All right, welcome everyone, my name is Raymond Chow, I appreciate you guys coming out early this morning. Welcome to AAPMR for the people who just arrived. So today we're going to give a talk about the advances in hand and upper extremity physiatry and this is a topic near and dear to my heart because I think that this is probably one of the next up and coming fields in physiatry and we have a great panel of experts here to kind of give us some updates about how management can be done for these conditions that typically aren't covered in a lot of detail in our pre-med residency so far. All right, so just going over our objectives today, I'm going to talk a little bit about why we're developing a field of hand and upper extremity physiatry and what conditions are seen in this specialty, subspecialty. We'll go over kind of how ultrasound can help us in terms of treating and diagnosing conditions in the hand and upper extremity. And then if you guys have more interest in it, we can talk about different resources that I'm working on developing to help with increasing the knowledge base in this area for physiatrists. So here are a bunch of conditions that I see in my clinic on the screen. I just want to get a show of hands, how many of these things, is there at least one condition on here that you have not seen before in your practice or heard of before? Good. Yeah, so as you can see, there are knowledge gaps in this area in our field. And I myself, even with additional training from my mentors that you'll meet later today, still took about a year or two years in practice to kind of know what these things are and how we can help these patients. And sometimes without knowing what these things are, these patients come to you and you're not going to know what to do with them. And then even though we're just talking about diagnoses that are zebras here, even the standard stuff that we see in the clinic that you have probably heard of or seen in your clinics, these conditions oftentimes are pretty hard to treat. Even though with cortisone injections or other modalities, we can get there probably 50 to 80% of these patients better, there's always that remaining kind of 10 to 20% that we don't have great solutions for. And sometimes even surgery isn't the right solution for them. So if we can build out this field even more, then we can research more into these areas and what we can do to help these types of patients with these more common conditions. Just want to get a show of hands on here. How many of you guys are holding on to a few of these patients that you see back and back again that we don't have a great fix for? Yeah. Yeah. So I think it's something that we can all relate to as something as physiatrists seeing outpatient musculoskeletal patients. Just going over a history of self-socialization, I'll start with PM&R on the side here. So PM&R is a relatively new specialty, even in medicine, starting in the 1930s and 1940s. And it wasn't until the 1990s that our outpatient musculoskeletal medicine practices started developing and self-socializing into those areas with accredited and non-accredited fellowships started happening. And around the 2000s, some physicians who either practiced as generalists or sports medicine eventually started working specifically on hand and upper extremity conditions. And there's a few of us around the country that do just self-socialize in that area. But right now, I think it's a mix of sports medicine trained and general physiatrists taking care of these types of patients. It seems like our outpatient musculoskeletal medicine realm of sub-specialties follows closely in line with the development of orthopedic sub-specialties as well. So hand surgery became a sub-specialty relatively late, around the same time PM&R was developing in the 1940s and 50s. And now, more recently, shoulder and elbow surgery is now developing as a sub-specialty. So going in line with, as they're self-socializing and seeing more of these patients and realizing that surgery isn't the best option for all these patients, there's more and more of a need for us to help with their non-operative patients and care. So the goal today is to first kind of create a collaborative environment with everyone to find out who sees these types of patients, wants to kind of further develop or care for patients with hand and upper training conditions, and then hopefully formalize a training program at some point to help develop this as a career option for future physiatrists. So we have a great crew of speakers today. We're going to go over each of the joints, a specific topic about each of these things, to just go over what we see. And I'm going to go first and talk about rock climbing injuries and finger injuries first. Then we'll, that'll be followed by Dr. Homer, who comes from Brigham and Women's Hospital. He'll be talking about ultrasound guided carpal tunnel release. Then that'll be followed by Dr. Betcher from Mayo Clinic. He'll be talking about ulnar-sided wrist pain. Then by Dr. Rowe, who will talk about treatment for lateral upper condylitis. And then by Dr. Goldring, who will talk about radial frequency ablation for the glenohumeral joint. Last two coming from Stanford as well. All right, so mine is going to be a pretty short talk to give more time for our experts to share their slides. So the reason I'm talking about this one in particular is because rock climbing is a growing sport in the United States. A lot of these treatments you'll see later on are primarily non-operative. So it's a good explanation for a place where hand PMR can fit into the spectrum of hand surgery and hand therapy currently. But I want to make sure everyone has at least a basic understanding of rock climbing first. So first of all, rock climbing is, as I said, it was a growing sport. There's been an increasing number of indoor climbing gyms developing with increasing number of patients and participants doing bouldering. It became an official Olympic sport in 2021 in the form of sport climbing, which I'll go over into more detail. And with that, I think has increased the number of adolescents and youth interested in the sport and potential injuries developing from that. Sport climbing is three disciplines in one. If you talk to any rock climber, they're saying this is not a true thing that they all do, but it combines the components of rock climbing. So lead climbing is climbing with a rope. You go as high as you can on a wall for 15 minutes high in six minutes. The second discipline in this is bouldering, where you climb a 4.5 meter high wall without any ropes. And that one's more of a technical challenge. And then the third part of it is speed climbing, which I hear no one really does regularly, but this is where you're racing to reach the top of a climbing wall as a one-on-one elimination pattern there. In terms of rock climbing holds, just to get everyone on the same page of these. So the safest grip pattern is an open grip or a jug hold. This is for your rounded holds. Your IPs are flexed about 20 degrees in this, so that keeps a pretty neutral pattern in your hand and puts less load on your fingers. The one type of hold that you hear most injuries coming from and the rock climbers are the most scared of is the crimp. These are for your more flat top holds where you can't do a rounded posture on it. With a full crimp, what defines a crimp is the PIP and 90 degrees of flexion here. The half crimp is a little bit safer where your DIPs are staying relatively neutral, and the full crimp is when your DIP becomes hyperextended in the hold. These are the most risky for rock climbers because they worry about pulley injuries, which can occur with this type of hold pattern. The third type of grip pattern I want to talk about is a pocket grip or pocket hold. That's when you can only fit one or two fingers into the hold. The recommendation for that is to use your long finger first, then followed by the ring finger if you have space, then your index finger. Most two-finger pocket holds are about the long and the ring finger. Even though people worry about the pulley injuries, it's probably these pocket grips that are leading to actually more injuries than the crimp. It's always a good thing to gain your history help if this happened during