Yeah, thank you so much for the introduction and welcome everybody who's joining us live and then those who are going to be joining us later when you view this, the recording. But we've been talking about this for a number of years and finally we're able to do this. Ideally, we were trying to do this in person, but I think we've got a good way to do it virtually, and our goal is to give you some insights on how to use ultrasound in the athletic training room setting. So the main goal today is really how do you use ultrasound and the point of care when you're seeing athletes in the athletic training room and how do you apply it both for a variety of musculoskeletal injuries as well as for some general medical conditions. The neat thing about ultrasound and being a team physician is that if you have this ability, it really enhances your ability to evaluate the athletes, makes you a much more valuable part of the team. You can do things more acutely, give the athletes information, the coaches, the athletic trainers, and oftentimes cut down on unnecessary additional imaging such as MRIs. At Stanford, we train our fellows to be complete team physicians so that they're not only treating chronic muscular conditions, but they become very adept at treating acute musculoskeletal injuries and sports-related trauma as well as treating general medical conditions. So our student athletes do not go to student health. We take care of all their health care needs and ultrasound can be helpful for even some of those conditions. So we've assembled how many of the top clinical ultrasonographers from around the country. These are all former Stanford sports medicine fellows who have all gone on to do amazing things. And so I'm really excited and proud to introduce everybody. First is Dr. Sarah Iser, and Dr. Iser is an assistant professor at Emory University. She's the associate medical director for the Atlanta Track Club Elite Team. She's also team physician for Emory and Georgia Tech cross-country and track and field teams. She's going to set us off with giving an introduction to point-of-care athletic training of ultrasound and some clinical pearls. Next will be Y.T. Chen, who is a lieutenant colonel in the U.S. Army. He's now based at Walter Reed National Military Medical Center, where he's the deputy service chief of the PM&R service and carries a couple hats in sports medicine as well as pain medicine. Even when Y.T. came here as a fellow, he knew more than most people I know in terms of ultrasound, so I can only imagine his skill level at this point. But he's going to go over some ways you can evaluate the sternoclavicular joint as well as the acromioclavicular joint, both for sprains as well as instability, as well as acute rotator cuff tears, glenohumeral dislocations, occult fractures, particularly of the greater tubercle, as well as axillary nerve injury. Next we have Dr. Kevin Mullins, who is a little bit under the weather today, but he's coming through for us and is still going to present. He is currently an assistant professor at UC Davis School of Medicine. His talk will focus on ultrasound for diagnosing acute knee ligament injuries, as well as dynamic testing for varus and valgus testing, as well as acute patellar and quadriceps tendon injuries. Next will be Dr. Annie Kulibara, who is currently a sports physiatrist at Kaiser Los Angeles, and she will review a classification system that we developed using ultrasound to grade bone stress injuries. She'll review some common patterns in the tibia, the fibula, the metatarsals, as well as how to diagnose thoracic ribcage fractures. Then we'll have Dr. Robby Diaz, who is at Kaiser Santa Clara, and he is on the Northern California Kaiser Permanente Biologics Committee, as well as a team physician at Saratoga High School. He's going to focus on ultrasound scanning techniques for ankle sprains, as well as lateral ankle and foot fractures, as well as some dynamic maneuvers, and that's the beauty of ultrasound is that you can do these dynamic maneuvers to really test the integrity of the ligaments. He's also going to touch briefly on Achilles ruptures. Donald Kessenin, who is currently an assistant professor and director of adaptive sports at the University of Texas Southwestern, as well as an assistant team physician at Dallas Baptist University, is going to focus on the FAST exam, and that's probably something most of you are not familiar with, but it's done in the emergency room, but it allows you to evaluate acute abdominal trauma, and in the athletic setting can be extremely helpful. And then finishing us off will be Dr. Mike Kadavy, who is a partner at Kansas City Orthopedic Alliance. He's team physician for KC Ballet, as well as the sporting KC professional soccer team. He has extensive experience with muscle injuries, taking care of particularly the soccer teams, and is going to go over an overview of how to use ultrasound to not only diagnose but classify these injuries. This is our outline, so we will finish up at about, I guess that would be 6.50, and if time permits, and I think we're going to have time, we will definitely stay on for a question and answer. So with that, I will hand it over to Dr. Razor, and thank you very much. All right, thank you for that wonderful introduction. I'm excited to be here with this great panel. And my job really is to set the stage that if you didn't think ultrasound was helpful for the athletic training room, hopefully by the end of this intro, you will, especially by the end of our whole panel. So I'm going to be talking about ultrasound for the athletic training room, kind of the settings that it's useful in and how we can specifically use it in these scenarios. So we'll talk about point of care ultrasound in the training room, we're going to discuss equipment and setup, talk about utility and applications of ultrasound, and then discuss some clinical pearls, including some diagnostic capabilities, which we'll go over very briefly. So talking about musculoskeletal ultrasound and the rise of it, you know, I often have patients mention, oh, this is such, you know, special new technology. I'm like, actually, ultrasound has been around for a while. We just really haven't used it for musculoskeletal purposes like we do now. So the first ultrasound instruments were developed 1940s, 1950s. And one of the first utilities in medicine was using the FAST exam. So looking for a thoracoabdominal bleeding initially started being used in 1970s. And then the FAST exam, which is going to be discussed later in this presentation was developed in the 1990s, became more standardized. Musculoskeletal ultrasound started to rise specifically in the US in 2005, and a little bit earlier in Europe prior to this. And one of the big benefits kind of quoted around that time was that reimbursement for MRIs was significantly higher than for ultrasound. So we start having a much more reasonable cost exam to be able to look at musculoskeletal conditions. And lots of different advantages of ultrasound. So we know it has good point of care access, very portable, especially with our newer ultrasounds that we can even have something as small as a probe with a cell phone, for example. Much more affordable. You can have good patient comfort. They don't have to be stuck in an MRI machine for 20 minutes to an hour. We have lack of ionizing radiation, and then real-time and dynamic imaging capabilities, which Dr. Fredrickson already touched on. So we've got a clinician who's able to do the ultrasound in real-time and has the knowledge of what's going on with the patient, as well as being able to do some patient education then and there and get feedback from the patient also. So we've got both diagnostic and therapeutic uses. And from the athletic training room standpoint, both of these certainly apply. The important part to think about with the treating clinician doing the ultrasound is that we have user-dependent results. So we've got to make sure that our ultrasonographers are well-trained. And at this point, we don't have the greatest regulation at this point in terms of being standardized. There's different options coming out to provide that reliability that we have that training, but certainly that's still work in progress. And increasingly, ultrasound training is being included in residency and fellowship training, especially folks who are going through sports medicine fellowships. You really can't go through training without having a lot of ultrasound, which is a great thing. So some of the settings that we're going to talk about today. So obviously, we're talking about the athletic training room, but I tend to lump the game sideline in with this as well. So we're talking about being on the sideline of a football game, soccer game. You've got acute injuries that may be happening, or you may be seeing folks that have ongoing injuries that you're seeing before the game or managing during the game, may have a race medical tent at the end of a race or mid-race that could be helpful as well. And then of course, in-office evaluation is still an important component of this too. So if we talk about the more acute purposes and how this can really make a change in game time decisions. We have a case of a 15-year-old male football player. We're at a high school game doing sidelining and he hops off the sideline because he gets hit in the lateral leg during a tackle and tells us that he fell to pop. Exam really isn't super remarkable, except that he's got some focal tenderness and at the lateral mid-leg. And the question is, is it fibula, is it peroneals? He's able to jog, really has minimal discomfort, and the question is, can he go back in? So we'll talk about, we'll revisit this case towards the very end, so I'll leave you in suspense. When we talk about equipment and setup, there's many different types of ultrasound machines at this point. We have the big hefty ones like the one in this picture here that we often think of kind of in the OB-GYN setting, but we certainly still have some of these very large ones that have a lot of capabilities and different bells and whistles. And then we also have machines that are smaller, like a laptop size, and even smaller, we've got ones where we have a probe that can fit into a cell phone. So definitely getting more and more portable, obviously the bigger screen with more bells and whistles will give us more detail, however, for point of care purposes, being on the sideline, being in the training room, super easy to have something that you can just bring in your pocket. Obviously, you need some ultrasound gel with this as well, and then thinking about using the exam table or even just positioning, so finding creative ways to find what you need to find and also do things from an ergonomic standpoint for yourself, protecting your own body. So in terms of our uses, so I touched on both diagnostic and therapeutic purposes. So can we diagnose if there's a tendon tear, a muscle strain, is there a dislocation? Therapeutic purposes, it can assist in saying, hey, is doing a relocation a safe thing to do? Is there a fracture that we can see? We do injections with it, so doing ultrasound guided injections, doing aspirations, so lots of roles from that standpoint. Also augmenting the physical exam. So more and more we're using this for what we call sonopalp patients. So if you can push on a place and reproduce the pain, what's underneath your probe when you're at that spot? And then simply being able to see what's going on. So I had this patient actually just a couple of days ago, I was taking a look after they had a lateral ankle sprain and it turns out, lo and behold, she's describing some catching locking type symptoms and instability. And she actually had a peroneus brevis tendon dislocation. So I was able to see that on ultrasound, something I otherwise would not have necessarily had been able to get that diagnosis without an MRI, which would be at a much later time. So we can really expedite care with this because we can have a better idea of what's going on by looking under the skin and taking a look at what's happening from the anatomical standpoint. So we can identify muscles, we can look at ligaments, we can look at tendon tears. We can identify fractures, whether those are acute or if these are more chronic fractures. So bone stress injury, which is more of what I see in my clinics. We can confirm dislocations and we may be able to evaluate for a fracture prior to relocation in the right setting. Certainly this is not going to be 100%, but certainly if you saw one, that would be able to tell you, hey, probably relocation in the acute setting is not the best idea. Dynamic real-time evaluations are helpful. So you can take a look at how things are moving. And we can identify locations of swelling. So we see an area of swelling and the question is, is there an abscess? Is this just subcutaneous swelling, more like a cellulitis? Is there a bursitis that we can see? Is there a joint diffusion? Do we have a fracture? And that's why there's swelling. So being able to locate where exactly that swelling is coming from can be very helpful and I'll frequently do this in my clinic. The FAST exam. So like I said, we're going to talk about that a little bit later as well. So being able to look for bleeding after having thoracic or abdominal trauma and then our guided injections. So if you're on the sideline and you've got superficial trauma, we may be looking for a hematoma, maybe looking for these dislocations, fractures, joint effusions, looking where edema might be coming from, muscle strains, ligament sprains, maybe looking for in more of the non-acute setting, maybe looking at overuse injuries. So maybe in the training room or the clinic, we're looking for teninopathies, we're looking for bone stress injuries, and then that thoracic abdominal trauma. So we want to know what is the question. So when we're urgently on the sideline, we've got to make game time decisions, what sorts of things are we going to look for? So is there a discrete fluid collection that we need to train? Is there a dislocation? Is there a danger in sending the patient back out in the game? So do we need to rule out a fracture or a tendon rupture, for example? Is there internal bleeding that tells us we need to take them out of the game? And usually if we're asking this question, we're probably not going to send them back in, but it may be able to expedite care should EMS be on the way and we can tell them what we saw. And then of course, the ongoing care component of this as well. So just a couple of pearls here. So looking at diagnostics, we know that rotator cuff tears, if we compare that to the gold standard of MRI, we've got a pretty darn high sensitivity and specificity when diagnosing a complete tear for relatively obvious reasons, less of a high sensitivity when we're looking at partial tears, but we still may be able to get some information from that. And then certainly looking at partial distal biceps tendon tears, we've got pretty high sensitivity from that standpoint as well. Looking at extremity fractures, pretty high sensitivity there as well, and this is compared to x-ray. Of course, if they've got a major injury, this is going to be a relatively straightforward but can still certainly be confirmatory. Our FAST exam has a pretty high sensitivity as well and specificity. And then when we're looking at swelling that we're concerned for infection, so cellulitis versus an abscess, point-of-care ultrasound has actually been shown to decrease inappropriate INDs by about 20%, which is pretty good. So we're not putting a needle or a scalpel through someone that turns out it's just the cellulitis that doesn't need to be drained. So if we get back to that case, our 15-year-old football player with lateral leg pain after a tackle, and the question is, can he go back in? He's able to jog, so maybe he's past that first step, but then you pull out your ultrasound and you take a look, throw this on the fibula, and it looks like he's got a fracture. So you're able to answer that question that, yeah, he's not going back in today and we've got to be able to take care of that. A couple ultrasound learning resources, so AIUM and ESSR are both great locations. ESSR has some really great comprehensive guides in terms of looking at different body parts with ultrasound, and they're free as well. So thank you for your time, and we'll go ahead and move on to the next person. Okay, I think I am up next. So I'm Dr. Chen, I go by YT Chen. Give me just one second, I'll pull up my presentation. Okay, good afternoon. Thanks again for being here and joining us and I'm again, my name is YT Chen. I was previously trained by Dr. Fredrickson, I'm very, very privileged to be here today to amongst this fabulous cohort and to share with everyone, some of our experiences, some of our thoughts as far as the use of ultrasound in the, you know, in the treatment and evaluation and treatment of our athletes. So yeah. So let's get started. Disclaimer, disclosure, I'm a DOD employee, I don't have any, I don't have anything to disclose here. And this is a fabulous setting at Walter Reed National Military Medical Center, where we treat our nation's heroes. So these are the conditions that we'll be going over and we'll be talking about their ultrasound findings and we'll go from there. So my task today is to share with everyone some of our thoughts as far as the shoulder evaluation in the athletic setting. And that's both in the training room, but I think also certainly also applies to a sideline as well. And as all of us know, you know, shoulder is a complicated joint to evaluate. It's a complicated joint to really assess correctly because of all the dynamic motion that it can perform. When it comes to shoulder evaluation, we really have to take an account of actual sports, the sports of choice, the participation history, or the injury history. And as we perform, as we're performing ultrasound evaluation, we really do have to, you know, it's probably not uncommon, it really is not uncommon to see a lot of, to see a lot of incidental Lomas per se, you know, and finding that may not actually be your pain generator. So I think, you know, when it comes to ultrasound evaluation of the shoulders, it's because all the things are there, very comprehensive exams really required. So what I would like to do for my portion of the talk is really to kind of home in on more of the subtle things that really kind of fall into the must not miss category. So that's where we'll go from here. Okay. So the first condition that I think we should start with is the external clavicular joint dislocation. It's a generally pretty rare condition, and sometimes it can be difficult to detect based on physical examination and even by radiology. And the dislocation, as we know, can come in both the anterior or posterior dislocation. And the posterior dislocation is one that's much more concerning due to the fact that it's a, due to the fact that with the posterior dislocation, now we are encroaching on the gray vessel, so the vasculatures, and that potentially can be an emergency. So