causes of common complaints. I have no disclosures, but per usual I'm willing to change this if I can get some help. Objectives. So first we're going to identify some keywords, symptom patterns, things in the history that might clue you in to thinking about something that's less commonly diagnosed. We should be able to compare and contrast the exam findings with what we usually see and the things that we need to be concerned about. We'll go through different body areas for this and describe the appropriate steps in workup and management for these conditions. These are the overall objectives for the session, but I want you guys to note this is not an in-depth review for each specific condition that we're going over. So I'm blessed to be up here. I'm blessed to say that each of these individuals have impacted and mentored me in some way. They're all much smarter than I am, even if they don't want to admit that, but I just want to thank you guys for helping me out here. The first speaker that we have today is board-certified in both PM&R and sports medicine. No longer in possession of their sheer strength or unyielding endurance of the youth, this person still manages with a passion for sport to manage athletes and patients of all ages and abilities from the University of Miami, Timothy Tu. All right, so I'm going over not so uncommon causes of shoulder pain. Let's start off with the case. So patient presents, what's the differential? We add on one word or a few words, shoulder pain. So now with each question our differential starts broad, gets more narrow. I change it to 22 year old. What's the differential now, right? Because we know there are certain conditions that affect one age group more so than another. Now it's the dominant side. Maybe frozen shoulder is moving down the list, but it is something to consider. Now I throw in that this patient is a female. It's important to know that certain conditions affect men more than women. In the shoulder it may be more myofascial. Now we're saying that it's worse with overhead activity. So that's important because, for example, cervical radiculopathy might be improved with overhead motions. Now I'm going to tell you she's an elite swimmer and it's worse with swimming in particular. So now we know it's exertional. We know that we're assuming that, you know, this person is well conditioned. So it's probably something that is more serious or something that we need to be more keen to. And now we're saying there's heaviness and numbness. So that kind of changes everything because rotator cuff typically does not cause these types of symptoms. Cervical radiculopathy can cause them, but it is less likely. So what is common? So the sound does not work. I promised people... Okay. Does it work? Because I promised people I would throw in some Game of Thrones. If not, I'll just do it myself. no it's okay so there was an interview between these two actresses where the one she's asking this person what her drink of choice is so for the guys in back there was just coming in sounds not working so I'm gonna give my best impression so the interviewer says what's your drink of choice and then the other person goes a Negroni I was about Spaghetti Otto Oh with Prosecco in it and the other person is stunning is it supposed to be timed but whatever all right incidents prevalence so we see these quite often these numbers are smaller than I expected but then you extrapolate it to millions of people and that's why our clinics are full with it cervical radiculopathy even though we see it fairly frequently is still much less common than rotator cuff and of course my fascia pains like a thousand percent so the first thing we're going to talk about is thoracic outlet syndrome I have no idea what time okay so basically there's a compression somewhere around the clavicle in the first rib neurogenic is much more common than venus which is much more common than arterial the true numbers for incidents and prevalence is are not known primarily because it's there's no real standard for diagnosis it's also quite difficult to diagnose people don't think about it so often so the numbers are probably much higher than reported in the literature and people acknowledge that so the first area of compression can be in the interscaling triangle next is the cost of clavicular space and finally in the sub coracoid space so any of these areas anywhere in between whether it's the nerves or the vasculature there can be compression and subsequently symptoms so you should consider it based on the types of symptoms and the distribution if the patient you know again we will see rotator cuff most commonly and if the pattern if the story doesn't fit the typical picture then we have to think outside of the box so this is these are what people report people with thoracic outlet syndrome report paresthesias in the upper extremity neck pain trapezius pain etc etc but for me one of the key things and it's actually not as common as the others is there's paresthesias in all five fingers so basically multiple dermatomes are being involved right so it's not one one strip of the upper extremity that we would expect in a specific radiculopathy it's going past the elbow which is not really consistent so often with rotator cuff so little things that a lot of symptoms non-specific and kind of diffuse another thing is if you're doing shoulder exam and everything just seems normal Nears Hawkins everything nice and intact you have to think that is come from somewhere else non-musculoskeletal adsen test we this is performed by having the patient take a deep breath look towards the affected side I palpate the pulse sometimes it goes away sometimes it doesn't but I always make sure to ask the patient if it's reproducing his or her symptoms if it is I consider it positive whether or not the pulse changes the right hyperabduction test is similar except there's no deep breath and the roost tests you have them up in the surrender position and just have them open and close their hands for apparently three minutes I've not done it that long but that is the right way to do it so when you encounter a patient and you're concerned the workup can include basically all of these EMG nerve conduction study assess the integrity of the nerves MRI looking for both brachial plexus as well as an MR and geography arms up and arms down because with certain positions there may be compression x-ray looking for musculoskeletal causes also evaluating for a cervical rib ultrasound you can assess the nerves as well maybe individual nerves for focal entrapment and a scaling and a pectoralis lidocaine injection can also be diagnostic if