<p begin="00:00:03.880" end="00:00:07.029" style="s2">this is a brief introduction to super<br />spin a dispatch ology</p>
<p begin="00:00:10.240" end="00:00:12.980" style="s2">we will begin by describing the bony<br />anatomy</p>
<p begin="00:00:12.980" end="00:00:16.470" style="s2">covered by the articular hailing<br />cartilage shown here</p>
<p begin="00:00:16.470" end="00:00:18.140" style="s2">in blue</p>
<p begin="00:00:18.140" end="00:00:22.580" style="s2">illustrated here is too long head of the<br />biceps tendon passing through the bicep</p>
<p begin="00:00:22.580" end="00:00:26.240" style="s2">ru to insert at the superior going on</p>
<p begin="00:00:26.240" end="00:00:29.650" style="s2">labor</p>
<p begin="00:00:29.650" end="00:00:32.520" style="s2">illustrated next is the supraspinatus<br />tendon</p>
<p begin="00:00:32.520" end="00:00:36.640" style="s2">as attach is to the greater tuberosity<br />at interior</p>
<p begin="00:00:36.640" end="00:00:39.860" style="s2">portion posteriorly the interest in a<br />distant</p>
<p begin="00:00:39.860" end="00:00:43.160" style="s2">wraps around the posterior surface the<br />humeral head</p>
<p begin="00:00:43.690" end="00:00:48.020" style="s2">to attach to the remainder the greater<br />tuberosity is lateral</p>
<p begin="00:00:48.020" end="00:00:51.020" style="s2">and post your your margins</p>
<p begin="00:00:51.820" end="00:00:55.590" style="s2">as the interest Benitez tendon attaches<br />to the post your your aspect of the</p>
<p begin="00:00:55.590" end="00:00:56.880" style="s2">greater tuberosity</p>
<p begin="00:00:56.880" end="00:01:02.330" style="s2">take note in about one-third Pittston<br />anti burst share an insertion point with</p>
<p begin="00:01:02.330" end="00:01:03.730" style="s2">two super spin eight assists</p>
<p begin="00:01:03.730" end="00:01:07.020" style="s2">post your your one-third its tendon as<br />well</p>
<p begin="00:01:07.020" end="00:01:10.050" style="s2">due to the oblique nature</p>
<p begin="00:01:10.050" end="00:01:14.690" style="s2">the interest in a dis is insertion<br />relative to the supraspinatus insertion</p>
<p begin="00:01:14.690" end="00:01:16.150" style="s2">to the greater tuberosity</p>
<p begin="00:01:16.150" end="00:01:20.100" style="s2">special care should be taken while<br />scanning through this section</p>
<p begin="00:01:20.100" end="00:01:23.100" style="s2">to avoid false-positive tears</p>
<p begin="00:01:24.109" end="00:01:27.759" style="s2">in developing these lateral rotator cuff<br />structures will be D</p>
<p begin="00:01:27.759" end="00:01:30.759" style="s2">subacromial sub deltoid versa</p>
<p begin="00:01:31.930" end="00:01:35.360" style="s2">this illustration shows a cross-section<br />the supraspinatus</p>
<p begin="00:01:35.360" end="00:01:38.360" style="s2">proximal to its insertion the greater<br />tuberosity</p>
<p begin="00:01:39.829" end="00:01:42.950" style="s2">primary focus this video will be the<br />relationship</p>
<p begin="00:01:42.950" end="00:01:46.140" style="s2">on the supraspinatus tendon with the<br />bicep tendon edits</p>
<p begin="00:01:46.140" end="00:01:49.110" style="s2">intercapital our segment</p>
<p begin="00:01:49.110" end="00:01:53.020" style="s2">this is the corresponding image the<br />supraspinatus tendon in cross-section</p>
<p begin="00:01:54.869" end="00:01:58.710" style="s2">highlighted here is the funeral at<br />proximal to the supraspinatus insertion</p>
<p begin="00:01:58.710" end="00:02:02.010" style="s2">the black gram is the articular<br />cartilage</p>
<p begin="00:02:02.010" end="00:02:05.190" style="s2">the lateral deltoid muscle run and cross<br />section as well</p>
<p begin="00:02:05.190" end="00:02:08.570" style="s2">at this level</p>
<p begin="00:02:08.570" end="00:02:12.350" style="s2">the interior super spin a distant is<br />well socialized while the posterior</p>
<p begin="00:02:12.350" end="00:02:14.470" style="s2">supraspinatus tendon is less</p>
<p begin="00:02:14.470" end="00:02:17.860" style="s2">identifiable due to its merger with the<br />interest in Ames</p>
<p begin="00:02:17.860" end="00:02:21.950" style="s2">highlighted in this image is the bicep<br />tendon also in cross-section with the</p>
<p begin="00:02:21.950" end="00:02:23.230" style="s2">supraspinatus tendon</p>
<p begin="00:02:23.230" end="00:02:26.120" style="s2">anterior margin</p>
<p begin="00:02:26.120" end="00:02:29.030" style="s2">from the transverse or cross-section<br />image we will now</p>
<p begin="00:02:29.030" end="00:02:33.840" style="s2">switch to the long axis more saddle cut<br />the supraspinatus tendon</p>
<p begin="00:02:33.840" end="00:02:36.840" style="s2">at the interior margin a greater<br />tuberosity</p>
<p begin="00:02:39.170" end="00:02:43.310" style="s2">here's the corresponding long axis<br />section the supraspinatus tendon</p>
<p begin="00:02:43.310" end="00:02:47.450" style="s2">as in search to greater tuberosity<br />highlighted here is the humeral head</p>
<p begin="00:02:47.450" end="00:02:52.500" style="s2">in greater tuberosity in profile it is<br />not uncommon to see a long axis deltoid</p>
<p begin="00:02:52.500" end="00:02:53.069" style="s2">muscle</p>
<p begin="00:02:53.069" end="00:02:58.319" style="s2">in relation to the long axis the<br />supraspinatus tendon highlighted in the</p>
<p begin="00:02:58.319" end="00:02:59.180" style="s2">next image</p>
<p begin="00:02:59.180" end="00:03:03.010" style="s2">is the long axis the supraspinatus<br />tendon as it answers to the greater</p>
<p begin="00:03:03.010" end="00:03:05.260" style="s2">tuberosity</p>
<p begin="00:03:05.260" end="00:03:08.260" style="s2">super spin anus pathological images</p>
<p begin="00:03:09.150" end="00:03:12.799" style="s2">this image demonstrates an interior<br />full-thickness tears well as a</p>
<p begin="00:03:12.799" end="00:03:16.299" style="s2">personal surface mid segment tear the<br />supraspinatus tendon</p>
<p begin="00:03:18.700" end="00:03:23.070" style="s2">here we have multiple terror citing no<br />volume loss identified</p>
<p begin="00:03:23.070" end="00:03:26.070" style="s2">in the transverse image</p>
<p begin="00:03:26.890" end="00:03:29.719" style="s2">here we have interior articular surface<br />tearing</p>
<p begin="00:03:29.719" end="00:03:33.290" style="s2">demonstrating by in los as Hypoluxo like<br />absence</p>
<p begin="00:03:33.290" end="00:03:35.700" style="s2">tendon fibers</p>
<p begin="00:03:35.700" end="00:03:38.430" style="s2">he rehashed post-operative retailer</p>
<p begin="00:03:38.430" end="00:03:42.030" style="s2">the interior super spin a distended<br />locating the exact site</p>
<p begin="00:03:42.030" end="00:03:46.530" style="s2">this terror is difficult as the bicep<br />tendon is not in its normally situated</p>
<p begin="00:03:46.530" end="00:03:51.390" style="s2">by typical group scanning from the<br />indeed biceps group posteriorly</p>
<p begin="00:03:51.390" end="00:03:55.970" style="s2">will reveal arced first in best landmark<br />the lateral greater tuberosity in</p>
<p begin="00:03:55.970" end="00:03:56.629" style="s2">profile</p>
<p begin="00:03:56.629" end="00:04:01.290" style="s2">scanning to post early may reveal<br />falsely normal rotator cuff as</p>
<p begin="00:04:01.290" end="00:04:03.690" style="s2">demonstrated in blue</p>