a pocket hold. Injury rates are luckily fairly low. It is a little bit higher with bouldering and a little bit higher with artificial walls or indoor climbing. The injuries, again, are most commonly to the long and the ring fingers, I think, due to the pocket holds and the nature of the forces placed on the fingers during a crimp hold. But the good news is that the majority of these are treated non-operatively, and most are able to return to sport usually within four months with non-operative treatments. On the right side there is a table of different injuries that can occur and their rates. You see most commonly on here, they mention a collateral ligament injury, which is an injury to the stabilizing structures on each side of a finger joint. But if you actually combine the middle three or four of these, these all relate to your flexor tendons and pulley injuries, and that actually, in total, collectively is the highest number of injuries in climbers. So next I'm going to go over three of these in a little bit more detail on what you'll see on ultrasound. So flexor tendon and pulley injuries, again, most commonly of what people are afraid of. So these are associated with the crimp holds. On ultrasound, you'll see on the side there that you're looking at the distance between the tendon and the phalanx. If that increases in terms of distance there, that suggests that the pulley is ruptured and is no longer holding that tendon down, and that will tell you that there's a pulley injury there. So in clinic, this is the thing that patients are most worried about, and you can luckily pretty easily with an ultrasound take a look and tell them whether they have a complete pulley injury or not based off of that criteria there. Most of these still improve a non-operative treatment. Very few actually end up needing surgery, and very few surgeons are going to operate on just a single pulley injury. What we've been using in our clinic are these pulley protection orthoses that put pressure on the A2 pulley when they're climbing, so it provides a passive type of support of what the pulley was doing natively before the injury occurred. The other thing that rock climbers will talk about is H-taping. Sometimes they'll preventively do H-taping. A recent study showed that that isn't super helpful for preventing the injury, but it's still a potentially useful option if a pulley does tear. Next are injuries around the joint, the PIP joint itself. These again occur with crimps, which put a lot of pressure on the PIP joint in general. In younger climbers, this can lead to epiphyseal stress injuries due to the growing growth plate in that area, which a picture on the ultrasound on the right there shows the saltus teres 3 fracture. There's still a debate about how best to treat these. The thought is that as rock climbers, a lot of attention is put on finger flexion, so the goal with the therapy right now is to try to work on finger extensors to try to balance out that force coupling to prevent further injury to that joint. The third one here are lumbrical injuries. These are things that can occur with those pocket holes that I talked about earlier. The lumbricals to the ring and small fingers are bipennate, meaning they have two heads. The thought behind those is that if you're in a pocket hole, one finger is bending, one finger is flexing while the other is extended, and that can lead to shearing injury of those muscles there. What you're looking for in ultrasound there is something called a theta sign, which is where it looks like fluid is surrounding the FTP tendon as you're scanning into the mid palm. That could be one sign of an injury there, and then otherwise you can look at the muscle architecture itself, which can sometimes have a hematoma or a strain appearance on the ultrasound there. Luckily, again, these tend to improve with therapy alone, but the goal there is to kind of avoid a load on specific isolated fingers for that period of time, about four to eight weeks, until that recovers. I know that was a whirlwind through rock climbing injuries, but we have a lot of great talks today. I don't want to take away their time, but as you can see here, it's a great spot for hand physiatry to kind of really fit in, because the rock climbers want someone who can ultrasound and give them a diagnosis without needing to necessarily go through a whole MRI process. They want to know if they have a pulley injury or not, whether they can still climb, because it's really hard to stop a rock climber from climbing, as I am learning. So you want to at least have the proper guidance for them, and then the hand therapists also want to know what's going on. Yes, they can try different modalities. Yes, they can try different stretches, but it's better when they know what exactly is going on. So I think this is a good spot for us to fit in. All right, thanks. So next, Dr. Homer is going to give us a talk about ultrasound guide carpal tunnel release. All right, hello. So ultrasound guided carpal tunnel release, as you know, is kind of an advanced ultrasound guided intervention and requires a lot of experience and special training. But it's also a very interesting and a very... I would say it's up and coming, but it's already coming. But I think we're going to see it more and more across the country, and we're going to see it infiltrate. It's appearing a lot in the hand surgery conferences. But as we all know, carpal tunnel syndrome, there's a lot of need there, and high prevalence, a lot of need for treatment. And there's a lot of issues with the recovery from the surgery that tend to slow a lot of the patients down from getting the treatment when they need it. So one of the important points that causes the problems after surgery is the location of the scar. It's right in those densely innervated tissues in the palm of your hand. So when you push yourself up for transfers, when you're gripping things, you know, that's really an important piece of real estate of your hand. So being able to consider displacing that to another site is a really important consideration. So one of the things that's particularly relevant to PM&R is when people use assistive devices. Or if they have special needs with their upper extremities for transfers and things, then it gets in the way even more than others. So there are probably times when these considerations come into play more than others. You know, when people have very hand-intensive jobs, when in particular they're in a position where taking time off of work just isn't feasible for them, or when they need treatment in both hands and it's already kind of a stretch for them to consider taking the time for one, let alone staged procedures, which the process could take several months. And then down the road, scar tenderness, it's becoming increasingly recognized in the hand surgery community how long scar tenderness can really last and how long it can affect patients. That it can be nine months or more on the regular. So why is ultrasound helpful for this? Well, it does a great job visualizing structures at all depths. And in some ways, you know, you can see the advantage of open surgery as a way to look directly at structures, but you can't look at all the layers at the same time. And if you put a camera in there, you can only see where the camera can see. And so in some ways, even though ultrasound is less direct, in another way it's almost more direct. And so it really gives you a great view of all these things. You know, endoscopic carpal tunnel release, as we all know, has been available for a long time, and it does provide some of these advantages, but it does require a thicker piece of equipment that's typically only accommodated in the OR, and everything that goes with that. And over the years, it's generally been associated with a slightly higher risk of transient nerve injury compared to open carpal tunnel release, which is one of the reasons why it isn't as widely performed. And it does have, again, limited visualization. So in 1997, Nakamichi described ultrasound-assisted mini-open carpal tunnel release and described the transverse safe zone. So this is a critical concept in ultrasound-guided carpal tunnel release in that we need to know that there's an area that's safe to cut. Now, a number