you perform this you give the patient a pain diary where they have to indicate changes in their symptoms whether it's pain numbness heaviness and ability to function for the next day or so every hour they should they should indicate whether it's better unchanged etc so this is an MRA for the patient I'm talking about with her arms down it's supposed to automatically play but sorry it's a video it doesn't really contribute much it just looks really cool this is an MRA of the same individual arterial with the arms up so we see nice contrast distribution in the in the vessels is actually really close like a 3d rotating image but I screen captured it packs all right here is a MRA Venus so everything looks good here but now we have her with her arms up and now you see on the left side that there is a pacification of the subclavian so this patient has a venus thoracic outlet syndrome as far as management physical therapy stretching out those muscles working on biomechanics you can inject those nerves you can inject Botox into those muscles that may be used to determine whether or not surgery is going to be the best option but if so Robbie Bowers from Emory has a really nice article here that's cited at the bottom just go Google Scholar Bowers thoracic outlet syndrome very nice article with workup management such a he has a I think he's doing a thoracic outlet syndrome ultrasound workshop right now all right round two real fast sub coracoid bursopathy what is it basically it's a bursal issue right under the coracoid process over the subscapularis so again based on where the pain is what sort of things are aggravating the pain we should consider this so as far as where is the pain you ask the patient to point if it's on the side we're thinking supraspinatus right that's that's what we see most commonly going down the lateral arm anterior pointing right to the biceps tendon if they're pointing right up on top we're thinking AC joint but if they're pointing a bit more medial then then it's not the typical picture it could be glenohumeral but that's more diffuse if it's more focal is probably you should consider the sub coracoid bursopathy so it hurts with certain activities like reaching across parallel parking or if you'd like to turn like this riding on the chalkboard I don't know if they have chalkboards anymore or with the the follow-through of a throw so all those things have one thing in common adduction right coming across the body so typically rotator cuff we're expecting pain worse with overhead reaching behind but if it's pain with coming across and not they're not pointing to the AC joint sub coracoid should be moving on up in the differential you can do a modified Hawkins same same maneuver but in an adducted position with ultrasound all right so this works that's because it's a gif I think so this is a dynamic assessment this is normal okay we have the coracoid process and subscapularis moving nicely underneath shout out to Shane Drake's in the house citing him here we got a the bursa down here here's a dynamic assessment you can see the bursa filling up you can assess for impingement dynamically physical therapy if you're gonna inject it use the ultrasound unless you want to give them pneumothorax or give them thoracic outlet syndrome be my guest don't be my guess use ultrasound so basically look for horses listen for zebras thank you very much so so the next speaker is an assistant professor at the University of Miami she's the director of the EMG right she's also the director of the medical student interest group another brilliant mind dr. Laura Huang thank you dr. to very kind as usual so I'll be discussing under recognized causes of elbow pain unfortunately I have no relevant disclosures we'll start with the clinical case of a 50 year old female with no medical history coming into your clinic for four months of right elbow pain she was previously diagnosed with tennis elbow or lateral epicondylitis she did not have any improvement with rest anti-inflammatories bracing or therapy on the most salient finding on your physical exam is that she has a point of maximal tenderness four centimeters distal to the lateral epicondyle that is reproduced with maneuvers like resisted finger and wrist extension so she's sent for an ultrasound it shows normal radial nerve anatomy she gets a diagnostic injection and immediate relief leading to the diagnosis of radial tunnel syndrome so I chose this condition because it's sometimes a misdiagnosis tennis elbow and the misdiagnosis lead to the wrong treatment plan which can contribute to patient dissatisfaction and risk transitioning to a more chronic problem so the other reason I chose this topic is because of the controversy around the very definition of radial tunnel syndrome and also the confusion around radial tunnel syndrome versus posterior interosseous neuropathy so some authors have suggested a more simplified way of looking at these diagnoses so that they are both diagnoses on the opposite end of the clinical spectrum of radial tunnel syndrome so on the more mild side this represents the traditional radial tunnel syndrome so more of a pain syndrome and on the severe side this represents posterior interosseous neuropathy so the objectives today will be to review the radial tunnel anatomy clinical signs and symptoms and evaluation and management so the radial tunnel is about five to eight centimeters in length it starts at the radial head going to the distal edge of the supinator muscle looking at this anterior view the radial tunnel is bordered laterally here by the brachioradialis and the extensor muscles and then medially by the brachialis and the biceps tendon so there are six common compression sites so starting proximally the radiocapitellar joint the fibrous proximal edge of the extensor carpi radialis brevis the recurrent radial artery also known as the leash of Henry the arcade of frosh which is the other name for the proximal border of the supinator muscle and the most common site of entrapment and then as we go more distally the nerve can be entrapped between the two heads of the supinator and then lastly not shown would be the distal edge of the supinator at which is the exit of the radial tunnel so this is just a table format of the compression sites the key takeaway here is that the more proximal the lesion the more likely the patient is to have sensory symptoms so patients the chief complaint will usually be pain with mild cases and with severe cases the patient's more likely to complain of weakness with finger extension so epidemiological data are limited because of the misdiagnosis under recognition and under