<p begin="00:04:03.690" end="00:04:07.900" style="s2">here's a corresponding normal rotator<br />cuff with the normally situated bicep</p>
<p begin="00:04:07.900" end="00:04:09.330" style="s2">tendon highlighted in blue</p>
<p begin="00:04:09.330" end="00:04:13.320" style="s2">where the dislocated is in red in this<br />case a long axis greater tuberosity</p>
<p begin="00:04:13.320" end="00:04:14.590" style="s2">would be a better</p>
<p begin="00:04:14.590" end="00:04:17.170" style="s2">landmark</p>
<p begin="00:04:17.170" end="00:04:20.220" style="s2">subtle interest substance carrying is<br />often harder to identify</p>
<p begin="00:04:22.470" end="00:04:26.460" style="s2">there is a hyper collect where over the<br />summer Camille bursa called Perry</p>
<p begin="00:04:26.460" end="00:04:27.380" style="s2">personal Sat</p>
<p begin="00:04:27.380" end="00:04:30.960" style="s2">and indicating layer that is the actual<br />bursal void</p>
<p begin="00:04:30.960" end="00:04:35.270" style="s2">followed by the supraspinatus tendon<br />itself area of interest here</p>
<p begin="00:04:35.270" end="00:04:38.630" style="s2">is the Dept or the concave and what<br />would normally be</p>
<p begin="00:04:38.630" end="00:04:41.630" style="s2">declined backs appearing mursal layer</p>
<p begin="00:04:44.530" end="00:04:49.000" style="s2">in long axis is normally contact<br />Trinkaus may actually be flattened</p>
<p begin="00:04:49.000" end="00:04:52.070" style="s2">instead of rounded as we see here again<br />take care</p>
<p begin="00:04:52.620" end="00:04:56.860" style="s2">to scan through the entire cast to avoid<br />any false positives</p>
<p begin="00:04:56.860" end="00:05:00.010" style="s2">as we have us demonstrated here as a<br />falsely</p>
<p begin="00:05:00.010" end="00:05:01.140" style="s2">mall cop and blue</p>

<p begin="00:00:05.100" end="00:00:06.790" style="s2">- [Voiceover] The<br />following are case studies</p>
<p begin="00:00:06.790" end="00:00:09.121" style="s2">presenting pictures of the posterior</p>
<p begin="00:00:09.121" end="00:00:12.497" style="s2">glenoid labrum and its abnormalities.</p>
<p begin="00:00:12.497" end="00:00:13.998" style="s2">In our anatomical review we have the</p>
<p begin="00:00:13.998" end="00:00:16.087" style="s2">posterior surface of the humeral head</p>
<p begin="00:00:16.087" end="00:00:19.265" style="s2">with articular hyaline cartilage in blue,</p>
<p begin="00:00:19.265" end="00:00:22.863" style="s2">the proximal origin of the infraspinatus</p>
<p begin="00:00:22.863" end="00:00:25.248" style="s2">tendon here in yellow, with the more</p>
<p begin="00:00:25.248" end="00:00:28.199" style="s2">laterally light blue<br />landmark of the greater</p>
<p begin="00:00:28.199" end="00:00:30.251" style="s2">tuberosity which will act as its</p>
<p begin="00:00:30.251" end="00:00:33.418" style="s2">insertion of the infraspinatus tendon.</p>
<p begin="00:00:34.419" end="00:00:37.328" style="s2">Highlighted here in green is the</p>
<p begin="00:00:37.328" end="00:00:39.911" style="s2">spine of the scapula with a red</p>
<p begin="00:00:40.949" end="00:00:43.821" style="s2">posterior acromion process, which</p>
<p begin="00:00:43.821" end="00:00:46.850" style="s2">serves as a great palpation point to begin</p>
<p begin="00:00:46.850" end="00:00:50.136" style="s2">the examination of the<br />infraspinatus tendon.</p>
<p begin="00:00:50.136" end="00:00:54.041" style="s2">Highlighted here in<br />purple is the posterior</p>
<p begin="00:00:54.041" end="00:00:57.753" style="s2">bony glenoid of the scapula, and the</p>
<p begin="00:00:57.753" end="00:01:00.703" style="s2">structure here in white represents</p>
<p begin="00:01:00.703" end="00:01:03.870" style="s2">the posterior glenoid labrum, which is</p>
<p begin="00:01:05.250" end="00:01:07.513" style="s2">only clearly identified by ultrasound</p>
<p begin="00:01:07.513" end="00:01:10.002" style="s2">and its approximate 9 o'clock position.</p>
<p begin="00:01:10.002" end="00:01:12.872" style="s2">Overlying these structures is the large</p>
<p begin="00:01:12.872" end="00:01:15.465" style="s2">infraspinatus muscle and tendon</p>
<p begin="00:01:15.465" end="00:01:18.838" style="s2">followed by the teres minor resting</p>
<p begin="00:01:18.838" end="00:01:23.010" style="s2">just inferior to the infraspinatus tendon.</p>
<p begin="00:01:23.010" end="00:01:25.559" style="s2">Corresponding ultrasound image here</p>
<p begin="00:01:25.559" end="00:01:27.573" style="s2">of the posterior glenoid labrum.</p>
<p begin="00:01:27.573" end="00:01:30.166" style="s2">We have highlighted here the bony</p>
<p begin="00:01:30.166" end="00:01:33.793" style="s2">glenoid of the scapula, followed by</p>
<p begin="00:01:33.793" end="00:01:36.816" style="s2">a highlighted image of the bony</p>
<p begin="00:01:36.816" end="00:01:40.359" style="s2">posterior humerus with a dark rim</p>
<p begin="00:01:40.359" end="00:01:41.962" style="s2">over the bone representing the</p>
<p begin="00:01:41.962" end="00:01:44.712" style="s2">posterior articular hyaline cartilage.</p>
<p begin="00:01:44.712" end="00:01:46.439" style="s2">Highlighted here would<br />be the infraspinatus</p>
<p begin="00:01:46.439" end="00:01:49.888" style="s2">muscle belly, which is seen obliquely</p>
<p begin="00:01:49.888" end="00:01:52.861" style="s2">in this slice, so that<br />we can have a clear image</p>
<p begin="00:01:52.861" end="00:01:56.370" style="s2">of the posterior glenoid labrum here,</p>
<p begin="00:01:56.370" end="00:01:59.826" style="s2">highlighted as a hyperechoic triangle.</p>
<p begin="00:01:59.826" end="00:02:02.553" style="s2">Internal and external rotations</p>
<p begin="00:02:02.553" end="00:02:04.805" style="s2">are great dynamic maneuvers for the</p>
<p begin="00:02:04.805" end="00:02:07.730" style="s2">posterior glenoid labrum,<br />as a greater tegrocity</p>
<p begin="00:02:07.730" end="00:02:12.285" style="s2">is brought posteriorly<br />towards the bony glenoid,</p>
<p begin="00:02:12.285" end="00:02:16.120" style="s2">the posterior glenoid<br />labrum is brought under</p>
<p begin="00:02:16.120" end="00:02:19.956" style="s2">tremendous stress, forcing a blunting</p>
<p begin="00:02:19.956" end="00:02:22.139" style="s2">of the posterior glenoid labrum.</p>
<p begin="00:02:22.139" end="00:02:24.222" style="s2">Seen here is a disruption</p>
<p begin="00:02:25.764" end="00:02:29.440" style="s2">of the normally homogeneous pattern</p>
<p begin="00:02:29.440" end="00:02:31.650" style="s2">of the posterior glenoid labrum.</p>
<p begin="00:02:31.650" end="00:02:33.461" style="s2">On external rotation this becomes</p>
<p begin="00:02:33.461" end="00:02:36.037" style="s2">even more noticeable as the tissue</p>
<p begin="00:02:36.037" end="00:02:40.037" style="s2">interfaces are brought<br />together and then relaxed</p>
<p begin="00:02:41.165" end="00:02:44.668" style="s2">under this dynamic stress maneuver.</p>
<p begin="00:02:44.668" end="00:02:47.634" style="s2">On internal rotation we may also see</p>
<p begin="00:02:47.634" end="00:02:50.603" style="s2">loose bodies deeper than the joint.</p>
<p begin="00:02:50.603" end="00:02:52.616" style="s2">This image of an external rotation</p>
<p begin="00:02:52.616" end="00:02:55.120" style="s2">reveals a false joint effusion.</p>