of devices have been used over the years, and companies are continuing to come out with new devices all the time. And I think that is going to be an important element of making this more widely available and affordable. But we have hook knife, we have saw blade, we have cutting thread, we have anterograde cutting devices. Some people are just using needles to fenestrate. And then even some have used radiofrequency. So the literature is really exploding on this. Up until 2017, there were a somewhat limited number, but things were getting moving. In 2017, one example is a device came out with safety balloons and started a registry, which actually has really increased the amount of data available monitoring this to show the world that this is a safe procedure. And that's been really helpful. And then kind of building on that, there have been a lot of peer-reviewed publications, including some randomized trials and meta-analyses. But the overall trend so far seen is that this is a safe procedure with comparable rates of complications to the existing accepted procedures. So a lot of literature coming out, and you can see even just in the past couple of years, a lot of hand surgery journal publications now, a lot of hand surgeons getting involved with this, showing potentially increasing acceptance of this in the hand surgery community, which is really important for us to all work together on this and have buy-in. So one of the first important studies on this, Rojo Manaute, in 2016 did a controlled trial with blinded assessment and showed a faster return to activity and less medication use after the procedure and a quicker release of the paresthesias compared to surgery. There's also been a number of cadaveric studies showing complete release, and there's been ultrasound and MRI studies showing complete release of the ligament as well as normalization of the shape of the carpal tunnel as well as the nerve. And importantly for PM&R, it's been demonstrated to be helpful in PM&R patients, post-polio, multiple sclerosis, paraplegia, manual wheelchair use, and the ability to immediately resume the use of these ambulatory aids after the procedure, which you can imagine, you know, especially for someone living alone, this could be the difference between requiring living in assisted facility versus going straight home, which is a big deal. So technical considerations. It's crucial to identify the appropriate anatomy and to develop a fluency with the ultrasound visualization of this carpal tunnel anatomy. Some of it can be quite tricky and requires a high number of hours, and if you're using ultrasound diagnostically and for injections, that's a great way to get that familiarity before you consider looking into this kind of thing. But the important thing is the transverse safe zone in both planes and confirming the safety before you enter and then confirming the appropriate positioning before you go ahead. So some of the crucial structures to consider. The palmar cutaneous branch, the thenar or recurrent motor branch, the third common palmar digital nerve, as well as on the ulnar side, the ulnar artery, and the fourth common palmar digital nerve, as well as the superficial palmar arch coming around that you see on the ulnar side as well as distally. And there can be variations for this, so you really have to look in this space and make sure there's not something there that wouldn't typically be there. So on top you can see the palmar cutaneous branch next to the FCR. Here you can see the athenar motor branch. This one's really tricky. It's really unlike most other nerves you see on ultrasound, and learning to see how it pierces the fascia is crucial. The third common palmar digital nerve is pretty easy to see. You can see it going there between the flexor tendons and the superficial palmar arterial arch. You can see distally, and you can use vascular imaging to watch it flow. So the transverse ape zone, you're looking between the median nerve and the ulnar artery and or the hook of the hamate, depending on which is more radial. And you just need to make sure that it's big enough to be safe. In some cases, especially if you don't have a ton of experience, you may decide that in particular patients it's not the appropriate treatment for them in your hands. Longitudinal safe zone to the superficial palmar arch distally. Here's an example of a retrograde hook knife cutting technique. So in summary, all the evidence so far is really showing a trend towards this being a safe and effective device compared to mini-open as well as endoscopic carpal tunnel release. And there is a trend towards earlier recovery. Some of the studies are showing a clear benefit, and others are showing that it's at least not inferior. I think we're going to see an increasing amount of evidence showing that it does provide a faster recovery, and, you know, there are, you know, logical reasons, you know, for that. But it just takes time, you know, to get this integrated into the hand community. Here's one of the reasons why you might want your hands after surgery, and I look forward to your questions later. All right. Good morning. Thanks, everyone, for coming here. Thanks for the invitation to be a part of this panel. So I've got a big task. I've got to cover ulnar wrist pain in 15 minutes. And so I'm going to focus on a couple of things in particular on the ulnar wrist. These are just our objectives today. One thing that I learned early in my hand rehab rotation, I think as a PGY3, was that ulnar wrist pain is oftentimes equated to the low back pain of the wrist. It is oftentimes vague, oftentimes insidious. Frequently there's not a great way to undergo or to come to one specific diagnosis. And so I think this framework makes us think about how we approach ulnar wrist pain from a diagnostic standpoint, similar to how we approach low back pain. Briefly just covering the ulnar wrist anatomy, I know this is a really busy slide, so I'm going to try and point out a couple of things. And so I always thought about the TFCC and the ulnar wrist as like a single structure. And then we started getting more into the detailed anatomy of the TFCC and the ulnar wrist structures and realized that this is really a conglomeration of structures that come together to form a functional unit. And that unit is different if we're in a supinated position, like here where we have tension through the volar TFCC structures, versus a pronated position. It changes the tension through the different structures. So when thinking about imaging these patients, whether it's with ultrasound or MRI, the position really does matter. We also note that structures that I initially thought were completely dissimilar come together. So we see that the ECU sub sheath actually attaches to the ulnar aspect of the TFCC ulnar collateral ligament. Looking from distal to proximal, so this particular image has the lunate and the tripetrium removed. And so we have ulnar over here and radial over here. This is what people refer to as that triangular disc, and so that's the structure that we're looking at. When people initially think about the TFCC, they think about this central disc and kind of ignore all of these other ligamentous structures that support this area. These are some of the things we're going to cover. We're going to focus really on the TFCC and ECU because I think these diagnoses are a little bit more challenging to come by and management is a little bit more nebulous for some patients. As far as the TFCC goes, we need to think about the different structures. So we think about that triangular disc that we mentioned, but there's a meniscus homolog, the ECU sub sheath contribution, the ulnar carpal ligaments, both dorsal and volar, the ulnar collateral ligaments, and then the radial ulnar ligaments, both dorsal and volar. When we think about the TFCC, oftentimes people equate this to the meniscus and think about the vascular supply of the TFCC as it relates to healing, just like we do with the meniscus and the knee. And just superimposing that last anatomy picture, I've flipped it so everything's a little bit backwards, but we see that within that triangular disc, this is that avascular region centrally as is demonstrated, I think, in 1986 when they first did the initial vascular