利用 POCUS 检查髋关节解剖和结构：髋关节后部

<p begin="00:00:01.740" end="00:00:03.870">- This webinar is on examining hip anatomy</p>
<p begin="00:00:03.870" end="00:00:05.700">and structure with<br />point-of-care ultrasound the</p>
<p begin="00:00:05.700" end="00:00:07.260">posterior hip.</p>
<p begin="00:00:07.260" end="00:00:10.110">This is part four of a<br />four-part series on the hip,</p>
<p begin="00:00:10.110" end="00:00:11.880">and you may view the<br />recordings of the rest</p>
<p begin="00:00:11.880" end="00:00:14.700">of the series on this<br />website listed up here.</p>
<p begin="00:00:14.700" end="00:00:17.910">Before we begin, please be<br />advised all attendees are muted.</p>
<p begin="00:00:17.910" end="00:00:19.410">You may type your questions into the q</p>
<p begin="00:00:19.410" end="00:00:21.660">and a box in the toolbar<br />located at the bottom</p>
<p begin="00:00:21.660" end="00:00:23.430">of your screen at any time.</p>
<p begin="00:00:23.430" end="00:00:25.410">We will conduct a q and<br />a session at the end</p>
<p begin="00:00:25.410" end="00:00:27.900">of the presentation and demonstration.</p>
<p begin="00:00:27.900" end="00:00:29.640">This webinar will be recorded in Archive</p>
<p begin="00:00:29.640" end="00:00:31.770">for future reference as well.</p>
<p begin="00:00:31.770" end="00:00:35.220">Our presenters today are Daniel<br />Shelton and Bill Medford.</p>
<p begin="00:00:35.220" end="00:00:36.570">Daniel Shelton is the director</p>
<p begin="00:00:36.570" end="00:00:38.490">of musculoskeletal market development</p>
<p begin="00:00:38.490" end="00:00:40.170">for Fujifilm Sona site.</p>
<p begin="00:00:40.170" end="00:00:41.520">Daniel spent 16 years</p>
<p begin="00:00:41.520" end="00:00:44.040">as a dedicated musculoskeletal sonographer</p>
<p begin="00:00:44.040" end="00:00:46.680">and 10 of those years have<br />been here at SonoSite.</p>
<p begin="00:00:46.680" end="00:00:49.080">He now leads musculoskeletal<br />market development</p>
<p begin="00:00:49.080" end="00:00:51.180">where he works to spread<br />the word about the benefits</p>
<p begin="00:00:51.180" end="00:00:53.220">of point-of-care ultrasound.</p>
<p begin="00:00:53.220" end="00:00:55.860">Bill Medford is the lead<br />musculoskeletal specialist</p>
<p begin="00:00:55.860" end="00:00:58.950">for Fujifilm SonoSite with<br />40 years of experience</p>
<p begin="00:00:58.950" end="00:01:01.800">as a sonographer, including<br />22 years specializing in</p>
<p begin="00:01:01.800" end="00:01:03.840">musculoskeletal sonography.</p>
<p begin="00:01:03.840" end="00:01:06.150">Bill is an expert in using<br />point-of-care ultrasound across</p>
<p begin="00:01:06.150" end="00:01:09.300">the breadth of MUS<br />musculoskeletal specialties.</p>
<p begin="00:01:09.300" end="00:01:11.550">Bill, I will turn it over<br />to you to get started.</p>
<p begin="00:01:12.420" end="00:01:14.820">- Well, thank you Laura<br />and welcome to everybody</p>
<p begin="00:01:14.820" end="00:01:19.740">to the final presentation in our posterior</p>
<p begin="00:01:19.740" end="00:01:21.360">hip webinar series.</p>
<p begin="00:01:22.350" end="00:01:24.960">And with that we'll move along.</p>
<p begin="00:01:24.960" end="00:01:28.260">Today what you're going to<br />see are images produced off</p>
<p begin="00:01:28.260" end="00:01:32.430">of the Sono site PX newly launched</p>
<p begin="00:01:32.430" end="00:01:34.230">about six months ago.</p>
<p begin="00:01:34.230" end="00:01:38.970">The PX office PX offers<br />unmatched image clarity</p>
<p begin="00:01:38.970" end="00:01:43.200">and a system design that will<br />be found to be very adaptable</p>
<p begin="00:01:44.400" end="00:01:46.320">in examination rooms.</p>
<p begin="00:01:46.320" end="00:01:50.400">Transducers cover the full<br />breadth of transducers</p>
<p begin="00:01:50.400" end="00:01:53.070">that you're used to<br />seeing with socy products.</p>
<p begin="00:01:53.070" end="00:01:57.930">Transducers that you'll see<br />utilized today include the</p>
<p begin="00:01:57.930" end="00:02:01.890">linear 15 to four megahertz<br />transducer as well</p>
<p begin="00:02:01.890" end="00:02:06.890">as the curved five to<br />one megahertz transducer.</p>
<p begin="00:02:07.200" end="00:02:11.880">Also, when we're doing<br />looking at structures with</p>
<p begin="00:02:11.880" end="00:02:16.110">that have SU anatomy,<br />that's very superficial.</p>
<p begin="00:02:16.110" end="00:02:19.320">We want to use a higher frequency probe</p>
<p begin="00:02:19.320" end="00:02:21.510">and our linear 19</p>
<p begin="00:02:21.510" end="00:02:25.920">to five megahertz transducer<br />offers the highest frequency</p>
<p begin="00:02:25.920" end="00:02:29.250">ever developed with sono site products</p>
<p begin="00:02:29.250" end="00:02:31.740">and results in</p>
<p begin="00:02:31.740" end="00:02:35.070">exceptional image clarity.</p>
<p begin="00:02:35.070" end="00:02:37.800">We won't have any<br />demonstrations of that today,</p>
<p begin="00:02:37.800" end="00:02:40.170">but for any superficial imaging,</p>
<p begin="00:02:40.170" end="00:02:42.900">certainly a transducer to consider.</p>
<p begin="00:02:46.140" end="00:02:50.370">The anatomy that we will be<br />covering today include D SI</p>
<p begin="00:02:50.370" end="00:02:55.370">joint, the gluteus maximus, piriformis,</p>
<p begin="00:02:55.860" end="00:03:00.640">quadrat, ephemeris, the<br />hamstring complex, as well</p>
<p begin="00:03:00.640" end="00:03:02.830">as the sciatic nerve</p>
<p begin="00:03:05.020" end="00:03:06.610">bony acoustic landmarks.</p>
<p begin="00:03:06.610" end="00:03:10.660">Always. Our starting point<br />in identifying anatomy</p>
<p begin="00:03:12.010" end="00:03:15.520">include the posterior<br />superior iliac spine,</p>
<p begin="00:03:17.200" end="00:03:18.820">- The sacro iliac joint,</p>
<p begin="00:03:21.160" end="00:03:22.930">the dorsal iliac wing,</p>
<p begin="00:03:25.000" end="00:03:26.590">the sacral foramina,</p>
<p begin="00:03:28.690" end="00:03:30.520">the greater sciatic foramen,</p>
<p begin="00:03:33.010" end="00:03:34.990">and the ischial tuberosity.</p>
<p begin="00:03:40.240" end="00:03:42.040">- Let's start with the SI joint.</p>
<p begin="00:03:42.940" end="00:03:46.270">The SI joint is a di arthrodial joint.</p>
<p begin="00:03:46.270" end="00:03:49.870">It's sacral surface is<br />covered with hy lung cartilage</p>
<p begin="00:03:49.870" end="00:03:54.130">and the iliac surface is<br />lined with fibrocartilage.</p>
<p begin="00:03:55.300" end="00:03:59.980">It is smooth in the young and<br />becomes irregular with age.</p>
<p begin="00:03:59.980" end="00:04:02.920">It can become unstable<br />due to ligamentous injury</p>
<p begin="00:04:02.920" end="00:04:07.840">or laxity, which can result<br />in instability and discomfort.</p>
<p begin="00:04:07.840" end="00:04:10.870">Ultrasound can be the procedure of choice</p>
<p begin="00:04:10.870" end="00:04:12.370">for therapeutic injection.</p>
<p begin="00:04:15.070" end="00:04:19.570">We begin our examination at the posterior</p>
<p begin="00:04:19.570" end="00:04:21.610">superior iliac spine</p>
<p begin="00:04:21.610" end="00:04:25.720">with the transducer placed<br />in a transverse body plane.</p>
<p begin="00:04:25.720" end="00:04:30.370">At the level of the PSIS either identify a</p>
<p begin="00:04:30.370" end="00:04:33.400">viable on the image or by palpation.</p>
<p begin="00:04:37.180" end="00:04:41.950">Once we've identified<br />the PSIS, we're going</p>
<p begin="00:04:41.950" end="00:04:45.250">to move the transducer distally</p>
<p begin="00:04:45.250" end="00:04:49.090">until we get this wider<br />portion of the SI joint,</p>
<p begin="00:04:51.280" end="00:04:54.640">which we see on this sonographic image.</p>
<p begin="00:04:54.640" end="00:04:57.670">And then we'll want to move the<br />transducer even a little bit</p>
<p begin="00:04:57.670" end="00:05:02.440">more distal to recognize<br />this narrower point of</p>
<p begin="00:05:02.440" end="00:05:03.820">the SI joint.</p>
<p begin="00:05:03.820" end="00:05:08.680">Note that when we're more<br />proximal, that the iliac side</p>
<p begin="00:05:08.680" end="00:05:13.300">has a steeper contour<br />down to this wider joint</p>
<p begin="00:05:14.950" end="00:05:18.250">as opposed to when we're more distally.</p>
<p begin="00:05:18.250" end="00:05:20.770">The iliac side is more flattened</p>
<p begin="00:05:21.880" end="00:05:25.240">and we see that the joint is narrower.</p>
<p begin="00:05:25.240" end="00:05:30.240">Injections can be<br />delivered at any location.</p>
<p begin="00:05:30.640" end="00:05:33.220">Some feel that the injection,</p>
<p begin="00:05:33.220" end="00:05:37.960">therapeutic injection is more<br />effectively delivered at this</p>
<p begin="00:05:37.960" end="00:05:41.350">narrower place where up</p>
<p begin="00:05:41.350" end="00:05:43.210">above in the wider portion</p>
<p begin="00:05:43.210" end="00:05:47.110">of the SI joint there are<br />more ligamentous constraints</p>
<p begin="00:05:47.110" end="00:05:51.490">and it's felt that the delivery<br />of injections may not be</p>
<p begin="00:05:51.490" end="00:05:56.200">as effective in in sliding<br />down into this narrower</p>
<p begin="00:05:56.200" end="00:05:57.890">portion of the joint space.</p>
<p begin="00:05:59.570" end="00:06:03.020">A needle is guided from medial to lateral</p>
<p begin="00:06:03.890" end="00:06:07.400">in plain when we're doing<br />injection guidance procedures</p>
<p begin="00:06:07.400" end="00:06:10.130">under ultrasound of the sacroiliac joint,</p>
<p begin="00:06:13.430" end="00:06:16.190">the gluteus maximus we<br />covered in our lateral hip,</p>
<p begin="00:06:16.190" end="00:06:18.380">but it is a posterior structure,</p>
<p begin="00:06:18.380" end="00:06:20.510">but it becomes a lateral insertion,</p>
<p begin="00:06:20.510" end="00:06:22.940">so we're covering it both places.</p>
<p begin="00:06:22.940" end="00:06:25.880">The gluteus maximus is<br />the primary extensor</p>
<p begin="00:06:25.880" end="00:06:26.960">muscle of the hip.</p>
<p begin="00:06:26.960" end="00:06:31.730">It also assists with external<br />rotation and abduction.</p>
<p begin="00:06:31.730" end="00:06:32.870">It is the largest</p>
<p begin="00:06:32.870" end="00:06:36.740">and most superficial<br />of the gluteal complex</p>
<p begin="00:06:36.740" end="00:06:40.850">and is innervated by the<br />inferior gluteal nerve.</p>
<p begin="00:06:43.610" end="00:06:47.210">Its origin is along the posterior aspect</p>
<p begin="00:06:47.210" end="00:06:48.620">of the dorsal ileum</p>
<p begin="00:06:49.730" end="00:06:54.650">and along the lateral aspect</p>
<p begin="00:06:54.650" end="00:06:58.160">and postal lateral aspect of the sacrum.</p>
<p begin="00:06:58.160" end="00:07:00.560">It will also blend with the lumbar fascia</p>
<p begin="00:07:00.560" end="00:07:04.700">and the sacral tubus ligament along</p>