<p begin="00:02:55.120" end="00:02:57.989" style="s2">What looks like a large<br />hypoechoic structure</p>
<p begin="00:02:57.989" end="00:03:00.406" style="s2">protruding from the<br />posterior joint surface</p>
<p begin="00:03:00.406" end="00:03:04.158" style="s2">is actually just contracted muscle belly,</p>
<p begin="00:03:04.158" end="00:03:06.759" style="s2">which contains a large amount of water,</p>
<p begin="00:03:06.759" end="00:03:09.946" style="s2">as well as a high incidence of anisotropic</p>
<p begin="00:03:09.946" end="00:03:13.604" style="s2">artifact due to the angle<br />of tendon insertion.</p>
<p begin="00:03:13.604" end="00:03:15.596" style="s2">Special care should be used when</p>
<p begin="00:03:15.596" end="00:03:17.774" style="s2">identifying a posterior joint effusion</p>
<p begin="00:03:17.774" end="00:03:21.028" style="s2">to overlay the infraspinatus tendon</p>
<p begin="00:03:21.028" end="00:03:24.559" style="s2">over the joint, creating an interface</p>
<p begin="00:03:24.559" end="00:03:28.401" style="s2">for fluid to rest that is not hypoechoic.</p>
<p begin="00:03:28.401" end="00:03:31.001" style="s2">By bringing this hyperechoic<br />interface over the</p>
<p begin="00:03:31.001" end="00:03:35.168" style="s2">joint space, it is easy to<br />identify joint effusions.</p>

<p begin="00:00:04.770" end="00:00:06.813" style="s2">- [Voiceover] The following<br />video is a description of the</p>
<p begin="00:00:06.813" end="00:00:10.262" style="s2">fuse quadriceps tendonosis<br />primarily to the rectus</p>
<p begin="00:00:10.262" end="00:00:11.838" style="s2">femurus portion.</p>
<p begin="00:00:11.838" end="00:00:13.081" style="s2">Here's the bony anatomy,</p>
<p begin="00:00:13.081" end="00:00:15.982" style="s2">associated with the suprapatellar region</p>
<p begin="00:00:15.982" end="00:00:17.695" style="s2">of the anterior knee.</p>
<p begin="00:00:17.695" end="00:00:21.917" style="s2">Superimposed CAT scan will<br />be modeling the quadricep</p>
<p begin="00:00:21.917" end="00:00:25.264" style="s2">tendon insertion to the<br />base of the patella,</p>
<p begin="00:00:25.264" end="00:00:28.097" style="s2">followed by the quadricep fat pad,</p>
<p begin="00:00:29.115" end="00:00:31.907" style="s2">which is seen here highlighted in yellow.</p>
<p begin="00:00:31.907" end="00:00:36.132" style="s2">Also here highlighted in<br />yellow is the prefemoral</p>
<p begin="00:00:36.132" end="00:00:40.299" style="s2">fat pad which surrounds the<br />anterior aspect of the femur.</p>
<p begin="00:00:41.765" end="00:00:43.404" style="s2">And highlighted here in blue is the</p>
<p begin="00:00:43.404" end="00:00:46.210" style="s2">Anterior Articular Hyaline Cartilage,</p>
<p begin="00:00:46.210" end="00:00:50.421" style="s2">and in light blue would be<br />the normal synovial recess,</p>
<p begin="00:00:50.421" end="00:00:52.334" style="s2">the Suprapatellar Bursa.</p>
<p begin="00:00:52.334" end="00:00:56.576" style="s2">Here is the corresponding<br />Normal Quadricep Tendon Image</p>
<p begin="00:00:56.576" end="00:01:00.016" style="s2">as the tendon fibers<br />insert to the highlighted</p>
<p begin="00:01:00.016" end="00:01:03.016" style="s2">Patellar base, the proximal surface.</p>
<p begin="00:01:04.580" end="00:01:08.953" style="s2">Highlighted here is the<br />anterior margin of the femur.</p>
<p begin="00:01:08.953" end="00:01:12.176" style="s2">Highlighted here in blue<br />is the fibrillar pattern</p>
<p begin="00:01:12.176" end="00:01:15.759" style="s2">of the normally situated<br />quadriceps tendon.</p>
<p begin="00:01:16.719" end="00:01:21.219" style="s2">Highlighted here in yellow<br />is the Quadricep Fat Pad,</p>
<p begin="00:01:21.219" end="00:01:25.696" style="s2">also highlighted here in yellow<br />is the Prefemoral Fat Pad,</p>
<p begin="00:01:25.696" end="00:01:28.789" style="s2">and next we have highlighted<br />here in light blue as the</p>
<p begin="00:01:28.789" end="00:01:32.314" style="s2">normally appearing synovial recess</p>
<p begin="00:01:32.314" end="00:01:34.804" style="s2">of the superpatellar bursa.</p>
<p begin="00:01:34.804" end="00:01:38.121" style="s2">To further demonstrate the<br />extensor mechanism of the</p>
<p begin="00:01:38.121" end="00:01:41.782" style="s2">quadricep tendon having the<br />patient tighten their quad</p>
<p begin="00:01:41.782" end="00:01:46.458" style="s2">will also force fluid into<br />the superpatellar recess.</p>
<p begin="00:01:46.458" end="00:01:48.992" style="s2">If no joint effusion is identified,</p>
<p begin="00:01:48.992" end="00:01:52.694" style="s2">this is one way to bring<br />out normal physiologic fluid</p>
<p begin="00:01:52.694" end="00:01:54.777" style="s2">between the two fat pads.</p>
<p begin="00:01:56.837" end="00:02:00.682" style="s2">This image shows a diffuse<br />formation of the more</p>
<p begin="00:02:00.682" end="00:02:04.268" style="s2">superficial layer of the quadricep tendon.</p>
<p begin="00:02:04.268" end="00:02:06.043" style="s2">Highlighted in white is a normal</p>
<p begin="00:02:06.043" end="00:02:09.012" style="s2">appearing base of the patella.</p>
<p begin="00:02:09.012" end="00:02:12.415" style="s2">Highlighted here is the<br />normal appearing interior</p>
<p begin="00:02:12.415" end="00:02:16.382" style="s2">surface of the femur followed<br />by a thickened quadricep</p>
<p begin="00:02:16.382" end="00:02:19.532" style="s2">tendon insertion proximal to its insertion</p>
<p begin="00:02:19.532" end="00:02:20.782" style="s2">of the patella.</p>
<p begin="00:02:22.255" end="00:02:25.073" style="s2">Highlighted here in yellow<br />is the normal appearing</p>
<p begin="00:02:25.073" end="00:02:29.472" style="s2">quadriceps fat pad followed<br />by the normal appearing</p>
<p begin="00:02:29.472" end="00:02:31.055" style="s2">prefemoral fat pad.</p>
<p begin="00:02:32.286" end="00:02:36.698" style="s2">Here we have in light blue<br />a more normal appearing</p>
<p begin="00:02:36.698" end="00:02:39.823" style="s2">physiologic amount of synovial fluid,</p>
<p begin="00:02:39.823" end="00:02:42.494" style="s2">and then red represents<br />the superficial layer</p>
<p begin="00:02:42.494" end="00:02:45.618" style="s2">of the quadricep tendon<br />which is now diffuse,</p>
<p begin="00:02:45.618" end="00:02:49.096" style="s2">indicating diffuse<br />tendonosis of the rectus</p>
<p begin="00:02:49.096" end="00:02:50.429" style="s2">femurus portion.</p>

<p begin="00:00:03.880" end="00:00:07.029" style="s2">this is a brief introduction to super<br />spin a dispatch ology</p>
<p begin="00:00:10.240" end="00:00:12.980" style="s2">we will begin by describing the bony<br />anatomy</p>
<p begin="00:00:12.980" end="00:00:16.470" style="s2">covered by the articular hailing<br />cartilage shown here</p>
<p begin="00:00:16.470" end="00:00:18.140" style="s2">in blue</p>
<p begin="00:00:18.140" end="00:00:22.580" style="s2">illustrated here is too long head of the<br />biceps tendon passing through the bicep</p>
<p begin="00:00:22.580" end="00:00:26.240" style="s2">ru to insert at the superior going on</p>
<p begin="00:00:26.240" end="00:00:29.650" style="s2">labor</p>
<p begin="00:00:29.650" end="00:00:32.520" style="s2">illustrated next is the supraspinatus<br />tendon</p>