because of the injury to the mediastinum, you know, trachea, the lungs. So this is really is a do not miss, generally a high energy impact kind of injury. So the scanning for this area is relatively straightforward. And hopefully this will be most doable if it were a unilateral injury. But even if it were bilateral, it still is not hard to tell. So as you can tell, see from the transducer that's parked on the, I'm sorry, the graphic that's on the left side of the screen, you can see that the blue square or blue rectangle represents the position of the transducer and is positioned directly over the SC joint. And the graphic on the middle is denotes a, you know, the white star is the manubrium and the red arrow denotes the clavicle, the clavicular head. And you can see that it's recessed posterior to the, you know, deeper to the manubrium compared to what a normal will look like, whereas the SC and the manubrium and the SC joint really should be in line. If anything, the clavicle should be just set interior or it's more superficial compared to the manubrium. So when in doubt, you can even image yourself, see what that actually should look like. If you're looking at one that's a little more subtle. I would recommend applying a very gentle pressure. Sonal palpation goes a long way in MSK evaluations. So that can also help you tell if there's any, if that is the pain generator, if that is the inter site. And if you look at the graphic on the center, you can see there's a lot of tissue edema, you know. So this is a high energy injury. So, you know, you certainly would expect a lot of local tissue disruption. You would expect to see a lot of edema, hematoma, you know, on inspection, there should be some telling sign as well, and certainly sonographically. So moving on to the next condition, clavicular fracture, ultrasound, you know, when I first started learning ultrasound, I was told that ultrasound has no place in the evaluation of bone and bony conditions. And then, you know, that tells you how long it has been when I was trained and how far the art has progressed. Later on, we have a huge section of my esteemed colleagues here will be sharing with everyone as far as the use of ultrasound for evaluation of bony conditions. And ultrasound certainly can be evaluated, can be used for the evaluation of bone conditions. And it certainly can, has a role to play in the evaluation of clavicular fracture. For the most part, you know, let your physical examination be the guide of your exam, where you should put your probe down. You know, you should, when you place the probe over the injured side, what you are looking for is any sort of cortical offset, irregularity, or any cortical breaks, you will not be surprised to find any local tissue changes as well. Ultrasound, in fact, has a very high positive predictive value and also negative predictive value as well. So it definitely is something that's worthwhile using for quick assessment prior to sending a patient off or sending your athletes out of the training room or off the sideline for an x-ray. Moving on to the next condition is the acromioclavicular sprain or any sort of associated instability. As we know, the AC joint sprain has been divided into different grades. And generally, grade three, grade four, that's the very important area to tell, or type three, type four is a very important area to actually make a distinction because once you cross the threshold being type four, you absolutely should be, you know, there's generally there's not any controversy as to whether or not this is a surgical case. So detection thereof is an important part. And where ultrasound can really make, can really be very helpful prior to sending the patient or your athletes off to get an x-ray. So what we're looking for here is a horizontal instability. So as you can see by the, as you can see by the graphics here off to the right, the probe is placed over the shoulder, you know, we can, and then what we're asking the patient to do is in the stress and the non-stress position, we're looking at a stress and a non-stress position. And non-stress position is the far right where the patient simply has the arm relaxed and the shoulder relaxed, arm draped by the side. And then the more stress condition is when you are asking your athlete to adduct, which they can simply perform. You can simply instruct them to place their hand on their contralateral shoulder. And then what we're looking for is the change in the appearance of the AC. What we are looking to see is really a change in the offset, right? So normally they're going, however they are aligned, you know, if this is the anterior view, so this is actually, the view is actually shooting more from the anterior to posterior. Normally the joint has certain amount of gapping, they may have a little more of a wing appearance to it. And you can kind of see the intra-articular portion. But in the stress view, what you are expecting to see is that, what you're looking for is a real change in the level between the acromion and the clavicle. So even, you know, in a stable joint, in an injured AC joint, you wouldn't really, I mean that joint is going to move, but it surely is not going to have a lot of change in the offset. And that change in the offset instead would then, is indicative of a high grade instability. And then generally we're looking at either grade four or type four and above, and hence these patients really require surgical evaluation and likely surgical care. Moving forward, the next topic we'll talk about is the acute rotator cuff tear. So this is probably, rotator cuff evaluation is absolutely where the ultrasound just absolutely shines, as Dr. Razor pointed out earlier, that ultrasound has a high sensitivity and specificity for rotator cuff tear, and also, you know, adequate, slightly lower than MRI in terms of partial tear in the sensitivity, but high comparables specificity to that of MRI. So the hard part here, I think, in my opinion, is, you know, to tell the difference between whether or not you have an incidental loma, that it's just always been there one way or another, or you're really looking at what is causing the patient's pain. So again, here, as we started off, everything in the patient evaluation, you know, plays a part, just like ENG, you know, ultrasound is an extension of your physical examination and your physical examination of the history should really inform you of the interpretation of the finding that you have. So again, hard part is to determine whether or not this is a incidental loma, and your physical examination is going to play a big part. But let's talk about what are the findings we're expecting to see. So in the direct finding, especially in high-grade tear, we're looking for any devoid of tendon substance. So if there is a tendon substance in where you are expecting to find tendon, obviously, you know, there probably is some form of high-grade tear. There are also indirect finding too, because sometimes, especially if your examination ability is limited due to patient factor, like patients in a lot of pain, maybe there's a limited ability to perform adequate exam, then you may have to go off on the more indirect findings, just be quick about it. So if there's compressibility, meaning there's the, you know, you're questioning whether or not you have inadequate visualization, or there's a fluid pocket, the way to determine there's a fluid pocket, which will be essentially the hematoma that's left over filled in the space from an acute tear and retraction or partial retraction, is fluid will be compressible. You know, that's just earlier today, I'm still in clinic, as everyone can see, you know, we were doing an evaluation on the shoulder. We're like, and we're looking at, we're not sure. And it was like, I asked the resident, can you compress that? Yes, you can. Oh, it's a tear. It's a fluid. Okay. Other things that we also look for is double cortex sign, which is a bright line at the, just over the cartilage. And then that's suggestive of a articular side partial tear, you know, that the tendon is now off of the bone of the cartilage. So now that space is then filled by fluid and the fluid, you know, presents an additional interface for echo, for echo reflection. And that presents as a bright line. Another thing that we look for is something called a pair, it's called a sagging paraversal fat sign. It's a mouthful, or we can also sometimes, I think other literature referred to as a paraversal fat sag sign. Essentially, you're looking for the contour of the rotator cuff instead of being full and consistent, but instead it takes on a more straight line compared to the underlying cortex. And the last thing is that you're finding a bicep, a bicep tendon effusion around the bicep tendon or the target sign at a bicepial groove. All of these are highly indicative of rotator cuff injury. And I am going to now move on to the some demonstrations of what they actually look like. So this, so right here, this is a pretty obvious, you know, we have a lot of cortical irregularity. We can also see that there's a bright line running across right here, then that'll be the double contour sign. You also have cortical irregularity, you have the obvious divorce of substance right here. So that's a very, so that's a good example of what a partial tear will look like. And here's the compressibility I was speaking of. You can actually see, sometimes if your imaging situation is not adequate, you may see, you may end up having a hard time determining whether or not you just have a suboptimal image versus is that really fluid. Again, the things, no, just, you know, let the knowledge of your physics guide you. If it's compressible, it's the, if it's compressible, it's not solid, it's a fluid. And over here, what we have is the tracing the bicep tendon. And, and what we're seeing is the target sign. Now it's pretty important, I'll play this one more time. At the beginning of this evaluation, when we are still in the bicep group, you do not see the bicep, the target sign around the bicep long head tendon. And the reasons because sometimes especially, you know, most of us spend probably most time in the, you know, in the upright position, so the fluid actually drained down. And then we're, so the target signs will be more accentuated as you go distal, it's less accentuated. It may not be the effusion or the, or that target sign may not be apparent where you are, if you're just inside a group. So that's something to keep in mind of. And then this one is what, this will be again, the devoid of substance right there. That's a high gray tear. Here's the middle, and this is just the image graphics right here in the middle, where we can see here in the middle on the lower graphic, you can see that this is the example of pair, the parabursal fat sac sign, or saccum parabursal fat. You can see that the bright line that outlines the subacromial bursa delineates between the delt, the layer of the deltoid and the supraspinatus tendon deep to it. And instead of having a very full, nice curvature contour of that parabursal fat is now, takes on a more flat appearance. Coupled with this hypocoic lesion, this is consistent with essentially some loss of tendon tissue from tear. So that again, this is a highly indicative of tendon tear and partial in this case. And lastly, this one, we have a good example of that, that double contour sign. This is the far bottom right image or video. So, sorry. So moving on. The next thing we'll talk about is bicep long head rupture. It certainly can happen. I would say my, it's a condition that certainly can happen, happen more often in older athletes, more in a, it's certainly something to think about in the throwing sports. Imaging of bicep long head is generally very doable, even in dated equipments, even in suboptimal condition. The heart, given that generally speaking, or relatively speaking, is a pretty shallow structure when it comes to the shoulder. Now, the general location we'll start the evaluation is over the anterior shoulder. What we're looking for is any sort of intra-substance tear, any sort of target sign around the tendon itself. And then if we are actually also, if we are seeing any sort of devoids of substance, like if you're seeing it right here and then on the left side, on the top left graphic, and then top right graphic, you go slightly distal, and now that space where you normally would be seeing the tendon now becomes devoid. And then that really makes you suspect a tendon rupture. We always look at orthogonal views. It's like x-ray, right? Or imaging study always requires orthogonal views. Then correspondingly, what you would expect is in long axis view over the anterior shoulder, you would see the tendon should go all the way through, but instead, as pointed out on the far left, on the bottom left graphic, instead of having a scene being all the way through, now you have a little bit devoid of substance where the arrowhead points out. And again, on the bottom right graphic, also you have essentially seemingly a gap in between the two pointing arrows that you have a hematoma filling that space instead of having the continuity of the tendon. One pitfall in the evaluation of the longhead bicep tendon of the anterior shoulder is to make sure you have to make sure that you are in the correct echo window in the imaging. So as many of you I'm sure know, no doubt know, bicep longhead is very, very susceptible to anisotropy. So that means a minute changes in the tilt of your transducer may influence its appearance. So always rule out anisotropies. So if you think you're looking at one of these picture on the right side where you don't see a tendon, just make sure you check your tilt a few times, just make sure that it's not just an anisotropy artifact that you're seeing, that the tendon still is in fact intact. Okay, moving on would be the pec tendon tear. Also a common injury, this pec tendon tear is, it can it can be pretty easily evaluated. Essentially we're just going to go continue in continuity with our bicep evaluation. We're going to just go distally if you like and simply you can even simply just track the bicep longhead tendon and what you expect is that you will as you go as you go distally you're then you're going to come across the tendon, the pec tendon, coming from medial to lateral and going over the bicep tendon. Now, pec tendon tear comes in many variants. As we know, it can happen much more distal. It can also have muscular scalp. It can also have a mild tendon junction tear as well. On physical examination, on high-grade tear, you would expect, you know, the loss of that axillary faux appearance. You would expect to the presence of hematoma in the area. But in low-grade tear, especially, maybe we're not in the, maybe the patient has a lower, maybe we're at a less acute situation. It may not be, it may be more subtle. So this, again, this is where sonopalpation can really play a role. If you see pathology, if you see the change in the tendon texture, if you actually see like this coiling appearance where the tendon no longer, no longer stays nice and flat and bright, we're finding NISOT, presence of NISOT. So the presence of the tendinopathic lesions, or if we're actually finding like a moderate to high-grade strain at the mild tendon junction, then those, those are the indicative of your pectoralis tendon tear. Okay. Moving on, greater tubercle fracture. So greater tubercle fracture tend to be associated with the glenohumeral joint dislocation. And it has to do with this very high energy and, you know, the extreme pull at the infraspinatus and the teres minor, resulting in the fracture of the, of the greater tubercle. It certainly can also happen in like direct below situations, it certainly can also happen in like direct below situations. So falling, contact sports, below to the shoulder, accidental impact by sporting equipments, all those things can be, can, can, can, can cause this condition. Now this tend to be a fracture that may go, may go undiagnosed for some time. So ultrasound really does play a role here again. So simply placing the probe over the greater tubercle area, and then you're looking for a cortical irregularity. You're looking for breaks in the cortex, offsets in the, in the, in the bony contour, or maybe even any associated hematoma that links to, as graph, as the, as you can see in this bottom right graphics, that there is this, this hematoma, this fluid effusion extending from the breaking cortex, not where the arrow's pointing at, but the one, but the little break that's more off to the right to it. So these are all telling signs that can be helpful in your evaluation, maybe where x-ray actually may miss. Okay. So now moving on to glenohumeral joint dislocation. So this one is, there's a study that demonstrates evaluate, there's a beautiful way to do the evaluation. It's a posterior shoulder, in a posterior approach. So simply by placing the, placing the probe in the posterior shoulder, maybe just a little inferior to the spine. So, and then, so now we're, we will be looking at the posterior shoulder. We have that view of glenoid and then, and then the humeral head. Normally we expect, you know, the graphic will look more like the right side, you know, this, this far right graphics of the hum, where you, you see the nice contour of the humeral head and you see the glenoid come to meet it. We always talk about it being like a, like a, you know, golf ball on the tee, right? And what we're looking for is the offset of these joints. Now this is where, if you're unsure what you're looking at, looking, having a contralateral normal shoulder, a ninja shoulder will be very helpful, but essentially we're looking at that contour, you know, there's a disruption of the contour. On the left side, we have a interior dislocation. So you can see the glenoid, but you really do not see the humeral head any longer, humeral head is in fact far anterior, so it's slightly out of view. And then on the, on the contour, on the far right graphics here, what you have is a posterior dislocation, where the humeral head is much more prominent. The shoulder, the glenoid is now, instead of having a nice contour that climbs up to that ice cream scoop or the golf ball, it sort of has a more abrupt appearance that jams into it. So this is a very nice view, you know, high, 100% sensitivity and specificity that evaluates both anterior and posterior shoulder. So this is a very easy protocol for the assessment of the shoulder. And lastly, you know, if you are suspecting a, a, you are suspecting or you have a glenohumeral joint dislocation, one of the most common associated neural, nerve injury is actually nerve injury. So it's always worthwhile to check that. So this one, you know, certainly if you, if the patient, the athlete has had a shoulder dislocation, it can be very painful, but we can perform this examination by just a, a, sorry, apologies, a isometric contraction and no dynamic contraction, no movement of the joints required. You're just going to ask the patient to dynamically, to isometrically contract the shoulder and