.374" end="00:01:09.936" style="s2">to the transducer beam</p>
<p begin="00:01:09.936" end="00:01:13.804" style="s2">and is seen as a bright,<br />hyperechoic, linear structure.</p>
<p begin="00:01:13.804" end="00:01:14.637" style="s2">The needle is slowly advanced</p>
<p begin="00:01:14.637" end="00:01:17.363" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:17.363" end="00:01:18.670" style="s2">until the tip is seen</p>
<p begin="00:01:18.670" end="00:01:21.824" style="s2">to puncture the anterior<br />surface of the muscle.</p>
<p begin="00:01:21.824" end="00:01:23.070" style="s2">The needle should be advanced</p>
<p begin="00:01:23.070" end="00:01:26.030" style="s2">until the needle tip lies<br />just above the bony surface</p>
<p begin="00:01:26.030" end="00:01:28.270" style="s2">within the conjoined tendon.</p>
<p begin="00:01:28.270" end="00:01:29.983" style="s2">Care should be taken to avoid</p>
<p begin="00:01:29.983" end="00:01:32.236" style="s2">the posterior cutaneous thigh nerve</p>
<p begin="00:01:32.236" end="00:01:35.297" style="s2">which often overlies the conjoined tendon.</p>
<p begin="00:01:35.297" end="00:01:38.047" style="s2">The needle should be aspirated<br />prior to the injection</p>
<p begin="00:01:38.047" end="00:01:39.720" style="s2">of the anesthetic agent.</p>
<p begin="00:01:39.720" end="00:01:41.937" style="s2">At the conclusion of the procedure,</p>
<p begin="00:01:41.937" end="00:01:43.992" style="s2">the hamstring muscle should be scanned</p>
<p begin="00:01:43.992" end="00:01:46.513" style="s2">using a short and long access approach</p>
<p begin="00:01:46.513" end="00:01:50.680" style="s2">to ensure that there is no<br />bleeding following the procedure.</p>