<p begin="00:00:32.520" end="00:00:36.640" style="s2">as attach is to the greater tuberosity<br />at interior</p>
<p begin="00:00:36.640" end="00:00:39.860" style="s2">portion posteriorly the interest in a<br />distant</p>
<p begin="00:00:39.860" end="00:00:43.160" style="s2">wraps around the posterior surface the<br />humeral head</p>
<p begin="00:00:43.690" end="00:00:48.020" style="s2">to attach to the remainder the greater<br />tuberosity is lateral</p>
<p begin="00:00:48.020" end="00:00:51.020" style="s2">and post your your margins</p>
<p begin="00:00:51.820" end="00:00:55.590" style="s2">as the interest Benitez tendon attaches<br />to the post your your aspect of the</p>
<p begin="00:00:55.590" end="00:00:56.880" style="s2">greater tuberosity</p>
<p begin="00:00:56.880" end="00:01:02.330" style="s2">take note in about one-third Pittston<br />anti burst share an insertion point with</p>
<p begin="00:01:02.330" end="00:01:03.730" style="s2">two super spin eight assists</p>
<p begin="00:01:03.730" end="00:01:07.020" style="s2">post your your one-third its tendon as<br />well</p>
<p begin="00:01:07.020" end="00:01:10.050" style="s2">due to the oblique nature</p>
<p begin="00:01:10.050" end="00:01:14.690" style="s2">the interest in a dis is insertion<br />relative to the supraspinatus insertion</p>
<p begin="00:01:14.690" end="00:01:16.150" style="s2">to the greater tuberosity</p>
<p begin="00:01:16.150" end="00:01:20.100" style="s2">special care should be taken while<br />scanning through this section</p>
<p begin="00:01:20.100" end="00:01:23.100" style="s2">to avoid false-positive tears</p>
<p begin="00:01:24.109" end="00:01:27.759" style="s2">in developing these lateral rotator cuff<br />structures will be D</p>
<p begin="00:01:27.759" end="00:01:30.759" style="s2">subacromial sub deltoid versa</p>
<p begin="00:01:31.930" end="00:01:35.360" style="s2">this illustration shows a cross-section<br />the supraspinatus</p>
<p begin="00:01:35.360" end="00:01:38.360" style="s2">proximal to its insertion the greater<br />tuberosity</p>
<p begin="00:01:39.829" end="00:01:42.950" style="s2">primary focus this video will be the<br />relationship</p>
<p begin="00:01:42.950" end="00:01:46.140" style="s2">on the supraspinatus tendon with the<br />bicep tendon edits</p>
<p begin="00:01:46.140" end="00:01:49.110" style="s2">intercapital our segment</p>
<p begin="00:01:49.110" end="00:01:53.020" style="s2">this is the corresponding image the<br />supraspinatus tendon in cross-section</p>
<p begin="00:01:54.869" end="00:01:58.710" style="s2">highlighted here is the funeral at<br />proximal to the supraspinatus insertion</p>
<p begin="00:01:58.710" end="00:02:02.010" style="s2">the black gram is the articular<br />cartilage</p>
<p begin="00:02:02.010" end="00:02:05.190" style="s2">the lateral deltoid muscle run and cross<br />section as well</p>
<p begin="00:02:05.190" end="00:02:08.570" style="s2">at this level</p>
<p begin="00:02:08.570" end="00:02:12.350" style="s2">the interior super spin a distant is<br />well socialized while the posterior</p>
<p begin="00:02:12.350" end="00:02:14.470" style="s2">supraspinatus tendon is less</p>
<p begin="00:02:14.470" end="00:02:17.860" style="s2">identifiable due to its merger with the<br />interest in Ames</p>
<p begin="00:02:17.860" end="00:02:21.950" style="s2">highlighted in this image is the bicep<br />tendon also in cross-section with the</p>
<p begin="00:02:21.950" end="00:02:23.230" style="s2">supraspinatus tendon</p>
<p begin="00:02:23.230" end="00:02:26.120" style="s2">anterior margin</p>
<p begin="00:02:26.120" end="00:02:29.030" style="s2">from the transverse or cross-section<br />image we will now</p>
<p begin="00:02:29.030" end="00:02:33.840" style="s2">switch to the long axis more saddle cut<br />the supraspinatus tendon</p>
<p begin="00:02:33.840" end="00:02:36.840" style="s2">at the interior margin a greater<br />tuberosity</p>
<p begin="00:02:39.170" end="00:02:43.310" style="s2">here's the corresponding long axis<br />section the supraspinatus tendon</p>
<p begin="00:02:43.310" end="00:02:47.450" style="s2">as in search to greater tuberosity<br />highlighted here is the humeral head</p>
<p begin="00:02:47.450" end="00:02:52.500" style="s2">in greater tuberosity in profile it is<br />not uncommon to see a long axis deltoid</p>
<p begin="00:02:52.500" end="00:02:53.069" style="s2">muscle</p>
<p begin="00:02:53.069" end="00:02:58.319" style="s2">in relation to the long axis the<br />supraspinatus tendon highlighted in the</p>
<p begin="00:02:58.319" end="00:02:59.180" style="s2">next image</p>
<p begin="00:02:59.180" end="00:03:03.010" style="s2">is the long axis the supraspinatus<br />tendon as it answers to the greater</p>
<p begin="00:03:03.010" end="00:03:05.260" style="s2">tuberosity</p>
<p begin="00:03:05.260" end="00:03:08.260" style="s2">super spin anus pathological images</p>
<p begin="00:03:09.150" end="00:03:12.799" style="s2">this image demonstrates an interior<br />full-thickness tears well as a</p>
<p begin="00:03:12.799" end="00:03:16.299" style="s2">personal surface mid segment tear the<br />supraspinatus tendon</p>
<p begin="00:03:18.700" end="00:03:23.070" style="s2">here we have multiple terror citing no<br />volume loss identified</p>
<p begin="00:03:23.070" end="00:03:26.070" style="s2">in the transverse image</p>
<p begin="00:03:26.890" end="00:03:29.719" style="s2">here we have interior articular surface<br />tearing</p>
<p begin="00:03:29.719" end="00:03:33.290" style="s2">demonstrating by in los as Hypoluxo like<br />absence</p>
<p begin="00:03:33.290" end="00:03:35.700" style="s2">tendon fibers</p>
<p begin="00:03:35.700" end="00:03:38.430" style="s2">he rehashed post-operative retailer</p>
<p begin="00:03:38.430" end="00:03:42.030" style="s2">the interior super spin a distended<br />locating the exact site</p>
<p begin="00:03:42.030" end="00:03:46.530" style="s2">this terror is difficult as the bicep<br />tendon is not in its normally situated</p>
<p begin="00:03:46.530" end="00:03:51.390" style="s2">by typical group scanning from the<br />indeed biceps group posteriorly</p>
<p begin="00:03:51.390" end="00:03:55.970" style="s2">will reveal arced first in best landmark<br />the lateral greater tuberosity in</p>
<p begin="00:03:55.970" end="00:03:56.629" style="s2">profile</p>
<p begin="00:03:56.629" end="00:04:01.290" style="s2">scanning to post early may reveal<br />falsely normal rotator cuff as</p>
<p begin="00:04:01.290" end="00:04:03.690" style="s2">demonstrated in blue</p>
<p begin="00:04:03.690" end="00:04:07.900" style="s2">here's a corresponding normal rotator<br />cuff with the normally situated bicep</p>
<p begin="00:04:07.900" end="00:04:09.330" style="s2">tendon highlighted in blue</p>
<p begin="00:04:09.330" end="00:04:13.320" style="s2">where the dislocated is in red in this<br />case a long axis greater tuberosity</p>
<p begin="00:04:13.320" end="00:04:14.590" style="s2">would be a better</p>
<p begin="00:04:14.590" end="00:04:17.170" style="s2">landmark</p>
<p begin="00:04:17.170" end="00:04:20.220" style="s2">subtle interest substance carrying is<br />often harder to identify</p>
<p begin="00:04:22.470" end="00:04:26.460" style="s2">there is a hyper collect where over the<br />summer Camille bursa called Perry</p>