reporting for example the gender incidence is reported as from being equal to female to male predominance of six to one severe cases are reported at an annual incidence of 0.03 percent and contrast that to something like carpal tunnel syndrome which is 0.1 percent so key differentiating factors on physical exam so mild cases will have focal point tenderness distal about five centimeters distal to the lateral epicondyle in severe cases you might appreciate atrophy of the forearm depending on the severity and chronicity of the problem as well as radial deviation with wrist extension so the wrist will radially deviate because the extensor carpi radialis muscles are spared while the extensor carpi ulnaris muscle will be affected the patient will also have weakness of finger and thumb extension so in this photo on the right hand of the patient they're not able to extend their thumb or index finger so provocative maneuvers so these are maneuvers we do with the intention of trying to elicit the patient's typical symptoms so if the provocative maneuver causes some sensation or pain that's not their typical symptoms I would not consider that positive so many of the ones used in evaluating for radial tunnel are similar to tennis elbow resisted supination resisted wrist extension and finger extension which is shown here in this table also known as mod fleas okay so the rule of nines test is another way to assess for radial nerve irritation so this is the anterior elbow and just distal to the elbow crease the forms divided into nine territories tenderness over one or two would suggest radial nerve irritation whereas tenderness over five or six would represent median or irritation the blue circles are controls so the the most useful diagnostic tools and coming up with this diagnosis are going to be a detailed history a good physical exam and then next I would consider ultrasound to evaluate for a space occupying lesion as well as considering a diagnostic block which would alleviate symptoms in the case of mild the next step I would consider would be electrodiagnostic testing especially if they're weak from the get-go because I would expect that to be normal in mild cases and abnormal for severe cases okay so it's important to know the anatomy of the radial nerve around the elbow as you're planning your electrodiagnostic study so as the radial nerve here in purple arrives at the elbow it's already given off branches to the triceps and anconius it then gives off branches to the brachioradialis the extensor corpi radialis longus and then splitting here into the green superficial sensory branch and the yellow deep radial motor branch so then the nerve dives into the supinator becoming the posterior interosseous nerve so this is the reason why you will have intact wrist extension but with radial deviation because this muscle the ecrl and ecrb are spared when when you were talking about compression more distally okay so the key findings with electrodiagnostic testing is that you may have slowing across the elbow segment when you're studying the radial motor nerve conduction needle emg i would expect it to be abnormal and anything innervated by the posterior interosseous nerve and sparing other radial nerve innervated muscles if you find anything unexpected which we sometimes do with adx that would warrant a you know kind of reassessment and reevaluation and expanding your study to evaluate for other mimics so mild cases are always treated conservatively activity modification bracing nerve glide exercises therapy anti-inflammatories and different types of injections surgical surgery treatment is usually reserved for folks who don't improve with conservative management for severe cases they should be evaluated for an underlying etiology so if a patient has a space occupying lesion like a cyst or an aroma that might be more amenable to surgical interventions whereas if they have something more generalized like neurologic amyotrophy or a systemic vasculitis not so amenable to surgery surgical intervention other treatment modalities include occupational therapy and bracing to prevent finger flexion contracture so small studies support the use of corticosteroid in both diagnostic and management so in the first study of 25 patients 16 of whom achieved long-term relief after the injection the other nine patients underwent surgical decompression seven of whom obtained lasting relief the second study looked at 54 patients with these symptoms 53 of whom had enlarged radial nerve and 53 of whom had immediate relief after a steroid injection another study of 40 patients had immediate relief with steroid injection and then good improvement in the dash which is the disability of arm shoulder hand it's a patient reported outcome measure and the visual analog scales at 12 and 52 weeks so another emerging procedure in the management of radial tunnel syndrome is ultrasound guided hydro dissection so different case reports have used variable injectates including saline lidocaine corticosteroid platelet-rich plasma and dextrose the techniques have been variable another study more recently used ultrasound guided hydro dissection with an injectate of 40 milligrams of kenalog and 10 to 20 cc's of one percent lidocaine they had lasting symptom relief at two years but of note some patients needed multiple procedures to get relief all right thank you so all right our next speaker just loves life always posts nice pictures of travels and food she is the director of pain medicine and interventional spine at the mount sinai in new york dr sue kim so nice to meet you all so i'm going to talk about the back and buttock pain and then not so uncommon causes of back and buttock pain so i'm specialized in pain medicine, so I deal with a lot of spine patients. And so, I'll be a little more focused on that area, so. Okay, starting with a very typical case, a 44-year-old female who came in. He was referred to me after having right groin, back, and buttock pain for two years. Yet, her pain diagram actually included the groin area and not her hip and the buttock area. She could not recall any precipitating event, and her pain was sharp, achy, and intermittent, and then it became more of an almost constant. It's worse with the prolonged walking and with leaning forward. It did wake her up at night, especially when she tried to change her position. No significant past medical history. And physical exam-wise, it was essentially normal, except that there was some tenderness over the buttock area and then GT area. And then there was a little tenderness over the paraspinal muscle as well. X-ray showed mild degenerative changes that was somewhat