supply studies of the ulnar wrist structures. Well, what does the TFCC do? We started talking about the anatomy first, just to give you a framework of what we're looking at. The TFCC is essential really for two things. One is wrist stability, and in particular the DRUJ stability, to some degree the ulnar carpal stability, but the DRUJ stability is really a central function of the TFCC, and in particular the foveal TFCC insertional structures. And then that central disc is really essential for load transmission. So when the wrist is loaded, about 20% of the wrist load goes through the TFCC central disc itself. However, that changes with wrist position. So when patients are in pronation and ulnar deviation, that actually increases the load through that central disc. And ulnar variance is another factor that really plays into this. So if a patient has like 2.5 millimeters of negative ulnar variance, that is where the ulnar articular surface is 2.5 millimeters proximal to the radius articular surface, that actually decreases that load to about 4%. But if someone has a ulnar positive variance, meaning that ulnar articular surface is distal to the radial articular surface by 2.5 millimeters, that doubles it. So it goes up to about 40% of your load goes through the TFCC. When we talk about TFCC injuries, these can be both acute and chronic. We tend to see a lot of chronic TFCC pathology. However, some individuals will come in with acute injuries, such as this young lady sliding into second base here. If she has that wrist in a pronated ulnar deviated position and sustains an axial load, we can see injuries to that TFCC structure in an acute setting. The chronic injuries tend to be very much in that same position, but a repetitive forceful load. So gymnasts, divers, racquet and club sport athletes, and individuals who are involved in swinging sports. This also poses, just like the ultrasound guided carpal tunnel release was mentioned previously, this poses a unique challenge for athletes who operate from a wheelchair base or patients who operate from a wheelchair base, as it's really hard to offload these structures. When we think about their history, they might note weakness, they might note pain, they might note popping, and they might note instability with wrist loading, and that's a really essential factor. If someone's complaining of instability in their wrist with loading, that's certainly something that should raise your index of suspicion for a TFCC injury. Think about our gymnasts and our cheer athletes who are putting all of their weight through their hands. That is not a normal thing our bodies are designed to do, and so they are uniquely susceptible to these injuries. On physical examination, I think it's really essential to look at a couple of things. I think one is evaluating that whole kinetic chain. I know we talk about that with almost all of our peripheral injuries, but shoulder range of motion, elbow range of motion, their pronation and supination are essential. I tend to ask my patients, the first thing on physical examination is point with one finger to where you hurt. In the knee, the quad tendon, the patellar tendon, the hamstring tendon, they're relatively large structures, and so someone can maybe trace their finger along an area and you could get a pretty good idea of what you're looking for. In the wrist, almost all of the structures are smaller than our fingertips, so if someone is pointing in a general region, it's very difficult to say what anatomic structure are they pointing to, and so one fingertip exactly where you feel the pain. One of the things that we look for in particular is this foveal tenderness, and so this is just distal to the ulnar styloid. It's dorsal to the FCU tendon in the piece form over the level of the wrist joint, and that's a very specific area for looking for TFCC injuries, in particular, ulnar-tricuitral ligament split tears. I want everyone to pull up their phone real quick and scan this QR code. We don't have time to go through the physical examination of the wrist. However, one of our hand surgeons at Mayo who is a specialist in ulnar wrist pain has put together this great video. It's about a 45-minute long physical examination of the wrist video, and so if you all take anything away from this today, it would be to watch that video that's housed online. These tests, none of them are perfect, but in combination, they can really help get you to the right diagnosis. I'll give you a couple of phones still out, so I'll give you one more minute to scan that QR code. From an imaging standpoint, MRI is really the gold standard at looking for TFCC injuries at this point. However, nano-arthroscopy, so these nano cameras are really coming into play as an essential feature for diagnostic purposes. These can be done in the office with local anesthetic. What we find surgically is that a lot of injuries noted during arthroscopy are missed on MRI. There's still debate right now on what sort of MRI we need. Should we be getting an arthrogram? Should we not? Should we be using 1.5 Tesla, .7 Tesla, 3 Tesla? I think if you have a 3 Tesla scanner, you can probably go without an arthrogram. I think there's still some debate on whether 1.5 Tesla machines should have an arthrogram at this point. From a classification standpoint, these are generally classified bipolar and into traumatic and degenerative, and this does have some impact on what treatment we choose. From a management standpoint, oftentimes with acute injuries, we will brace patients, and what we find is that putting them in a simple wrist splint is not sufficient to offload the TFCC. You really need to put someone in a Munster style or a Delta style cast. That eliminates the pronation and supination that loads that TFCC structure. There's really limited data on the success of bracing, though, and so we usually give our patients an option of this. In athletes, there's even less data on whether this is helpful. A lot of times, people want to play through ... My background is sports medicine, so I see a lot of athletes that want to play through their injury, and there's really limited data on in-season management of these injuries. However, anti-inflammatories are frequently used, occasionally injections, and we talk about load distribution. There's this little splint right here that some people can wear while they're competing, and that does increase load tolerance in the setting of a TFCC injury. From a rehab standpoint, proprioceptive training is essential. With a foveal disruption of the TFCC, the proprioception through the wrist is lost similar to with a lateral ankle sprain, and rehabilitation of that proprioceptive training is key. From a surgical management, the treatment is based on their pathology. Central disc injuries, which are relatively avascular, are typically debrided similar to how a white zone meniscus tear, if it was surgically treated, would typically be debrided. Peripheral tears oftentimes have excellent vascular supply, and especially if they involve ligaments, those can be reconstructed, and that is, in particular, essential for individuals who complain of instability in their wrist. So when those foveal fibers are disrupted and there is DRUJ instability related to that TFCC injury, a repair is oftentimes necessary. All right. We've got four minutes to get through the last five things. So we're going to talk quickly about the ECU. The ECU is a little bit more straightforward than the TFCC. However, we have a variety of different conditions that involve the ECU. That includes tendinopathy, tenosynovitis, and instability, and they are not always the same. We need to remember that the ECU, when a patient is in a pronated or a neutral position, that tendon runs from the elbow to the hand in a straight fashion. However, when the patient is supinated, after the tendon passes through the ECU groove and beneath the sub-sheath, that tendon actually takes a turn, so that promotes instability within that tendon. Patients oftentimes complain of pain in a similar location to the TFCC with ulnar deviation, pronation, and supination, very similar in history to TFCC injuries. Excessive supination and pronation maneuvers, especially when they're forceful, think of like scooping ice cream, is oftentimes