<p begin="00:04:26.460" end="00:04:27.380" style="s2">personal Sat</p>
<p begin="00:04:27.380" end="00:04:30.960" style="s2">and indicating layer that is the actual<br />bursal void</p>
<p begin="00:04:30.960" end="00:04:35.270" style="s2">followed by the supraspinatus tendon<br />itself area of interest here</p>
<p begin="00:04:35.270" end="00:04:38.630" style="s2">is the Dept or the concave and what<br />would normally be</p>
<p begin="00:04:38.630" end="00:04:41.630" style="s2">declined backs appearing mursal layer</p>
<p begin="00:04:44.530" end="00:04:49.000" style="s2">in long axis is normally contact<br />Trinkaus may actually be flattened</p>
<p begin="00:04:49.000" end="00:04:52.070" style="s2">instead of rounded as we see here again<br />take care</p>
<p begin="00:04:52.620" end="00:04:56.860" style="s2">to scan through the entire cast to avoid<br />any false positives</p>
<p begin="00:04:56.860" end="00:05:00.010" style="s2">as we have us demonstrated here as a<br />falsely</p>
<p begin="00:05:00.010" end="00:05:01.140" style="s2">mall cop and blue</p>

<p begin="00:00:10.011" end="00:00:12.732" style="s2">- Today we're going to<br />examine the shoulder.</p>
<p begin="00:00:12.732" end="00:00:15.420" style="s2">There are multiple protocols<br />available for the shoulder,</p>
<p begin="00:00:15.420" end="00:00:17.859" style="s2">however I've found some<br />simplified techniques</p>
<p begin="00:00:17.859" end="00:00:20.246" style="s2">and I think what's most important is</p>
<p begin="00:00:20.246" end="00:00:22.034" style="s2">to maintain a consistent protocol</p>
<p begin="00:00:22.034" end="00:00:23.825" style="s2">and repetitively go over it and over it</p>
<p begin="00:00:23.825" end="00:00:26.716" style="s2">until you're comfortable<br />with what exam works for you.</p>
<p begin="00:00:26.716" end="00:00:29.474" style="s2">In looking at the shoulder, I<br />recommend that the patient's</p>
<p begin="00:00:29.474" end="00:00:31.301" style="s2">in the seated position.</p>
<p begin="00:00:31.301" end="00:00:34.226" style="s2">I prefer to stand behind the<br />patient so that I can look</p>
<p begin="00:00:34.226" end="00:00:36.676" style="s2">at the screen, which is in front of me</p>
<p begin="00:00:36.676" end="00:00:40.572" style="s2">at approximately a 2<br />o'clock window for me so</p>
<p begin="00:00:40.572" end="00:00:42.879" style="s2">that the patient and myself<br />can both look at the screen</p>
<p begin="00:00:42.879" end="00:00:45.242" style="s2">an interact and educate the patient while</p>
<p begin="00:00:45.242" end="00:00:47.103" style="s2">I'm doing the scan.</p>
<p begin="00:00:47.103" end="00:00:48.370" style="s2">In examining the shoulder,</p>
<p begin="00:00:48.370" end="00:00:50.207" style="s2">there are some important<br />principles to follow.</p>
<p begin="00:00:50.207" end="00:00:53.130" style="s2">First of all, when holding the transducer,</p>
<p begin="00:00:53.130" end="00:00:56.656" style="s2">it's easiest to have the<br />notch of the transducer</p>
<p begin="00:00:56.656" end="00:00:59.875" style="s2">always facing upwards or<br />cephalad on the patient.</p>
<p begin="00:00:59.875" end="00:01:02.803" style="s2">That will always be your<br />lighthouse so to speak</p>
<p begin="00:01:02.803" end="00:01:05.888" style="s2">of exactly where you are, so I<br />always keep the notch upward,</p>
<p begin="00:01:05.888" end="00:01:08.234" style="s2">as well as looking at the<br />upper left hand corner</p>
<p begin="00:01:08.234" end="00:01:12.265" style="s2">of the screen to making sure<br />I know exactly where I am.</p>
<p begin="00:01:12.265" end="00:01:14.020" style="s2">I'm going to using a linear transducer</p>
<p begin="00:01:14.020" end="00:01:16.130" style="s2">and this is a high frequency probe,</p>
<p begin="00:01:16.130" end="00:01:18.232" style="s2">which allows us the optimal resolution</p>
<p begin="00:01:18.232" end="00:01:20.033" style="s2">in musculoskeletal imaging.</p>
<p begin="00:01:20.033" end="00:01:21.860" style="s2">With examination of the shoulder,</p>
<p begin="00:01:21.860" end="00:01:23.764" style="s2">I prefer the musculoskeletal setup.</p>
<p begin="00:01:23.764" end="00:01:26.767" style="s2">I press the exam button<br />and I check to make sure</p>
<p begin="00:01:26.767" end="00:01:29.740" style="s2">that I'm on the musculoskeletal<br />setting and press select.</p>
<p begin="00:01:29.740" end="00:01:33.431" style="s2">Next it's important to know<br />what depth you'd like to do</p>
<p begin="00:01:33.431" end="00:01:35.743" style="s2">for the exam and here for starters,</p>
<p begin="00:01:35.743" end="00:01:40.296" style="s2">I'm going to begin at 3.3,<br />which is noted on the screen.</p>
<p begin="00:01:40.296" end="00:01:43.922" style="s2">I can move up or down and<br />the closer to the surface</p>
<p begin="00:01:43.922" end="00:01:48.089" style="s2">of the skin, the better clarity<br />and resolution I'll have.</p>

<p begin="00:00:09.961" end="00:00:12.478" style="s2">- Next we're going to<br />view the patella tendon</p>
<p begin="00:00:12.478" end="00:00:14.561" style="s2">in its longitudinal view.</p>
<p begin="00:00:15.568" end="00:00:19.401" style="s2">I'm going to place the<br />transducer just beneath</p>
<p begin="00:00:20.518" end="00:00:23.988" style="s2">the patient's patella, maintaining contact</p>
<p begin="00:00:23.988" end="00:00:25.821" style="s2">on the patient's knee.</p>
<p begin="00:00:26.918" end="00:00:29.447" style="s2">Here we see the fibers<br />of the patellar tendon,</p>
<p begin="00:00:29.447" end="00:00:31.794" style="s2">attaching on the patella.</p>
<p begin="00:00:31.794" end="00:00:34.143" style="s2">Next we're going to follow<br />these fibers distally</p>
<p begin="00:00:34.143" end="00:00:37.153" style="s2">as they attach on the tibial tubercle.</p>
<p begin="00:00:37.153" end="00:00:38.621" style="s2">And here we see the distal attachment</p>
<p begin="00:00:38.621" end="00:00:40.538" style="s2">on the tibial tubercle.</p>
<p begin="00:00:42.457" end="00:00:46.162" style="s2">Generally, I'll scan the<br />patellar tendon three times,</p>
<p begin="00:00:46.162" end="00:00:49.530" style="s2">once in the center, and<br />then once to each side,</p>
<p begin="00:00:49.530" end="00:00:51.869" style="s2">to view the entire tendon.</p>
<p begin="00:00:51.869" end="00:00:55.286" style="s2">In this case medially and next laterally.</p>
<p begin="00:01:05.601" end="00:01:07.440" style="s2">Next we're going to<br />view the patellar tendon</p>
<p begin="00:01:07.440" end="00:01:09.812" style="s2">in cross-sectional view.</p>
<p begin="00:01:09.812" end="00:01:11.617" style="s2">I'm going to place the transducer</p>
<p begin="00:01:11.617" end="00:01:14.824" style="s2">beneath the patient's patella,</p>
<p begin="00:01:14.824" end="00:01:17.741" style="s2">just overlying the patellar tendon.</p>
<p begin="00:01:19.514" end="00:01:22.200" style="s2">In here we're going to<br />see a circular pattern</p>
<p begin="00:01:22.200" end="00:01:24.182" style="s2">of the patellar tendon in cross-section,</p>
<p begin="00:01:24.182" end="00:01:26.881" style="s2">looking for any abnormalities.</p>
<p begin="00:01:26.881" end="00:01:29.906" style="s2">I'm going to scan distally<br />down to the tibial tubercle,</p>