expected for her age. MRI of lumbar spine showed some degenerative disease at L45 with some degenerative changes in the facet joint as well. MRI of the right hip, there was no significant acute findings. There was just some arthritic changes. So by the time that she came to me, she had numerous injections. So she underwent medications, you name it. She tried all kinds of muscle relaxant, physical therapy. She was still getting the chiropractic care, which has been going on for over a year. And she tried the TENS unit, really nothing worked. And in terms of injection, she was pretty much getting injections every two months. Like started with a GT injection, hip inter-articular diagnostic, then with injection and steroid injections, she got PRP injection. She also got the L45 epidural injection. She didn't get the facet injection, but she also got the SI joint injection. Literally, she got everything that you can actually think of. And she was actually referred to me specifically for ilioanguinal nerve block, with a diagnosis of chronic low back pain, lumbago, and ilioanguinal neuropathy, and greater tracheotomy bursitis. So this is the case. I mean, I think we see a lot of these type of patients. They are coming in with multiple areas of pain. And it's just easier for us to think that this is coming from one isolated area, rather than just combine and see the bigger picture. And then think about, if there's any one source of the ideology that can cause all of these symptoms. That's the reason why I chose this topic. So let's think about the dermatome, because I'm, again, a pain specialist. I always think about the dermatome when it comes to pain. And also this patient, it just felt like this was more of a nerve related issue over musculoskeletal issue, because her pain was not really directly associated with activities like a weight bearing or trunk movement. It was coming and going. Couldn't really identify a clear alleviating factor or aggravating factor. That was the reason why I thought about the dermatome. But when you think, I mean, I think you are very familiar with these dermatome, right? This is what we go by, this is what we use for easy classification. So in her case, she had inguinal pain, which was L1. She had the buttock pain, which is probably L4-5, and she had the GT pain. So it's really hard to kind of connect to one level if you try to think this is coming from spinal origin. And then I think that's the reason why she got L4-5 epidural injection, because her back pain was somewhere in this area, which she didn't show any improvement. This is another dermatome that I wanted to show you. Have you seen this dermatome before? So this is a dermatome, dermatome map of the dorsal ramus of the spinal nerve. So we have, we know that there is one in the spinal cord. We have a dorsal root and ventral root, and they get combined in a spinal nerve. That's about a one centimeter or so. And it goes through the neuroforamen, and then it branches to ventral ramus and dorsal ramus, right? And the ventral ramus is the one that we're really familiar with, that forms all the peripheral nerves. What does the dorsal ramus do? It still branches to medial, intermediate, and lateral branches. And it does innervate the muscles and the skins in the back. That's why we're able to draw this type of dermatome. When you look at it, with the ventral rami dermatome, this area is L4-5. With dorsal rami dermatome, this area, this is L5, is T12 and L1. So it's completely different. So with what, so medial branches you might be a little more familiar with, because medial branch blocks, radiofrequency that we do for facelidropathy is becoming more and more popular. You might not have heard of much of a lateral branches or intermediate branches. So what do they do? They are essentially, it's a kind of mixed motor and sensory. They innervate long, more superficial rectal spinae muscles as it peers through. And then it becomes a cutaneous nerve, and that's what you see from here. So it innervates the skin and the posterior side. And this is a course of that dorsal rami. Actually, there is more of a communication between multiple levels. This is a T12 because it has a rip, it's a 5, 4, 3, 2, 1. So this is a T12 lateral branch. And it travels down and peers through the thoracolumbar fascia and become more cutaneous nerve. This is L1, the same thing, L2, the same thing. So they really descend about three to four segments as it travels down. That's why you have to think about, if they have any pain at L4, 5 level, you have to think about, maybe they have a problem, like three or four segments above. Then once it peers through the thoracolumbar fascia, then it forms clunial nerves. So for the ones that are formed from T12 to L4-ish, that's what we call a superior clunial nerve. There are male clunial nerves and inferior clunial nerves, but that's not my topic today, so I'm not gonna go over that. So we're gonna focus on the superior clunial nerves. So as I think you can see it here, these are the nerves that comes from the higher up, like T12, L1, L2, and goes through the thoracolumbar fascia, which inserts into the iliac crest, appears through it, and then goes over and become more cutaneous and innervates in the skin of the buttock area. As you can see, there are multiple branches, so you can't say it's a superior clunial nerve as in nerves. So you may have three or four or five nerves already branched approximately. There are not many calaveric studies out there, because these nerves are so small. The biggest diameter that they found was two millimeter. So it is really, really hard to do the dissection. There are probably about five anatomic studies out there. They all describe a different course and different branches, and it is really variable. But the one thing that was pretty much consistent was the most medial branch of the superior clunial nerve, so they call it a medial superior clunial nerve. It's not medial clunial nerve, it's a medial superior clunial nerve, because medial clunial nerve is different. It's coming from a much lower level. So medial superior clunial nerve, it passes through the most medially, but as it passes through the iliac crest, it passes through the fibrosis tunnel. The thoracolumbar fascia is thicker as it goes medially, so as it goes through it, it goes through the tunnel. Sometimes it has a groove in the iliac crest. And because of that, this one is the one that gets entrapped the most. And it's described as somewhere between seven to eight centimeter when it was first described, but other people say it's about five to nine centimeters from the midline, depending on