<p begin="00:07:04.700" end="00:07:07.100">with the tensor fascia lata.</p>
<p begin="00:07:07.100" end="00:07:09.590">Its connection to the</p>
<p begin="00:07:09.590" end="00:07:13.010">IT band stabilizes the<br />femur along the surface</p>
<p begin="00:07:13.010" end="00:07:16.850">of the tibia while<br />standing during relaxation</p>
<p begin="00:07:16.850" end="00:07:19.370">of the extension extensors ultimately</p>
<p begin="00:07:19.370" end="00:07:22.460">to insert on on gertie's<br />tubercle of the tibia.</p>
<p begin="00:07:23.300" end="00:07:24.800">A more proximal point</p>
<p begin="00:07:24.800" end="00:07:29.780">of insertion is along the<br />gluteal tuberosity of the femur.</p>
<p begin="00:07:30.860" end="00:07:34.610">Daniel, I'll turn it over to<br />you to demonstrate the SI joint</p>
<p begin="00:07:34.610" end="00:07:36.050">and gluteus maximus.</p>
<p begin="00:07:41.150" end="00:07:43.580">- All right, thank you<br />Bill. I am gonna wait on</p>
<p begin="00:07:43.580" end="00:07:44.660">that to go full screen.</p>
<p begin="00:07:44.660" end="00:07:47.180">There we are. Thanks for<br />joining us again today.</p>
<p begin="00:07:47.180" end="00:07:48.800">In front of me, I've got a sono site PX</p>
<p begin="00:07:48.800" end="00:07:50.120">and our live model here.</p>
<p begin="00:07:50.960" end="00:07:52.160">Just to orient everybody,</p>
<p begin="00:07:52.160" end="00:07:54.290">because you're gonna see a<br />few different camera angles.</p>
<p begin="00:07:54.290" end="00:07:56.540">We've got proximal this way,</p>
<p begin="00:07:56.540" end="00:07:58.940">which may be I'll be doing the right hip.</p>
<p begin="00:07:58.940" end="00:08:02.150">They're laying down on their belly, so</p>
<p begin="00:08:02.150" end="00:08:04.910">proximal distal is this way.</p>
<p begin="00:08:04.910" end="00:08:08.780">And then from our upper camera angle,</p>
<p begin="00:08:08.780" end="00:08:12.170">I've labeled in the corners<br />up here, proximal and distal.</p>
<p begin="00:08:12.170" end="00:08:14.810">And then you can see the<br />same camera on the bottom.</p>
<p begin="00:08:14.810" end="00:08:18.200">So I know when we're,<br />when we're zoomed in here,</p>
<p begin="00:08:18.200" end="00:08:19.730">it can be a little bit disorienting,</p>
<p begin="00:08:19.730" end="00:08:22.520">but I do want to kind of point<br />that out ahead of time so</p>
<p begin="00:08:22.520" end="00:08:25.580">that everybody's familiar<br />with what we're viewing here.</p>
<p begin="00:08:25.580" end="00:08:29.180">So we've got proximal this<br />way, we distal this way.</p>
<p begin="00:08:29.180" end="00:08:31.100">And then just like we<br />do in all the other hip</p>
<p begin="00:08:31.100" end="00:08:34.760">and pelvis courses,</p>
<p begin="00:08:34.760" end="00:08:37.310">I do wanna talk a little bit<br />about patient modesty here.</p>
<p begin="00:08:37.310" end="00:08:40.430">This is the posterior<br />hip. This is no exception.</p>
<p begin="00:08:40.430" end="00:08:42.050">So what I've got is two blankets here</p>
<p begin="00:08:42.050" end="00:08:43.790">that I'll be scanning<br />kind of through a window</p>
<p begin="00:08:43.790" end="00:08:45.170">that I open up.</p>
<p begin="00:08:45.170" end="00:08:48.140">I've already tucked the blanket<br />into the upper part of the</p>
<p begin="00:08:49.160" end="00:08:51.500">pants because we're gonna be<br />right up here on the SI joint</p>
<p begin="00:08:51.500" end="00:08:53.390">and working our way inferiorly.</p>
<p begin="00:08:53.390" end="00:08:55.470">So for this first part<br />of the presentation,</p>
<p begin="00:08:55.470" end="00:08:57.360">I'm coming from the top side down</p>
<p begin="00:08:57.360" end="00:09:00.060">and I've got the shorts pulled down here,</p>
<p begin="00:09:00.060" end="00:09:02.100">and they are tucked in here.</p>
<p begin="00:09:03.270" end="00:09:04.740">I've got this second blanket here just</p>
<p begin="00:09:04.740" end="00:09:07.020">to expose the upper part of the hip there.</p>
<p begin="00:09:07.020" end="00:09:11.820">So our, our ileum being</p>
<p begin="00:09:11.820" end="00:09:15.810">here and sacrum being here, I<br />can, I can palpate that PSIS,</p>
<p begin="00:09:15.810" end="00:09:18.840">which will be the beginning<br />of our examination.</p>
<p begin="00:09:20.220" end="00:09:21.810">Gonna have a little bit of gel here.</p>
<p begin="00:09:21.810" end="00:09:25.140">Again, this is the 15 to<br />four L 15 four transducer.</p>
<p begin="00:09:26.760" end="00:09:28.170">I'm gonna spin the transducer around.</p>
<p begin="00:09:28.170" end="00:09:31.080">I had the orientation marker facing medial</p>
<p begin="00:09:31.080" end="00:09:33.840">or to the midline, and I just went ahead</p>
<p begin="00:09:33.840" end="00:09:37.470">and maybe by luck plop<br />down right on the PSIS.</p>
<p begin="00:09:37.470" end="00:09:38.820">That may not always happen.</p>
<p begin="00:09:38.820" end="00:09:40.920">So if it doesn't, let's talk about going</p>
<p begin="00:09:40.920" end="00:09:44.460">and finding that that more<br />superficial bony landmark.</p>
<p begin="00:09:46.950" end="00:09:49.140">So if you just set the<br />transducer down and, and,</p>
<p begin="00:09:49.140" end="00:09:51.630">and you're kind of wondering<br />where you might be, we need</p>
<p begin="00:09:51.630" end="00:09:53.400">to find a bony prominence, okay?</p>
<p begin="00:09:53.400" end="00:09:54.990">And if it's this with the slope on it,</p>
<p begin="00:09:54.990" end="00:09:56.520">this is the ileum here.</p>
<p begin="00:09:56.520" end="00:09:59.550">And what we're gonna do is<br />just follow that ileum up high,</p>
<p begin="00:09:59.550" end="00:10:03.060">high, high, high until<br />it's meets its most peak.</p>
<p begin="00:10:04.200" end="00:10:06.630">And then I'm gonna go proximal<br />to distal to find the,</p>
<p begin="00:10:06.630" end="00:10:09.270">the absolute apex of<br />that thing right there.</p>
<p begin="00:10:09.270" end="00:10:10.980">Now, if you start more midline,</p>
<p begin="00:10:10.980" end="00:10:13.140">you may catch this flat<br />plate of the sacrum</p>
<p begin="00:10:13.140" end="00:10:14.790">and the spine of the sacrum.</p>
<p begin="00:10:14.790" end="00:10:18.360">So here's one of the spinous<br />processes of the sacrum here,</p>
<p begin="00:10:18.360" end="00:10:21.300">and we're just gonna<br />follow that down laterally.</p>
<p begin="00:10:21.300" end="00:10:23.580">Now, don't stumble on the first thing</p>
<p begin="00:10:23.580" end="00:10:25.440">that looks like a joint.</p>
<p begin="00:10:25.440" end="00:10:27.090">Those are just sacral foramen.</p>
<p begin="00:10:27.090" end="00:10:30.840">This could be S two or S one<br />depending on how proximal I am.</p>
<p begin="00:10:30.840" end="00:10:33.930">But I need to go even<br />more lateral until we see</p>
<p begin="00:10:33.930" end="00:10:36.630">that high riding bony peak of the PSIS.</p>
<p begin="00:10:36.630" end="00:10:40.530">So what I'm doing there is I'm,<br />I'm planting the medial side</p>
<p begin="00:10:40.530" end="00:10:43.200">of the transducer with a<br />finger like I did in a lot</p>
<p begin="00:10:43.200" end="00:10:44.940">of other body parts like the elbow</p>
<p begin="00:10:44.940" end="00:10:47.010">where we pivot and windshield wiper.</p>
<p begin="00:10:47.010" end="00:10:50.130">And I'm just gonna be moving<br />my thumb across this way</p>
<p begin="00:10:50.130" end="00:10:53.010">until I see that PSIS really nice.</p>
<p begin="00:10:53.010" end="00:10:56.100">And what that does is it, it<br />really nicely opens the joint</p>
<p begin="00:10:56.100" end="00:10:58.950">for the upper SI joint<br />or the superior SI joint.</p>
<p begin="00:10:58.950" end="00:11:00.450">And you can even see the anti tropic</p>
<p begin="00:11:00.450" end="00:11:02.430">artifact of these ligaments here.</p>
<p begin="00:11:02.430" end="00:11:04.560">So that that lets you know<br />that we're in the ballpark.</p>
<p begin="00:11:04.560" end="00:11:06.840">And as Bill mentioned, if we're<br />coming in for an injection,</p>
<p begin="00:11:06.840" end="00:11:10.170">it's gonna be from midline<br />to lateral this way.</p>
<p begin="00:11:11.640" end="00:11:15.360">Now let's follow that<br />joint, the PSIS being easier</p>
<p begin="00:11:15.360" end="00:11:17.580">to follow inferiorly.</p>
<p begin="00:11:17.580" end="00:11:20.820">We're gonna follow that<br />inferiorly, inferiorly inferiorly</p>
<p begin="00:11:20.820" end="00:11:23.820">until it completely disappears<br />into the superior sciatic</p>
<p begin="00:11:23.820" end="00:11:26.130">framing, which would be<br />here in the piriformis is</p>
<p begin="00:11:26.130" end="00:11:27.600">down here, which we'll get to.</p>
<p begin="00:11:27.600" end="00:11:29.250">But that tells me that I've gone</p>
<p begin="00:11:29.250" end="00:11:32.070">beneath the inferior SI<br />joint, which is right here.</p>
<p begin="00:11:32.070" end="00:11:35.670">You can see that joint<br />really nicely right there.</p>
<p begin="00:11:36.900" end="00:11:39.420">Not this space right here.</p>
<p begin="00:11:39.420" end="00:11:41.850">So this is the most inferior<br />margin of the ileum.</p>
<p begin="00:11:42.690" end="00:11:45.090">And if I drop my thumb inferiorly,</p>
<p begin="00:11:45.090" end="00:11:49.020">you'll see it disappear<br />completely and the sacrum remains.</p>
<p begin="00:11:49.020" end="00:11:52.710">So right here is that scro iliac joint,</p>
<p begin="00:11:52.710" end="00:11:55.540">and you can see the joint<br />really nicely on the cyte px.</p>
<p begin="00:11:58.390" end="00:12:01.300">Superficial to that, these are<br />the fibers of the glute max.</p>
<p begin="00:12:01.300" end="00:12:03.040">They're oblique, they dive this way.</p>
<p begin="00:12:03.040" end="00:12:04.870">So they're crossing my<br />transducer obliquely</p>
<p begin="00:12:06.610" end="00:12:07.750">and you can see them jumping up</p>
<p begin="00:12:07.750" end="00:12:10.540">and over to dive onto the sacrum here.</p>
<p begin="00:12:10.540" end="00:12:13.570">So what I'm gonna do, I know<br />that they slant this way</p>
<p begin="00:12:13.570" end="00:12:17.110">to wrap over the tr so<br />I'm just gonna pivot</p>
<p begin="00:12:18.100" end="00:12:19.180">the transducer this way</p>
<p begin="00:12:19.180" end="00:12:22.330">until we elongate the muscle<br />fibers of the glute max.</p>
<p begin="00:12:26.080" end="00:12:27.790">And it's a very broad muscle.</p>
<p begin="00:12:27.790" end="00:12:30.070">I can follow it right across the ileum.</p>
<p begin="00:12:30.070" end="00:12:33.790">And it's not necessarily a<br />part of a examination protocol</p>
<p begin="00:12:33.790" end="00:12:36.160">on the posterior hip, even though</p>
<p begin="00:12:36.160" end="00:12:38.950">the more applications we find<br />to do ultrasound on the hip,</p>
<p begin="00:12:38.950" end="00:12:40.120">especially the posterior hip,</p>