just look for the deltoid, dynamic contraction of the deltoid. So in summary, you know, I think what I presented here is a quick secondary screen for major do not miss events. Again, it's still very important to kind of put everything together. Ultrasound is an, is a powerful tool, but nevertheless, it's an extension of your physical examinations, extension of the history. We still need to have a comprehensive, comprehensive view of the entire patient in order to apply the ultrasound evaluation in the most fruitful manner. But this protocol that, you know, that we reviewed can be executed very quickly. It flows in a single direction while perform, while help you catch all the do not misses here. Okay. All right. We'll save all the questions till the end, I believe. And then with that, I will turn over to the next presenter. All right. Thank you so much, Dr. Chen. Really appreciate that awesome presentation on the shoulder. I'll be sharing my screen now next. Okay. So as Dr. Fred mentioned earlier, I'm a little bit under the weather, so I will be keeping my camera off for this presentation. I have the opportunity to review ultrasound of knee ligaments. My name is Kevin Mullins. I'm an assistant clinical professor at the University of California Davis, and also serve as a team physician for our Sacramento Republic professional soccer team here in town. And I have no disclosures. So we'll be covering the major ligaments in the knee and ultrasound evaluation and techniques, including the ACL, MPFL, medial collateral ligament, posterior cruciate ligament, and lateral collateral ligament. These first three we'll spend the majority of our time on, as these are the most commonly injured ligaments and would be most relevant for the athletic training. The equipment that I'm using in most of my clinics would be the SonoSite X4, and I'm also recommending the linear array transducer for the assessment of all knee ligaments. We'll be starting with ACL, and I just want to make a note, my goal is to also convince all of you to think of ultrasound in some of these acute injuries. Traditionally, obviously MRI would still be of the most importance, but I do want to try and win you over in considering ultrasound use, especially in the athletic training room. So just a brief overview of ACL injuries. There's over 2 million annual ACL injuries worldwide. Demographics more common in female athletes than male have a ratio of 4.5 to 1. And as we all know, mechanisms can be either non-contact pivoting injury or a blow to a lateral aspect of the knee. Now, our current diagnostic approach, well, the gold standard for diagnosing ACL would be arthroscopy. But of course, we are all familiar with MRI. And some of the more recent data showing how sensitive and specific MRI is for detecting a complete ACL injury, 87% and 93% specific, and then a partial ACL quite ranges from 40 to 75% sensitive and 62 to 89% specific. But I really want to focus on the current pitfalls of MRI. And those being there's a high burden of costs, limited availability and time. And of course, there's folks who have contraindications to MRI. Of course, when I'm taking care of my professional soccer players, the costs and time aren't really factors. We can typically get an MRI the same day or the next day for these athletes and cost isn't really a concern. But on the far opposing side of that, I also run a free sports medicine clinic here in Sacramento, providing free care to our community. And there it's hard enough just to get an x-ray sometimes as opposed to an MRI. So that's where ultrasound can really play an even greater role in the treatment of your patients. Similar as well, some of the local high school teams may not have the same type of resources as say, the professional athletes. So I really want to hit home that point when we consider ultrasound for the athletic training room. I here present some evidence for ultrasound. So Wang 2018 performed a systematic review and meta-analysis, looked at four studies involving 246 patients and found that the ultrasound used in detecting complete ACL tears was as sensitive as 90% and specific as 97%. And something that Dr. Fred mentioned at the very beginning was how ultrasound can be a benefit when we're dynamically observing our patients as well, as opposed to just a static image of the MRI. And of course, we already talked about the lower cost and shorter time as well needed for ultrasound. Another study just as recent as 2019 was a retrospective review, 247 patients. So they went up to the 246 from the previous study, underwent ultrasound and arthroscopy for complete ACL tears. And this study found that ultrasound detecting complete ACL tears was 88% sensitive and 82% specific for partial ACL tears, less sensitivity there, 52% and 89% specific. So of course, it's important to understand the anatomy of the ACL. So we have our anterior medial bundle, which restrains that anterior tibial translation. Of course, we are assessing this with our anterior drawer test. And so it's tightest inflection. And then our posterior lateral bundle, which is responsible more for the rotational stability and plays a role with our pivot shift test, the tightest in extension. I remember Dr. Fredrickson helped to teach me the pivot shift test, how to correctly do that when I was a fellow. All right. And so we also have the femoral attachment. The anterior edge of the ACL is demarcated by the lateral intracondylar ridge. Then the anterior medial and posterior lateral bundles attachments are separated by the bifurcate ridge. Then of course, the tibial attachment is anterior. So let's talk about the scanning technique then for looking at the ACL. You should only need about 10 minutes of time for the whole assessment. And again, as I mentioned earlier, the linear array transducer is what I recommend for utilizing on this. I usually will start with the patient placed in the supine position. You want to maximally flex the knee as much as it can go passively. And so you start always by placing your transducer on the patella tendon. Then you want to rotate the transducers. The proximal tip is rotated towards the medial border of the lateral femoral condo. Here's an image of this same patient here, looking at the ideal view. So we have our tibia, our patella, hops back pad, the patella tendon overview, then our ACL, which is right deep. And looking at the dynamic assessment of the ACL, you essentially just want to take the knee and extend and flex movement of the knee. This is called the direct, the dynamic direct sign. And so normally, which we'll show you here, typically, what you see is that ACL and the hoppus fat pad is moving upward in an upward trajectory. If there's no upward movement of the ACL and hoppus fat pad, then this would be indicative of complete tear. And then if there's lessened movement, this could be potentially a partial tear. And you would also want to always compare to the contralateral knee. Here's an example showing, depicting a diagram of an intact ACL, and that those arrows are showing the upward movement of the ACL and hoppus fat pad under normal circumstances with flexion extension. Here's an example of a torn ACL. So first, we don't really see the ACL in view. Secondly, when we flex and extend, there is no motion of hoppus fat pad, which would be indicative of a complete ACL tear. In addition to the anterior view, we can also scan posteriorly. And so in this case, you want to place the patient in a prone position, and ideally with the knee flexed about 10 to 15 degrees. So as you can see here, I'll usually use a towel to place underneath the extremity to allow that slight flexion. Moutner, in 2018, describes three indirect signs of an acute ACL tear, acute being defined as less than six weeks, with a positive predictive value of 91.8 to 96.8%. Here's a closer view of our transducer for the very first sign, which is called the femoral notch sign, and we'll go over that right now. So here, looking at the various signs that we talked about, the femoral notch sign, there is the PCL or the posterior capsule sign, and then there's a PCL wave sign as well. As you can imagine, with multiple signs combined, our sensitivity and our specificity increases. So two or three signs, these are some of the numbers that we're looking at based on their study. So let's go ahead and take a look at those. So the very first one here is called the femoral notch sign. So in A, similar to the picture I provided, this is the ultrasound probe position on the posterior knee. For B, this is an anatomical drawing showing the positive posterior ultrasound findings at the femoral intercondylar notch. So in C, this is essentially normal. This is what you would be seeing in a patient who has no ACL tear. But in D, pay special attention here to the asterisk. So this is a hypoechoic collection, which would be indicative of essentially an ACL tear. And then there's some mass effect as well, displacing the intercondylar fat pad medially. Here, we can see the same on MRI, which correlates to our positive ultrasound finding. Now moving on to the PCL wave sign, which is really assessed at the same time as the capsule sign, capsular sign. So you just want to take your transducer, rotate 90 degrees on the posterior knee. And so here is again, another drawing depicting the PCL. And as you can see, it's in a wave type pattern. And then we'll talk about the capsule sign as well. But we see essentially some protrusion of that posterior capsule. So in C, this is essentially a normal knee. And then here, we can see there's some protrusion of that posterior capsule, in addition to more of a wavy appearance of the PCL. And we mentioned the capsule sign as well, which can be assessed with the same view. A and C are essentially normal. And then B, we can see that protrusion. We can also sometimes see thickening of the PCL as well, which would all be indicative of an indirect ACL sign. And we really hit home, hopefully, the point of there being two or three signs. That's really the sweet spot for diagnosing ACL rupture with utilizing these indirect signs. Next, I want to talk about the medial patella femoral ligament. So a quick overview, most injuries occur in the second or third decade of life. Risk factors include any type of ligament dyslexia, patella alta, trochlear dysplasia, and excessive lateral patella tilt. Our mechanism is typically a non-contact twisting injury. The knee can be extended and externally rotated, or less commonly, it can be a direct blow. And looking over passive stability for the knee, the kneecap, the MPFL is a primary restraint within the first 20 degrees of knee flexion. Patellar femoral bony structures assist with deeper aspect of knee flexion. And of course, we also have our vastus medialis, which provides dynamic stability. X-rays should still be done, ideally, for these patients. It can also give you an idea of the underlying bony anatomy. Our AP views specifically would evaluate the extremity alignment inversion, lateral views, looking at trochlear dysplasia, and the sunrise merchant would be great assessing our lateral patella tilt. So looking at, again, some of the data, because my goal here is to convince all of you that these are great conditions to utilize ultrasound for. In 2014, there's a study that assessed 97 patients for the accuracy of MRI versus ultrasound in comparison of arthroscopy for confirmed MPFL tears. And MRI was found for a complete tear to be 80% sensitive, 95% specific, and 92% accurate, while a partial tear was 81.6% sensitive, 95% specific, and 91% accurate. Now we compare that in the same study to high-frequency ultrasound, which we find pretty impressive numbers. Complete tear is at 86.3% sensitive, 96.3% specific, and 94% accurate. Partial tear is 90% sensitive, 96% specific, and 94% accurate. And looking at the anatomy, which is important anytime we start an ultrasound scan within the knee, there was a 2017 systematic review that assessed 67 relevant anatomical studies. And so our MPFL is this hourglass, essentially structure that originates here in this triangular space between the adductor tubercle and the medial femoral epicondyle and the gastrocnemius tubercle. And then it attaches on the supramedial aspect of the patella. So for this scanning technique, typically I'll have the patient in the supine position. Knee can be in full extension or flexed just to about 15 degrees. And the transducer is placed long axis to the ligament. So here's a closeup of assessing that MPFL. And the nice thing, just like we talked about the ACL, is you can always perform both a static and a dynamic assessment. And so I will usually perform both the dynamic assessment with and without ultrasound. And we'll look at some images in just a little bit of how that can be helpful. In this case, we would be grading based on number of quadrants that the patella is, the translation of the patella, but also a key component is the apprehension test. So I'm also paying close attention to my patient and seeing if they're really tightening up or quite apprehensive about me translating the patella. So here's a case, a 32-year-old female who sustained a complete MPFL rupture at its femoral attachment. And so in picture A, we can see a static ultrasound examination shows the MPFL discontinuity at the femoral attachment, which is this white arrow, with decreased echogenicity in surrounding edema. Now in B, this is a dynamic evaluation and you can see how it can be helpful. And so in the transverse view here, there's increasing distance and gap forming between the adductor tubercle margin and the valsal ligament, which is again, this white arrow. And here's an MRI, which is correlating to everything that we are seeing in real time on the ultrasound. Case number two, this is identical to a 17-year-old football player I just saw six days ago in clinic who had a complete MPFL rupture at its patella insertion. And so here in picture A, we can see static ultrasound again showing that MPFL discontinuity, and hopefully everyone can see that, the patellar insertion, which is that white arrow, with decreased echogenicity in surrounding edema again. Here with our dynamic evaluation, that space widens and we're able to see the valsal ligament in that white arrow. And then again, a correlation to MRI. In this case, we have a 24-year-old man with a combination of a complete MPFL rupture at its femoral attachment in addition to the mid substance. So you can have lesions in two areas of this ligament if it's traumatic enough. And so in A, we have a static image depicting. In B, this is moving over towards that femoral attachment and you can appreciate lesions at both sites. And then we have a correlation of the MRI finding. In C, this is more for reference. Remember, it's always important just to compare to the contralateral knee. In my case, six days ago, the athlete actually had a prior MPFL injury of the contralateral knee. So that was one of the rare instances where I didn't have a comparable normal. But in this case, this is how the contralateral knee would be normal. Lastly, we have case number four. This is 25-year-old female with a partial MPFL tear at its patella insertion and an osteochondral lesion as well at the inframedial patella. And so we can see that lesion, the osteochondral lesion here underneath the patella on the MRI, and then the partial tear here and the partial tear there of the MPFL. So four different cases, all with MPFL injuries, but presenting quite differently. Here in town, we also have a surgeon who is quite keen on ultrasound-guided surgical repairs for the knee, and it's Dr. Hirahara. He published in 2017 a case series of 10 cases where he performed ultrasound-guided surgical repairs for the MPFL and found it to be quite successful. His indications and contraindications to ultrasound-guided repair are listed as such. I want to point out the key points for contraindications if they have severe trochlear dysplasia. If it's a mid-substance tear, he doesn't have as much success. And then also if there's a combination of patella femoral achondromalacia, which is severe. Next, I want to talk about the medial collateral ligament. So very, very common. The number one ligament is injury of the knee, approximately 40% of knee ligament injuries, and probably goes underdiagnosed. Just as many of us know, grade one MCL, maybe it's not even evaluated by the physician. More common in males than females. And the mechanism of injury would be a valgus stress to the knee. Contact is more common than non-contact. And here we can see a combination of an associated ACL tear. We also look for a medial meniscus tear and the finding of pellegrinia steata. Again, looking at the data, there's actually surprisingly not as much in regards to comparing MCL ultrasound to MRI. I wonder if it's because it's commonly used in practice, but nonetheless, in 2017, the most recent, there was a point-of-care ultrasound with MRI comparison for medial knee injuries. They found MCL tear to be 83% specific for ultrasound, to be 83% specific for MCL tears. And we can see here, they had a list of the ultrasound findings and how that correlated to the MRI that was done. Say one downside to this is the MRI was used as the gold standard. But again, if it's an isolated MCL, we wouldn't often be doing arthroscopy for these patients. So it was probably a reasonable comparison as the gold standard. Looking at the anatomy of the medial collateral ligament, we have the superficial femoral attachment, which goes from the medial epicondyle, one centimeter anterior and distal to the adductor tubercle. And then the tibial attachment, proximal tibia, periosteum, 4.5 centimeters distal to the joint line, and just deep and posterior to our pes anserine. And then there's the deep MCL, which is located in the layer three of the medial knee, adjacent to the knee joint capsule. So going back to our positioning for the MCL assessment, this one's a quick scan, five minutes maybe. You can use your linear array. I typically will start in the supine position with the knee actually flexed to 90 degrees and the transducer and long axis to the tibia. And then also assess at zero degrees full extension, similar in long axis again. And here we can see a closeup of that transducer positioning. Also, you want to be assessing not only in a long axis, but also short axis as well. So here are some pictures of the same patient. We see the femur, tibia distal, MCL overlying, medial joint line. And so when we scan, we want to make sure that we're scanning the full length of that MCL from the femoral attachment all the way down to the tibial attachment. And as I tried to hit home the point, ultrasound with all of these can provide a dynamic assessment that is not available on MRI. And so in this case, you typically will also want to be scanning the knee in flexion to 30 degrees and also the knee at zero degrees due to the role of just the MCL versus additional ligaments with laxity. And so you want to apply a valgus stress to the knee. And here I demonstrate providing some of that stress and then watching dynamically on the ultrasound, there's widening