their body habitus. So this is something that we can focus on when it comes to superior clunial nerve. So, I mean, it has a really long course, right from T12 down to iliac crest to go to the buttock. There are three main sites where it can get entrapped or get irritated. The most approximately as it comes out from the foramen, the second as it goes through the paraspinal muscle. So paraspinal muscle is long and very strong. As it contracts, if it gets into the spasm, then it can kind of entrap or irritate. The last one is as it passes through the thoracolumbar fascia. So those are the three main ones. I'll start with the superior clunial neuropathy, which is the most distal one. Because that's kind of really gaining popularity, and people started doing injections for this a lot. It was first described by Maine, Dr. Maine, in 1989. So it has been reported for a really long time. And a lot of time in the earlier literatures are coming from surgical literatures because they tend to injure it while they're doing bone harvesting for bone graft or doing the bone marrow biopsy. And that's when a lot of catabolic study and anatomical studies came out to avoid any direct injury to the nerve. But also, recently, there are more reports coming out that, again, thoracolumbar fascia is a fascia that's attached to the muscle. So someone who has really tight latissimus dorsi and gluteus maximus, they kind of make the entire thoracolumbar fascia really tight. Like someone who has Parkinson's disease, they tend to have these type of issues as well. Incidence varies from 1.6 to 14, it's really wide range, right? The reason is because it's underreported. So some people who are, some doctors who are familiar with this, they will overcoil it. Some people, doctors who are not familiar with it will undercoil it. So that's about 1.6 to 14%. We don't have an exact instance. There's really no good diagnostic test for this. So we rely on the location of pain, tenderness to palpation, and negative findings in all other studies. Like, there's nothing in the spine, and there's nothing in the hip, and they don't respond. And that's when we actually think about this. Since this is a cutaneous nerve, you can have a TINL sign. So when you tap on that area, they may have radiating pain in that region. Treatment-wise, it's interesting. You can do physical therapy. There are case reports out there that they successfully treated this entrapment neuropathy with a physical therapy. And we do a lot of injections, landmark-based. Nowadays, they do fluoroguided injections, which I really don't recommend because first, there's variability of the course of the nerve. And second, it's smaller than two millimeter. I don't think you can reliably get it with a fluoroguided. And ultrasound-guided is possible, I'll show you the picture. But again, it's a really small nerve, so it's really hard to find. So you have to be prepared, spending longer time to find this nerve. Then, if you can find it, then you can do the radiofrequency ablation. And I've seen the report that they started doing the peripheral nerve stimulator, which really makes sense because this one will cover a broader area, and it's gonna cover multiple branches. This is the ultrasound image that we took with Dr. Lee, thank you, Dr. Lee. So this is a proximal, this is a course of the clonial nerve. You can see here, and then you can see how small it is. And it has its own compartment. And as it goes more distally, you can see that it's kind of, I could follow the course. And when you inject around the nerve, you get the prestigia and the distribution. So next site of entrapment or compression is the paraspinal muscle. I'm not gonna spend too much time on it. It travels through the rectospinal muscle, so when you have a trigger point, you can have the same symptom. This patient actually ended up having this trigger point injection. Let me see, how do I click it? Can you click the video? So and if you can see, this is medial, this is lateral, and this is lamina. And this is rectospinal muscle, this is quadriceps lumborum, this is, here is iliopsoas muscle, and this is abdominal cavity. And I place the needle, and when it touches a deeper layer, then it twitches. Can you click one more time? There was a twitch. So she had a lot of twitches, and so I was able to break most of it after two or second or third trigger point injections. The last one is a thoracolumbar junction syndrome. So this is the most proximal site. So it's not, people sometimes interchange the actual diagnosis, thoracolumbar syndrome, main syndrome, or subarachnoid neuropathy, but actually it's not. It's way more, happens way more proximal. Dr. Main reported it in 1981, and he said, it's a low back pain, pseudo visceral pain, pseudo hip pain, pseudo pubic pain. Because they come in with these symptoms, identical to what my patient presented with. It's a really heterogeneous term, because it does include everything that can possibly happen at that level, a T12L1, either arthropathy of the facet joint, or disc herniation, or actually the entrapment of a lateral branch of dorsal ramus, but it, you know, that's why it's a really heterogeneous term. So that kind of means, in terms of treatment, you have to go by why they developed the symptoms, or this entrapment. Presentation, as I said, they come in with this weird clustered symptoms. And again, they have a tenderness over the iliac crest, and, but at the same time, they have a tenderness over the TL junction, where you can reproduce the symptom. And treatment-wise, it's pretty much the same. Therapeutic exercise, diagnostic medial lateral branch blocks, emphasis at joint injection, radiofrequency ablations for this. So this is different from superior colineal nerve. At times, if I can't really identify the superior colineal nerve itself, but I know that this is coming from this level, then I go up and then do this procedure, because I'm kind of capturing way more proximal. So those are the three conditions that I wanted to go over for the pain originating from the dorsal rami of the spinal nerve. There are two more conditions that I included that I see very often, that as a differential diagnosis, when they're coming in with these type of symptoms, is one is gluteus medius enthesopathy. So that's exactly, I don't know if this picture, I mean, this mechanism, the way the force works, it's very similar to how the athletic fibrology works. So there's very thick fascia, the muscles are pulling in different directions, and gluteus medius tend to get a lot of enthesopathy. So in this case, if I go into the sub-q layer, then I cannot reproduce the pain. But