<p begin="00:12:40.120" end="00:12:42.370">the more it may become<br />somebody's protocol.</p>
<p begin="00:12:42.370" end="00:12:45.070">But if clinically indicated,<br />you would want to chase these,</p>
<p begin="00:12:45.070" end="00:12:47.140">the, the, the origin of these fibers,</p>
<p begin="00:12:48.760" end="00:12:50.950">you can actually see the glute max jump up</p>
<p begin="00:12:50.950" end="00:12:52.930">and over the sacrum here<br />to that lumbar fascia</p>
<p begin="00:12:52.930" end="00:12:56.440">that bill mentioned right there,<br />that little feathery edge.</p>
<p begin="00:12:56.440" end="00:12:59.410">So that's pretty neat. I'm<br />gonna go even more inferior.</p>
<p begin="00:12:59.410" end="00:13:02.620">More inferior, more inferior<br />until we see the glute max</p>
<p begin="00:13:03.760" end="00:13:08.230">really tapered up onto what looks like</p>
<p begin="00:13:09.160" end="00:13:10.660">the spine of the sacrum.</p>
<p begin="00:13:10.660" end="00:13:14.440">And we're actually down here<br />at the coddle epidural anatomy.</p>
<p begin="00:13:14.440" end="00:13:19.240">So that's actually the sacral<br />cornew that we're seeing here.</p>
<p begin="00:13:19.240" end="00:13:21.700">Maybe for a different<br />subject in pain management</p>
<p begin="00:13:21.700" end="00:13:24.430">or something, we'll go over<br />the cocal epi epidural anatomy.</p>
<p begin="00:13:24.430" end="00:13:26.800">But following that glute<br />max laterally, laterally,</p>
<p begin="00:13:26.800" end="00:13:31.800">laterally, you can see how nice<br />and parallel the fibers are.</p>
<p begin="00:13:32.050" end="00:13:35.020">And I'm sure Bill will mention<br />when we get to piriformis,</p>
<p begin="00:13:35.020" end="00:13:37.810">which is right here, just how nice</p>
<p begin="00:13:37.810" end="00:13:39.160">and parallel they are to each other.</p>
<p begin="00:13:41.740" end="00:13:43.030">Bill, did I miss anything so far</p>
<p begin="00:13:50.080" end="00:13:52.990">while Bill unmutes I'll, I'll<br />keep scanning that glute max.</p>
<p begin="00:13:55.540" end="00:13:57.250">I'm gonna add a little bit<br />of gel getting a little</p>
<p begin="00:13:57.250" end="00:13:59.440">dry. There</p>
<p begin="00:13:59.440" end="00:14:00.440">- We go.</p>
<p begin="00:14:00.440" end="00:14:01.660">Daniel, I'm back on the PowerPoint now.</p>
<p begin="00:14:01.660" end="00:14:02.260">- Alright. All right,</p>
<p begin="00:14:07.180" end="00:14:08.350">go ahead Bill.</p>
<p begin="00:14:08.350" end="00:14:11.800">- Okay, let's move to the piriformis.</p>
<p begin="00:14:11.800" end="00:14:12.940">Daniel mentioned</p>
<p begin="00:14:12.940" end="00:14:17.260">that piriformis fibers<br />do parallel the fibers</p>
<p begin="00:14:17.260" end="00:14:19.990">of the overlying gluteus maximus</p>
<p begin="00:14:21.490" end="00:14:26.320">and the piriformis courses<br />like the gmax diagonally</p>
<p begin="00:14:26.320" end="00:14:29.950">its origin is on the anterior sacrum,</p>
<p begin="00:14:29.950" end="00:14:33.850">specifically three bundle<br />attachments between the first</p>
<p begin="00:14:33.850" end="00:14:37.060">and second, second and third and third</p>
<p begin="00:14:37.060" end="00:14:40.420">and fourth anterior sacral foramina.</p>
<p begin="00:14:40.420" end="00:14:44.770">It exits through the<br />greater sciatic foramen</p>
<p begin="00:14:47.620" end="00:14:49.990">and inserts onto the superior aspect</p>
<p begin="00:14:49.990" end="00:14:52.310">of the greater trocanter.</p>
<p begin="00:14:52.310" end="00:14:56.420">Also to be aware of is a sciatic nerve</p>
<p begin="00:14:56.420" end="00:15:00.080">as it comes out from what is</p>
<p begin="00:15:00.080" end="00:15:05.000">behind the piriformis muscle<br />to cross over in front</p>
<p begin="00:15:05.000" end="00:15:06.898">of the Jemele eye and raders.</p>
<p begin="00:15:06.898" end="00:15:11.420">And ultimately the quadratus femes us 17%</p>
<p begin="00:15:11.420" end="00:15:15.440">of sciatic nerves, however,<br />run through the piriformis</p>
<p begin="00:15:15.440" end="00:15:20.300">and predisposes this subgroup<br />to tingling, numbness</p>
<p begin="00:15:20.300" end="00:15:25.160">and pain along the sciatic nerve<br />and deep into the buttocks.</p>
<p begin="00:15:26.930" end="00:15:31.820">So where do we begin<br />when we look for the look</p>
<p begin="00:15:31.820" end="00:15:36.350">for the piriformis muscle, we're going</p>
<p begin="00:15:36.350" end="00:15:38.145">to begin at the PSIS</p>
<p begin="00:15:41.030" end="00:15:44.510">and our transducer is going<br />to, as where we started</p>
<p begin="00:15:44.510" end="00:15:49.130">with the SI joint is going<br />to be placed as the PSIS.</p>
<p begin="00:15:50.120" end="00:15:54.470">Our next transducer movement<br />is going to slide laterally</p>
<p begin="00:15:54.470" end="00:15:58.760">with the lateral aspect of<br />the transducer towed in.</p>
<p begin="00:15:58.760" end="00:16:01.130">We're going to employ<br />the heel toe maneuver,</p>
<p begin="00:16:01.130" end="00:16:03.410">this being the heel, this being the toe.</p>
<p begin="00:16:03.410" end="00:16:05.750">We're gonna tow in to</p>
<p begin="00:16:05.750" end="00:16:10.730">to level out this iliac wing so that</p>
<p begin="00:16:10.730" end="00:16:14.420">we have a continuous appearance</p>
<p begin="00:16:14.420" end="00:16:17.660">of bone on the under surface of</p>
<p begin="00:16:17.660" end="00:16:19.730">what here is gluteus medias.</p>
<p begin="00:16:21.230" end="00:16:24.320">Once we have established that we're going</p>
<p begin="00:16:24.320" end="00:16:28.100">to slide the transducer distally</p>
<p begin="00:16:28.100" end="00:16:31.880">and oblique the transducer to correspond</p>
<p begin="00:16:31.880" end="00:16:35.900">with the diagonal course<br />of the piriformis.</p>
<p begin="00:16:37.730" end="00:16:40.970">So directly transverse up here</p>
<p begin="00:16:40.970" end="00:16:45.260">to demonstrate the iliac<br />wing slide down until we lose</p>
<p begin="00:16:45.260" end="00:16:47.360">that continuous iliac wing</p>
<p begin="00:16:48.200" end="00:16:51.890">and begin to see the sciatic foramen.</p>
<p begin="00:16:51.890" end="00:16:55.430">Once we lose that bit of bone up here</p>
<p begin="00:16:55.430" end="00:16:57.050">and we come to</p>
<p begin="00:16:59.150" end="00:17:02.240">the sciatic foramen, we begin to see,</p>
<p begin="00:17:02.240" end="00:17:06.230">once we oblique the transducer<br />along the diagonal course,</p>
<p begin="00:17:06.230" end="00:17:09.140">we'll begin to see the piriformis</p>
<p begin="00:17:11.840" end="00:17:14.840">adjacent anatomy that<br />might help us identify.</p>
<p begin="00:17:14.840" end="00:17:18.320">This is again, the sciatic nerve</p>
<p begin="00:17:18.320" end="00:17:20.450">and the superior gluteal nerve.</p>
<p begin="00:17:20.450" end="00:17:23.810">And the associated vessels in particular</p>
<p begin="00:17:23.810" end="00:17:25.460">might turn on color doppler</p>
<p begin="00:17:25.460" end="00:17:28.640">and recognize the inferior gluteal nerve,</p>
<p begin="00:17:28.640" end="00:17:29.900">gluteal artery here.</p>
<p begin="00:17:32.600" end="00:17:37.310">So the sonographic appearance is again,</p>
<p begin="00:17:37.310" end="00:17:39.650">fiber's very parallel to one another,</p>
<p begin="00:17:39.650" end="00:17:42.830">gmax piriformis.</p>
<p begin="00:17:44.030" end="00:17:48.230">And we can use a dynamic<br />maneuver by flexing the knee</p>
<p begin="00:17:48.230" end="00:17:53.190">and rotating the femur to see translation</p>
<p begin="00:17:53.190" end="00:17:55.860">of the piriformis back and forth.</p>
<p begin="00:17:57.150" end="00:17:59.040">I'm sure Daniel will be demonstrating</p>
<p begin="00:17:59.040" end="00:18:01.140">that in our lives scanning.</p>
<p begin="00:18:08.400" end="00:18:12.570">Moving a little further south,<br />we'll go from the piriformis.</p>
<p begin="00:18:12.570" end="00:18:14.070">We'll cross over the GLI</p>
<p begin="00:18:14.940" end="00:18:19.020">and the OB trait to the quadratus fems.</p>
<p begin="00:18:20.305" end="00:18:22.950">Quadratus femoris is an external rotator</p>
<p begin="00:18:22.950" end="00:18:24.510">and adductor of the thigh.</p>
<p begin="00:18:24.510" end="00:18:27.240">It also assists in<br />stabilizing the hip joint.</p>
<p begin="00:18:28.110" end="00:18:30.990">Its origin is at the lateral margin of the</p>
<p begin="00:18:30.990" end="00:18:32.550">- Ator ring.</p>
<p begin="00:18:36.930" end="00:18:37.930">And</p>
<p begin="00:18:41.850" end="00:18:44.520">- And I, I'm sorry, its lateral margin is</p>
<p begin="00:18:44.520" end="00:18:48.606">that the ator ring just superior<br />to the ischial tuberosity,</p>
<p begin="00:18:48.606" end="00:18:51.780">which is where we'll find<br />the hamstrings inserts.</p>
<p begin="00:18:53.370" end="00:18:57.000">It's distal insertion is<br />on the quadrat tubercle</p>
<p begin="00:18:57.000" end="00:18:59.970">and the inter tro enteric<br />crest of the posterior</p>
<p begin="00:19:01.020" end="00:19:04.980">medial femur right along here</p>
<p begin="00:19:05.820" end="00:19:08.550">and here on the sonographic image.</p>
<p begin="00:19:08.550" end="00:19:12.600">So this is the quadratus<br />femes. Where do we begin?</p>
<p begin="00:19:12.600" end="00:19:14.940">We place the transducer at</p>
<p begin="00:19:14.940" end="00:19:17.100">or near the gluteal fold</p>
<p begin="00:19:17.100" end="00:19:20.400">where we'll recognize the<br />bony acoustic landmark</p>
<p begin="00:19:20.400" end="00:19:24.330">of the ischial tuberosity medially.</p>
<p begin="00:19:24.330" end="00:19:26.700">And laterally we'll recognize the femur</p>
<p begin="00:19:27.930" end="00:19:31.050">quadratus femoral bridges that gap.</p>
<p begin="00:19:31.050" end="00:19:33.540">This is the ischial femoral space</p>
<p begin="00:19:33.540" end="00:19:36.420">and is a zone of impingement</p>
<p begin="00:19:36.420" end="00:19:40.200">of the overlying sciatic nerve.</p>
<p begin="00:19:40.200" end="00:19:42.240">Dynamic maneuvers can help</p>
<p begin="00:19:43.410" end="00:19:47.850">us recognize snapping that<br />may occur due to a lessening</p>
<p begin="00:19:47.850" end="00:19:48.930">of this distance</p>
<p begin="00:19:48.930" end="00:19:53.760">and snapping at the ichi femoral space.</p>
<p begin="00:19:57.325" end="00:20:00.450">Okay, Daniel, I'll turn it over to you.</p>
<p begin="00:20:04.920" end="00:20:08.040">- All right, thanks Bill. As<br />Bill mentioned, we are going</p>
<p begin="00:20:08.040" end="00:20:11.100">to go inferiorly on the hip now,</p>
<p begin="00:20:11.100" end="00:20:14.490">and I've re draped the hip,<br />we're still proximal this way,</p>
<p begin="00:20:14.490" end="00:20:17.610">but I've got the shorts now up</p>
<p begin="00:20:17.610" end="00:20:19.800">and I've, I've taken the time to tuck</p>