painful, and in patients where tenosynovitis is identified so they have warmth, redness, swelling, or sonographic findings or MRF findings of tenosynovitis, we really should consider rheumatologic-type conditions. From a physical examination standpoint, people oftentimes point a little bit dorsal to the TFCC and a little bit proximal as a location of pain. The ECU synergy test and ice cream scoop test, both of those are also in that video you scanned earlier, are helpful. From an imaging standpoint, patients will oftentimes have a shallow groove if they have instability. They may have ulnar minus variants, so looking at our initial x-rays, that AP x-ray of the wrist, ulnar positive variants makes us think about TFCC, ulnar minus variants makes us think about ECU. We know that instability within the ECU tendon at various positions in asymptomatic patients is there, and so don't rely on that as your primary finding. You really need to always have a bilateral comparison. That's why ultrasound is probably better than MRI for these types of conditions. You really want to assess at which degree their tendon is unstable. So if you're considering someone with ECU instability as their primary problem and you're thinking about putting them in that Munster or Delta cast that we talked about for the TFCC, if you brace them in a position of instability, that subsheet doesn't have a chance to heal. So I always measure where their tendon is stable so when we get them fit for a cast, we can say they need to be pronated at least 30 degrees for their tendon to be stable or at least 50 degrees for their tendon to be stable. With acute instability episodes, we aim for at least six weeks of non-surgical treatment in a cast and surgically repair the subsheet in episodes of persistent instability. I'm just going to move past this to cover a couple of other diagnoses in my last minute here. Ulnar carpal impaction is certainly another condition that has a little bit more dorsal-rated symptoms. This is another one where you'll see an ulnar positive variance on your x-rays. You may find that there's degenerative changes in that ulnar carpal articulation or cystic change within the lunate. MRI oftentimes reveals the finding of that cystic change within that proximal lunate adjacent to the ulna. Physical examination is usually notable primarily for tenderness at that dorsal ulnar articulation and treatment is similar to other degenerative conditions of joints where we talk about splinting and immobilization and inflammatory possible injections. And then from a surgical standpoint, if these fail to improve, you can consider an osteotomy and ulnar shortening or a wafer procedure. The wafer procedure is only indicated if there's less than four millimeters of ulnar positive variance. Piso-triquetral osteoarthritis is another one where we frequently overlook this condition. This is just distal to the TFCC where there's degenerative changes in that articulation between the pisiform and triquetrum. We typically see this sonographically better than we do radiographically. But CT scan also shows that degeneration very well. All right. And then I'm going to skip DRU-JOA in order to give everyone else a chance here and take questions at the end. Thank you. Good morning, great to see you in California. San Diego weather is much better than San Francisco. I flew in from San Francisco, so enjoy the weather here while you're here. So I think I'll do the elbow. I work with Dr. Chow. I do the sports medicine, but my mentor recommend the sports medicine, the upper extremity and the hand training as well. I was not quite sure, because my mentor said it's the lowest hanging fruit, but I was not quite sure. But looking back, I think the mentor was right. For those who are interested in upper extremity, you'll be busy. Dr. Chow is a business provider in our group. And some who are tired of seeing all body parts, probably you can focus on upper extremity as well. That's the pitch for upper extremity. So those are my disclosures, mostly related to the research. So elbow condition, there are many different conditions like other parts in upper extremities. So most commonly, tendinosis, that's what I see. Also arthritis, bursitis, all the collateral ligaments. Also some other nerve issues like a cubital tunnel, radial tunnel syndrome. And also I want to mention the vascular conditions as well. Not very common, but once in a while I see those patients. Couldn't explain otherwise. Acute pain in the forearm or upper arm. And then Doppler showed SVT as well. So kind of find the answer finally with treated condition. So those are the things. But at the sake of our time and our focus on elbow tendinopathy, I think everybody's an expert. So I can't say I know more than I do about just introduce how I practice in our group. So diagnosis are quite straightforward. So either you can use a location of the symptoms, can tell us where the pain is coming from. Physical exams also relatively straightforward compared to other body parts. So you already have a pretty good idea what's going on with the patient. Then you can still add an MRI or ultrasound depending on availability. Usually ultrasound can be used. I don't use ultrasound all the time to confirm the diagnosis at the first visit, but you can add it on. Or MRI can be done as well. So I agree, I think, and I agree the ultrasound is good enough. I don't have to use MRI. So Bhakta and others actually did a study and how good ultrasound is in detecting common extensive tendon tear. It showed a good sensitivity and accuracy and very good specificity in detecting tear. And when it comes down to the high grade tear, which is more like sensitive, whether which direction they need to go, then it showed 100% accuracy. So ultrasound can detect the issues in the elbow tendon fairly well. On top of that, I think ultrasound has more benefit that we can use ultrasound as a longitudinal measurement for their treatment outcome. In addition to 2D or B-mode images, you can use Doppler scan. I use microvascular flow more often now than adopted from hepatology. The top images, that's color Doppler. It shows the gray hypoechoic lesion. It works, it's usually here. You can see the hyperemia. And the bottom one is not power Doppler, it's a microvascular, it's a software enhanced images. It can detect a low flow of inflammation better. So we found this helpful in assessing the patient as well. But let me show you another slide. This is not the common extensive tendon. This is actually from UCL. And when we assess the patient, MRI showed a little bit of tear. We use a color Doppler. Before we did the procedure for this patient, we were not able to see any hyperemia, but with the microvascular on this side, we are able to detect this condition. So clinically, we're still learning it. We just put out case reports and then we're learning it more. We try to use it more, but I think, I hope in the future, we can measure the patient response to the treatment in a more objective way. Sometimes the patient come with like 70% improvement, but they come with the lingering pain, but we can't really explain that well. Sometimes microvascular flow images can explain things well. So it can be helpful to find the answer with the patient. So going back to elbow issues, I usually, patient come with that, I try to explain the nature of the elbow tendinosis. Basically, it's a self-limited condition. Stress versus the healing. So try to control too much stress if they do too much work with their elbow and upper extremities. And also discouraging patient, not patient from using a steroid injection. Some patient come and get the injection done, get it over with. I try to recommend, spend some time to discourage the idea. And based on the severity and also patient preference, we find the best solution. So usually the initial treatment, activity modification, wrist splint, neutral or counterforce brace. A lot of patient already tried a counterforce brace by the time they come to see me. And I also like to use NSAID and also nitroglycerin. So the question is a wrist splint versus a counterforce brace. There's other randomized control trial. That's what I use as my reference. The wrist splint demonstrated a bit better outcome than counterforce brace. So I use