once I get to the tendon, then they say, that's exactly where my pain is coming from. This is fairly common. The next one is the quadriceps lumbora myofascial pain, which is not as common as gluteus medius enthesopathy. But this is also common, especially for the patients coming in with a severe back pain and buttock pain, after they had a fusion. So this muscle is a stabilizer, so they can still have isometric contraction and they can get into myofascial spasm, even though they're fused. So this is something that I do. Again, here's the quadriceps lumbora, my needle is coming from here. This is midline, this is erector spinae muscle, you can see the psoas muscle. You just have to be careful with the kidney and the peritoneal space when you're doing this. Yeah, that's it, dude. Thank you. All right, the next speaker is the program director of the residency program at Sunrise Health and Mountain View Medical Center. He's a clinical associate professor at the Kerkorian School of Medicine, University of Las Vegas, and he's definitely the best looking of the bunch. Dr. Siwon Lee. Thank you very much, Dr. Tu. It's good to be here with really smart speakers and then my mentors, Dr. Park, and also my colleagues. There's nothing really much to disclose. And Dr. Tu already went over learning objective, so I try to focus on the content. So mine is very, very brief. And I like to start with the approach to the growing pain. This is the area I'm gonna cover. So there are many different approaches. One is based on the statistics, how common the condition is. The other one, I guess, as a physiatrist, we have really sound knowledge of structures. So if you approach the regional MSK pain based on the surface anatomies, that can be very useful. So if you have an imaginary line of growing triangles, which is defined by ASIS, pubic tubercle, and midline between ASIS and superior portal of the patella. You can classify those structures in the groin into these four categories. So usually we ask patients where the most pain is. And if they point a specific surface landmark, you can use this knowledge. So this is approach by Dr. Farvey and published in the British Journal of Sports Medicine years ago. So for example, if the patient present with a groin pain, and if patient can locate the pain is in the groin triangles, you can think about couple of structures. And as you can imagine, as you can see in these pictures, not every structure is exactly fit in the categories. So there is some room of errors, margins, so you have to think about that. In PMNR talks, physiatry conference, if I don't go over ultrasound, I'm missing something significant. We have ultrasound, I guess, in most of our clinics. And with the knowledge of the regional structures, anatomies with the ultrasound, it can be very, very useful to approach the diagnosis. So there are actually wonderful articles this month from American Journal of PMNR from Europe about the dynamic ultrasound exam of the hip. So if you can go over that video gallery, it will be very useful. In any ultrasound, I would like to say that one view is no view. But if you can start with what you are familiar with. For example, the hip joint, if you put the probe in the oblique sagittal view, or oblique view, then you can produce these images. And then you can go rotate about 90 degrees to have obtained a second view. And then Dr. Kim went over greatly about extrinsic cause or referred pain. So we are focusing on the regional areas, but also always think about referred pain from different anatomic locations. Including the radiculopathy, myofascial pain syndrome, Dr. Kim went over thoroughly. But also, less commonly, but you have to think about, at least if the patient has risk factors for vasculopathies, or if there is any red flag, think about the medical conditions as well. Then I will start with the case. So this is a 43-year-old female with groin pain. Pain started without any injuries or traumas. Pain is intermittent with movement, especially squatting, prolonged sittings, and stair climbing. And also she complained and she's worried about intermittent clicking with pain. There was no red flag on neurological exam. There was no focal neurological deficit. We did a lot of provocative tests, which were all negative. And x-ray of the hip prior to the visit was negative. So in terms of painful clickings, we know that it's not a big problem, but some patients are very concerned, especially when it comes with pain and when it started new. So there are lots of other differential, but this is pretty common, I guess, cause we see in the clinics. So lateral, in my practice, probably most common clicking in the hip region is lateral clickings. Basically, iliotibial band rubbing on top of the greater trochanter. Anterior clickings is usually what patients are concerned, because time to time they have a pain in the groins. It can be from either between two tight muscles, between the rectus femoris and iliopsoas, or it can be intra-articular, which is pretty rare, at least in my practice, or the iliopsoas muscles rubbing on top of iliopectineal eminence. So think about those differentials for clicking. And this is ultrasound of the patients. So normally you see the rectus femoris muscles inserting to the AS, sorry, anterior inferior iliac spine, which is called the direct tendons, and then there is indirect going to the S-tabulum of the hip joint. But these patients actually have a pretty significant cascifications at the insertion of AIIS. And then when she does, actually from the internal rotation of the hip to the external rotation and abductions, she can reproduce these clickings. I wish I could preserve the video. I had it, but I lost it somewhere. But usually some patients can actually make the sound, make the clicking, so instead of we are doing a lot of maneuvers, we can ask patients to produce. And then one thing is when you do ultrasound to record it, it has to be very slow to track it, but actually slow movements sometimes doesn't cause clicking, so you have to balance it. So rectus femoris tendinopathy is pretty common, as we know, and this is the muscle get tight, and this is the muscle traverse two joint, like hip joint as well as knee joint. But most of the pathologies we know is in the myotendinous junctions. So sometimes in the groin regions where the rectus femoris attaches originate often under-recognized. And you can see that some of the movement dancers do requires hip extension as well as knee flexions. They can definitely cause the strains as well as the, even in some young youth patients, they can have aversion fractures of AIIS. For this patient, she's