<p begin="00:20:19.800" end="00:20:22.590">and protect the the<br />patient's undergarments.</p>
<p begin="00:20:22.590" end="00:20:24.720">And then what we're<br />gonna do is just expose</p>
<p begin="00:20:24.720" end="00:20:25.920">down to the gluteal fold.</p>
<p begin="00:20:25.920" end="00:20:29.460">So what we're gonna be looking<br />at now is the inferior SI</p>
<p begin="00:20:29.460" end="00:20:31.800">joint, and we're gonna<br />walk our way to the ilium</p>
<p begin="00:20:31.800" end="00:20:33.120">and then we're gonna go south into</p>
<p begin="00:20:33.120" end="00:20:35.130">that superior sciatic foramen.</p>
<p begin="00:20:35.130" end="00:20:37.170">And that will help us find the piriformis.</p>
<p begin="00:20:37.170" end="00:20:40.050">So left side of the screen<br />again is gonna be medial,</p>
<p begin="00:20:40.050" end="00:20:42.600">and we're looking for<br />a bony landmark there.</p>
<p begin="00:20:43.440" end="00:20:46.930">So let's find out which part of the, the</p>
<p begin="00:20:46.930" end="00:20:48.400">inferior SI joint that is.</p>
<p begin="00:20:48.400" end="00:20:50.920">It looks like I fell right on it.</p>
<p begin="00:20:50.920" end="00:20:55.210">So what we're gonna do<br />is follow this ileum.</p>
<p begin="00:20:55.210" end="00:20:58.870">Now let's follow the ileum<br />laterally, laterally, laterally.</p>
<p begin="00:20:58.870" end="00:21:01.570">There we go. And all I'm<br />gonna do is just fall into</p>
<p begin="00:21:01.570" end="00:21:02.680">that superior satic notch.</p>
<p begin="00:21:02.680" end="00:21:04.780">So it's just a little short movement</p>
<p begin="00:21:04.780" end="00:21:06.940">and I can already tell<br />I'm in that ballpark</p>
<p begin="00:21:06.940" end="00:21:09.370">because I can see that superior<br />gluteal artery just resting</p>
<p begin="00:21:09.370" end="00:21:10.900">right here.</p>
<p begin="00:21:10.900" end="00:21:13.450">And what we're gonna do is<br />throw our color feature on,</p>
<p begin="00:21:13.450" end="00:21:15.100">and I wanna be able to<br />see that little artery.</p>
<p begin="00:21:15.100" end="00:21:17.710">And what that's doing is just<br />a clue to say, Hey, I'm about</p>
<p begin="00:21:17.710" end="00:21:20.620">to hit the superior satic foram.</p>
<p begin="00:21:20.620" end="00:21:22.630">And you're gonna see<br />that that artery start</p>
<p begin="00:21:22.630" end="00:21:25.540">to shoot straight up and down,<br />headed towards my transducer</p>
<p begin="00:21:25.540" end="00:21:28.840">as it wraps up and around the<br />inferior margin of the ileum.</p>
<p begin="00:21:28.840" end="00:21:31.240">So the very, very next<br />structure underneath that</p>
<p begin="00:21:32.170" end="00:21:35.530">is gonna be our piriformis here.</p>
<p begin="00:21:35.530" end="00:21:39.580">So diagnostically, L 15,</p>
<p begin="00:21:39.580" end="00:21:42.610">great transducer to look<br />at all these little fibers.</p>
<p begin="00:21:42.610" end="00:21:46.480">And I can see this big pizza<br />slice headed laterally over</p>
<p begin="00:21:46.480" end="00:21:48.610">the isum.</p>
<p begin="00:21:48.610" end="00:21:52.990">So here we have isum piriformis,</p>
<p begin="00:21:54.790" end="00:21:58.780">inferior gluteal artery,<br />superior gluteal artery.</p>
<p begin="00:21:58.780" end="00:22:01.780">And I think the, I always relate things</p>
<p begin="00:22:01.780" end="00:22:03.190">to food for some reason.</p>
<p begin="00:22:03.190" end="00:22:04.540">So I do, I think the piriformis just</p>
<p begin="00:22:04.540" end="00:22:05.650">looks like a big pizza slice.</p>
<p begin="00:22:05.650" end="00:22:08.140">It's a triangular shape structure.</p>
<p begin="00:22:08.140" end="00:22:10.360">It's gonna go up and over the isum.</p>
<p begin="00:22:10.360" end="00:22:11.920">As Bill mentioned, we start</p>
<p begin="00:22:11.920" end="00:22:13.540">to see the superior jamella right here</p>
<p begin="00:22:13.540" end="00:22:15.580">as it rests right on top of there.</p>
<p begin="00:22:15.580" end="00:22:18.520">And then just before we get to<br />the isum down here, we've got</p>
<p begin="00:22:18.520" end="00:22:19.990">that sciatic nerve,</p>
<p begin="00:22:19.990" end="00:22:23.710">or at this point could be the<br />distal lumbar complex still,</p>
<p begin="00:22:23.710" end="00:22:27.100">but here it is as a nice<br />tight group of nerve.</p>
<p begin="00:22:27.100" end="00:22:29.590">So it's probably already<br />sciatic at this point,</p>
<p begin="00:22:30.850" end="00:22:32.290">but this is nerve.</p>
<p begin="00:22:32.290" end="00:22:35.470">And then up over the isum<br />is the superior jamella.</p>
<p begin="00:22:35.470" end="00:22:37.930">And then just resting on top<br />of that superior jamella,</p>
<p begin="00:22:37.930" end="00:22:41.710">if I keep going laterally,<br />is the piriformis</p>
<p begin="00:22:41.710" end="00:22:43.900">muscle in this thin strand is starting</p>
<p begin="00:22:43.900" end="00:22:47.890">to make itself into the<br />piriformis tendon procedurally</p>
<p begin="00:22:47.890" end="00:22:48.910">and dynamically.</p>
<p begin="00:22:48.910" end="00:22:50.560">I like to switch over to<br />the curvilinear probe.</p>
<p begin="00:22:50.560" end="00:22:52.240">So I'm gonna take a second to do that.</p>
<p begin="00:22:52.240" end="00:22:54.910">And I'm gonna select the<br />C five one transducer</p>
<p begin="00:22:54.910" end="00:22:57.250">with a musculoskeletal exam type</p>
<p begin="00:22:57.250" end="00:22:58.720">to get a broader field of view.</p>
<p begin="00:22:59.620" end="00:23:01.960">And if your general<br />patient population is not</p>
<p begin="00:23:01.960" end="00:23:03.640">of the body habitus of our model today,</p>
<p begin="00:23:03.640" end="00:23:04.870">you're really gonna want to consider</p>
<p begin="00:23:04.870" end="00:23:06.700">getting a carline probe.</p>
<p begin="00:23:06.700" end="00:23:09.130">So I'm starting with the<br />left side of the screen again</p>
<p begin="00:23:09.130" end="00:23:11.770">to the patient's medial side,</p>
<p begin="00:23:13.870" end="00:23:15.700">things are gonna look<br />a little bit different.</p>
<p begin="00:23:15.700" end="00:23:18.010">So I wanna go find a familiar landmark.</p>
<p begin="00:23:18.010" end="00:23:21.220">So what I have to do is<br />find my inferior SI joint</p>
<p begin="00:23:21.220" end="00:23:23.560">or any of the part of the sacrum is fine,</p>
<p begin="00:23:23.560" end="00:23:26.440">and then move the probe<br />laterally to the ileum.</p>
<p begin="00:23:26.440" end="00:23:28.990">So here this big ski<br />slope here is the ileum,</p>
<p begin="00:23:28.990" end="00:23:31.090">the inferior part of that slope.</p>
<p begin="00:23:31.090" end="00:23:32.260">I'm aiming the beam all the way</p>
<p begin="00:23:32.260" end="00:23:33.640">to the anterior pelvis actually.</p>
<p begin="00:23:33.640" end="00:23:38.380">So here's minimus medias maximus.</p>
<p begin="00:23:38.380" end="00:23:40.090">So just to give you an idea<br />of the broad field of view</p>
<p begin="00:23:40.090" end="00:23:44.020">that we get with the<br />C five one transducer.</p>
<p begin="00:23:44.020" end="00:23:46.220">It's really nice just to get you oriented.</p>
<p begin="00:23:46.220" end="00:23:48.470">So let's follow the ileum now south.</p>
<p begin="00:23:48.470" end="00:23:53.090">And I need to see the ileum<br />split into two pieces there.</p>
<p begin="00:23:53.090" end="00:23:55.970">So left side of the screen,<br />sacrum side of the screen,</p>
<p begin="00:23:57.350" end="00:24:00.380">I see this opening, but I<br />still see two bony landmarks.</p>
<p begin="00:24:00.380" end="00:24:04.280">So sacrum here and the<br />beginnings of the isum here.</p>
<p begin="00:24:05.930" end="00:24:09.620">Back to our pizza slice piriformis here.</p>
<p begin="00:24:10.580" end="00:24:13.310">If I wanted to check my<br />work on the inferior part</p>
<p begin="00:24:13.310" end="00:24:14.480">of the ileum, you can see</p>
<p begin="00:24:14.480" end="00:24:17.480">that superior gluteal artery<br />pulsating really nicely</p>
<p begin="00:24:17.480" end="00:24:18.500">activate the color feature.</p>
<p begin="00:24:18.500" end="00:24:19.820">Again, check your work,</p>
<p begin="00:24:19.820" end="00:24:22.040">make sure you're still<br />familiarizing yourself,</p>
<p begin="00:24:22.040" end="00:24:25.010">but you can just see the<br />more broad field of view</p>
<p begin="00:24:25.010" end="00:24:27.050">that you get outta the<br />coline and more appreciation</p>
<p begin="00:24:27.050" end="00:24:29.660">for the whole structure as that</p>
<p begin="00:24:29.660" end="00:24:32.960">that superior gluteal artery<br />is just hugging the border,</p>
<p begin="00:24:32.960" end="00:24:34.640">the piriformis there.</p>
<p begin="00:24:35.930" end="00:24:37.940">Get my arrow back out here. So this is the</p>
<p begin="00:24:37.940" end="00:24:39.440">piriformis. Yeah, bill, go ahead</p>
<p begin="00:24:39.440" end="00:24:41.000">- Real quick.</p>
<p begin="00:24:41.000" end="00:24:44.150">Show how the angle of the transducer is</p>
<p begin="00:24:44.150" end="00:24:46.580">because frequently the most, one</p>
<p begin="00:24:46.580" end="00:24:48.560">of the most common mistakes I see,</p>
<p begin="00:24:48.560" end="00:24:50.780">and I I'm sure you do too, is</p>
<p begin="00:24:50.780" end="00:24:53.600">that the transducer isn't oblique</p>
<p begin="00:24:53.600" end="00:24:57.320">to go along the diagonal<br />course of the piriformis.</p>
<p begin="00:24:57.320" end="00:25:00.740">- That's true, bill, I just<br />kind of instinctively did that</p>
<p begin="00:25:00.740" end="00:25:03.710">because I've just, I've just<br />scanned so many of the hips.</p>
<p begin="00:25:03.710" end="00:25:04.940">But when you're first learning this,</p>
<p begin="00:25:04.940" end="00:25:07.670">and I stumbled through a lot<br />of things on the posterior hip,</p>
<p begin="00:25:07.670" end="00:25:10.490">it's kind of the final frontier<br />on in terms of the joints</p>
<p begin="00:25:10.490" end="00:25:12.320">that we typically cover for me.</p>
<p begin="00:25:12.320" end="00:25:13.910">And I did find it useful to go ahead</p>
<p begin="00:25:13.910" end="00:25:15.350">and elongate the glute max.</p>
<p begin="00:25:15.350" end="00:25:17.420">Remember that those are<br />running parallel to each other.</p>
<p begin="00:25:17.420" end="00:25:19.520">And the glute max is such<br />an oblique structure.</p>
<p begin="00:25:19.520" end="00:25:21.080">We need to pivot our transducer</p>
<p begin="00:25:21.080" end="00:25:24.740">and set ourselves up for the<br />long axis of the piriformis.</p>
<p begin="00:25:24.740" end="00:25:25.790">So there you can see</p>
<p begin="00:25:25.790" end="00:25:27.530">and I can palpate the trope to find out.</p>
<p begin="00:25:27.530" end="00:25:30.650">So here's tr and I'm<br />aiming right at the trope.</p>
<p begin="00:25:30.650" end="00:25:32.060">It's not a horizontal structure,</p>