of the gap between the tibia and the femur. So three to five millimeters would be considered a grade one, six to 10 millimeters, grade two and greater than 10 millimeters, grade three. We had an athlete, a high school athlete kicker who sustained a lateral blow to the knee on a, I think it was a punt. We were able to bring him back to the ultrasound, back to the training room where we had an ultrasound and could quantify exactly how much opening was with the MCL tear, which was a pretty neat to be able to do right there in the athletic training room. Here are a couple of cases that I want to just highlight. This is an old medial collateral ligament rupture with calcifications of the steata pellegrini, which we can see here in the longitudinal view than here in the transverse view. Also, if you look closely, it appears that this MCL is a bit thickened as well than our usual. Here's another case of a partial medial collateral ligament rupture with a defect here in the deep layer and an intact superficial layer. Next, we have a full thickness medial collateral ligament rupture involving both the superficial and the deep layers. Again, always wanting to look in longitudinal and transverse. Then lastly, this is an interesting case where there were some cystic lesions caused by MCL friction with this bony spur. So we can see the cystic lesions here within the MCL ligament. And again, I'll bring in Dr. Hirahara, who I mentioned it previously, is keen on using ultrasound for some of his surgical techniques. He here is discussing the management of MCL injuries, although recognizing that typically conservative management is recommended. Those who are having trouble returning to play, he will consider a repair. And he actually has a video, if you're very interested in watching it, on his own website showing from start to finish his procedure under ultrasound, utilizing a two millimeter wide suture tape that he claims allows for early functional rehab. So, an interesting case. And just to really wrap up here, these are less common injuries to be found in isolation, but I just wanted to at least highlight the proper positioning for our, looking at our posterior cruciate ligament, the ultrasound placement. We already looked over this when we were talking previously about indirect ACL signs. Here, those open arrowheads show the PCL. This is the fat pad with an asterisk. And so, looking at the posterior knee, and then the lateral collateral ligament. Similarly, much like the MCL, aligning in extension and looking in long axis at that ligament as well. But again, these would be less common, at least seen in the athletic training room scenario. So, that's it. I appreciate all of you guys listening up here. Hopefully I convinced you and provided some evidence of how we can utilize ultrasound in athletic training room. And I had to leave this article here at the end for one of my colleagues who will be speaking later. Just this year, our minor league soccer team had a big win over a major league soccer team, the Sporting KC. So, we're celebrating having a great season thus far. Thank you. Thanks, Dr. Mullins. I'm gonna be pulling up my slides right now. All right. Hello, everyone. I'm Dr. Ann Kuwabara, and I'm one of Dr. Fredrickson's most recent sports fellowship graduates. I just graduated a few months ago, and today I will be going over ultrasound skills specifically for looking at bones. Don't have any disclosures. And for bones on ultrasound, as everyone previously mentioned, one of the greatest benefits of ultrasound is it's accessible and it's a dynamic modality that in the bone context can help look at bony surfaces. It's not usually something to do, something that can evaluate bones fully on its own, but it's a great adjunct to other modalities, including X-rays, CT scans, and MRI studies. So, what does bone look like, normal bone on ultrasound? It's usually a hyperechoic, which means brighter or white continuous line is what the outer cortex looks like. And then sometimes there can be normal disruptions in the cortex for nutrient arteries, as you can see here in B. And to check if it's a nutrient artery, you can turn on the color flow. As you can see in C, and in our younger population, you can also visualize growth plates that are between the metathesis and epiphysis. And sometimes there are bony prominences at the insertions of tendons and ligaments. So, first I'm gonna go over, my presentation is more of a pictorial overview, so we'll be looking at a lot of images, starting with most common and then ending with more rare etiologies. So, here's images of fractures in four different patients. So, you can see that all of these have cortical discontinuity or a break in the bony cortex. And sometimes if they're displaced, they can have a step-off deformity. And if it's a relatively new fracture, you can also see hemorrhage, which is characterized by the curved arrows on this slide. And in A, this is a fracture of a rib, B is a proximal phalanx, and C is a humerus, and D is a coracoid process. And here's another picture of a humerus diaphysial fracture, and you can see a little bit of periosteal lift here. So, that's caused by a little bit of hemorrhage from the fracture. And here is what an occult fracture of the greater tuberosity looks like on ultrasound. And this was helpful for this case in this situation because x-rays were normal, and it's a very subtle finding that we were able to confirm with CT and MRI. And here is an image of a rib fracture. So, in A, this is the acute finding, and then in B is the axial section with some callus forming. And here's an image of a sternum fracture, and you can see what it looked like on CT here. And here is an image of a fibular neck fracture here, combinated so that you can see the multiple pieces. And this was in the context of a reduction of a distal tibia and fibula fracture. So, the bottom slides are actually the displaced, and the top slides are when it's back in place, and then here, the displacement and replacement that you can see on ultrasound. And here are some images of a scaphoid tubercle occult fracture. So, sometimes if you're suspecting a fracture and you're not sure if this is anything at turning on the color flow when these situations are helpful because it can show that there's acute inflammation and edema going on. Here's another picture of trapezium tubercle occult fracture. I think the point of all these slides is to demonstrate that even if you have high suspicion and your x-rays are normal, it's good to use ultrasound to screen and then get further imaging, such as a CT, to find those occult fractures. And here's one of the lateral malleolus. So, there's subtle edema here that's more distinctly visualized with the color flow and then confirmed with CT. And for some fracture complications, sometimes if a fracture is left for a while in the healing process, they can irritate the tendons, which is shown in this image in B and in cross-section in A. And then nerves can also be injured or entrapped in fractures. So this is what the, you can see some nerve swelling here compared to smaller circumference of the nerve, more proximally. And for our pediatric population, you can see growth plate injuries, which on ultrasound look like bony irregularity, widening, and a little bit of offset at the physio plate. And then ultrasound is also helpful in evaluating union versus non-union. So in figure 1A, this is what a non-union would look like after a fracture has been healing for a while. And then in figure 1B, you can see the callus formation here. And also look for unions post-surgically. And in this image, there's something called a posterior reverberation artifact, indicating that there's some irregularity or non-healing in this area here. And for more post-surgical complications, you can also visualize screws here in A, and then a little bit is coming out here in C. And you can also see effusions. In this image C, this is showing interarticular hip effusion. And this is showing hemarthrosis. So on this ultrasound, all of the tendons looked good, but there's a little bit of heterogeneous fluid collection here, which is hemarthrosis or blood and swelling from a non-displaced fracture. And similarly, in this image, there's something called lipohemarthrosis. So in a big fracture, there's a lot of fat cells that are emitted from the fracture site, and they can create a little line here. And here's what a Hilsack's lesion looks like on ultrasound right here, which correlates to this region on MRI and CT. And this is something we saw last year during fellowship, Freiberg disease. So this is flattening of the head of the second metatarsal visualized on ultrasound. And you can also see osteochondral injury or fragments. So this piece here in A correlates to this piece here in C, which was scraped off from this area on the humeral head. And for gamekeepers, ultrasound can help visualize little avulsion components. And it can also evaluate. Here's an ultrasound image of the palmar plate and a little avulsion here and there. And here's an image of an avulsion off of the AIIS right here, ultrasound image here. And another avulsion of the tibial tendon. Here's the bony fragment here on ultrasound, and this is the confirmation on CT. And there's something called an os peroneum that can be an anatomic variant. And this patient here is the normal side in D and the fractured side in C. And these are the two pieces seen on ultrasound. And here's an image of an ATFL avulsion. ATFL is right here, avulsion fragment in this area. And moving on to stress fractures, this is an image of stress fracture of the femoral condyle. There's cortical discontinuity here, confirmed on MRI studies. And here's an image of a tibial shaft stress fracture, subtle discontinuity. And when stress fractures are healing, you can also see findings of periosteal thickening and edema. And another stress fracture of the calcaneus, showing again that periosteal thickening and edema, and they keep setting. A closer view of those os peroneum photos. And some images of metatarsal stress fracture, so again, that periosteal thickening, edema. And here's a picture of a periosteal fracture of the periosteal adenoma. And these are images of sesamoid stress fractures. And this is an image of a healing metatarsal stress fracture. So in this setting, there's a little bit of callus here. Not able to clearly see, maybe a little bit of a callus formation on an x-ray. And these are findings from one of the studies that Dr. Fredrickson previously did for bone stress injuries, as opposed to stress fractures that we were just looking at. Bone stress injuries can also potentially be viewed on ultrasound. And their classic findings include periosteal thickening or elevation and calcified bone callus, a little bit of corticosteroid. A little bit of cortical irregularity, subcutaneous edema, depending on how acute you're caching it, and the color, hyperemia, or vascularity. So these are findings of early bone stress injury. And I think the main difference is for bone stress injury, you're not going to see those cortical breaks or step off deformities. Here's one that we saw last year during fellowships So what we noticed is when bone stress injuries are healing, they have more of an irregular wavy cortex. More images. And higher grade bone stress injuries can have those cortical breaks or irregularities. Here's some callus formation. And when bone stress injuries are healing, you can also see a phenomenon called posterior shadowing, similar to the reverberation from the nonunion slide. Here's healing stress fracture, the right fifth metatarsal. Now moving on to what infections look like. That Dr. Reiser mentioned earlier. So for infections in the bony context, you can also see abscess-like formations. And if the bone is involved, there's often cortical discontinuity and tracts connecting the abscess to the bone. And then here's an example of a septic sternoclavicular joint. And if an infection has been going on for a long time, it also can erode the bone. And here's an example of osteomyelitis, bony erosion here. And here's an example of a subperiosteal abscess, so the bone is not directly involved in this case. And more rare, probably not gonna see it in the training room, but I will just include some tumors. So for osteochondroma, this is a benign finding that is often seen in young people with osteochondroma. And what osteochondromas look like are, they're usually pointing away from the joint surface and they have their own separate cortex with a cartilage cap, typically. Here's an image on cross-section with the classic cartilage cap. And then here's another osteochondroma here in long axis and short axis over the humerus. And sometimes if it's at a mobile location, it can also be associated with a little bursa formation that can be associated with pain. And here's an example of aneurysmal bone cysts, another benign lesion. And here's an example of an osteosarcoma. So this is a more aggressive cancerous lesion and usually aggressive lesions are associated with some bony irregularity. Example of a sarcoma, also associated with bony irregularity and a heterogeneous mass. And this is an example of an Ewing sarcoma. And here are examples of osseous metastases. And what mets look like on x-ray is classically defined as a picky bite lesion right here. So to summarize for the masses or tumors, generally benign tumors have well-developed well-defined cortical borders, whereas things that are more aggressive are gonna have more irregularity. And that would be a good indication to work that up further with further imaging. And finally, for our older population, you may encounter some chronic conditions. So heterotopic ossification, you can see which is bone formation outside of the normal skeleton. Here's an example here. And rheumatoid arthritis, generally an ultrasound looks like a lot of edema and some cortical irregularity as well. And it's also affects the synovium portion the most, most significantly. And here's an example of tenosynovitis where the swelling is causing a lot of hypoecogenicity around the tendons. And this is just to demonstrate that sometimes hypervascularity can be very subtle. So applying very light pressure may be needed to identify subtle hyperemia. And these are the erosions seen in rheumatoid arthritis. Here's an example of a rheumatoid nodule. And psoriatic arthritis, similar to rheumatoid arthritis can also cause erosions, but the one differentiating thing for psoriatic arthritis is they may also have areas of bony proliferation. And for gout, there's a classic double contour sign, which is seen right here. And this is from the ureate crystal deposition on top of the hyaline cartilage. And here's what a gouty tophis looks like. And some tophi may be associated with erosions and hyperemia. And here's gouty tenosynovitis. So here's a tendon, and here's the gouty deposition surrounding the tendon. And an example of osteoarthritis at the first MTP joint. There's little osteophytes here and here. And osteoarthritis at the trapezium, also defined by small osteophytes. And finally, I have some congenital lesions. So in our pediatric population, these are potentially some incidental things that you can see. So an asymptomatic os acromiale is here in the bottom, sometimes this bony area doesn't fuse completely, so there can look like there's a separate bony island. And it's specifically here in B and here on the CT scan. And some people can have a bipartite patella, seen here on all of them. Ultrasound. And some of these symptomatic lesions can create some hypervascularity and hyperemia on color flow. And here's an avulsed accessory navicular. So here's the original navicular and the bony fragment. And C is what it originally looked like, and B is after avulsion. And some people's hook of their hamate do not fuse. So this is what a fracture looks like versus the os hamuli. And this is what it looks like on ultrasound. And in the feet, you can see bony coalitions right here in C. And last few conditions are bony hyper or hypoplasia. So there's certain abnormalities of overgrowth or undergrowth of certain bone areas. So this is an overgrowth of the peroneal tubercle. And this is undergrowth of the hook of hamate. And this is hypoplasia or undergrowth of the glenoid, which can be associated with shoulder subluxations or dislocations. And lastly, hypoplasia of the sternal foramen. This person didn't have their sternum fully closed, so they were actually able to see the heart in this image. So to summarize, for acute occult fractures, you want to look for discontinuity of the bony cortex with or without step-off deformities if they're displaced. If you're concerned for it, you can look for avulsions at tendon and ligament attachments. For the pediatric population, you can assess their growth plates. And you can also diagnose bone stress injuries looking for those findings of hyperechoic callus, periosteal thickening, and soft tissue edema. And broad strokes overview for infections, chronic arthritic conditions, and aggressive tumors, you're going to see a lot of cortical erosion, heterogeneous masses that may or may not be contained in one piece, whereas more benign tumors are usually enclosed. And for the osteochondroma, for example, remember that they have the little cartilage cap. And then for congenital lesions, you can usually see two defined unfused bone centers, and they still can cause symptoms and inflammation. And sometimes you can see that with the hyperemia or hypervascular findings on colored ultrasound. These are my references, and I will pass it off to the next presenter. All right, I think that's going to be me. So I'll turn on that video here. Please let me know if you can't hear me. I was having some mic issues earlier, but my name is Dr. Robbie Diaz. Let me share my screen. And I'll be talking about using the ultrasound for the ankle in the sideline and training room. I'll be talking about more of the sideline. That's where I use it most often. And first of all, I just want to thank Dr. Fred and Dr. Mullins for inviting me to be part of this presentation. So far, great talks, and I'm always learning something new, so I miss attending these conferences. And hopefully in the future, we can do this again, if you're invited to do it more in person, to get these great ultrasound views and teach other people. And so, first of all, I don't have any disclosures for this talk. And my overall game plan for this presentation is, you know, it's going to be highlighting some of the relevant anatomy of the anterior and lateral posterior ankle. This is more of a practical approach. I'll be a little bit less reviewing some of the in-depth literature, but just important positioning and scanning techniques I use on the sideline, especially we don't have that much time to scan. So it's not meant to be a full, in-depth, comprehensive review of the entire ankle exam, and we won't be going over any ankle injections. And this is more targeted towards our resident fellow level. But briefly, first kind of reviewing some of the indications of using ultrasound for the