it as more like therapeutic brace for a couple of weeks, see how they do. And then they do better with any other treatment. When they go back to their normal life or sports, they can use a counterforce brace as more like a protective brace. That's how I explain to my patient. And also like to use nitroglycerin as well. And we deliver usually 1.2 milligram per day when I prescribe it, usually 0.1 milligram per hour. So 12 hours on, 12 hours off. And need to use this a longer period of time. They don't see the outcome right away. Usually I keep them on almost 30 days, even longer. When you prescribe it, discuss like other medication like erectile dysfunction medication that can bottom out blood pressures. And also that can cause a headache from vasodilation and those issues you need to discuss with the patient. But those are the things that I try as a first step. Then first or second step. And then if those are not effective and patient not patient enough to wait and see what happens, then we discuss some interventions there. As you know, the steroid PRP shockwave, I call it MINT, minimally invasive needle tenotomy. And there is open surgery provided by our surgeons in our group. But the most of them are referred to our clinic first before they do the open surgery for them. So shockwave. Applies energy to the interface of a two substance with differing acoustic impedance. And proposed mechanism of action is energy promote tissue healing and possibly reduce the pain. So that's the mechanism. I looked up the literature if there's any good support to that idea. There are several systemic review. I like this better because they only review the RCTs. And there are five authors that did not see a significant difference between shockwave versus sham. And there one author did publish two studies thought it was helpful. The next one actually compared a shockwave with PRP and PRP with exercise and then exercise only shockwave plus exercise. All of them demonstrated improvement. But PRP with exercise group demonstrated more significant extent of improvement than others. So PRP wins a little bit more here. For those who really likes the shockwaves, there is a data supporting shockwave as well. The shockwave and PRP demonstrated similar outcome but both demonstrate improvement. And interestingly, the PRP demonstrated faster symptom resolution, which was counterintuitive to me, but that's what they found. I found that was interesting and I wanna introduce this finding to you as well. So I think there need more study to be done. Adam Tempore is doing a lot of research. So hopefully we have a better idea for that. Then we'll move on to PRP injections. Then minimal side effects, that's the benefit. That's the first body part PRP was used in MSK world and downside is a cost. It's quite expensive depending on where you get injection done. I think a cortisone is still better in terms of effectiveness, but also the study showed that cortisone injection group demonstrated higher recurrence rate of tendinosis a year later. And it can cause a tendon damage as well. So I try to discourage that treatment options. Then it comes down to which PRP is better. So then ricocyte-poor, ricocyte-rich, when I learned it, ricocyte-rich for tendon, ricocyte-poor for the joint. But since 2014, the ricocyte-poor, the usage of ricocyte-poor PRP increased. This meta-analysis demonstrated that in case of lateral epicondylitis, they did not see a significant difference. So it probably make your practice easy and simple. Sometimes you don't have to have a two different formula, you don't have to train the two people, I mean two different ways to prepare the PRP. But I think it's more importantly, we probably need to work on PRP optimization and the PRP actual number. That's what we are discussing more with the synovial joint, the joint. So probably we need to change our focus rather than ricocyte concentration. Then probably need to focus on the platelet counts and to see which dosage or which numbers are working better for the patient. Then if that's not working, are we going to the common extensor? That's what surgeons do, three centimeter incision and the debridement, reattachment, things like that in the extensive, in the longer period of recovery. The minimally invasive surgery still make a one centimeter incision. So going through the same process. So with help of ultrasound, as you see the other body parts, we can use the different devices called the percutaneous tenotomy. With the ultrasound guidance, the needle will be, I'm sorry, the ultrasound guidance, we do the numbing medication, like I use a ropibacaine as my preferred analgesics and we make a stab incision only like two millimeter, very small, it doesn't leave much scar there. Then the one of device is going in. One device from one company use a supersonic stream of water, kind of cleans out, irrigate the damaged tissue. Then the other system use ultrasonic power and only divide, let me see if the video, yeah, it's working. So right bottom just kind of cleans out the damaged tissue only, the top one is a multiple needle penetration by using this device. So every device works a little different way. And whether it's working or not, I think from our review, PRP and MINT both are a similar outcome and then safety was my biggest concern and then MINT was a fail to get. And not only from my data and then other, Dr. Ken Mottner, others, they did a retrospective review, they got the similar outcome as well. So I think that can be considered as a treatment option. So let's see, so in conclusion, when it comes down to treatment option, this is my table. So you may have a different table, different opinion, that's totally fine, but that's how I usually come up with that when there are many options, but one option does not stand out clearly well. So effectiveness, longevity, safety, and the cost, and then we'll just put it there. I think it's definitely the most effective, but not quite safe option. I see PRP and MINT is kind of similar in terms of effectiveness. When it comes down to the cost, I think PRP is most expensive, Shockwave followed that because both are out of pocket, and then MINT, in my case, it is covered by insurance. So I think I give a patient an option what to choose. Other than that, as a summary, I always do non-invasive treatment option first and have a patient to understand the pathophysiology a bit better. So wrist splint medication, some rehab, and most importantly, activity modification. Then I use ultrasound or MRI or both to understand the structure better. I tend to go with Shockwave with low-grade injuries because I still don't want to push the big needle into the tendon when there's no big structural changes, and our review showed that high-grade tear, we're still okay with using MINT devices there. So I like to go with the Shockwave and the PRP for the low-grade. High-grade, I give an option of PRP or MINT to our patient. So then we have a conversation and we'll choose the best option for this. I think I'm still on time, right? When you gave me a warning, I thought I was too late. Thank you. Hi, everybody, I'm Annie. I'm excited to be here. Last but not least, the shoulder. So I'm gonna be talking about the treatment of chronic shoulder pain with radiofrequency ablation or RFA. So we'll briefly go over the background of RFA just so that everybody knows what I'm talking about, and then we'll specifically talk about the procedural technique of RFA as it pertains to the shoulder, and then go through some of the current literature on the topic. So what is radiofrequency ablation or RFA? You might also hear it referred to as neurotomy. Those terms are interchangeable, but you're essentially, you're using targeted thermal damage of sensory nerves to reduce pain from any given structure, in this case, the shoulder joint. And this is accomplished with specialized probes or percutaneous needles. The tip of them heats up by this high-frequency alternating current. It results in ion oscillation and heat production, and then you're able to burn or create a lesion around the tip of the needle. And what you can see pictured here are two of the conventional radiofrequency ablation needles. The yellow one is a single tine at the end, whereas the blue one has three little