<p begin="00:25:32.060" end="00:25:35.000">it's a very much a vertically<br />oriented oblique structure.</p>
<p begin="00:25:35.000" end="00:25:38.151">So here we have GL glute, max, max,</p>
<p begin="00:25:39.170" end="00:25:42.500">long axis, piriformis, long axis,</p>
<p begin="00:25:42.500" end="00:25:44.720">and you can even see some<br />of the central tendon</p>
<p begin="00:25:44.720" end="00:25:46.520">of the piriformis starting<br />to show itself here.</p>
<p begin="00:25:47.360" end="00:25:51.530">As we get over to the is<br />yum superior isum here,</p>
<p begin="00:25:51.530" end="00:25:53.030">right on the upper margin of the isum,</p>
<p begin="00:25:53.030" end="00:25:54.200">here's our superior Jamila.</p>
<p begin="00:25:58.190" end="00:26:00.590">With more penetration out of<br />a lower frequency transducer,</p>
<p begin="00:26:00.590" end="00:26:03.140">you can very nicely see the<br />inferior gluteal artery,</p>
<p begin="00:26:03.140" end="00:26:05.780">the sciatic nerve down a little deeper.</p>
<p begin="00:26:05.780" end="00:26:07.550">We get into some pudendal<br />structures, maybe</p>
<p begin="00:26:07.550" end="00:26:09.560">for a pain management<br />talk we could get into.</p>
<p begin="00:26:10.460" end="00:26:13.040">But for the general survey,<br />we're gonna keep following</p>
<p begin="00:26:13.040" end="00:26:14.660">that piriformis out laterally.</p>
<p begin="00:26:14.660" end="00:26:16.430">And we start to see that that posterior</p>
<p begin="00:26:19.280" end="00:26:22.490">femoral acetabular joint here, neck</p>
<p begin="00:26:22.490" end="00:26:25.490">of the femur trope starting<br />to make itself known here.</p>
<p begin="00:26:26.510" end="00:26:27.530">I do see a lot</p>
<p begin="00:26:27.530" end="00:26:30.020">of people struggle when they're<br />looking for a piriformis.</p>
<p begin="00:26:30.020" end="00:26:33.470">They start at the trope<br />and they call just any</p>
<p begin="00:26:33.470" end="00:26:35.240">of these rotating structures.</p>
<p begin="00:26:35.240" end="00:26:37.160">A, a piriformis.</p>
<p begin="00:26:37.160" end="00:26:38.720">When when I was first learning</p>
<p begin="00:26:38.720" end="00:26:43.410">to do posterior hip a<br />while back, I made the miss</p>
<p begin="00:26:43.410" end="00:26:46.950">call when doing external rotations</p>
<p begin="00:26:46.950" end="00:26:49.590">and just looking for the trope here.</p>
<p begin="00:26:50.910" end="00:26:52.800">And we call, oh, there's our piriformis.</p>
<p begin="00:26:52.800" end="00:26:54.720">And we got really excited.<br />I'm gonna bring the arrow</p>
<p begin="00:26:54.720" end="00:26:56.730">to the spot that we got excited about.</p>
<p begin="00:26:56.730" end="00:26:59.730">Saw a huge wavy flag tear right there.</p>
<p begin="00:26:59.730" end="00:27:01.290">I mean, what else could that be?</p>
<p begin="00:27:01.290" end="00:27:03.060">It's the big it it,</p>
<p begin="00:27:03.060" end="00:27:06.420">it's the big rotating muscle<br />we see on the anatomy scan.</p>
<p begin="00:27:06.420" end="00:27:07.800">And we sent it out for an MRI</p>
<p begin="00:27:07.800" end="00:27:10.440">and it came back as an wouldn't, you know,</p>
<p begin="00:27:10.440" end="00:27:12.060">as a quadratus femoris tear.</p>
<p begin="00:27:12.060" end="00:27:14.310">And that's when we really<br />got to learn, hey, we need</p>
<p begin="00:27:14.310" end="00:27:15.330">to take a little bit more time</p>
<p begin="00:27:15.330" end="00:27:18.240">and start with our bony<br />landmarks from the pelvis,</p>
<p begin="00:27:18.240" end="00:27:20.910">from the ileum, work our way south</p>
<p begin="00:27:20.910" end="00:27:22.470">from the superiors static<br />notch where, you know,</p>
<p begin="00:27:22.470" end="00:27:26.370">it originates on the<br />anterior sacrum there.</p>
<p begin="00:27:26.370" end="00:27:28.050">And so the two bones<br />we have in the, in the,</p>
<p begin="00:27:28.050" end="00:27:29.220">in the view here,</p>
<p begin="00:27:29.220" end="00:27:30.270">and I'm gonna try to bring the leg where</p>
<p begin="00:27:30.270" end="00:27:31.650">you can see me rotate.</p>
<p begin="00:27:31.650" end="00:27:33.690">Upper left is sacrum.</p>
<p begin="00:27:34.650" end="00:27:36.780">Mid screen right is the isum.</p>
<p begin="00:27:36.780" end="00:27:40.050">And all I'm gonna do is<br />just rotate passively.</p>
<p begin="00:27:40.050" end="00:27:41.430">Don't let the patient do it for you</p>
<p begin="00:27:41.430" end="00:27:43.050">because it'll start activating all the,</p>
<p begin="00:27:43.050" end="00:27:44.340">the surrounding gluteal structures</p>
<p begin="00:27:44.340" end="00:27:45.720">and it'll move your transducer.</p>
<p begin="00:27:46.740" end="00:27:48.960">Also an angle consideration is not</p>
<p begin="00:27:48.960" end="00:27:51.810">to stay per just perpendicular to the skin</p>
<p begin="00:27:51.810" end="00:27:54.210">because these structures tend to dive away</p>
<p begin="00:27:54.210" end="00:27:55.710">when the patient is laying down</p>
<p begin="00:27:56.700" end="00:28:00.570">and you are looking, say<br />at a skeletal model, the</p>
<p begin="00:28:00.570" end="00:28:05.570">the ileum is not flat this way<br />the ileum is diving this way</p>
<p begin="00:28:05.940" end="00:28:08.730">like two plates obliquely oriented.</p>
<p begin="00:28:08.730" end="00:28:11.220">And what I need to do is aim into</p>
<p begin="00:28:11.220" end="00:28:15.450">that big ileum wing<br />this way, not this way.</p>
<p begin="00:28:15.450" end="00:28:17.550">So I need to be 90 degrees to the ileum</p>
<p begin="00:28:17.550" end="00:28:20.310">before I get down into the piriformis.</p>
<p begin="00:28:20.310" end="00:28:22.920">So starting with our familiar<br />bony landmarks, again,</p>
<p begin="00:28:22.920" end="00:28:24.630">we have our big ileum here.</p>
<p begin="00:28:24.630" end="00:28:26.760">We can see glute max and mead</p>
<p begin="00:28:26.760" end="00:28:29.460">and I'm just gonna fall into<br />that superior satic notch.</p>
<p begin="00:28:29.460" end="00:28:32.490">You can see the bones opening<br />up right there closing up.</p>
<p begin="00:28:32.490" end="00:28:37.490">So I'm scanning superior,<br />inferior, superior, inferior.</p>
<p begin="00:28:37.620" end="00:28:42.360">And now I'm gonna oblique the<br />probe and go long axis there.</p>
<p begin="00:28:42.360" end="00:28:46.200">And all I'm doing now is, is<br />just confirming my location</p>
<p begin="00:28:46.200" end="00:28:48.390">of the piriformis with the internal</p>
<p begin="00:28:48.390" end="00:28:51.150">and external rotations passively.</p>
<p begin="00:28:51.150" end="00:28:54.390">Gotta do this passively or it'll<br />be a very frustrating exam.</p>
<p begin="00:28:55.590" end="00:28:58.620">- Daniel, while you're<br />there, we have a question</p>
<p begin="00:28:58.620" end="00:29:00.840">and we usually wait until we're finished.</p>
<p begin="00:29:00.840" end="00:29:04.980">But while you're there, we have a request</p>
<p begin="00:29:04.980" end="00:29:07.200">to see if you can show the sciatic nerve</p>
<p begin="00:29:08.160" end="00:29:12.660">pause just a little bit and<br />point it out for people to see.</p>
<p begin="00:29:12.660" end="00:29:14.400">Please.</p>
<p begin="00:29:14.400" end="00:29:15.750">- You bet. Right here,</p>
<p begin="00:29:15.750" end="00:29:18.870">see this triangular wedge<br />resting against the isum.</p>
<p begin="00:29:18.870" end="00:29:22.530">So this is sciatic nerve, it's lateral</p>
<p begin="00:29:22.530" end="00:29:24.510">to the arterial structures</p>
<p begin="00:29:24.510" end="00:29:27.060">of the inferior gluteal<br />artery in the pudendal.</p>
<p begin="00:29:27.060" end="00:29:29.040">And you could follow it down</p>
<p begin="00:29:29.040" end="00:29:32.610">and watch it stay on the edge<br />of the isum and then jump up</p>
<p begin="00:29:32.610" end="00:29:34.950">and over that neck of the isum here.</p>
<p begin="00:29:36.360" end="00:29:37.590">And we'll get into the remainder</p>
<p begin="00:29:37.590" end="00:29:40.260">of the sciatic nerve when we<br />get into quadratus femoris.</p>
<p begin="00:29:40.260" end="00:29:41.860">But I'm still just<br />following that sciatic nerve</p>
<p begin="00:29:41.860" end="00:29:44.800">where my arrow is using.</p>
<p begin="00:29:44.800" end="00:29:46.990">Well it gets lost in a<br />little bit of anisotropy.</p>
<p begin="00:29:46.990" end="00:29:50.500">Let's start right back up here again.</p>
<p begin="00:29:54.700" end="00:29:58.660">There, there is where, lemme<br />go right back to where I was.</p>
<p begin="00:29:58.660" end="00:30:00.430">So here's our piriformis.</p>
<p begin="00:30:00.430" end="00:30:02.260">Sciatic is sitting just right here</p>
<p begin="00:30:02.260" end="00:30:03.970">and it's not just a centimeter</p>
<p begin="00:30:03.970" end="00:30:05.050">or so of motion,</p>
<p begin="00:30:05.050" end="00:30:07.300">you're gonna see the<br />sciatic nerve climb upwards</p>
<p begin="00:30:09.940" end="00:30:10.600">there</p>
<p begin="00:30:24.010" end="00:30:25.930">and it is still subject to anti atropy.</p>
<p begin="00:30:25.930" end="00:30:28.480">So I kind of, kind of let<br />it get away from me there,</p>
<p begin="00:30:28.480" end="00:30:30.340">but here it is, it's a flat ribbon at this</p>
<p begin="00:30:30.340" end="00:30:31.885">point over the isum.</p>
<p begin="00:30:31.885" end="00:30:35.620">So let's follow that,<br />that nerve right here.</p>
<p begin="00:30:51.970" end="00:30:53.650">I keep remembering to move my arrow</p>
<p begin="00:31:07.000" end="00:31:07.720">and more distally.</p>
<p begin="00:31:07.720" end="00:31:10.330">It's really nicely, reliably<br />found right here on top</p>
<p begin="00:31:10.330" end="00:31:12.400">of the quadratus femoris<br />as this little triangle.</p>
<p begin="00:31:12.400" end="00:31:15.946">So screen left, we've got<br />our ischial tuberosity</p>
<p begin="00:31:15.946" end="00:31:17.980">and our hamstring origins.</p>
<p begin="00:31:17.980" end="00:31:20.770">And then right here is the sciatic nerve.</p>
<p begin="00:31:20.770" end="00:31:22.960">And then here's that quadratus femoris.</p>
<p begin="00:31:22.960" end="00:31:25.150">And we could try to trace<br />that proximally to see</p>
<p begin="00:31:25.150" end="00:31:27.610">that little, see the, an<br />isotropic transition it's trying</p>
<p begin="00:31:27.610" end="00:31:29.095">to make right there.</p>
<p begin="00:31:29.095" end="00:31:34.030">So this is inferior<br />jamella here it is on top</p>
<p begin="00:31:34.030" end="00:31:36.430">of there, there's the sciatic.</p>
<p begin="00:31:36.430" end="00:31:38.020">What I'm having to do is rotate my probe</p>
<p begin="00:31:38.020" end="00:31:39.610">and head back up towards the sacrum.</p>
<p begin="00:31:39.610" end="00:31:41.380">And here's where it's still<br />kind of a flat ribbon.</p>