ankle and looking at how it could be a tool for triaging ankle trauma in the acute setting, especially in the emergency department or on the sideline. And so, in 2017, the ESSR updated their consensus for using ultrasound for the ankle. And so in that consensus, they looked at the level of evidence and the strength of recommendations for using ultrasound for the ankle. Grade two recommendations are suggesting ultrasound is equivalent to using other imaging techniques for certain injuries. And grade three was suggesting ultrasound should be used as a first choice level of technique compared to others. And in our talk, kind of focusing a lot on our ankle lateral ligaments, so looking at the ATFL, the CFL, and their strength of recommendations is pretty strong, along with looking at any tendon tears in the ankle. And there's growing support and growing evidence for assessing more fractures, bony avulsion injuries, and definitely testing for ankle joint instability. In this quick study in Sweden, they took a look at using ultrasound as a form of triage for ankle trauma in the emergency department setting. And so they trained junior orthopedic surgeons with just a 30-minute training session on MSK ultrasound of the ankle. And they were using ultrasound to see if it could be a triage tool to see if x-rays were needed to further evaluate the patients. And so in this study, they had 122 patients. All of them had ultrasound. All of them had x-ray when they had positive Ottawa ankle rules. Out of the total 23 fractures that were confirmed, all 23 of them by ultrasound were identified as having a significant fracture or having other finding that they couldn't rule out a fracture by ultrasound. On the ultrasound interpretations, they identified 13 of having other findings are uncertain if there's a fracture, and then they identified potentially 24 fractures. So out of this 37, 14 patients ended up having unnecessary x-rays triaged by ultrasound. But if using just Ottawa ankle rules, out of that 122, only 28 patients would not need x-rays. So what they found out, you know, if we're solely using ultrasound as a triage decision factor to get x-rays, 85 x-rays could have been avoided. And ultrasound appeared in this study to be superior to only using Ottawa ankle rules for getting x-rays. The second study, kind of the same story. Using ultrasound in acute bony foot and ankle fractures in the emergency department, the ultrasound operators had a two-day training in MSK ultrasound compared to 30 minutes in the other study. They only included those patients with Ottawa foot and ankle rules positive as part of the study, and all these had x-ray and also an ultrasound. And those that had a positive finding for a fracture, ultrasound was 90% sensitive and 90% specific in terms of finding a significant bony injury in those who are Ottawa positive. And so using both ultrasound and Ottawa foot and ankle rules together, this could potentially reduce 80% of x-ray requests in the emergency department. So therefore, you know, saving the patient for unnecessary radiation, saving time, and also money in the emergency department. And so we can kind of extend this over to our sideline use. And so switching over to the sideline, I always like to do a case example to kind of illustrate what we'll be reviewing next. And so this is one of my 18-year-old high school senior football wide receivers. He was going up for jumping for a 50-50 ball and landed awkwardly on his left foot and ankle and felt a pop in his lateral foot and ankle. He had moderate difficulty walking off, and his pain was in the anterior lateral ankle. On his inspection on exam, you know, he had some early lateral foot and ankle swelling, tenderness over the lateral malleolus ATFL area near the base of the fifth metatarsal. His range of motion was mildly reduced. His strength was largely intact, but he had some pain with eversion. His special testing, you know, was a little limited as the injury just happened, so he wasn't really tolerating an anterior jaw or a tailored tilt at that time. But his Thompson test and the ankle external rotation tests were negative. And so thinking about a differential for lateral ankle pain, I always try to create my differential in different categories. Is this a tendon injury? Is this a bone injury? Is this ligament injury? Cartilage? And so although, you know, this athlete's story, injury story seems pretty simple, it can be really hard, especially in the acute setting on the sideline as you're experiencing different stresses on the sideline that you don't get in the clinical environment. And it's also difficult to get a full physical exam because the patient is just so much in pain as it just happened. You're having coaches, players, and parents, you know, asking, when can he go back in the game? What do we do next? And you always have to keep an eye on one on your patient that you're examining, but then when he's on the sideline, you also have to keep the other eye on the game that's still going on and identifying more injured players that you need to go see, especially if you have a limited support staff or limited medical equipment, as I do on high school. I just have an athletic trainer, but especially with football games, it can get extremely busy very quick. And you're not only just treating your athletes, you're also treating non-athletes, as we'll see in my case number two. And so there's that importance of getting a need of getting expedited diagnosis to quickly assess potential return to play, or do I keep this person out, or do I need to send this person out right away, or can they wait the next day? So that's when ultrasound can be very helpful, especially in those limited physical exams. You're able to obtain quick high-yield information. Ultrasounds, as technology progresses, are getting more and more portable, especially with the handheld versions. I personally use a handheld version. It's definitely easier to carry around on the sideline. And it can be useful, especially when we have less resources, such as having an X-ray machine nearby. And most importantly, I think, especially for the foot and ankle, it's that you can do a dynamic exam. Of course, using ultrasound, there are some limitations. It's user-dependent. But as we saw in the first two quick studies, that even with a short training, you can identify high-yield information, such as fractures. And then portable, especially handheld ultrasound machines, the quality is not up to par yet to some of those super turbocharged clinic ultrasounds, but definitely technology is improving, and I still find it very useful to use on the sideline. But you're also limited to the types of probes that you have available to you. Personally, most of them have only just a linear probe. Not too many have a curve or a hockey stick as a portable version yet. And so, you know, you're evaluating your patient. How do I keep this all organized? What should I be scanning? You know, how do I keep a mental checklist? And so AMSSM, they have very great ultrasound scanning protocols, especially in sports. If you're a sports fellow, you should be looking these up for full diagnostic exams. However, in the sideline environment, you don't have the time as a luxury. And so you kind of have to be selective in what you're scanning, based, tailored to your physical exam. The ones I commonly are scanning are the ones checked off in red of the anterior, posterior, and lateral ankle. But my personal quick checklist, looking at the anterior ankle ultrasound, is looking at that tibial-tailored joint recess, looking at that tailored dome, plus or minus looking at the dorsal, tail, and uvicular joint, along with this ligament, kind of looking at this distal tibia, median malleolus to check to see if we're seeing a subtle fracture or an old injury. Typically, I'm not really scanning in depth the anterior tendons of the ankle. But if time permits or, you know, they're injured in that area, then, of course, you know, spend more time in that area. So taking a look at our tibial-tailored joint anteriorly, we have our tibia on the left, and we have our talus on the right. Scanning more distally, you can get into the dorsal, tail, and uvicular joint and looking at its ligament. So let me – got a couple videos here, kind of how I scan them. The videos aren't totally linked, synced up, but synced up enough. And we're kind of getting into the tailored neck, head junction, and then we're definitely getting that dorsal, tailored, and uvicular joint and that ligament there. You can see some of the bulging fractures in that area. Essentially, what I'm getting in this view is, you know, is there a large ankle joint effusion? That typically clues me. There's a major structural injury going on, whether it's a fracture or we have a complete, you know, ligament tear. That's – we're just building up swelling inside the anterior ankle. This is our normal patient, so we don't have any significant effusion here. Also getting a view of the tailored dome. And so getting that tibial tailored joint view and then flipping your Ultrasound Pro to be more short access to the joint but more long access to the tailored dome. And so on the left, we have more of the medial aspect of the tailored dome and on the right, more of the lateral. We can see some of our anterior ankle tendons on top there. But looking at the tailored dome, seeing the cartilage nice and black, anechoic, nice and healthy. Here, we're trying to assess, you know, is there any major cartilage or bone injury that would suggest that there's an osteocondrial defect? That can sometimes happen in an ankle sprain clinical scenario. And when you have time and if your physical exam, you know, points you towards this, you can also take a look at the anterior ankle tendons. How I remember their organizations, THD or, you know, Tom Hates Dick. So tibialis anterior, extensor hallucis longus, extensor digitorum longus going from medial to lateral. So tibialis anterior, EHL, EDL, and then you have your neurovascular bundle. So scanning here, video. So I start off a little bit more medial over that tibialis anterior. That's the easiest one to identify. Even without that ultrasound, just plop it right over there. And then I start going more lateral to kind of to see the EHL and the EDL. I typically try to use anisotropy to try to identify the tendons, but this is going to be your EHL. And then the EDL is going to be popping up right here. So you have your deep peroneal nerve, that honeycomb appearance, and then you have your dorsalis pedis. That's blood vessels there. And to kind of wrap up the anterior ankle, a quick patient has pain or swelling on that anterior medial ankle. I'm always taking a look at the medial malleolus to see if there's any subtle cortical irregularities or a bone step off. This is just a fracture or an avulsion injury on that side. I also scan short axis as well to the tibia. Shifting over to the lateral ankle, my quick checklist on the sideline. I'm looking at that distal fibula, ruling out those avulsion fractures or distal fibula fracture, taking a look at the major ligament structures such as your AITFL. If you're thinking of more of a high ankle sprain, syndesmotic injury, ATFL, which is the most common ligament injury in the ankle, along with your CFL at second. Then taking a look at the two lateral ankle tendons and the base of the fifth metatarsal. So similar to the medial now, just taking a look at the distal fibula lateral malleolus to see if there's any subtle fractures or avulsion injuries there. The meat and potatoes of this talk is more over the lateral ankle ligaments. And so, as I said, the more major ones are going to be your ATFL and CFL. The posterior talofibular ligament is also important. However, it's rarely injured alone, and it's very difficult to visualize on ultrasound. And typically, when you have an injury to this ligament, you're dealing with an ankle dislocation most of the time. And then you also have your high ankle sprain with the AITFL. And so how I organize my ultrasound scanning for the ligaments, I kind of think of using a clock. And the center of my clock is going to be my lateral malleolus, and I put one end of my transducer probe on the lateral malleolus. And I either start at the AITFL or the ATFL, but we'll start here at the two o'clock position. And that gives you that view of the AITFL. And then you swing or sweep this end of your transducer downwards to that four o'clock position, and you get a nice view of your ATFL. And then you keep swinging and sweeping that transducer all the way to the seven o'clock position to get that nice view of the CFL. We'll have an example of how I do that in a sec. So starting with the two o'clock position, we have the AITFL. And so going from the lateral malleolus to the tibia, we have a normal ligament here, nice straight fibular pattern. We don't see any big anechoic or hypochoic defects. This is just a picture of the probe placement, but I have videos here. And my normal subject, lateral malleolus, tibia, and then you get that view of the AITFL. And let's see quickly that video. And here I'm demonstrating dynamic external rotation, trying to widen that space. And definitely with complete ruptures of this ligament, you'll see the space between the lateral malleolus and the tibia widened up. And when you do see that, always compare it to the contralateral side if you have time to confirm. Now shifting down to the four o'clock position evaluating your ATFL. So lateral malleolus getting that talus in view and then similar to the AITFL kind of see that nice linear fibular pattern of the ligament there and this is our normal example lateral malleolus talus going across here and so to test this ligament if you're concerned for a high grade tear or complete tear you do your ankle anterior door test. This can be one of the most difficult ones to do depending on the size of your patient but this is how I do it. I typically have my transducer and my hand over that as to trying to stabilize that area over the tibia and the fibula and then I'm trying to anterior sublux that talus with my opposite hand there. So let me show that one more time and it's the corresponding view and so you have a it's very rare to find somebody with a normal ATFL but at my normal patients that were my PAs and they've never had an ankle sprain. So alternatively there's some other positions that you can do and I do this sometimes with my big ankles such as my with my linemen's where I can't hold their ankle at all is I just have them put their their foot on the floor and I'm then the floor helps stabilize that foot and I'm pushing posterior against the tibia to try to sublux that tibia from the from the talus. That's another view another way to do that or sometimes if you have your athletic trainer around or a student athletic trainer sometimes I have you know sometimes I have them hold my transducer while I'm doing the anterior drawer or vice versa holding the transducer. And our last major ligament our CFL at that seven o'clock position so the CFL going from the lateral malleolus to the calcaneus it acts as they describe it as a hammock that is underneath our peroneal tendons our longus and brevis so longus and brevis and when you have the foot in a neutral position or the ankle in neutral position the ligament is a little bit less tight it's a little bit more loose to kind of really get a good view of the entire or most of the ligament you know you put them in dorsiflexion that stretches out that ligament to get that good view. It's quite normal to get this artificial anisotropy here just as the ligament changes positions there but getting into dorsiflexion can help correct some of that. And in our normal patient so we have our lateral malleolus calcaneus and then we have the CFL coming in here and we have our peroneal tendons turn on the video here and this is me doing a tailored tilt test and you can see stretching that that ligament there. I like putting them on side-lying and putting a towel underneath their ankle and it already puts them in a rested inversion position. I find that's a little bit more comfortable for the patients especially in the acute setting and then I'm just focusing on just bringing them back to ankle neutral and then put them back into an inversion. And so putting it all together the full clock sweep there starting at two o'clock AITFL we're going to the four o'clock for the ATFL and then lastly the CFL and so I think this is the most exciting part of the exam I like to do and so ATFL already came out of position but now we're getting the talus in position coming up in position there there we go and we got the ATFL coming to view and we'll be going into the CFL at the seven o'clock position and we're getting our peroneal tendons coming in view and get that CFL coming in and we have that artificial anisotropy there and then I put place in the patient more dorsiflexion to stretch out that CFL ligament there. And so some examples of ligamentous injury to the various lateral ankle ligaments so we have examples from Bianchi you know ATFL partial tear CFL partial tear and a complete tear of the AITFL and so with our you know mild sprains or partial tears you know compared to a normal ligament the ligament is going to be nice and swollen you're going to either have focal or diffuse areas of hypoecogenicity plus or minus you'll see some widening on dynamic stress testing of the joint spaces there but typically you can see the entire ligament intact going to a more of a rupture compared to a normal tendon we're definitely going to see a anechoic or hypoechoic defect representing a hematoma and we can also see this the stump ends of the ligaments that completely ruptured and retracted backwards and definitely going to be seeing some widening on stress testing compared to your normal contralateral side and the most important uh lateral two lateral ankle tendons are going to be your peroneus longus and brevis I'm mostly usually focusing more on the brevis as it attaches more on the base of the fifth metatarsal but they you know approximately near the lateral malleolus they share a common tendon sheath when we're dealing with tenosynovitis or sometimes even partial tears that tendon sheath collects fluid along there more distally in the foot they tend to separate at the peroneal tubercle and they go into their different insertion sites peroneal brevis at the fifth metatarsal and the peroneus longus goes underneath the foot to the medial cuneiform the first metatarsal I most commonly don't follow the longest because it can be difficult to go underneath the foot and it can be a little tough with a portable ultrasound the quality when we're dealing with any peroneal instability symptoms or subluxation such as a case Sarah gave in terms of the peroneal brevis subluxing out commonly that's going to be your superior peroneal retinaculum that holds that those two peroneal tendons together and that typically is torn allowing the peroneal brevis to sublux out with eversion and circumduction of the foot it's a little bit difficult to view on some of the portable