prongs at the end. So the three-tined prong needle allows for a larger lesion. So these are, again, these are the conventional RF needles. You might also hear about cooled RF. That involves circulation of fluid around the tip of the needle. In both instances, you're accomplishing the same thing. The technology is just what differs. And so in terms of the history of radiofrequency ablation in the musculoskeletal system, this actually dates back to the 1970s. It was at that point that they started using this to treat facet-mediated pain in the back, and I think that's where most of us in musculoskeletal medicine are aware of the use of RFA, is in the treatment of back or neck pain. But then in the 1990s, they applied that technology. They started using it to treat the SI joint, and then the early to mid-2000s, the knee, the hip, and most recently, the shoulder. And the indications for RF for chronic pain are pretty similar, you know, across the various joints. Again, it's chronic and severe joint pain. In most instances, it's because of severe arthritis. This is pain that hasn't responded to your traditional treatment options, physical therapy, oral medications, topical agents, injections. As far as the shoulder is concerned, certainly patients have had a steroid injection, insurance permitting, maybe you've tried hyaluronic acid or gel. But when none of these things are working and they have, you know, ongoing chronic pain, more days than not, and they either are not a surgical candidate for the shoulder, that would be a reverse or a total shoulder where they don't want surgery. RF is really, that's where RF comes in. This is never the first thing that you're doing for people. And then the only other instance or group of people that I think about are people who have had surgery and then still have pain afterwards. I get a lot of referrals from the surgeons for that. So in terms of the shoulder, a little bit of the anatomy in terms of the innervation to the shoulder. We know that the shoulder gets feeling from four nerves, the suprascapular, axillary, subscapular, and lateral pectoral nerves. The technique that I'm going to describe is a motor sparing technique where we're targeting three of those four nerves. So we're targeting branches of the suprascapular, axillary, and lateral pectoral, not targeting the subscapular. And what you can see here in the picture, and this is based on cadaveric studies where they've actually dissected and traced the path of these nerve fibers, is that we have what are called safe zones. So you can ablate these nerves at a point where they've already given off their motor or muscular branches and all that's left are sensory fibers so that you don't run the risk of knocking out motor or muscle function. And again, you're just knocking out feeling or sensation. So in the case of the suprascapular nerve, that safe zone is on the posterior superior glenoid rim. The axillary nerve can be targeted along the inferior portion of the greater tubercle of the humerus. Both those targets are posterior, so in the back of the shoulder. And then the lateral pectoral nerve can be accessed anteriorly over the coracoid. And we know that the suprascapular nerve in particular is responsible for 70% of the sensation to the shoulder joint. So if you're just targeting the suprascapular nerve, and that's really where this procedure began, was just by focusing on treatment of that nerve, kind of like a suprascapular nerve block, you knock out a large percentage of the sensation to the shoulder, to the joint. But in adding these other sensory branches, the goal is how much sensation, how much pain can we reduce? If we can knock out more of the sensory nerves, ideally you can improve your outcomes in terms of pain reduction. So then what does an ablation actually entail? So the first thing is, the way I describe it to patients is we don't want to burn nerves unnecessarily. We want to prove to ourselves that this is a procedure that a patient is actually going to benefit from. And the way that we accomplish that, it's the same thing that we do in the spine. You do a diagnostic block. So you have the patient come in and you numb up your three nerves. Most of us, I think, are using a standardized anesthetic, one ml of half percent bupivacaine. And then you send them home and they keep a pain diary. And you're comparing pain before and after. If their index pain is improved by at least 50 percent, they qualify to move ahead with the ablation. Again, insurance permitting. But from a procedural standpoint, again, you're trying to mimic, I describe it as a test injection. This is what it would feel like to have the ablation. So both that part of the procedure, along with the actual ablation itself are performed typically under fluoroscopic x-ray guidance in a surgery center or the OR. As I mentioned before, two of your nerve targets are in the back and one is in the front, which means that the procedure is sort of two steps. The first part, the patient lays prone and you can see here that you're able to adjust your C-arm so that you can visualize those anatomic landmarks or targets. I'll show you x-ray pictures next. But you get your two posterior targets and then midway through the procedure, the patient turns over, they lay supine and then you're able to access your anterior target. So it's a little bit cumbersome but you get it done. So then these are some x-ray images you can see on the left posterior, the right is anterior. The axillary nerve branch is being targeted at the inferior part of the greater tubercle and then you can see the needle over the superior posterior glenoid rim that's targeting your suprascapular articular sensory nerve branch. One thing we've learned is that the larger the lesion, the better the outcomes, the more of the nerve you're likely to burn. So the recommendations that do exist are basically that you do a couple of lesions or a couple of burns in those posterior targets. So in the case of this axillary nerve needle, I would move that needle a few millimeters superiorly and in the case of the suprascapular needle, I would move it a few millimeters inferiorly to do my second burn. Some practitioners will do a few needles simultaneously. They'll just line them and do like a strip lesion but again the idea is just to create a larger burn. And then the anterior target, again your lateral pectoral branch over the coracoid, it's a much smaller surface area so one lesion is usually sufficient for that location. Before you actually do the lesion though, you do some motor testing. So you turn on the needle or you stimulate at a voltage and frequency that would stimulate a motor nerve ensuring that there isn't any motor activation. Again, it's just another safety mechanism in place that you are in fact over sensory branches and not motor branches, which again you're pretty confident about anyway given your anatomic location but it is another safety mechanism. And then before doing the ablation but after doing your motor testing, you inject more local anesthetic to make the burn itself more tolerable. And then outcomes and patient expectations is very important. So first thing is it takes about a month, maybe six weeks to kick in. That has to do with the fact that the nerve is still able to send signals despite being ablated. That has to do with the ovarian degeneration. So what I'll tell patients is that you can expect a gradual improvement in your shoulder pain. It's not going to be as immediate as like a steroid injection but that over the course of the next month you should notice improvements. We follow up at about four to six weeks and touch base then. That's where really the maximum effects can be felt. The pain relief is temporary. We're in the periphery so the nerves are able to regenerate about a millimeter a day. So we'll tell people that you can expect the effects to last six months to a year and then we can repeat the procedure annually if they find it beneficial. And then the expectation is really not 100% pain relief but rather a reduction in pain severity. And this just has to do with the fact that with these larger joints you're really not, you're not knocking out every sensory branch like we discussed. So there is still some feeling left in the joint. So I'll