<p begin="00:31:46.060" end="00:31:48.700">- I would say that I've<br />found it helpful to go down</p>
<p begin="00:31:48.700" end="00:31:51.520">to the quadratus femes<br />and the ischial tuberosity</p>
<p begin="00:31:51.520" end="00:31:52.990">and identify it at that label</p>
<p begin="00:31:52.990" end="00:31:56.560">and then follow it up to the piriformis.</p>
<p begin="00:31:56.560" end="00:31:58.540">- That's what I just,<br />that's what I just did.</p>
<p begin="00:31:58.540" end="00:32:01.120">And it kind of highlighted<br />that anti isotropy,</p>
<p begin="00:32:02.506" end="00:32:04.930">but here it is trying to, trying</p>
<p begin="00:32:04.930" end="00:32:06.850">to maintain that perpendicularity.</p>
<p begin="00:32:06.850" end="00:32:09.640">But I'm, what I'm finding myself having</p>
<p begin="00:32:09.640" end="00:32:13.450">to do is almost like a<br />rainbow of the transducer</p>
<p begin="00:32:13.450" end="00:32:15.160">to stay 90 degrees to the nerve</p>
<p begin="00:32:15.160" end="00:32:16.600">as it curves up and over theum.</p>
<p begin="00:32:17.590" end="00:32:21.580">So here it is, nerve sciatic,<br />sciatic, sciatic, sciatic.</p>
<p begin="00:32:23.410" end="00:32:27.760">Remain that 90 degree<br />relationship as I climb up</p>
<p begin="00:32:27.760" end="00:32:31.600">and over and I'll find myself</p>
<p begin="00:32:31.600" end="00:32:33.010">down at the quadratus.</p>
<p begin="00:32:38.350" end="00:32:39.350">Oh, there it is.</p>
<p begin="00:32:40.340" end="00:32:44.360">- I think that's great. Daniel.<br />One other, one other thing.</p>
<p begin="00:32:44.360" end="00:32:45.560">Sure. One more time.</p>
<p begin="00:32:45.560" end="00:32:47.630">Could you demonstrate the dynamic,</p>
<p begin="00:32:50.390" end="00:32:53.540">dynamic motion of the piriformis?</p>
<p begin="00:32:53.540" end="00:32:55.880">- Sure. So back to our familiar landmark,</p>
<p begin="00:32:55.880" end="00:32:57.140">I'm gonna lose the arrow for a minute</p>
<p begin="00:32:57.140" end="00:32:58.220">because I need two hands.</p>
<p begin="00:33:00.020" end="00:33:03.260">Come up here to the sacrum</p>
<p begin="00:33:04.130" end="00:33:06.830">and the big tip here<br />is as you go laterally</p>
<p begin="00:33:06.830" end="00:33:09.530">to aim back into the ileum, okay,</p>
<p begin="00:33:09.530" end="00:33:12.530">so we're aiming into the<br />ileum, not 90 degrees,</p>
<p begin="00:33:12.530" end="00:33:15.485">to the skin, into the ileum.</p>
<p begin="00:33:16.605" end="00:33:19.970">And we see that big<br />ski slope of the ileum.</p>
<p begin="00:33:19.970" end="00:33:23.390">And what I'm gonna do is just<br />fall down keeping the sacrum</p>
<p begin="00:33:23.390" end="00:33:24.860">in the upper left portion of the screen.</p>
<p begin="00:33:24.860" end="00:33:27.920">That would be one of my<br />other scanning tips, pearls</p>
<p begin="00:33:27.920" end="00:33:31.580">that I'm observing while I'm,<br />while I'm sitting here talking</p>
<p begin="00:33:31.580" end="00:33:34.250">to you guys, sacrum upper left</p>
<p begin="00:33:34.250" end="00:33:37.130">and I'm gonna watch this,<br />this horizontal bony structure</p>
<p begin="00:33:37.130" end="00:33:39.140">split into two pieces here.</p>
<p begin="00:33:39.140" end="00:33:40.580">When I see those two pieces,</p>
<p begin="00:33:40.580" end="00:33:42.950">I know I'm in the<br />superior sciatic foramen.</p>
<p begin="00:33:43.970" end="00:33:47.270">You're gonna tilt the probe or rotate it.</p>
<p begin="00:33:47.270" end="00:33:49.070">In this case I just went clockwise</p>
<p begin="00:33:50.060" end="00:33:53.000">and that opens up that big triangular</p>
<p begin="00:33:53.000" end="00:33:55.340">pizza slice shaped piriformis.</p>
<p begin="00:33:55.340" end="00:33:57.770">And I'm gonna confirm that just</p>
<p begin="00:33:57.770" end="00:34:00.860">by doing passive rotations<br />internally and externally.</p>
<p begin="00:34:01.790" end="00:34:05.540">And I'm on the medial or yeah,<br />more medial side of the isum.</p>
<p begin="00:34:08.150" end="00:34:10.460">And you can see this muscle,</p>
<p begin="00:34:11.660" end="00:34:16.660">the more external rotation I apply,</p>
<p begin="00:34:17.180" end="00:34:20.180">which would be internal rotation I guess.</p>
<p begin="00:34:27.080" end="00:34:28.250">I hope that answers your question.</p>
<p begin="00:34:29.090" end="00:34:31.640">- Very good, thank you.</p>
<p begin="00:34:31.640" end="00:34:32.870">We, I'll share my screen</p>
<p begin="00:34:32.870" end="00:34:35.720">and we'll move on to the hamstrings.</p>
<p begin="00:34:44.360" end="00:34:48.590">So the hamstrings originate<br />from the ischial tuberosity.</p>
<p begin="00:34:48.590" end="00:34:52.550">They can, they contribute to<br />assisting with hip extension</p>
<p begin="00:34:52.550" end="00:34:54.770">and knee flexion as each</p>
<p begin="00:34:54.770" end="00:34:59.060">of the hamstrings muscles<br />traverse the both the hip joint</p>
<p begin="00:34:59.060" end="00:35:00.080">and the knee joint.</p>
<p begin="00:35:01.280" end="00:35:05.600">There are three muscle tendon structures</p>
<p begin="00:35:05.600" end="00:35:08.900">that comprise the the hamstrings,</p>
<p begin="00:35:08.900" end="00:35:11.720">the semimembranosus muscle tendon, as well</p>
<p begin="00:35:11.720" end="00:35:15.800">as the semi tendonosis and<br />long head of the biceps.</p>
<p begin="00:35:15.800" end="00:35:20.540">The semimembranosus muscle<br />tendon group originates off the</p>
<p begin="00:35:20.540" end="00:35:24.140">sup lateral issue, tuberosity</p>
<p begin="00:35:24.140" end="00:35:28.760">and inserts onto the medial epicon dial.</p>
<p begin="00:35:31.940" end="00:35:35.930">So the semimembranosus<br />here comes underneath</p>
<p begin="00:35:36.930" end="00:35:38.190">the semit</p>
<p begin="00:35:38.190" end="00:35:41.520">and the biceps to insert right here</p>
<p begin="00:35:44.550" end="00:35:46.260">on the ischial tuberosity.</p>
<p begin="00:35:47.160" end="00:35:48.390">And then it comes down</p>
<p begin="00:35:48.390" end="00:35:51.900">and inserts on the medial tibial condyle.</p>
<p begin="00:35:53.220" end="00:35:54.870">The semi tendinosis</p>
<p begin="00:35:54.870" end="00:35:58.050">and long head of the biceps are conjoined</p>
<p begin="00:35:59.100" end="00:36:02.740">the postal and the insert on<br />the postal lateral ischial</p>
<p begin="00:36:02.740" end="00:36:06.720">tuberosity as one point of origin.</p>
<p begin="00:36:08.010" end="00:36:12.390">There are two heads to the<br />bicep tendon, a long head</p>
<p begin="00:36:12.390" end="00:36:14.790">and a short head proximally.</p>
<p begin="00:36:14.790" end="00:36:19.790">The short head originates from<br />the line aspera of the femur.</p>
<p begin="00:36:19.860" end="00:36:21.540">The in the insertion</p>
<p begin="00:36:21.540" end="00:36:24.570">of the biceps femorals<br />is on the fibular head.</p>
<p begin="00:36:24.570" end="00:36:26.820">And at this point the long head</p>
<p begin="00:36:26.820" end="00:36:31.820">and the short head have<br />become a common tendon</p>
<p begin="00:36:31.920" end="00:36:36.240">to insert as</p>
<p begin="00:36:36.240" end="00:36:40.110">as a single tendon onto the fibular head.</p>
<p begin="00:36:41.490" end="00:36:44.820">The semi tendinosis, on the other hand,</p>
<p begin="00:36:44.820" end="00:36:49.650">inserts on the antrum medial<br />tibia as one of the pez</p>
<p begin="00:36:49.650" end="00:36:51.840">and serene tendons.</p>
<p begin="00:36:51.840" end="00:36:56.550">All of the hamstrings are<br />innervated by the tibial branch</p>
<p begin="00:36:56.550" end="00:36:58.080">of the sciatic nerve.</p>
<p begin="00:36:58.080" end="00:36:59.940">So where do we begin?</p>
<p begin="00:37:00.930" end="00:37:03.690">We begin again at the gluteal fold</p>
<p begin="00:37:04.830" end="00:37:06.030">or near it,</p>
<p begin="00:37:06.030" end="00:37:10.650">at which point we'll<br />recognize the hyper coic bony</p>
<p begin="00:37:10.650" end="00:37:12.330">acoustic landmark</p>
<p begin="00:37:12.330" end="00:37:17.190">of the issue tuberosity<br />shape much like a matter horn</p>
<p begin="00:37:18.450" end="00:37:23.130">with a bony prominent peak<br />over the, over the top</p>
<p begin="00:37:23.130" end="00:37:27.480">of which we will see<br />on the lateral aspect,</p>
<p begin="00:37:27.480" end="00:37:30.960">the conjoin tendon of the semit</p>
<p begin="00:37:30.960" end="00:37:34.560">and the biceps femoris also just lateral,</p>
<p begin="00:37:34.560" end="00:37:38.370">as Daniel just covered<br />nicely in his live demo.</p>
<p begin="00:37:38.370" end="00:37:41.580">The sciatic nerve will be identified</p>
<p begin="00:37:45.300" end="00:37:49.290">if we turn the transducer 90 degrees now.</p>
<p begin="00:37:49.290" end="00:37:51.420">And we look at</p>
<p begin="00:37:51.420" end="00:37:54.540">these structures in the long axis,</p>
<p begin="00:37:56.280" end="00:38:00.990">we'll see the ischial<br />tuberosity superficial,</p>
<p begin="00:38:00.990" end="00:38:03.000">we'll see the conjoint tendon</p>
<p begin="00:38:04.350" end="00:38:07.590">and deep to that as we fall off the bone,</p>
<p begin="00:38:08.430" end="00:38:10.740">we'll see the semimembranosus tendon.</p>
<p begin="00:38:11.850" end="00:38:14.790">This, these are the tendon only portions</p>
<p begin="00:38:14.790" end="00:38:18.270">of the hamstrings complex proximally.</p>
<p begin="00:38:18.270" end="00:38:22.470">If we follow them more<br />distally, we'll we'll see.</p>
<p begin="00:38:22.470" end="00:38:26.490">And we'll want to interrogate<br />the myotendinous junction.</p>
<p begin="00:38:26.490" end="00:38:29.340">The biceps is the most commonly torn,</p>
<p begin="00:38:29.340" end="00:38:33.660">the most common running tear is a</p>
<p begin="00:38:33.660" end="00:38:37.390">musculo tenderness tear<br />that you'll only see</p>
<p begin="00:38:39.190" end="00:38:41.950">that you frequently will see<br />just immediately adjacent</p>
<p begin="00:38:41.950" end="00:38:43.630">to the central tendon.</p>
<p begin="00:38:43.630" end="00:38:46.630">A little further distal from here,</p>
<p begin="00:38:53.560" end="00:38:55.000">the sciatic nerve.</p>
<p begin="00:38:55.000" end="00:38:59.830">We're going to begin<br />where Daniel demonstrated</p>
<p begin="00:38:59.830" end="00:39:01.540">before, I like</p>
<p begin="00:39:01.540" end="00:39:04.870">to interrogate it beginning<br />at the piriformis.</p>
<p begin="00:39:06.790" end="00:39:11.170">We're going to position our<br />transducer along the piriformis</p>
<p begin="00:39:11.170" end="00:39:14.115">so that again, we see the,</p>
<p begin="00:39:14.115" end="00:39:16.090">the thicker portion of the piriformis.</p>
<p begin="00:39:16.090" end="00:39:17.920">By the way, piriformis, the Latin</p>
<p begin="00:39:17.920" end="00:39:22.630">for piriformis is pear shaped<br />as opposed to the pizza slice</p>