ultrasounds but that superior peroneal retinaculum is this hypo thin hypochoic line here outlining over the peroneal tendons near the lateral malleolus and so this is just examples uh of scanning the peroneal tendons over that lateral malleolus and short axis view to the tendons uh you can see the brevis breaking off and sorry you can see the brevis at the longest and scanning distally assessing if there's any major uh anechoic fluid surrounding the tendons assessing if any tears and coming to the peroneal tubercle you can see them splitting off and then I typically fall to the fifth metatarsal and looking at that more and long axis to the tendons where you can identify interstitial split tearing we have our longest which is on top of the brevis here nice fibular straight pattern of the tendons don't see any discontinuity or any major hypochoic defects there and so the usefulness of ultrasound and identifying peroneal tendon tears one study they and those patients that needed a peroneal tendon surgery they all got an ultrasound exam prior to surgery and those patients you know ultrasound was 100 sensitive and 85 specific so the ultrasound potentially can be very helpful identifying those those tears and so normal again long axis peroneus longest brevis and then we have our abnormal full thickness rupture of the peroneus longest you can see the anechoic cleft defect there representing hematoma fluid you can see the the ends of the peroneal tendon here and they're separating and wrapping up the lateral ankle I always finish up with a looking at the base of the fifth metatarsal especially at that peroneal tendon insertion site so we have the base of the fifth here and we're getting into more to the shaft of the metatarsal nice straight smooth cortical surface there no identifiable fractures on this normal patient and I also look in short axis view as well if I'm suspicious of any fractures there but going back to our right receiver I don't have his sideline ultrasound views as my ultrasound machine is getting serviced now but he ended up having a mild ankle sprain of the ATFL there was no rupture he had some pain you know with everting but his peroneal tendons were intact and so he had another reason why his eversion was hurting this because he had a subtle base of the fifth metatarsal fracture and so this is the proximal and distal and we can see the cortical irregularities and breaking breakage there and then more in the shaft is more smooth this was taken about two weeks after his injury when he came into clinic to follow up with me and so on the sideline he had more of a hematoma formed here uh and a lot of swelling in that area as well just a moment uh you can also turn on the color flow you can actually see some hyperemia and in that area so these were his x-rays about two weeks out very subtle but looking at that base of the fifth metatarsal you can see that lucency line there blowing it up here and that's that same view here same lucency here and then also we can see maybe the second one which that we can see on the ultrasound machine and then this is his ankle x-ray one of the leak views and you can also see that base of the fifth metatarsal fracture as well going to our last case uh as i said uh you're not only treating the athletes but also the non-athletes and so one of my football coaches uh before the game was practicing with uh his team and then he was dropping back for a pass and then suddenly all of a sudden fell to the floor uh he's described as having a sensation that he got kicked in the back of his heel his calf and he was unable to walk on his own power um i saw him probably about 20 minutes later when i arrived um before game time uh and at that time he had a lot diffused ankle swelling mostly in the back of the ankle definitely had an attendant defect in that Achilles area uh range of motion strength especially plantar flexion were limited uh and his Thompson tests he had a little bit of plantar flexion response but definitely abnormal to the opposite side and so my quick checklist for posterior ankle ultrasound scanning um majority is just that Achilles tendon and with the dynamic exam scanning the Achilles tendon all the way up to the myofascial uh junction uh meeting up with the gastroc to see if there's any myofascial uh junction tears and sometimes just quickly looking if there's any major fluid collection in the bursa um this may clue you in that there might be a terror or partial terror going on and so this is my scanning of that Achilles tendon um have the patient lying prone i like to get them into dorsiflexion to really stretch out that Achilles tendon uh and uh scanning the tendon all approximately to uh that myotendinous junction um and uh what i like to do especially Achilles as i like to scan very quickly first to get to the lay of the land and then come back uh scan more slowly to catch those subtle uh findings this is our normal patient getting to that myotendinous junction and then i also examine it in short axis via going back down so seeing that Achilles tendon form more and more uh nice and hyper echoic elliptical uh you can use anisotropy as your advantage to identify tendons if you're totally unsure or using other ankle tendons and all the way up to the calcaneus there uh dynamic exam of Achilles consists of placing the patient in dorsiflexion plantar flexion and seeing that Achilles tendon travel back and forth when you're questioning if there's a full rupture or high partial thickness you know where you'll see less movement of that Achilles tendon and also you can do the Thompson test which kind of gives you that same response as well and so in our case he had a new Achilles rupture uh he this was actually his second he had one that was about 15 20 years ago that was managed non-operatively he didn't want surgery for this one but he's like he was so scared like i have to be in a cast for six to nine months again and he was quite happy that i told him we don't really cast that long anymore uh and i didn't have his sideline pictures but uh his uh sideline picture looked very equivalent to this uh so we have it it was more of a longitudinal tear and it became more oblique i used to always think there are always transverse Achilles rupture but they more typically look like this and so you definitely have discontinuity of the tendon structure hematoma in those areas and then on dynamic you plantar flexion you'll see those two ends of those stumps come together of the tendon and then when you put in stretch them and dorsiflexion they you see the separation there and so um he is about three months out uh so i have a couple of his views here uh so distally on that tendon here this area is his area of his first rupture he has a lot of calcific deposition from that and it's a very severe tendinosis changes of that Achilles tendon this is the area of his more recent Achilles tendon tear but he already is starting to form a little bit tendon um not much scar tissue there and then um this is just looking at short axis view on that um and we should be able to get to where his calcific uh deposition is honestly his first rupture looks worse than this uh second uh and then on let's try to get that dynamic view again this is dynamic uh testing here i'm getting him in plantar flexion dorsiflexion using Thompson test and you can see that tendon moving back and forth so he's healing pretty well he feels great he's able to do a heel lift or a heel raise already and then this is uh the area of his calcific deposition within his Achilles tendon from his first rupture uh here's another example uh of a healing Achilles rupture this guy was about six to seven weeks out uh so falling more uh distally uh going more proximally it will run into that when going more proximally it will run into that tear here and so this is his area of his tear you can see uh hyper-echoic uh you know scar tissue formed in that area you can see some intact tendon uh more superficially there uh and then he has some tendinosis changes a little proximal to that this view here uh was more uh testing dynamically uh six to seven weeks i was a little bit more gentler on the dorsiflexion plantar i don't want anything to re-rip but he as you can see he would it's forming together and he's getting a response there so uh wrapping up uh in terms of the ankle ultrasound there's great support using ankle uh ultrasound for acute ankle injuries especially in the acute setting it's a potential triage tool to help reduce unnecessary x-rays you can do quick training and you can catch a lot already there's great level evidence and support for using it to identify ligament injuries tendon injuries bone injuries low cost successful becoming more and more portable and those portable machines are or handheld machines are getting better in technology and you can get some quick high yield diagnostic information to help uh your return to play decisions so here are my references and thank you very much Perfect. Thank you, Dr. Diaz. Let me go ahead and share my screen. My name is Donald Kassidanon. I first wanted to, like others on this lecture, say thank you to Dr. Mullen, to Dr. Fredrickson for getting us together. I feel really honored to be part of this group. Currently, I'm at UT Southwestern down in Dallas, Texas, and I am going to go over the FAST exam today, which is a little bit different than the other topics we've gone over, but also something very, very useful for the probably more so sideline coverage, but also occasionally the training room. So, and disclosures, I definitely do not have any. For objectives, today I'm going to describe the indications and limitations of bedside ultrasound and trauma. We'll also learn how to understand how to perform the eFAST protocol in the setting of trauma, and then identify relevant local anatomy, then provide examples of pathologies that can be detected on the eFAST, and finally recognize the relevant pitfalls in the detection of these pathologies. Now, I know this is, as like a physiatry conference, I'm sure the FAST exam is something that we're typically familiar with in PM&R, but I think a lot of us doing intern years may have had exposure to this. I know during my trauma rotation, I did this on pretty much any trauma that came in, and it is technically a very, pretty simple exam to perform and very useful for the sidelines. So the FAST exam, it stands for the Focused Assessment with Sonography and Trauma. The objective of the FAST exam itself are to detect intra-abdominal free fluid, and also to detect pericardial fluid. And then there's also an eFAST, which stands for extended FAST, and that's in order to help detect hemothorax and pneumothorax. And as Dr. Reiser kind of alluded to in her introduction talk, the FAST exam is one of the first uses for ultrasound in kind of the medical field. Now, in terms of benefits of the FAST exam, it can be performed very, very rapidly. It's not invasive, it's very inexpensive, it's easily repeatable, and it's highly specific for the need to go for a therapeutic laparotomy. Limitations include if you have kind of a thicker patient, it may be hard to identify some of the structures. Also, if someone has subcutaneous emphysema, it may also distort some images and make it hard to look for the free fluid. And then finally, it's nonspecific in terms of if you do see free fluid in the abdomen or the thorax, you might not necessarily know where it's coming from. Now, just as a review before we go into like the protocol, so for peritoneal fluid drainage, which is primarily what we're looking for in the FAST, remember that fluid tends to pull in predictable locations. So usually these patients who have had trauma are usually supine, so a lot of the fluid kind of goes posteriorly. And then we're looking at the upper quadrants as well as the pelvis. So if you really want to get a sensitive exam for the upper quadrants, it's best to put them in Trendelenburg. And then just as a reminder, Trendelenburg is whenever you're laying down, but your head is like lower than your legs. And then for the pelvis, then you want to have reverse Trendelenburg where the head is actually above the legs to allow gravity to pull down fluid down toward the pelvis region. Okay, in terms of FAST exam components, typically I go in this order. So right upper quadrant, left upper quadrant, then suprapubic, and then finally cardiac. This shows the view for subxiphoid, but we'll also go over the parasternal view. And then whenever you want to do the extended FAST, you also include the lung fields. In terms of transducer selection, you really want to get a low frequency transducer because you're looking at deeper structures. So you can either use a curvilinear, which is pictured here on the left, or a phased array, which is here on the right. They each give good penetration for you to see the abdomen and thorax. However, note that the smaller footprint with the phased array, if you have one, tends to be better, especially for the parasternal cardiac view. That way you're not capturing a bunch of the rib, which can cause rib shadowing and make it difficult to see some of the structures. Unfortunately for my presentation, I don't have a phased array in my clinic. So I use the curvilinear, which still gave pretty good images. So we first start with the right upper quadrant. So in terms of propositioning, you place it kind of over here, indicator. You want to put the indicator toward the patient's head so that superior on the patient or cranial on the patient is equivalent to left on the screen. And then you aim for like the eight to 11th rib spaces. And really you want to angle your transducer posteriorly. Saying this is a great image and showing what I mean by angling posteriorly. So here, if you look, if you're on the right side, this is posterior anterior, and then here you have your liver, and then here you have your kidney. You're really trying to find that junction between the liver and kidney. And you can see if you're angling your transducer anteriorly you're probably going to miss the kidney. So you really want to point this backwards or posteriorly. And then you slide the probe around to avoid rib shadow. And in terms of the image, here is what you would typically see. These are all going to be normal images until I show you some images of pathology as my patient did not have any abdominal or thoracotrauma anytime recently. So here I'll show you the labeled image. So this is superior and this is inferior. And then this entire area right here, you can see the liver. So this is kind of the superior edge of the liver and this is the inferior edge. And then here you have your kidney. And then in between, this is Morrison's pouch. So if anybody has to have any free fluid, you would see, you know, anechoic area right here in Morrison's pouch. And then here's an image of the, or here's the diaphragm. And then whenever you do the image, make sure that you're really sweeping the area. So you're seeing all the border of the Morrison's pouch. And when I say sweeping, like if here is the probe, then you really want to come up and down on it. So this is a video of me kind of sweeping through the area and we can see throughout Morrison's pouch, we don't see any fluid there. Next, you can do the left upper quadrant. So you'll just flip over to the left side of the patient, indicator once again to the patient's head. This time you can go a little bit higher at the eighth and ninth rib space. Rib shadowing may be challenging. That's just because this view where the spleen is tends to be a little bit more difficult to locate. And it's actually a little bit more posterior. So one of the rules that you can often follow is make sure that your knuckles are pinched down into the bed. Otherwise you're probably a little too anterior to see your view. And then occasionally you can ask the patient, you know, if they're still with it, to inhale, to displace anatomy a little bit more inferiorly as the lungs expand. And that might give you a better image as, you know, you're kind of hiding away from the shadows. So left upper quadrant, it looks very similar to the right upper quadrant view, but in this case, you know, you don't have liver on the left side. So this is all spleen right here. So here are the labels, and then you have kidney right here, and then right below that's the diaphragm. And if you were to have any kind of free fluid in this area, it would be right in between the spleen and kidney. And then once again, you want to make sure that you sweep through the entire area. So just kind of sweep through, make sure you're not missing any sort of free fluid. Next, we'll go down to the suprapubic region. So in terms of propositioning, you're basically just aiming at the bladder. So you go midline cranial to the pubic bone. You always want to do a transverse view as well as a longitudinal view. And I'll show you what I mean by that. So this is a transverse view. You know, my subject was male, but if you were to have a female, this is like a great view to see what you expect to see within your image. So as you're going down, you'll see a bladder here, in a female, you'll see uterus, and then behind that, you'll see like intestines slash rectum. In males, you know, we don't typically have uteruses. So sometimes you'll be able to see a prostate if someone has like BPH, or if you're at the right angle, but most younger patients, you may not see the prostate. So here's my transverse view on my subject. So with labels, you know, this area filled with fluid is the bladder, and then right below it's the intestines. And then in between the bladder and intestines, you have your paltrum douglas. So this would be where you would find any sort of like pelvic free fluid. And then here is a video which is kind of sweeping superiorly and inferiorly to make sure that you don't miss anything. And then this is a longitudinal view. So in this case, superior is up here, inferior is here. Once again, we see our bladder. In this case, in a longitudinal view, you'll often see the prostate. So here it is right here, and then intestines below that, and then the paltrum douglas is in between there. So you make sure you want to sweep left and right on this one. So here is the video for that. And then once you're done with the suprapubic view, then we go on to the cardiac, which is the fourth and last portion of the traditional FAST exam. So for the cardiac exam, this is probably the one that's a little technically most difficult. You can either use the subxiphoid view or the parasternal view. And really you're looking for three main things when you're here. You're looking for cardiac activity, making sure that the heart is beating. Then you can look for a pericardial effusion. And then if the pericardial effusion is bad enough, occasionally you'll see some right ventricular collapse from the pressure from the fluid. So in terms of propositioning for the subxiphoid view, this one might be uncomfortable for the patient, but usually after they have a trauma, they don't typically notice you doing this. You really want to kind of put the transducer down flat onto the patient's epigastrum