doing great with the activity modifications, and we are thinking about giving injections, but she was doing okay with just a course of NSAID. The second case, I covered one, soft tissue pathologies like the muscles. The other one is, I'd like to go over the bony pathologies. So this is a patient I saw last year. It's a 39-year-old female with groin pain. Same thing, pain started without any injuries. She reported pain actually began after delivery of her child, second child, and there was no significant past medical histories. So whenever we see young patients with groin pain, we think about sports and then female athletic triad and stress fractures, or if you see probably the groin pain in the middle age or older others, I mean we jump on the hip osteoarthritis, but if you don't see those typical patterns, you think about other less recognized or uncommon differential. So she had x-rays prior to the visit. X-ray was normal, and also she actually had the extensive workup already done before coming to me, and she had MRI. MRI shows visual insufficiency fractures in the femoral neck, and then she had so many workup, including endocrinologies and even genetic workups. So I just briefly went over the stress fractures, but also other bony pathologies causing groin pain include transient osteoporosis, premenopausal osteoporosis, and also metabolic bone disease. Osteonecrosis, as we know, AVN, has to be recognized. If you don't think about the risk factors, this can be really missed at the early stage. Later stage, patient has so disabling pain, they will get workup by one way or the other, but early stage, you can miss. And septic arthritis, red flag is not really very, it can be very important in medical legal perspective, but there are several studies that are arguing about utilities because everyone has at least one red flag, but at least I recommend our residents to document it. It helps us to actually formulate differential diagnosis. For example, the cancers and then leukemia, or lymphoma if you're dealing with the children or adolescents. And after the extensive workup, our conclusions was actually for that patient was a transient osteoporosis of the hip because we ruled out almost everything. Stress fractures, there is no reasons, and then she had also genetic test for the osteoporosis imperfectus and then a lot of other differentials. This is not very common, and then also it can be complicated by fractures like her, but most of time, it's a transient. So having knowledge of this rare condition sometimes can be educational or also therapeutic to the patients, knowing the natural course. So keep those thing in mind, and thank you. Thank you. is the Chief Medical Officer and Senior Vice President at Burke Rehab Hospital in Westchester, New York. Another brilliant person, very good to talk to, pick her brain, especially if you're a female. She's a very good advocate for women in medicine. Thank you, Dr. Mugano-Park. Thank you. I'm setting up my timer so you can go to the next session on time, I promise. Okay, so good morning, and thank you, Dr. Thieu, for the generous introduction. So today what I'm going to talk about is the uncommon, quote-unquote, but the title of this whole session is not so uncommon. So actually the cases that I'm going to present is not that uncommon. The learning objective is that open the foot is a neglected organ. So we learn very little during the medical school or even in the residency training. So I'm going to go through a little bit of anatomy and the common injuries of the nerves specifically. And what are the things in the clinical examination and history which can help us to make a diagnosis and guide us, the interventions. So the first thing we have to keep in mind is history is 90% of the diagnosis. So somebody comes in. but you really don't find anything. And also, patient says that, oh, where is the pain? But they cannot pinpoint where the pain is. Actually, those are the key clues for diagnosing foot nerve lesions. Also, the trauma, so we ask, did you get hurt? But often patients, they do not understand that surgery can be actually a trauma, so this needs a proactive inquiry. In the physical examination, as I said earlier, we are trained to look for red flags, swelling, deformity, and more positive findings. But here, again, the focus is, look for not having any finding is a very important. So, what is the approach? So, we always talk about nerve irritation. So, that means that something is irritating that nerve. So, removing that irritant will be the first step, and addressing the underlying biomechanical causes that can contribute to the patient's lesion will be important. This person is obviously setting himself up for the deep. So, there are tVR nerve, peroneal nerve, saphenous nerve, and superficial saphenous nerve, and peroneal nerve, but we are not going to have time to go through the whole thing. So I'm going to focus on the superficial peroneal nerve and some of the tVR nerve lesions. And if I ask the resident, what do you know about any nerve lesion in the foot? They will say, I know Tassel-Turner Syndrome. So what is Tassel-Turner Syndrome? And they have this analogy of thinking about carpal tunnel happening in the feet, but that's really not true. So Tassel-Turner, the tVR nerve branches are many, and they can be compressed or irritated in many different combinations. So it's actually very hard to make that diagnosis. So superficial peroneal nerve, the intravenous sites, the frequent ones, starting from the about 12 centimeter above the lateral myelolus, where the nerve actually is coming out of the muscle compartment and become cutaneous. And this is one nerve we can actually see in the physical examination. So doing a plantar flexion and slight inversion, actually this picture is actually showing the nerve. So in the history, they come and often, oh, I had an ankle sprain a couple of months ago, but I still have a problem. And this is a very important clue. And as I said earlier, the arthroscopic surgery or other trauma can be also contributing. So focusing on this proximal entrapment, the muscle, which is peroneus brevis muscle, longus is at that time already tendon. And we often think about, oh, the entrapment meaning that the orifice where the nerve is coming out is too tight. But in this case, it's the opposite. Actually the orifice where the nerve is coming out is too big, and it allows the muscle come together with the nerve. And actually the muscle... are doing the activities, and they do not necessarily have a sensory loss, which is most of the cases. In this particular case, however, had a very classic sensory