<p begin="00:01:29.906" end="00:01:32.374" style="s2">slowly looking for irregularities.</p>
<p begin="00:01:32.374" end="00:01:34.045" style="s2">We'll begin to see the<br />tendon slowly disappearing</p>
<p begin="00:01:34.045" end="00:01:36.545" style="s2">and into the tibial tubercle.</p>

<p begin="00:00:09.660" end="00:00:12.635" style="s2">- Next we're going to examine<br />the patient's medial meniscus</p>
<p begin="00:00:12.635" end="00:00:14.523" style="s2">and medial collateral ligament.</p>
<p begin="00:00:14.523" end="00:00:17.067" style="s2">The medial collateral<br />ligament lies just on top</p>
<p begin="00:00:17.067" end="00:00:21.067" style="s2">of the meniscus and can<br />be seen on the same image.</p>
<p begin="00:00:21.067" end="00:00:22.351" style="s2">To identify this structure</p>
<p begin="00:00:22.351" end="00:00:24.887" style="s2">I'm going to place my tranducer</p>
<p begin="00:00:24.887" end="00:00:27.186" style="s2">in the longitudinal plane</p>
<p begin="00:00:27.186" end="00:00:29.269" style="s2">and palpate the patient's</p>
<p begin="00:00:30.736" end="00:00:32.982" style="s2">joint in the center.</p>
<p begin="00:00:32.982" end="00:00:35.482" style="s2">Place the probe over that area</p>
<p begin="00:00:36.889" end="00:00:40.236" style="s2">and center the meniscus<br />in my screen for viewing.</p>
<p begin="00:00:40.236" end="00:00:44.481" style="s2">The medial meniscus is<br />a wedge-like structure.</p>
<p begin="00:00:44.481" end="00:00:46.812" style="s2">To determine if there is acute trauma</p>
<p begin="00:00:46.812" end="00:00:50.060" style="s2">we can put color doppler on the meniscus.</p>
<p begin="00:00:50.060" end="00:00:52.372" style="s2">Here there's no significant trauma</p>
<p begin="00:00:52.372" end="00:00:55.582" style="s2">or suggestion of any<br />increased vascularity.</p>
<p begin="00:00:55.582" end="00:00:58.526" style="s2">In addition we can zoom<br />in to the meniscus.</p>
<p begin="00:00:58.526" end="00:01:01.955" style="s2">I do this by pressing the zoom button,</p>
<p begin="00:01:01.955" end="00:01:05.117" style="s2">squaring the image, centering it</p>
<p begin="00:01:05.117" end="00:01:07.945" style="s2">and pressing the zoom once again.</p>
<p begin="00:01:07.945" end="00:01:10.177" style="s2">And here I visualize the meniscus</p>
<p begin="00:01:10.177" end="00:01:12.937" style="s2">which appears healthy with<br />no significant trauma.</p>
<p begin="00:01:12.937" end="00:01:14.481" style="s2">Overlying the meniscus</p>
<p begin="00:01:14.481" end="00:01:17.833" style="s2">lies the medial collateral ligament.</p>
<p begin="00:01:17.833" end="00:01:20.865" style="s2">Which is a band-like<br />structure that we can see</p>
<p begin="00:01:20.865" end="00:01:23.782" style="s2">directly above the medial meniscus.</p>
<p begin="00:01:24.770" end="00:01:27.694" style="s2">I recommend starting<br />at the medial mensicus</p>
<p begin="00:01:27.694" end="00:01:30.698" style="s2">to identify the medial collateral ligament</p>
<p begin="00:01:30.698" end="00:01:33.441" style="s2">and then tracing the<br />ligament at it's proximal</p>
<p begin="00:01:33.441" end="00:01:35.769" style="s2">and then distal insertion.</p>
<p begin="00:01:35.769" end="00:01:39.211" style="s2">We begin by following<br />from the medial meniscus.</p>
<p begin="00:01:39.211" end="00:01:42.102" style="s2">Seeing the medial collateral ligament</p>
<p begin="00:01:42.102" end="00:01:45.674" style="s2">approximately to the femoral condyle.</p>
<p begin="00:01:45.674" end="00:01:47.685" style="s2">It's important to have<br />knowledge of the anatomy</p>
<p begin="00:01:47.685" end="00:01:48.705" style="s2">and know that the direction</p>
<p begin="00:01:48.705" end="00:01:51.983" style="s2">that the medial collateral<br />ligament travels.</p>
<p begin="00:01:51.983" end="00:01:52.922" style="s2">So we're going to travel</p>
<p begin="00:01:52.922" end="00:01:57.366" style="s2">the medial collateral<br />ligament approximately</p>
<p begin="00:01:57.366" end="00:02:01.183" style="s2">while looking at the screen<br />to maintain an accurate image.</p>
<p begin="00:02:01.183" end="00:02:04.262" style="s2">We see the medial collateral<br />ligament bending down</p>
<p begin="00:02:04.262" end="00:02:07.129" style="s2">and heading towards the attachment</p>
<p begin="00:02:07.129" end="00:02:09.605" style="s2">at its proximal end here.</p>
<p begin="00:02:09.605" end="00:02:11.348" style="s2">We're going to begin at our starting point</p>
<p begin="00:02:11.348" end="00:02:13.692" style="s2">which will be the medial meniscus</p>
<p begin="00:02:13.692" end="00:02:15.566" style="s2">and follow it distally</p>
<p begin="00:02:15.566" end="00:02:17.487" style="s2">along to its insertion.</p>
<p begin="00:02:17.487" end="00:02:20.173" style="s2">Following along here<br />you see the thick band</p>
<p begin="00:02:20.173" end="00:02:22.350" style="s2">of the medial collateral ligament.</p>
<p begin="00:02:22.350" end="00:02:25.115" style="s2">It actually inserts quite distally</p>
<p begin="00:02:25.115" end="00:02:28.425" style="s2">and what we can also see down<br />here are important structures</p>
<p begin="00:02:28.425" end="00:02:32.028" style="s2">known as the pes anserine tendons.</p>
<p begin="00:02:32.028" end="00:02:34.402" style="s2">These appear at the right of the screen</p>
<p begin="00:02:34.402" end="00:02:37.569" style="s2">as three discrete tendons of darkness.</p>

<p begin="00:00:09.866" end="00:00:11.390" style="s2">- Next, we're gonna move laterally</p>
<p begin="00:00:11.390" end="00:00:13.801" style="s2">and examine the patient's lateral meniscus</p>
<p begin="00:00:13.801" end="00:00:17.193" style="s2">and lateral collateral ligament.</p>
<p begin="00:00:17.193" end="00:00:18.361" style="s2">It's an important landmark</p>
<p begin="00:00:18.361" end="00:00:19.832" style="s2">so we're gonna hold the transducer</p>
<p begin="00:00:19.832" end="00:00:22.582" style="s2">with the notch facing superiorly.</p>
<p begin="00:00:23.920" end="00:00:27.073" style="s2">An important landmark on the<br />patient is the fibular head.</p>
<p begin="00:00:27.073" end="00:00:30.548" style="s2">I'm going to palpate the fibular head</p>
<p begin="00:00:30.548" end="00:00:32.327" style="s2">and place the transducer so that</p>
<p begin="00:00:32.327" end="00:00:34.265" style="s2">the bottom edge of the transducer</p>
<p begin="00:00:34.265" end="00:00:36.827" style="s2">is in contact with the<br />patient's fibular head.</p>
<p begin="00:00:36.827" end="00:00:38.922" style="s2">And that should give us a direct view</p>
<p begin="00:00:38.922" end="00:00:40.852" style="s2">of the lateral meniscus.</p>
<p begin="00:00:40.852" end="00:00:42.158" style="s2">It's important to keep your image</p>
<p begin="00:00:42.158" end="00:00:45.175" style="s2">at the center of the screen<br />to get the best view.</p>
<p begin="00:00:45.175" end="00:00:48.327" style="s2">Here we can see the<br />patient's lateral meniscus.</p>
<p begin="00:00:48.327" end="00:00:49.727" style="s2">Overlying the meniscus is</p>
<p begin="00:00:49.727" end="00:00:53.903" style="s2">the lateral collateral ligament<br />which we'll look at next.</p>
<p begin="00:00:53.903" end="00:00:56.711" style="s2">The meniscus appears as<br />a wedge-shaped structure</p>