tell patients I'm not turning the volume off, I'm turning the volume down. And I think that that's really important that people don't expect to come out feeling like they did when they were 25. In terms of the risks and the benefits, you know, like any injection, any procedure, there's a risk of infection, bleeding, worsening pain. Some of the risks that are more specific to the ablation, neuritis, so irritating the nerve, particularly if you get a partial lesion instead of burning all of it. I honestly, I haven't really seen that as much of an issue with ablation. I see that more as an issue with cryoneurolysis or nerve freezing. But it is quoted in the literature. The skin burn I think is something else to be aware of. That can happen if the tip of your needle isn't deep enough. So if you're too close to the skin surface. Again, that happens more in the genicular or the knee procedure, not so much with the shoulder. The shoulder targets are usually deep enough that that's not an issue. Weakness, again, we go to all of these lengths. This is a motor sparing technique so that we're not creating weakness. And falls is for genicular, not the shoulder, obviously. And then the benefits, I mean the overall goal of this procedure is to reduce pain for longer periods of time, negating the need for steroid injections, medications, and potentially surgery. So in terms of the literature, it is admittedly a little bit sparse relative to what you'd like to see. But it begins in the early 2000s. Initially people were doing pulsed RF, which is sort of almost full RF, but not quite. So the results don't last as long. But again, specifically just targeting the suprascapular nerve. And then over time, again, this goal to have a motor sparing technique target more of the sensory innervation to the shoulder. So people started trying ablation to other nerve branches. And it was really in 2020, Ekman et al., they were the first, at least from what I could tell, to publish a paper outlining the technique that I was describing today, the three nerves motor sparing. And so in this initial paper, it was a retrospective study. 27 of the 34 participants underwent RFA. It was a mix of conventional and cooled RF. And they defined a successful treatment as an improvement in their pain of 50% or more. And so initially they show that 47.4% responded or had a positive outcome, which isn't great. You'd like to see certainly a higher responder rate. But I thought one of the things that's worth noting, and this is something one of the authors pointed out, is that five of the seven patients who underwent RF with larger lesions, they did have a positive response. So that's a 71% responder rate. So again, it's a small N, but making that case that larger lesions could have a significant impact. And then in 2021, Tinarello et al., they looked at the same three nerves but with a cooled RF. This was a retrospective study with 14 participants. And they followed up... The first study was, I think, followed up just out to three months. They took this out to six months, which is really what we care about and what we should be accomplishing is longer length of pain reduction. And so in this study, 92.8% or 93% of patients had a successful outcome at both one and six months. Success, again, being defined by a greater than 50% improvement in shoulder pain. And then in 2022, Tran et al. was another cooled RF study. This was a prospective study, 12 participants, and they did find statistically significant improvements in VAS or pain scores up to six months out. And then in 2023, so last year, Albici et al., they came out with this narrative review. They basically looked at all the literature that exists on shoulder radiofrequency ablation. I've highlighted a couple of the papers that are included in that narrative review. I think Ekman et al., they do a good job of basically explaining, at this point we have the anatomy pretty well sorted out. We know where these sensory nerve branches are. We just need to target them effectively. And then these other authors have again made the point, we need more studies demonstrating that. There's one more paper kind of hot off the press this year. Jane et al., it's the most updated systematic review. Again, looking at all the literature that we've reviewed, we've talked about. And they found 29 studies where there's evidence to show that RFA in the shoulder can provide lasting relief, improve function, and reduce disability. It was interesting though that 22 of the 29 papers that they highlight really are just focusing on targeting of the suprascapular nerve, whereas the technique we've talked about today, hopefully you should get even better results by targeting more nerve branches. But certainly there is a paucity of literature in terms of randomized control trials, larger participants. But I think that's where the future is. It's certainly great to have an alternative when people have chronic severe glenohumeral OA and can't have a shoulder replacement and you exhaust steroid injections. So this is what we're working on. Thank you. All right. I know your brains are now completely filled with knowledge already from the first session of this morning. My brain certainly is a little bit swollen itself. We have a few minutes for Q&A. Let's go ahead here. Thanks for this actually good gathering of upper extremity rehab. The question is about the ablation. You said there are four nerves used. So the force, I don't remember the name, but any specific reason you don't do the burning for this force or it doesn't make a difference with the outcome? The subscapular. Or it is hard to access. So we don't tend to target the subscapular given its location. It's harder to access safely and it's not responsible for, in my opinion, enough sensory involvement to warrant that. I think there are some people that are trying it, but from a technical standpoint. So you are saying do you use a standard RF needle or there are times you use a Venom needle? Pardon me? For the ablation, do you use a standard or Venom needle? It's a special radio frequency probe. I use Nimbus is the type of needle. Okay. A striker has two kinds of needle. One is the standard that you need to do re-burn when you do ablation for the low back. There is what's called Venom needle, which has like the V. So this, we don't do re-burn. So did you try like the Venom so that it will cancel? And the question is that if I do the Venom, do I need to re-burn? So I use the three prong, the needle that makes the larger lesion. And in the posterior targets, I do two burns next to each other. I think some people will use multiple needles to make a strip lesion like I was saying. In terms of re-burning, you know, if the pain comes back at six months... Sorry, maybe I... No, I mean re-burn during the procedure. So like for example... Yes. So what kind of needle you use? You said... Nimbus. Nimbus. Yeah. But you didn't use a striker or Venom needle before? I haven't used that, no. Or Derose is another of the three prong. When we use for the low back or the neck, we use it because it make a larger size of burning, maybe one centimeter, so that's why. Yeah, yeah. Thank you. Any other questions from the audience? Otherwise, we'll stay around the area too if we need. Hi, thank you for the talk. I just had a question. For the minimally invasive carpal tunnel release, do they need any kind of bracing afterwards? They just go home? I'm just wondering, are there any restrictions at all or... So that would be provider-dependent, but a lot of providers are not using any bracing afterwards. It's literally just a bandage. And return to activity is tolerated for some. And some will say just to decrease activities for a period of time, but bracing, no. I don't want to keep everyone who, if they have other talks, our experts will stay in the front here, so if you guys have questions, feel free to come up. And if anyone's interested in heading up Bristol Neophysiology, reach out. We'd love to connect to build out the specialty further. But thank you for your time today.

hand physiatry

upper extremity

Physical Medicine

Rehabilitation

ultrasound diagnosis

carpal tunnel release

ulnar wrist pain

Triangular Fibrocartilage Complex

radiofrequency ablation

elbow tendinopathy

PRP injections