and try to slide underneath the ribs. The indicator is toward the patient's right, and then you angle the transducer toward the patient's left shoulder, because remember the heart is kind of toward the left side. And then you usually want to increase depth on your screen because you have to get a little further deep to see then all the chambers of the heart. And then on the subxiphoid view, this is known as a four chamber view. The apex is going to be to the right of the screen, and then the left side at the bottom of the screen. So here is the image that I got for my cardiac diphoid view. So you can see right here, this is a left ventricle. This is a right ventricle. Then you have your right atrium right here and your left atrium, and this is the apex of the heart. And then, you know, just superior to all of that, you have your liver sitting up there. And then this, you can make sure that the cardiac activity is good. You can really see the left ventricle pumping well. The other view, the parasternal long axis view may give you a little bit more detailed view, but keep in mind, the subxiphoid's probably better to do during a setting of trauma because it's typically done a little bit quicker. So for probe positioning for the parasternal view, you're left of the sternum, and then you go, you aim for the second to fourth intercostal space, and you want the probe indicator to be toward the patient's right shoulder. And you're really looking at the sagittal planes. You really want to try to get in between the ribs, otherwise you'll have too much rib shadowing. And then this will give you a three-chamber view. You'll get a good, the reason why you don't see the right atrium is because it's kind of hidden behind the aortic outflow tract in this view. So here's my image here. So you'll see your left ventricle, your right ventricle, left atrium, and the aortic flow tract kind of hiding the right atrium behind it. And then we want to make sure, with the cardiac activity, here's a video for that, with the left ventricle also giving a good pump. Now, in terms of pathology, when you're looking at like a, for a pericardial effusion, this is one that's pretty bad. So you can see a large amount of posterior peri, I'd say this posterior pericardium, and then you see a large effusion surrounding the heart. On top of that here with the right ventricle, if this was a video, you would see that it's pretty much, even during diastole, it's like not filled, it's pretty much collapsed, and that's a good thing. Not filled, it's pretty much collapsed, and that just means, you know, they have a lot of pericardial fluid and you start getting worried about them going to tamponade. And then finally, the extended FAST was added on a little bit later. So this is an additional four-view, this is in addition to the four-view traditional FAST exam, and this includes evaluation for hemothorax or pneumothorax. So there's really two main additional components for this. You really want to expand your right upper quadrant and left upper quadrant views to visualize the diaphragm, and then you also want to scan the anterior chest to look more for a pneumothorax. So for the expanded view of the upper quadrants, you slide the probe cranially to view the diaphragm and liver interface. So usually you're down here, but you kind of slide your probe up here, and then normally the diaphragm acts as a mirror, so the liver appears to be on either side. So here's an example of that. So you see your diaphragm here, you see your liver, and then because the diaphragm is acting as a mirror, you'll see it looks like it's liver on the other side, and the spine or thoracic spine stops right there. However, if you have fluid within the thoracic cavity, then you have this pleural effusion, and then you can see that thoracic spine continues to extend throughout. So that would be indicative of a likely hemothorax or some sort of pleural effusion. Then the anterior chest view. This is the one view that if you have time to switch, going to a high-frequency linear transducer tends to give you a better image because it's more of a shallow structure you're looking at, but if you still have just a curvilinear, it tends to work well too. And you're looking at the anterior chest wall, and the indicator is located toward the patient's head, and you can either slide down the chest wall to interrogate each rib inner space, or you can just mainly scan in the second intercostal space, which is between the second and third ribs. And the reason being is because remember that air is very, it goes to wherever there's the least gravity dependence. So if the patient is supine, it usually goes anteriorly. And then most of the time patients are a little bit in reverse Trendelenburg. So then the air tends to rise up into their chest. So, looking up in the anterior superior portion of the lung or chest wall tends to be the most sensitive in terms of determining small pneumothoraxes. So here are the images that I got for left lung and right lung. The right lung one is a little bit better. So you can see the ribs right here and the intercostal muscles in between, and then you'll see lung pleura right here. You'll typically see the lung pleura sliding, and then you'll see this on the videos. So, let me show you this. So you can see like the motion in each of these. This is in B mode. And in B mode, if you don't see that lung sliding, then you are, you know, that's pretty much indicative of a pneumothorax. If there's ever a question, you can also, some machines have M mode, and that's just looking at this one location, looking at motion. And normally you would see more of a sandy beach looking thing right here, but then if you ever see a barcode, which, so this describes like a barcode sign, then that is indicative of a pneumothorax. All right. And then just comparing to like, you know, some other modalities we might look at for pneumothoraces, supine chest x-rays, they miss up to a third of all pneumothoraces, and it's only really 50 to 70% sensitive at detection. It's also inaccurate for anterior pneumothoraxes due to air layering. However, ultrasound, you can detect the small or anterior pneumothoraces, and also has a sensitivity of 92 to 100%, which is pretty much equal to a CT scan, and it has a negative predictive value of 99 to 100%. So pearls and pitfalls of doing an eFAST exam is be sure to scan each upper quadrant with the beam angle toward the bed posteriorly. You also want to scan the pelvis in both transverse and longitudinal axis. Body habitus can really be a limit imaging, so especially the cardiac. So, you know, just practice and then just be aware of that. Also, it does not detect retroperitoneal hemorrhages. So if someone is, you know, having a hard time keeping consciousness or, you know, having, you think that they're losing blood somewhere and the FAST exam is negative, you have to keep this in the back of your mind. And also like all the ultrasound topics we're talking about today, it's somewhat operator dependent, but like I said, the FAST exam is typically something you can pick up pretty quickly. So summary of the protocol. Remember, I usually go right upper quadrant, left upper quadrant, suprapubic, then cardiac, and then do my eFAST exam after that. And then just to tie this in together clinically, this is a blunt abdominal trauma algorithm, which is typically what you'll be using it for on the sidelines. So if someone does have a blunt abdominal trauma, you do the FAST exam. If it's positive and they're stable, then you'll have them get a CT scan at the hospital. If it's unstable, they'll likely need to go straight to the OR. Otherwise, if it's indeterminate FAST exam and they're stable, they'll need a CT. If they're unstable, either OR or diagnostic peritoneal lavage. And finally, if your FAST exam is negative and the patient's stable, then you can observe them and repeat it. If they're still unstable, then you want to consider the retroperitoneal hemorrhage and then repeat a FAST. And then I wanted to thank Dr. Smith, who is one of our pediatric ER fellows for his body as my model, and also his mind helped me with this presentation. Otherwise, here are my references. And then I'll take questions at the end. And otherwise, I will pass the baton to Dr. Kadabi. Kevin, are you on here? Can you hear me? Yeah. I can hear you all here. It's not allowing my screen share. It takes me to the security and privacy settings when I went on the screen share. The security and privacy settings on your computer, is that right? Yes. I've never had that happen before with the Zoom. Is that something everyone else has had too or am I just- Yeah, no problem. As soon as you redownload or get a new computer or an update that needs to be changed. What we can do, we have two options here. We're right on time, so we're doing good on time. You can either send your slides. If you've made any changes to the slides or if you'd like one of us to share it, we can do that. Or you can update your security settings and then re-log on to Zoom. That should only take a couple of minutes. What we can do right now, Kevin, why don't we take time for questions while Mike- Oh, good point. I'll log in, log out, and try to secure your stuff. Thank you. I'll be right back. Yeah, while we're waiting, does anybody have any questions that you want to put in the chat? Let me see. I know that- There was a great question earlier, which I addressed in chat from Alexander, asking about being able to see a Saigon fracture with an ACL injury. Absolutely. That's a really good point. Similar to, as we talked about the pellegrinia steata with an MCL, you can also see a Saigon fracture. It could increase your sensitivity, but remember that a Saigon fracture is not always specific for just an ACL. You could have a posterior lateral corner injury or an MCL injury, and sometimes those can also be seen with a Saigon fracture. It's a really good point and something that I'll certainly include in the future for this talk. And Dr. Kadavy, as we're taking additional questions, just want to let you know that our AAPM and our staff do have your slides available if you would like them to share them from the main hub. I've made a lot of changes since then. I'm emailing them to you right now, Kevin, and we'll see if perhaps that works. Lots of videos like everyone else's, so it might take a little bit to get there. But it's downloading to the drive right now. It looks like there's a question in the chat from Andy. If you had a suspicion for a splenic laceration and wanted to ultrasound it on the sideline, how quickly might you expect to see fluid on exam? Andy, yeah, that's a good question. I think it really just depends on the severity of the actual splenic laceration. Obviously, if it's a huge one and it ruptures, you'll see fluid immediately. I think if it's more of a leak, I will say the FAST exam is good for sideline stuff, but if you have any sort of small suspicion for any sort of abdominal trauma with a possible like more of a small splenic laceration, I typically have a low threshold and send patients to the hospital to be further evaluated. The FAST exam, while we're waiting for EMS, may just give the EMS as well as the hospital a little bit more information if we can find that out. Does anybody want to share one of the most interesting things or the most useful way you have found ultrasound in the training room? What are you guys really using this for the most of all? We're covering a lot, but what's your go-to with this? I would say, bread and butter wise, I think I'm most often trying to diagnose acute rotator cuff tears. I'm in one of the interdisciplinary orthoclinics where we share the same patients, and a lot of the post-op patients, the orthopedic surgeons are asking me to diagnostically scan and see if they have any sort of re-tear as well. We use it a lot, too. I would say for hamstring tears, it's really effective acutely because you want information right away, and you're not going to get an MRI on everybody anyway, so ultrasound can be really helpful. I think for me, sometimes seeing a negative exam actually has a lot of value, so you're performing the examination with the patient, you're watching, you're interpreting the exam to them, you're contextualizing your finding for them, and then to be able to find something positive is what this talk has been, everyone's doing an amazing job, I'm learning so much, but also telling the patient, telling your athlete, you don't have this, you don't have that, everything's fine, there's a lot of value in helping your athlete get a better understanding of his or her condition, or lack thereof, and they can have, in those settings, it really gives them the confidence to return to play, and to trust in their therapist and in their physician, so that's where I really find a lot of value. Yeah, absolutely, absolutely. Great. Dr. Kadabi, are you still waiting? I emailed my talk to Dr. Mullins, who sent it on to APNR, so I think it should be- I'm opening it from my end right now, and yeah, we're still doing very well on time, we had 10 minutes for Q&A, I'm just closing my previous PowerPoint to be able to share this one here. All right, really appreciate your help, I've done a lot of Zoom talks, and I'm sure it's, I know it's a user error on my part, I'm now part of the old crowd, the old guy tech problems crowd. Dr. Chen, I know that you had, when you were a fellow, you became very interested in looking at the chlorochromia ligaments, we can go over that later, so. Roger. All right, well, hello everybody, first off, thank you for your patience, big thanks to Kevin Mullins and Dr. Fred for organizing and putting this together, very honored to be part of this group. And I'm in a wonderful, great, beautiful city of Kansas City, and I'm very fortunate to be a team physician for our soccer teams, Sporting Kansas City, which is one of our, which is the MLS team, the Major League Soccer team in town, I also take care of a couple other teams, but related to this talk, the soccer team is super relevant, I spend somewhere between one and three hours per week on the sidelines, scanning players, usually at halftime and after a game, between the two sporting soccer teams, mainly the first team, and Sporting has two ultrasounds, which is also a luxury, they have a desktop based ultrasound in the training room, and then at the stadium, they have a portable ultrasound, and they are, you know, obviously the big one is the best one, but having an ultrasound has been life changing for us and our athletes, and we've saved a lot of scans and made a lot of diagnoses, so go ahead and go to the next slide. My only disclosure is I'm a consultant for Arthrex, and I do some of their teaching, next slide. So muscle scanning technique, we're going to start with, first off, finding your anatomy, identifying each muscle, and finding each mild tendon disjunction. We're going to focus on the hamstrings, and I appreciate Dr. Fredrickson's segue into my talk, because this is where I spent 90% of my time on the sidelines scanning is muscle injuries. He obviously has a lot of muscle injuries, and so I'm going to focus on hamstrings, since that's the most common. You want to scan the whole muscle, because you may miss something, a lot of these muscle injuries will hurt two inches away from where the actual muscle injury is, because gravity will pull the blood, the fluid distally, and the actual injury will be a couple inches cranial to where they're pointing. I've been fooled on that before. And then you want to scan surrounding muscles, because sometimes you'll have two muscles that are involved, or sometimes you think it's a neural muscle, and then you go next door and you find an injury. And then a couple other speakers have hit on color doppler and its value to looking for an acute injury, and ability to compare to the other side. So let's start at the lateral hamstring, because the biceps long head is by far the most commonly injured muscle. And this is a screenshot starting at the distal lateral hamstring with the biceps short head in view in its muscle form. And then just superficial to it, you have the thin band like tendon of the biceps long head, just superficial to it. And then of course, the common peroneal nerve is just medial to both of these. Don't confuse the common peroneal nerve for one of the hamstring tendons. You won't be the first one, but you'll never hear the end of it. So we're going to start here, go ahead and click next slide. And this video is going to show a scan progressing from here approximately. So first start looking at the short head of the biceps. And then what we see right above that is the long head of the biceps comes into view, and it just takes over the screen as a short head of the biceps. We get to its origin on the linear Asper on the femur. Can you reclick play on that video? And so now I want you to focus on the long head of the biceps. So that short head is the muscle belly. And then I want you to focus right above the long head of the biceps, which is going to be right, right above the short head. This is the long head. And boy, you might have to click and can you click play again, or you might have to click just a little over and see if it'll keep going. So watch above the short head of the biceps, that long head shows up right there. So that's when the long head shows up. The short head then disappears as we pass its origin along the linear Asper. And then at this point, right smack dab in the middle of the screen is the sciatic nerve. We saw the common peroneal and the tibial nerves at their bifurcation. Now we're at sciatic nerve territory. So let's click to the next slide and we're going to get to the next way to scan one more click. And we'll see our positioning for this one, which is just proximal to midline of the thigh, where we see the sciatic nerve in the middle of the screen. And then right above it, go one click back, go click left. The aponeurosis of the long head biceps tendon is that comma shape. That white hyper-echoic comma shape is the aponeurosis, the long head biceps, arguably the most important thing you're going to scan in your ultrasound of the hamstrings. And then the muscle belly for the long head biceps is above it is superficial to it and surrounding it. So what I want you to do, we're going to play this video a couple of times. We're going to start at the mid thigh and we're going to press proximally and go and hit play. And watch that aponeurosis, that comma shape right here. Watch that comma shape as we progress cranially. And right here, we have the conjoint tendon with the semimembranosus tendon below. And can you play that one more time? Let's watch that one more time. I want you to watch that aponeurosis, which is right above the sciatic nerve, that comma shaped aponeurosis. And once we get about two seconds from the end, can you click pause on that video? So keep your eye on the aponeurosis and then right here, right there, that's perfect. Go back just a smidge, actually, maybe a little more, a little more, a little more. Yeah. So right here, right in the middle of the