loss. And then you see a little dot. There was a very specific tenderness. So this was a classic entrapment neuropathy of the superficial peroneal nerve in proximal lesion. So what we did is we were able to actually identify where actually the orifice was. So the other cause is actually the arthroscopic surgery and this is the most common complication post arthroscopic surgery. So it's about two to three cases per hundred cases, so that's quite common. And if you're doing a physiatry practice, you will definitely is that cross-section of the ankle. This is posterior. You see the Achilles tendon. That's the lateral and that's medial. So you see a little yellow thing is superficial peroneal nerve and how close it is to And similarly, on the medial side, these are the two actually saphenous nerve. They are also damaged frequently to do so. Another important point is that this relationship between the portal and the nerve is very dynamic, depending on what position the ankle is. So when you're moving the ankle, actually dorsiflex, dorsiflexion, then the nerve actually moves laterally a little bit. you're working with, you know, identified under a location prior to that, that can be helpful preventing from happening this. This was a tennis player, he presented with an omnisampane in this area. Very demarcated, well demarcated area. When you see his foot on the right side, the first MTPJ was a little swollen, and you don't see a EHL tendon contour as good as the other side. So, when you examine his general, you know, regular shoes, he made a relief by cutting off that area, and the x-ray shows osteoarthritic changes. So, this person actually had a superficial peroneal nerves, a hollow core branch to the big toe, which was irritated by his shoes. So, the interesting part was that only he had the symptoms about three month after he uses his tennis shoes, as soon as he buys the new pair, the pain was okay, it went away. So, what was happening was, when you look at this old footwear, which is easily bending because, you know, the worn of the sole, wearing of the sole, and the upper material was irritating the hollow core branch of the superficial peroneal nerve, as soon as he gets the new athletic footwear, he was fine. So, sometimes, it's really looking at the relationship of a patient's behavior and footwear, and that may be the best solution for most of these patients. So, this is a little interesting topic, you know, what is the general rule for when to replace the athletic footwear? So, typically, about 350 miles of running, but when I was a resident, it was 600 miles. So, it tend to be kind of getting shorter, and I'm not sure why. And then, also, obviously, you know, how much of exercise you're doing is important. You might as well ask the wife. Yeah, so the branches, moving on to the tibial nerve. So the tibial nerve branches are many, and medial planta, which supplies the sensation of the heel, but don't forget, this also supplies the sensation of our heel back pad. And then medial lateral planta, where we know, and then first branch of the lateral planta nerve, which crosses the heel, going to the lateral side of the foot, and supplies the ADQ muscles. So just going further distally, then you see the medial planta right here under the navicular, lateral planta nerve, and the first branch of the lateral planta nerve, which is Baxter's nerve. And when you see the Tassar tunnel surgery, sometimes post-surgical cases, and the patient is not better, one of the reason they are not better is that the release of the Tassar tunnel was incomplete. So I want to draw your attention here. This is not Tassar tunnel, it's all the way down, and these Tassar tunnels are compartmentalized. Make sure that the surgeon does release all the way down, it's important. So this is a middle-aged man who presented with pain in this location, and also had some sensory loss, in yellow circled area. So it's clearly medial planta nerve, and patient was treated for plantar fasciitis, including a patient was given this high arch insoles. But patient actually got worse from it. So this was actually case of a jogger's foot, where the medial planta nerve was actually even worse with the high arch support. And the jogger's foot was only reported 1979. It was a three case report, and in this case report they clearly say do not give high arch insoles, because that's gonna make it worse. So just keep that in mind, how many times we physicians are so enthusiastic, try to. So this is actually a picture, but I have a video showing that where the jogger's foot nerve entrapment of the medial plantar nerve, which is so closely related to the flexor distorum longus. Oh, yes, okay. flexor hollosis longus, which is closer to the bone, and then this is flexor dystrum longus, and then they are all together with nerve and two tendons. That's why this is such a common location for internment. So what are the causes? These are the, look at the study. Who did the study? It's an orthopedic foot and ankle or podiatric. This was 13 minutes, so I have one more minute. And then, so often the study is biased toward something like space-occupying lesions, but in reality what the patient population we see is already who has a flat feet, which was combined with high arched shoes. So this person, instead of arch, we relieved it. And this was a failed tarsal tunnel cases. So in this particular patient, you can see the surgical site. And this was where the patient pain was. Patient was given another high arch in sore. So when you can see that the person's MRI ADQ was specifically atrophied. Nothing else. It was lateral plantar nerve, which was not saved. So what we did. So, outcomes of Tusser-Turner syndrome, remember, there is more than 68 procedures for certain disease. What does it tell you? It tells you that not a single one is working properly. And, yeah, I bet this is gonna go up. And then the other important thing is, we often say that, oh, you know, non-operative intervention failed, you go to surgery. That is not a right logic, you know. And then the outcome is not the greatest. So, there is a huge role for the physiatrist to address this issue. Despite of what the CMS and everybody else... Looking for something, it's not shown. And I think that's a harder, harder thing unless we are being really mindful about this. Ultrasound EDX, use wisely. It's not a panacea. All right, does anyone have any questions? Going once. All right, well, thank you very much.

shoulder pain

elbow pain

back pain

buttock pain

foot pain

thorough history

underlying causes

nerve entrapments

soft tissue pathologies

biomechanical factors

diagnostic tools