<p begin="00:39:22.630" end="00:39:23.890">that you were talking about, Daniel.</p>
<p begin="00:39:23.890" end="00:39:27.250">I must agree though that it<br />is shaped more like a pizza,</p>
<p begin="00:39:27.250" end="00:39:29.710">a slice of pizza than a pear.</p>
<p begin="00:39:29.710" end="00:39:34.210">But the piriformis than<br />we'll see the sciatic</p>
<p begin="00:39:34.210" end="00:39:36.910">nerve and adjacent to it,</p>
<p begin="00:39:36.910" end="00:39:39.910">the inferior gluteal artery.</p>
<p begin="00:39:43.210" end="00:39:47.650">If we slide the transducer distally now</p>
<p begin="00:39:47.650" end="00:39:48.745">past the gli</p>
<p begin="00:39:48.745" end="00:39:53.110">and the ator to the isum, again this is</p>
<p begin="00:39:53.110" end="00:39:57.005">that same image where we<br />see the ischial tuberosity,</p>
<p begin="00:39:57.005" end="00:40:00.550">the conjoin tendon and<br />slightly lateral to it.</p>
<p begin="00:40:00.550" end="00:40:03.190">We'll see the sciatic nerve</p>
<p begin="00:40:04.360" end="00:40:06.220">always good when you're looking at the</p>
<p begin="00:40:06.220" end="00:40:07.720">sciatic nerve at this level.</p>
<p begin="00:40:07.720" end="00:40:11.020">See this is, we don't, the<br />depth of this image isn't set</p>
<p begin="00:40:12.490" end="00:40:15.040">to image the quadratus femes.</p>
<p begin="00:40:15.040" end="00:40:18.280">But at this level, always wise</p>
<p begin="00:40:18.280" end="00:40:20.560">to just look at the quadratus femes,</p>
<p begin="00:40:20.560" end="00:40:23.560">there are dynamic<br />maneuvers that can be done</p>
<p begin="00:40:23.560" end="00:40:26.890">to demonstrate ischial femoral impingement</p>
<p begin="00:40:26.890" end="00:40:30.220">and snapping that may occur due to that.</p>
<p begin="00:40:31.510" end="00:40:36.100">And recognize decrease in</p>
<p begin="00:40:36.100" end="00:40:40.000">space here that could<br />contribute to irritation</p>
<p begin="00:40:40.000" end="00:40:41.380">of the sciatic nerve.</p>
<p begin="00:40:42.370" end="00:40:46.030">Once we move slightly<br />more distal, we're going</p>
<p begin="00:40:46.030" end="00:40:50.320">to be in the upper portion<br />of the posterior thigh</p>
<p begin="00:40:50.320" end="00:40:52.420">where we'll see the conjoining tendon</p>
<p begin="00:40:52.420" end="00:40:57.070">and its myo tendonous component</p>
<p begin="00:40:57.070" end="00:41:01.090">with the biceps femoris laterally,</p>
<p begin="00:41:01.090" end="00:41:04.390">the semi tendinosis medially.</p>
<p begin="00:41:04.390" end="00:41:07.120">We'll see the typical tadpole shape</p>
<p begin="00:41:07.120" end="00:41:09.310">of the semimembranosus tendon</p>
<p begin="00:41:09.310" end="00:41:12.040">and the underlying semimembranosus muscle.</p>
<p begin="00:41:12.040" end="00:41:14.230">So myo tendinous junction</p>
<p begin="00:41:14.230" end="00:41:17.770">and laterally we'll identify the</p>
<p begin="00:41:17.770" end="00:41:19.240">- Sciatic nerve.</p>
<p begin="00:41:23.890" end="00:41:25.090">That concludes</p>
<p begin="00:41:25.090" end="00:41:29.080">- The PowerPoint presentation.</p>
<p begin="00:41:29.080" end="00:41:30.970">Daniel, I'll let you finish it up</p>
<p begin="00:41:30.970" end="00:41:34.370">with a live model demonstration<br />of structures please.</p>
<p begin="00:41:36.320" end="00:41:38.690">- Alright, thanks Bill.<br />So I've switched back over</p>
<p begin="00:41:38.690" end="00:41:42.740">to the L 15, linear 15<br />megaherz transducer.</p>
<p begin="00:41:44.690" end="00:41:47.150">There we go. And I'm gonna<br />re-expose the hip back here</p>
<p begin="00:41:49.130" end="00:41:51.110">and pick up where we left off.</p>
<p begin="00:41:51.110" end="00:41:53.780">This time my bony landmark<br />is gonna be the ischial</p>
<p begin="00:41:53.780" end="00:41:55.190">tuberosity and lateral.</p>
<p begin="00:41:55.190" end="00:41:57.890">I should see that, that<br />sciatic nerve really nicely.</p>
<p begin="00:41:57.890" end="00:41:58.940">And to check my work,</p>
<p begin="00:41:58.940" end="00:42:03.500">we'll look at the quadratus<br />femoris again, left side</p>
<p begin="00:42:03.500" end="00:42:05.450">of the screen will be medial.</p>
<p begin="00:42:05.450" end="00:42:09.350">And if, if you joined late, you<br />can see in the upper corner.</p>
<p begin="00:42:09.350" end="00:42:13.010">This is superior, this is<br />inferior, this is lateral,</p>
<p begin="00:42:13.010" end="00:42:14.270">this is medial here.</p>
<p begin="00:42:14.270" end="00:42:17.330">So I'm gonna place the<br />transducer down here</p>
<p begin="00:42:17.330" end="00:42:20.180">where I believe I should<br />find initial tuberosity.</p>
<p begin="00:42:20.180" end="00:42:23.420">If I don't see one right<br />off the bat, what I have</p>
<p begin="00:42:23.420" end="00:42:25.400">to do is just follow<br />these shadowing structures</p>
<p begin="00:42:25.400" end="00:42:27.105">up more medially.</p>
<p begin="00:42:27.105" end="00:42:31.730">Here we go. So let's find out<br />which kind of bone this is.</p>
<p begin="00:42:31.730" end="00:42:33.680">I'm gonna follow it down<br />and see if it, it comes</p>
<p begin="00:42:33.680" end="00:42:36.080">to a nice point and that's<br />gonna be our ischial tuberosity.</p>
<p begin="00:42:36.080" end="00:42:38.180">I've run outta gel, so I'm<br />just gonna squeegee some gel</p>
<p begin="00:42:38.180" end="00:42:39.890">down more inferiorly.</p>
<p begin="00:42:39.890" end="00:42:44.480">There we are. So we've<br />got this, this prominent</p>
<p begin="00:42:44.480" end="00:42:48.080">bony peak here, just lateral to</p>
<p begin="00:42:48.080" end="00:42:51.026">that prominent bony peak<br />of the ischial tuberosity.</p>
<p begin="00:42:51.026" end="00:42:53.090">We can see that conjoin tendon structure</p>
<p begin="00:42:53.090" end="00:42:54.320">starting to show itself.</p>
<p begin="00:42:55.280" end="00:42:56.750">I'm gonna keep moving laterally just</p>
<p begin="00:42:56.750" end="00:42:58.730">to orient myself a bit more.</p>
<p begin="00:42:58.730" end="00:43:02.300">So here's quadratus femoris,<br />here's that sciatic nerve.</p>
<p begin="00:43:03.530" end="00:43:05.090">So we can see all those<br />structures really nice.</p>
<p begin="00:43:05.090" end="00:43:06.170">So we know we're in the ballpark, we</p>
<p begin="00:43:06.170" end="00:43:07.220">know where we need to be.</p>
<p begin="00:43:08.450" end="00:43:10.280">Do now to differentiate these fibers,</p>
<p begin="00:43:10.280" end="00:43:12.710">I'm gonna bring my depth up because I can,</p>
<p begin="00:43:12.710" end="00:43:16.460">we want a more shallow depth<br />and a more high resolute image</p>
<p begin="00:43:16.460" end="00:43:21.140">and we're gonna use tropic<br />artifact to our advantage</p>
<p begin="00:43:21.140" end="00:43:24.530">and kind of split apart<br />these layers here. So Dan,</p>
<p begin="00:43:24.530" end="00:43:26.570">- I'm gonna interrupt just for a second.</p>
<p begin="00:43:26.570" end="00:43:28.940">I know the image from<br />your PX doesn't translate</p>
<p begin="00:43:28.940" end="00:43:31.520">to the zoom presentation perfectly.</p>
<p begin="00:43:31.520" end="00:43:33.530">I'm gonna have you just decrease your</p>
<p begin="00:43:33.530" end="00:43:35.450">gain just a little bit.</p>
<p begin="00:43:35.450" end="00:43:38.750">- Oh good. Good call Bill<br />Zoom definitely does.</p>
<p begin="00:43:38.750" end="00:43:39.230">- Thank you.</p>
<p begin="00:43:44.990" end="00:43:47.390">- Hopefully that's better. Very good.</p>
<p begin="00:43:47.390" end="00:43:50.150">So we could see these layers<br />differentiate themselves here</p>
<p begin="00:43:50.150" end="00:43:53.480">on the, on the hamstrings<br />kind of common origin.</p>
<p begin="00:43:54.440" end="00:43:58.190">Deep down here we've got<br />the deeper semi menos,</p>
<p begin="00:43:58.190" end="00:44:00.020">semi tendinosis, overlaying that</p>
<p begin="00:44:00.020" end="00:44:02.360">and laterally at that conjoin structure.</p>
<p begin="00:44:02.360" end="00:44:05.360">We've got our biceps femoris<br />and we could trace these down</p>
<p begin="00:44:05.360" end="00:44:08.630">and watch the biceps femoris<br />tendon move its way laterally</p>
<p begin="00:44:09.710" end="00:44:11.600">and its extended muscle belly here.</p>
<p begin="00:44:12.530" end="00:44:16.130">And semi tendinosis would<br />be our next landmark,</p>
<p begin="00:44:16.130" end="00:44:17.360">just slightly medial to that.</p>
<p begin="00:44:17.360" end="00:44:22.250">And underneath the semi tendon</p>
<p begin="00:44:22.250" end="00:44:24.950">or the biceps femoris, here's<br />our s static nerve just</p>
<p begin="00:44:24.950" end="00:44:26.810">as a a reference.</p>
<p begin="00:44:26.810" end="00:44:29.540">So I'm down at the, the,<br />the gluteal fold again,</p>
<p begin="00:44:30.530" end="00:44:32.430">here we've got tendinosis.</p>
<p begin="00:44:33.510" end="00:44:36.360">Let's use isotropy to<br />our advantage here. This.</p>
<p begin="00:44:38.400" end="00:44:41.310">So even though there's a component here,</p>
<p begin="00:44:47.250" end="00:44:51.495">our more superior showing tendon<br />right here medially is our</p>
<p begin="00:44:51.495" end="00:44:54.510">semimembranosus, this little cleft edge.</p>
<p begin="00:44:54.510" end="00:44:58.050">And let's watch it join up<br />with the semi tendinosis</p>
<p begin="00:44:58.050" end="00:45:00.120">and then the, the biceps<br />femoris laterally.</p>
<p begin="00:45:00.120" end="00:45:02.520">So you can almost get all<br />three of 'em in a row,</p>
<p begin="00:45:02.520" end="00:45:05.135">even though there is a<br />conjoin component to it.</p>
<p begin="00:45:05.135" end="00:45:08.580">Here is biceps femoris,</p>
<p begin="00:45:08.580" end="00:45:12.690">semi tendinosis, semi menos.</p>
<p begin="00:45:12.690" end="00:45:15.330">This this little isolated shadow here.</p>
<p begin="00:45:15.330" end="00:45:18.090">So I'm just barely rocking<br />the transducer like we do the</p>
<p begin="00:45:18.090" end="00:45:20.760">biceps tendon in the groove to see</p>
<p begin="00:45:20.760" end="00:45:21.840">what subtleties we can get.</p>
<p begin="00:45:21.840" end="00:45:23.820">What you don't wanna do is<br />get in the habit of calling</p>
<p begin="00:45:23.820" end="00:45:26.310">that a tendinosis, even though<br />that's in the name of one</p>
<p begin="00:45:26.310" end="00:45:28.920">of the, one of the tendons.</p>
<p begin="00:45:28.920" end="00:45:33.150">That is not a, a pathology<br />if you can get it to fill in.</p>
<p begin="00:45:33.150" end="00:45:36.510">So an isotropy back<br />here is really helpful,</p>
<p begin="00:45:36.510" end="00:45:37.920">but it can also be very misleading</p>
<p begin="00:45:37.920" end="00:45:40.650">and we don't wanna call things<br />degenerated if they're not.</p>