screen, we have the long head biceps femoris, which has already combined with the semitendinosus tendon and is the conjoint tendon. And then just a little bit deep to that end, to the right or medial, we have the semimembranosus tendon and then down left a couple of centimeters down deeper into the, to the left or laterally, we have the sciatic nerve. This is important view. I want you to keep this view in mind with that long head biceps and semitendinosus conjoint tendon is right in the middle and a smidge superficial to the middle of the screen. All right. So let's go to the next slide here and we're going to move on and go click one more time. And we're going to go ahead and move on to the medial hamstrings here. So the medial hamstrings are fun for a lot of reasons. The semimembranosus muscle in this view. So we have on the, on the right side is medial. The semimembranosus is the more medial of the medial hamstrings. The semitendinosus is going to be on the left. Now these muscles, you can think of these in terms of what they're doing around the knee at the distal, this distal thigh. The semitendinosus is a tendon distally. So we call it semitendinosus. Semimembranosus has a very distal muscle belly. So we call it semimembranosus. Now approximately it's the opposite. So the semitendinosus is going to be the larger muscle in the proximal thigh. Semimembranosus is going to be tendinous in the proximal side. So there are really two good ways, just like with the lateral hamstrings, there are two good ways to identify which is your semitendinosus and which is your semimembranosus. Both of them are great. I do them both depending on where the injury is, but I want to show you both. So starting just proximal to the mid thigh, a little bit medially, you see this inverted triangle. That is the semimembranosus. How do you remember that? That's the semimembranosus. Go ahead and click. Well, semimembranosus, the letter M is full of triangles, right? Go ahead and click and then click again and click again. Lots of triangles in semimembranosus. Semimembranosus is an inverted triangle at the mid to proximal thigh. Semimembranosus is a very exciting muscle as you go up proximally also with that video that I just showed you. So it's a muscle that definitely stands out. Now we're going to start right at this image and we're going to start at the mid to proximal thigh and we're going to start scanning distally. So I want you to keep your eye on that inverted triangle, semimembranosus, which is right in the middle of the screen. The first thing I do, if you have trouble finding it, is put some pressure on it. Use some sonopalpation to identify that semimembranosus and it really stands out against his neighbors. So once you found that semimembranosus, go ahead and click again. Next slide. Now we're going to start advancing distally and watch that semimembranosus. Watch that semimembranosus as it enlarges from its aponeurosis. You might actually have to click and drag it over to the right. Click on the, click on the bar below hand. You might have to manually drag it over with your mouse. Yeah. You want me to just drag it like this here? Yeah. That's, that's perfect. Give you a little more work to do, but I want you to watch the semimembranosus and you see that semimembranosus enlarging as the myotendinous junction, which in this case is deep and lateral or left, uh, gives off more muscle fibers. And as we get farther away, the semimembranosus now is nearly completely tended. So if, uh, if you wouldn't mind doing that exact same slow motion scan again, now I want you to keep your eye on the muscle, just lateral or left of the semimembranosus, watch the semitendinosus. So it's on the left side of the screen and we see that. So I tend to notice this muscle. Now it's starting to shrink as it collapses on its app at distal aponeurosis, which is a superficial and medially. And right around here, it really collapsed fast. You can see that tendon in a very superficial aspect, right in the middle of the screen. It's nearly completely collapsed on the tendon. Whereas the semimembranosus at this point is still very much a large muscle and is deep to that. So that's how you find it. The semimembranosus approximately I go to advance to the next slide. Now let's say we started one more, one more click. Let's say we started to scan right here, which is the distal medial thigh and that semitendinosus remember is a tendon. So this is the most superficial aspect of this scan. We see this flattened oval tendon of the semitendinosus, which is so easy to find. If you ever have trouble with your orientation, start here. This one is absolutely foolproof. We have our semitendinosus oval tendon at the most superficial aspect of the screen. Semimembranosus just deep to it. It's still a large muscle at this point. It's still not completely tendon yet. Now go ahead and advance to the next slide. What we're going to do is we're going to scan proximally. So watch the semitendinosus at the top of the screen. That semitendinosus, it's just going to start to give off its muscle fibers right there. And then here it is getting larger and larger, and it's about to turn into that inverted triangle. So let's watch that one more time. Watch that semitendinosus at the superficial aspect of the screen. Good. Now let's watch one more time. Instead of watching the semitendinosus, I want you to watch the semimembranosus, which again, that's, I'm sorry, the semimembranosus, which is that big muscle that is deep. That semimembranosus is deep. It gets pushed to the medial aspect. And right here is it's in its triangular shape that we saw earlier with the semi-membranosis. All right, go to the next slide. So, important things to notate are which muscle it is you see the injury in. When you scan, first thing, scan a lot of muscles, scan a lot of hamstrings, get good at scanning and knowing your anatomy, know what normal looks like. Then, once you know your anatomy, you wanna scan your injured muscles, you're gonna notate which muscle it is that is injured. And the next part of scanning is identifying which part of the muscle in the muscle unit is injured. And this is most often the muscle belly or the myotendinous junction. Myotendinous junction injuries, these have a very different prognosis than your muscle belly injuries. This is essentially the spine of your muscle. This is where a lot of the tensile strength comes from, so these take much longer to heal. And then, less often, you'll have injury to the actual tendon. So, then you wanna notate what the percentage of disruption is from a cross-section view. So, if we're looking at the biceps femoris long head in a cross-section or transverse view, like we just were, you wanna notate, is this 50% of the muscle that is edematous? Is this 10%, is it 90%? What's the cross-section percentage of that total muscle in that view that is disrupted with edema? And then, perhaps most importantly, is the length of the tear and the length of edema. There have been many studies showing that this very directly relates to the length of time these athletes are gonna be out. Color doppler is important. And this is also important later on when you're doing your follow-up scans, two weeks, four weeks, six weeks, eight weeks later, and a lot of people use this to help denote when an athlete is ready to really begin their return to play protocol, not get back on the field full speed, but get back to 80 or 90% of effort in training. Old injuries are real easy to see on ultrasound. I would argue easier than MRI. And often this looks like a hyperechoic area within the muscle or at the myotendonous junction. And so you wanna note whether you see this, where you see this, if the new injury is happening at the same location, that can be hard to see. And then identifying a hematoma. This is the one incontrovertible area that we can intervene in our athletes with a muscle injury that will quicken their return to play. If an athlete has a hematoma more than three or four milliliters of volume and you aspirate it, it will get them back more quickly. And so this is something that gets me excited on the sidelines when I see this. There's a lot of argument of when do you aspirate it? Do you let the bleeding finish? You don't wanna wait too long. Do you not wanna wait too soon? That's a whole nother discussion to have. All right, next slide. So there are several different criteria out there and most of them use MRI for their standard, for classifications. And we've started using this in major league soccer, which is the British Athletics Muscle Injury Classification. And this came out in 2014. And since then, it has been validated very nicely with a length of time and return to play. And once again, it's an MRI classification system that has two criteria. One is a grading system, zero to four, zero, one, two, three, four, so really five grades. And then the other is a subclassification within each grade, A, B, and C. Next slide. So let's start talking about the grades. Grade zero is a normal MRI. That doesn't mean the athlete is not injured. That doesn't mean the athlete is not hurt. That just means MRI is normal. And this doesn't have a perfect correlation with ultrasound because often in my experience, we've been able to pick up some milder injuries on ultrasound than the MRI will pick up. We often get both for our high dollar players on our team. A grade one injury is, what that is on MRI is an area with less than 10% of the cross-section of that muscle with high stir signal. And on ultrasound, that correlates to an area of edema less than 10% of cross-section of that muscle. Or a grade one is also less than five centimeter length of edema or less than one centimeter fiber disruption. These things will become very second nature for you to start looking at the cross-sectional area of edema, the length of the edema, and the length of the actual tear. Very important things, and your eyes will immediately go to these when you start doing a lot of these scans. So that's a grade one. A grade two muscle strain is 10 to 50% cross-sectional area of that muscle is involved with a length of edema, five to 15 centimeters in length, and a disruption or a tear less than five centimeters. And a grade three is over 50% of the cross-section of that muscle is edematous. And the length of edema over 15 centimeters with length of tear over five centimeters. These grade three strains, these are generally six, eight, 10 week return to play injuries. So they really can give some valuable information. Grade four muscle strain, this is a complete tear of the muscle mountainous junction or the tendon, these are a little less common. And so we divide these into a sub-classification system based on what the location is within the muscle tendon unit. And so if it's just in the muscle belly, that's a grade A. If it's involves the mountainous junction at all, it's a B. And if it involves the entire tendon, it involves the tendon, we call it a grade C tenderness. And so in order, that is roughly the order of severity for sub-classification. A's generally heal quicker than C's. All right, next slide. So I wanna give you guys a case to kind of bring everything together here. And this is one of our athletes. Go ahead and go to the next slide. This is one of our athletes who is a defender who was sprinting backwards and he grabbed his thigh while he was sprinting, he was down. He hopped off the field, couldn't, he was not able to really use his leg at all to walk and so did a very quick exam. He didn't let us do much to his thigh and we got him back after the game and this is what we saw. So the image on the left is a short axis, which is that view that you see me scanning this proximal hamstring. And this is that view that we went back and forth on at the proximal thigh where we have the sciatic nerve is kind of looks like a tadpole in this view. It's an oval kind of tadpole looking thing in the middle, lower two thirds left side. So that's lateral to everything else on this, to the other tendons on the screen. That is the sciatic nerve. Now, if you go just medial or right to that, that oval shaped tendon, that's a semi-membranosis. And then just above that, if you guys see where that pointer is, pointer, can you move over about two centimeters to your right? There is this, not quite that far, just on that same picture. Yeah, I'm not sure where my pointer is right now. Oh, right where you are, just a smidge to the right. Is it showing up on the screen? A little more to the right. Yeah, so that circle that he is on the bottom part of right there is right in the middle of the screen. That, which is hypoechoic with anechoic areas. That used to be his conjoined tendon. That was the long head biceps tendon and semi-teninosis tendon. This is a complete rupture of the long head biceps and semi-teninosis conjoined tendon that occurred in this athlete while he was sprinting. So, and then surrounding that, you see some edema in the muscle surrounding. So now let's go to the picture on the right, that long axis, and we see muscle fibers on top. Below that, you see what was the conjoined tendon going from mid left to bottom-ish right. Left is proximal, on the right is distal, and just about a quarter over from the left side of that image, the tendon you can't see anymore. And that is the end of that tendon. That's where that tendon ruptured. And then everything else from there over right above the LAX and all the way over to where my distal marker is, all of that used to be conjoined tendon. So click next. What grade would this be? A 4C, it's a grade four because it is a complete rupture of a muscle or a tendon, and it's a C because that involves tendon. So just to give some closure, this is actually the first case of a complete proximal tendon rupture, a grade 4C injury that we had had on our sporting team. This case was exactly a year ago when this happened. And so we had to sort of call around the league. How do you, are you guys treating these? Because these are sort of unique injuries. It wasn't an avulsion. So it's a unique injury. And so we treated him non-op. That was how we had heard from the other team physicians around the league. And it took him about three and a half to four months to get back, but he is back playing as if this never happened. He's doing well. And then funny enough, so in the 26 years that Sporting Kansas City has been in the MLS, this was the first. Three months later, we had the second exact same thing. So I spent a lot less time scanning the second athlete once this happened, and that's gonna be your pattern. Once you see one of these, whatever grade, you get good at it and you recognize it much more quickly next time. So go ahead and go to the next slide. That's it. That's all I have. And I'm gonna pass the mic back to Dr. Mullins, Dr. Fred. And if we have any other questions from the audience, go ahead and bring them up to us. Dr. Fredrickson, did you have any closing remarks? Thank you so much, Dr. Kadavy. That was a really fantastic presentation. I appreciate those images and that unique case. Yeah, I didn't really have anything to finish with. I would just say thanks everybody for the amazing presentations. I mean, I learned a lot from everybody. I think, you know, when you leave fellowship and you get into your areas of expertise, everybody finds things and discovers things that are unique to your practice and you become sort of an expert in your own little areas. So thanks for sharing it. I think a lot of people are gonna end up watching this more, the recording, just given the times. So I don't see a ton of questions yet on the chat other than what we already went over. I would just say if anybody has maybe one pearl that they didn't cover, if you wanted to share it before we close off. Like one pearl from your particular practice that you think, you know, like you gotta know this. Mike, anything you didn't cover? My one pearl would be to develop your history and exam skills first. Ultrasound is important. It's very helpful. It's totally changed my life and my athletes' lives, but your history and exam is always, always, always more important than whatever you see on your screen. Yeah, I would echo that for sure. Yeah. How about Sarah, anything? Yeah, so I see a lot of bone stress injuries and I think ultrasound can be a great route to go. If you have any suspicion and nothing's showing up, it's not gonna be 100%, but sometimes it'll surprise you and show you things you weren't expecting. And oftentimes, if you're gonna treat just based on an X-ray without an MRI, it can be a great thing to show an athlete, to say, hey, we see something and this is what we're looking at. Otherwise, when we're just saying, hey, I think there's bone marrow edema, but I don't have something to show you, it can be a little bit tougher. So I think from an education standpoint, I think it's really helpful to do ultrasound with a patient there to do the education piece. Yeah, particularly as Anne mentioned, the metatarsal, the tibia, fibula, ribs, I mean, those are very accessible areas for ultrasound. And what we found is you don't necessarily have to get an MRI with those, particularly in areas that are considered low risk entries. Yeah. Yeah, I'll just add on to that. So from the bone perspective, if the X-rays are negative and you have a strong clinical suspicion for a fracture or bony involvement, ultrasound's a great tool to help confirm that. Well, I know you already talked about the rotator cuff. Yeah, Robbie, anything? Yeah, I mean, at least in the clinical setting, I find ultrasound is a very helpful tool, not only diagnostically, but also kind of doing a therapeutic ultrasound exam for patients. Starting to do a lot in my acute Achilles tendon ruptures and following them along as they're rehabbing. And sometimes that patient just needs that reassurance, like, oh, am I healing correctly? And it's just very easy to kind of use the ultrasound and see the tendons moving back and forth and they get super excited and just always keeping a positive outlook for the recovery. Yeah, I know our surgeons determine whether to treat non-operatively or not, based on how much gap you have when you put them in a plantar flexion. So ultrasound, it's going to give you that word somewhere, I won't. And then just to finish up, I think we're a little over, but Donald, I know that you're doing a lot now with adaptive sports and certainly everybody did that during fellowship, but any ways you're using ultrasound with your adaptive sports athletes? Yeah, I think a lot of care for adaptive athletes tends to be less funded than for non-disabled athletes. So having ultrasound instead of in place of MRI for a lot of the rotator cuff issues and the vulture athletes has been really, really valuable to the vulture basketball teams I'm taking care of. I think I can treat them pretty much just with the ultrasound and they don't have to pay a bunch for the MRIs. Great. Well, I think we are past our time limit. So just again, thank you everybody. It was a great session and I look forward to next year.

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