<p begin="00:00:56.711" end="00:00:59.816" style="s2">with a homogeneous pattern throughout.</p>
<p begin="00:00:59.816" end="00:01:04.339" style="s2">A tear may show dark<br />patterns within the meniscus</p>
<p begin="00:01:04.339" end="00:01:09.184" style="s2">as well as fluid leaking into<br />the surrounding joint space.</p>
<p begin="00:01:09.184" end="00:01:11.516" style="s2">If we suspect meniscal trauma,</p>
<p begin="00:01:11.516" end="00:01:13.665" style="s2">sometimes we'll use color Doppler</p>
<p begin="00:01:13.665" end="00:01:16.097" style="s2">and see if there's an acute inflammation</p>
<p begin="00:01:16.097" end="00:01:19.267" style="s2">or significant injury demonstrated.</p>
<p begin="00:01:19.267" end="00:01:22.350" style="s2">To do this, I activate color Doppler.</p>
<p begin="00:01:25.350" end="00:01:28.155" style="s2">And if there was any acute trauma,</p>
<p begin="00:01:28.155" end="00:01:30.919" style="s2">once the probe is<br />stabilized and not moving,</p>
<p begin="00:01:30.919" end="00:01:32.955" style="s2">we'd see the increased vascular activity,</p>
<p begin="00:01:32.955" end="00:01:34.288" style="s2">which we do not.</p>
<p begin="00:01:35.621" end="00:01:38.470" style="s2">An additional feature<br />that we may be able to do</p>
<p begin="00:01:38.470" end="00:01:40.719" style="s2">is to zoom in on a structure.</p>
<p begin="00:01:40.719" end="00:01:43.052" style="s2">To do this, I'll press zoom.</p>
<p begin="00:01:45.507" end="00:01:47.587" style="s2">Center over the desired region</p>
<p begin="00:01:47.587" end="00:01:49.337" style="s2">and press zoom again.</p>
<p begin="00:01:51.009" end="00:01:52.866" style="s2">And now I see a blown up image</p>
<p begin="00:01:52.866" end="00:01:55.071" style="s2">of the patient's lateral meniscus.</p>
<p begin="00:01:55.071" end="00:01:58.320" style="s2">As well as the surrounding<br />lateral collateral ligament,</p>
<p begin="00:01:58.320" end="00:02:02.165" style="s2">which is the band seen<br />at the top of the screen.</p>
<p begin="00:02:02.165" end="00:02:04.623" style="s2">Again, seeing a homogeneous<br />image of the meniscus</p>
<p begin="00:02:04.623" end="00:02:07.123" style="s2">with no indication of tearing.</p>
<p begin="00:02:08.308" end="00:02:09.678" style="s2">The next structure to image</p>
<p begin="00:02:09.678" end="00:02:12.572" style="s2">lies just above the lateral meniscus,</p>
<p begin="00:02:12.572" end="00:02:15.170" style="s2">which is the lateral collateral ligament.</p>
<p begin="00:02:15.170" end="00:02:17.776" style="s2">Maintain the transducer<br />in the superior position</p>
<p begin="00:02:17.776" end="00:02:21.327" style="s2">with the notch facing<br />towards the patient's head.</p>
<p begin="00:02:21.327" end="00:02:23.989" style="s2">An important landmark is the fibular head.</p>
<p begin="00:02:23.989" end="00:02:25.368" style="s2">I like to keep the fibular head</p>
<p begin="00:02:25.368" end="00:02:28.179" style="s2">in the center of the<br />transducer beneath it.</p>
<p begin="00:02:28.179" end="00:02:30.846" style="s2">Which will allow me to visualize</p>
<p begin="00:02:31.707" end="00:02:35.461" style="s2">the distal attachment of the<br />lateral collateral ligament.</p>
<p begin="00:02:35.461" end="00:02:36.933" style="s2">Here we can see fibers of</p>
<p begin="00:02:36.933" end="00:02:38.409" style="s2">the lateral collateral ligament</p>
<p begin="00:02:38.409" end="00:02:40.868" style="s2">attaching on the fibular head.</p>
<p begin="00:02:40.868" end="00:02:43.858" style="s2">Next what we do is trace this<br />lateral collateral ligament</p>
<p begin="00:02:43.858" end="00:02:47.616" style="s2">up to its attachment on the<br />lateral femoral condyle.</p>
<p begin="00:02:47.616" end="00:02:50.415" style="s2">We follow the lateral collateral ligament</p>
<p begin="00:02:50.415" end="00:02:53.374" style="s2">as it continues to pass above the condyle.</p>
<p begin="00:02:53.374" end="00:02:57.541" style="s2">And eventually we'll taper<br />back onto the upper condyle.</p>

<p begin="00:00:09.429" end="00:00:11.263" style="s2">- We're going to review the knee exam,</p>
<p begin="00:00:11.263" end="00:00:13.106" style="s2">but before we get started, there are a few</p>
<p begin="00:00:13.106" end="00:00:16.420" style="s2">important principles to be aware of.</p>
<p begin="00:00:16.420" end="00:00:18.967" style="s2">Some of the ultrasound settings need to be</p>
<p begin="00:00:18.967" end="00:00:21.396" style="s2">taken care of before we do the exam.</p>
<p begin="00:00:21.396" end="00:00:24.996" style="s2">Firstly, we look to see<br />that we have the machine</p>
<p begin="00:00:24.996" end="00:00:28.064" style="s2">set up for musculoskeletal.</p>
<p begin="00:00:28.064" end="00:00:30.413" style="s2">We do this by pressing the exam button</p>
<p begin="00:00:30.413" end="00:00:32.838" style="s2">on the machine, which will identify</p>
<p begin="00:00:32.838" end="00:00:35.806" style="s2">that we are in musculoskeletal mode.</p>
<p begin="00:00:35.806" end="00:00:39.566" style="s2">We will click select, and<br />we are ready to begin.</p>
<p begin="00:00:39.566" end="00:00:42.024" style="s2">I recommend using a linear transducer,</p>
<p begin="00:00:42.024" end="00:00:44.595" style="s2">which is between eight and 13 hertz.</p>
<p begin="00:00:44.595" end="00:00:46.425" style="s2">When using this transducer, it's important</p>
<p begin="00:00:46.425" end="00:00:47.965" style="s2">to stay with a consistent method,</p>
<p begin="00:00:47.965" end="00:00:49.331" style="s2">so that you're always confident</p>
<p begin="00:00:49.331" end="00:00:52.370" style="s2">of where you are when<br />you're scanning the patient.</p>
<p begin="00:00:52.370" end="00:00:55.384" style="s2">I recommend keeping the<br />notch of the transducer</p>
<p begin="00:00:55.384" end="00:00:59.336" style="s2">always in the superior aspect,<br />always pointing upwards</p>
<p begin="00:00:59.336" end="00:01:02.484" style="s2">toward the patients head,<br />as well as immediately</p>
<p begin="00:01:02.484" end="00:01:04.710" style="s2">toward the patient's body.</p>
<p begin="00:01:04.710" end="00:01:06.440" style="s2">You can correlate this with the machine,</p>
<p begin="00:01:06.440" end="00:01:09.597" style="s2">because there's a dot in<br />the upper left hand corner</p>
<p begin="00:01:09.597" end="00:01:11.343" style="s2">of the screen, which will orientate you</p>
<p begin="00:01:11.343" end="00:01:15.343" style="s2">as far as your scanning<br />or injection techniques.</p>
<p begin="00:01:37.566" end="00:01:40.015" style="s2">We're going to begin<br />scanning the right knee.</p>
<p begin="00:01:40.015" end="00:01:42.546" style="s2">I like to begin the scan by starting</p>
<p begin="00:01:42.546" end="00:01:45.722" style="s2">at the quadriceps tendon,<br />with the transducer</p>
<p begin="00:01:45.722" end="00:01:49.860" style="s2">with the notch facing<br />towards the patient, upwards,</p>
<p begin="00:01:49.860" end="00:01:52.338" style="s2">In a longitudinal plane.</p>
<p begin="00:01:52.338" end="00:01:54.671" style="s2">As my landmarks, I'm going to use</p>
<p begin="00:01:54.671" end="00:01:57.414" style="s2">so the bottom of the<br />transducer is touching the top</p>
<p begin="00:01:57.414" end="00:01:59.476" style="s2">of the patella tendon.</p>
<p begin="00:01:59.476" end="00:02:02.797" style="s2">I can clearly see the fibers<br />of the quadriceps tendon</p>
<p begin="00:02:02.797" end="00:02:06.797" style="s2">attaching on the patella<br />here at the distal end.</p>
<p begin="00:02:10.854" end="00:02:13.448" style="s2">It's important to maintain<br />contact on both ends</p>
<p begin="00:02:13.448" end="00:02:17.757" style="s2">of the transducer, to<br />get an accurate image.</p>
<p begin="00:02:17.757" end="00:02:20.725" style="s2">I'm going to scan up<br />and down the quadriceps</p>
<p begin="00:02:20.725" end="00:02:23.166" style="s2">to detect any abnormality.</p>
<p begin="00:02:23.166" end="00:02:26.755" style="s2">Clinically, if I suspected<br />a tear more approximately,</p>
<p begin="00:02:26.755" end="00:02:29.677" style="s2">I would examine further,<br />but for most purposes,</p>
<p begin="00:02:29.677" end="00:02:31.260" style="s2">this is sufficient.</p>
<p begin="00:02:39.323" end="00:02:40.645" style="s2">Next, we are going to take a look</p>
<p begin="00:02:40.645" end="00:02:42.922" style="s2">at the patient's cartilage, with the knee</p>
<p begin="00:02:42.922" end="00:02:45.368" style="s2">in the flex position.</p>
<p begin="00:02:45.368" end="00:02:48.440" style="s2">By holding the transducer<br />with the notch facing</p>
<p begin="00:02:48.440" end="00:02:50.963" style="s2">towards the patient,<br />in the medial position</p>
<p begin="00:02:50.963" end="00:02:54.385" style="s2">and placing the probe in cross section,</p>
<p begin="00:02:54.385" end="00:02:57.135" style="s2">just above the patient's patella.</p>
<p begin="00:02:59.037" end="00:03:01.789" style="s2">Here, I see a clear image of the patient's</p>
<p begin="00:03:01.789" end="00:03:04.517" style="s2">medial and lateral epicondyles,</p>
<p begin="00:03:04.517" end="00:03:07.758" style="s2">with cartilage shown in<br />the area of blackness.</p>
<p begin="00:03:07.758" end="00:03:10.524" style="s2">In demonstration of<br />arthritis or chondropenia,</p>
<p begin="00:03:10.524" end="00:03:13.675" style="s2">we can measure from the<br />center of the cartilage,</p>
<p begin="00:03:13.675" end="00:03:17.154" style="s2">as well as at the edge of each<br />epicondyle and compare them</p>
<p begin="00:03:17.154" end="00:03:20.829" style="s2">to standards to determine<br />the grade of osteoarthritis.</p>
<p begin="00:03:20.829" end="00:03:23.087" style="s2">By freezing the image, I can now measure</p>
<p begin="00:03:23.087" end="00:03:24.684" style="s2">the cartilage thickness.</p>
<p begin="00:03:24.684" end="00:03:27.999" style="s2">I press the caliper button<br />and I locate the center</p>
<p begin="00:03:27.999" end="00:03:31.895" style="s2">of the cartilage and I<br />can measure the distance</p>
<p begin="00:03:31.895" end="00:03:33.812" style="s2">of cartilage thickness.</p>
<p begin="00:03:37.059" end="00:03:39.941" style="s2">I can measure the cartilage<br />thickness at the point</p>
<p begin="00:03:39.941" end="00:03:44.108" style="s2">of each lateral condyle and<br />compare these to normal values.</p>

<p begin="00:00:09.612" end="00:00:12.755" style="s2">- Next we're going to examine<br />the infraspinatus tendon,</p>
<p begin="00:00:12.755" end="00:00:15.965" style="s2">as well as the glenohumeral<br />joint and labrum.</p>
<p begin="00:00:15.965" end="00:00:16.828" style="s2">We look at these together</p>
<p begin="00:00:16.828" end="00:00:19.011" style="s2">because they're in the same window.</p>
<p begin="00:00:19.011" end="00:00:21.627" style="s2">So what I like to do is<br />stand behind the patient,</p>
<p begin="00:00:21.627" end="00:00:26.507" style="s2">in this study, and use the<br />patient's scapular border</p>
<p begin="00:00:26.507" end="00:00:28.705" style="s2">as a landmark and follow their scapula</p>
<p begin="00:00:28.705" end="00:00:31.555" style="s2">across to the acromion that you'll feel.</p>
<p begin="00:00:31.555" end="00:00:34.660" style="s2">To allow the physician to<br />easily identify the structures,</p>
<p begin="00:00:34.660" end="00:00:36.775" style="s2">we recommend that you have the patient</p>
<p begin="00:00:36.775" end="00:00:37.919" style="s2">take their right hand,</p>
<p begin="00:00:37.919" end="00:00:39.384" style="s2">if we're examining the right shoulder,</p>
<p begin="00:00:39.384" end="00:00:42.823" style="s2">and reach across to the opposite shoulder.</p>
<p begin="00:00:42.823" end="00:00:46.199" style="s2">And I place the probe,<br />again facing medially</p>
<p begin="00:00:46.199" end="00:00:50.199" style="s2">towards the patient,<br />always maintaining contact.</p>
<p begin="00:00:52.264" end="00:00:53.895" style="s2">What we're able to do with ultrasound,</p>
<p begin="00:00:53.895" end="00:00:56.680" style="s2">if some of the images appear<br />a bit dark from shadowing</p>
<p begin="00:00:56.680" end="00:00:59.663" style="s2">we can adjust with a feature called gain.</p>
<p begin="00:00:59.663" end="00:01:03.024" style="s2">And there's a control on the<br />bottom of my ultrasound machine</p>
<p begin="00:01:03.024" end="00:01:05.775" style="s2">that will allow me to<br />brighten the lower aspect</p>
<p begin="00:01:05.775" end="00:01:07.791" style="s2">of the patient's shoulder.</p>
<p begin="00:01:07.791" end="00:01:10.199" style="s2">So I'm just going to<br />increase my depth here,</p>
<p begin="00:01:10.199" end="00:01:12.680" style="s2">next I'm visualizing the tendon fibers</p>
<p begin="00:01:12.680" end="00:01:16.688" style="s2">of the infraspinatus in a fibular pattern,</p>
<p begin="00:01:16.688" end="00:01:19.527" style="s2">looking for any abnormalities.</p>
<p begin="00:01:19.527" end="00:01:21.815" style="s2">Oftentimes if I'm suspecting a problem</p>
<p begin="00:01:21.815" end="00:01:23.575" style="s2">with the infraspinatus tendon,</p>
<p begin="00:01:23.575" end="00:01:27.064" style="s2">I'll request the patient to<br />externally rotate their arm.</p>
<p begin="00:01:27.064" end="00:01:30.320" style="s2">I'm going to have you slowly<br />push here, with your palm up.</p>
<p begin="00:01:30.320" end="00:01:33.653" style="s2">Just push your arm out, against my hand.</p>
<p begin="00:01:44.224" end="00:01:45.416" style="s2">So next we're gonna visualize</p>
<p begin="00:01:45.416" end="00:01:47.695" style="s2">the patient's glenohumeral joint,</p>
<p begin="00:01:47.695" end="00:01:49.847" style="s2">as well as their posterior labrum.</p>
<p begin="00:01:49.847" end="00:01:52.903" style="s2">In many patients we can<br />see their posterior labrum</p>
<p begin="00:01:52.903" end="00:01:55.432" style="s2">if they have a thin body habitus.</p>
<p begin="00:01:55.432" end="00:01:57.327" style="s2">And what we're looking for here</p>
<p begin="00:01:57.327" end="00:02:00.111" style="s2">is the posterior labrum that we can see,</p>
<p begin="00:02:00.111" end="00:02:01.671" style="s2">as a triangular pattern</p>
<p begin="00:02:01.671" end="00:02:05.007" style="s2">at the inferior aspect of the screen,</p>
<p begin="00:02:05.007" end="00:02:09.344" style="s2">as well as some cartilage<br />at the glenohumeral joint.</p>
<p begin="00:02:09.344" end="00:02:13.511" style="s2">This is the site of many<br />intra-articular injections.</p>