<p begin="00:45:40.650" end="00:45:43.380">So now I'm gonna take one of<br />these tendons here in this case</p>
<p begin="00:45:43.380" end="00:45:45.660">we'll we'll focus on menos</p>
<p begin="00:45:45.660" end="00:45:49.380">and rotate the probe so<br />that the pro, the left side</p>
<p begin="00:45:49.380" end="00:45:52.650">of the screen is facing proximal.</p>
<p begin="00:45:52.650" end="00:45:53.910">So we've got our isum here</p>
<p begin="00:46:00.480" end="00:46:00.900">laterally.</p>
<p begin="00:46:00.900" end="00:46:03.150">It's really nice to see<br />biceps femoris go ahead</p>
<p begin="00:46:03.150" end="00:46:05.880">and shoot off and go do its own thing.</p>
<p begin="00:46:05.880" end="00:46:09.360">And I could follow that,<br />that more laterally oriented</p>
<p begin="00:46:09.360" end="00:46:10.560">structure pretty easily.</p>
<p begin="00:46:10.560" end="00:46:13.380">I'm gonna bring my pro more medial now</p>
<p begin="00:46:13.380" end="00:46:16.860">and focus more on the semi menos</p>
<p begin="00:46:16.860" end="00:46:19.200">and tendinosis area here, which we</p>
<p begin="00:46:19.200" end="00:46:20.220">can see really, really nicely.</p>
<p begin="00:46:20.220" end="00:46:22.290">It looks like a lot of<br />tendons always insert</p>
<p begin="00:46:22.290" end="00:46:23.430">like a big bird's beak.</p>
<p begin="00:46:23.430" end="00:46:26.370">And we see that same pattern<br />back here on another tuberosity</p>
<p begin="00:46:26.370" end="00:46:28.710">on the body, on the ischial tuberosity.</p>
<p begin="00:46:29.760" end="00:46:33.090">So we've got our conjoin<br />tendon here superficially</p>
<p begin="00:46:33.090" end="00:46:35.880">and then deep, deep, deep down here where</p>
<p begin="00:46:35.880" end="00:46:37.890">as Bill pointed out, I'm not sure if gains</p>
<p begin="00:46:37.890" end="00:46:39.000">coming through on zoom.</p>
<p begin="00:46:40.770" end="00:46:42.630">I'm gonna auto this,</p>
<p begin="00:46:42.630" end="00:46:44.250">- Try your TGC deep.</p>
<p begin="00:46:45.420" end="00:46:46.350">- Yeah, there we go.</p>
<p begin="00:46:54.690" end="00:46:55.920">Hopefully that helps.</p>
<p begin="00:46:55.920" end="00:46:59.520">- Yeah, notice that we're<br />trying to go. There we go.</p>
<p begin="00:46:59.520" end="00:47:01.680">You're seeing a little bit there Daniel.</p>
<p begin="00:47:01.680" end="00:47:03.270">The semimembranosus deeper,</p>
<p begin="00:47:03.270" end="00:47:07.080">but this is with the,<br />give you an idea of how</p>
<p begin="00:47:07.080" end="00:47:10.860">nice the penetration is with the linear 15</p>
<p begin="00:47:10.860" end="00:47:12.750">to four megahertz transducer.</p>
<p begin="00:47:14.760" end="00:47:17.430">- Very true. Most of these<br />higher frequency transducers</p>
<p begin="00:47:17.430" end="00:47:19.080">don't have much of a range to them.</p>
<p begin="00:47:19.080" end="00:47:21.630">And this, you know,<br />we're scanning 15 to four</p>
<p begin="00:47:21.630" end="00:47:23.640">so really depends on where<br />we are in the screen,</p>
<p begin="00:47:23.640" end="00:47:26.580">how deep we're trying to shoot,<br />whether I'm in res or gen.</p>
<p begin="00:47:26.580" end="00:47:28.650">And I've dropped my frequency<br />down to the gen spectrum.</p>
<p begin="00:47:28.650" end="00:47:31.120">So I'm on the lower lower<br />end of that bandwidth,</p>
<p begin="00:47:31.120" end="00:47:33.070">which is really helping<br />me with penetration here.</p>
<p begin="00:47:39.370" end="00:47:41.470">I'm gonna move laterally to my sciatic</p>
<p begin="00:47:41.470" end="00:47:43.780">and I'm gonna go cross section again,</p>
<p begin="00:47:43.780" end="00:47:46.270">find our ischial<br />tuberosity, check our gain</p>
<p begin="00:47:46.270" end="00:47:47.980">with zoom, which looks a little hot.</p>
<p begin="00:47:47.980" end="00:47:50.830">I'm gonna hit auto. There we go.</p>
<p begin="00:47:50.830" end="00:47:52.000">Auto's doing a really good job.</p>
<p begin="00:47:52.840" end="00:47:56.020">So ischial tuberosity<br />again here we have our,</p>
<p begin="00:47:56.020" end="00:47:57.310">our sciatic nerve</p>
<p begin="00:47:59.320" end="00:48:01.420">and quadratus femoris<br />just to check our work.</p>
<p begin="00:48:01.420" end="00:48:03.970">And I kind of already went<br />through the sciatic so I'd,</p>
<p begin="00:48:03.970" end="00:48:06.010">I'd find that to be redundant</p>
<p begin="00:48:06.010" end="00:48:07.690">to trace the sciatic approximal</p>
<p begin="00:48:09.760" end="00:48:12.670">time on it just a short time ago.</p>
<p begin="00:48:12.670" end="00:48:16.660">- Let's just follow distally,<br />Daniel to the upper thigh to</p>
<p begin="00:48:16.660" end="00:48:17.500">- You. Got it.</p>
<p begin="00:48:17.500" end="00:48:19.930">- Yeah. - So what I'm gonna<br />do is add a little bit of gel</p>
<p begin="00:48:19.930" end="00:48:24.930">'cause I know, I know I'm<br />about to follow a track here</p>
<p begin="00:48:25.300" end="00:48:29.080">and it might even be nice to see it split</p>
<p begin="00:48:30.220" end="00:48:33.910">if, if, if I've set the camera</p>
<p begin="00:48:33.910" end="00:48:36.490">to go down there.</p>
<p begin="00:48:36.490" end="00:48:37.630">- Oh, very<br />- Good. Looks like I did.</p>
<p begin="00:48:39.555" end="00:48:42.526">Okay, so quadratus femoris</p>
<p begin="00:48:43.480" end="00:48:44.770">back up here at the isum.</p>
<p begin="00:48:44.770" end="00:48:47.380">Here we are and let's</p>
<p begin="00:48:47.380" end="00:48:50.410">follow this structure here.</p>
<p begin="00:48:50.410" end="00:48:52.060">Sciatic nerve distally distally,</p>
<p begin="00:48:52.060" end="00:48:54.670">distally cross-section is the way to go.</p>
<p begin="00:48:54.670" end="00:48:56.020">I know that these nerves look really,</p>
<p begin="00:48:56.020" end="00:48:58.150">really pretty and long axis.</p>
<p begin="00:48:58.150" end="00:48:59.050">- Let's just turn,<br />let's just turn the game</p>
<p begin="00:48:59.050" end="00:48:59.830">down just a little.</p>
<p begin="00:48:59.830" end="00:49:03.400">Daniel. Thank you. Perfect.</p>
<p begin="00:49:03.400" end="00:49:04.540">- You bet it's blinding you.</p>
<p begin="00:49:05.680" end="00:49:09.910">Okay, so sciatic nerve<br />distally, distally distally.</p>
<p begin="00:49:09.910" end="00:49:11.680">Keep following it distally.</p>
<p begin="00:49:11.680" end="00:49:14.380">And we should start<br />seeing an offshoot here</p>
<p begin="00:49:14.380" end="00:49:16.390">of the common peroneal</p>
<p begin="00:49:16.390" end="00:49:18.670">or common fibular nerve<br />depending on when you went</p>
<p begin="00:49:18.670" end="00:49:21.460">to med school or started learning this,</p>
<p begin="00:49:26.830" end="00:49:27.970">I figured we'd already see it start</p>
<p begin="00:49:27.970" end="00:49:29.590">to bifurcate, but we're not quite there.</p>
<p begin="00:49:31.660" end="00:49:36.190">So here's the popliteal<br />fossa where my hand is</p>
<p begin="00:49:36.190" end="00:49:40.300">and maybe I missed the bifurcation.</p>
<p begin="00:49:40.300" end="00:49:45.300">It should have already. There it is.</p>
<p begin="00:49:45.340" end="00:49:47.590">Okay. So right where my<br />arrow is, you can see the</p>
<p begin="00:49:49.450" end="00:49:51.640">bifurcation take place right there.</p>
<p begin="00:49:53.290" end="00:49:55.120">That's just not separated. Hang on.</p>
<p begin="00:50:02.380" end="00:50:07.300">Oh that's not right 'cause<br />it's gonna follow the</p>
<p begin="00:50:07.300" end="00:50:09.370">biceps femoris just as a scanning pearl</p>
<p begin="00:50:15.405" end="00:50:18.550">because I sure would not think to see,</p>
<p begin="00:50:18.550" end="00:50:21.040">- I think the main thing is<br />Daniel, let's just go down</p>
<p begin="00:50:21.040" end="00:50:24.430">as far as the Mercedes-Benz<br />sign to show how</p>
<p begin="00:50:24.430" end="00:50:26.350">to identify the conjoin tend,</p>
<p begin="00:50:26.350" end="00:50:30.140">and you're right there, the<br />conjoin tendon, more superficial</p>
<p begin="00:50:30.140" end="00:50:34.790">between the biceps femorals and<br />the, and the semi tendinosis</p>
<p begin="00:50:34.790" end="00:50:36.410">and then the semiosis,</p>
<p begin="00:50:36.410" end="00:50:39.860">that tad pole shaped<br />structure there to the left.</p>
<p begin="00:50:39.860" end="00:50:42.380">Yep. And then the sciatic nerve so</p>
<p begin="00:50:42.380" end="00:50:46.370">that folks can identify at that level</p>
<p begin="00:50:46.370" end="00:50:49.760">where the nerve is and the<br />two tendons in question.</p>
<p begin="00:50:49.760" end="00:50:53.030">That's a very common<br />location for hamstring,</p>
<p begin="00:50:53.030" end="00:50:54.470">my tendonous injury.</p>
<p begin="00:50:56.540" end="00:50:59.450">- Great point Bill. And I<br />really like that Mercedes-Benz,</p>
<p begin="00:51:00.830" end="00:51:02.780">that's a thing to put in the slides.</p>
<p begin="00:51:07.275" end="00:51:08.630">- I also wanna leave a little time</p>
<p begin="00:51:08.630" end="00:51:10.370">for questions if there are any.</p>
<p begin="00:51:13.730" end="00:51:16.280">- Now's the time.<br />- Yeah, go ahead.</p>
<p begin="00:51:16.280" end="00:51:18.650">If you have any questions,<br />put 'em into the q and a box</p>
<p begin="00:51:18.650" end="00:51:20.450">and we will address those.</p>
<p begin="00:51:20.450" end="00:51:23.390">- Yeah, this has concluded<br />the normal part of the exam</p>
<p begin="00:51:23.390" end="00:51:25.520">and we're happy to stick<br />around for a few minutes and,</p>
<p begin="00:51:25.520" end="00:51:27.650">and just answer these questions on the fly</p>
<p begin="00:51:27.650" end="00:51:30.470">however you want them to, to be addressed.</p>
<p begin="00:51:30.470" end="00:51:33.380">If there's something that<br />you'd like reviewed again</p>
<p begin="00:51:33.380" end="00:51:35.180">that we did cover.</p>
<p begin="00:51:35.180" end="00:51:38.270">And depending on the subject<br />that we didn't cover,</p>
<p begin="00:51:39.110" end="00:51:40.400">there's also an opportunity</p>
<p begin="00:51:40.400" end="00:51:41.810">to cover a few of those things too.</p>
<p begin="00:51:41.810" end="00:51:45.230">But I think, you know, posteriorly bill</p>
<p begin="00:51:46.430" end="00:51:51.080">orienting to the superior</p>
<p begin="00:51:51.080" end="00:51:54.650">sciatic foramen is just,<br />it's just the way to go.</p>
<p begin="00:51:54.650" end="00:51:56.600">I'm just following the<br />sciatic of long axis,</p>
<p begin="00:51:56.600" end="00:51:57.830">which has seemed, seems</p>
<p begin="00:51:57.830" end="00:51:59.900">to be helping me out quite a bit compared</p>
<p begin="00:51:59.900" end="00:52:00.900">- To earlier.</p>
<p begin="00:52:00.900" end="00:52:04.580">Good question here, Daniel<br />is issue bursa, right?</p>
<p begin="00:52:04.580" end="00:52:08.330">As it arcs over the top<br />of the conjoint tendon.</p>
<p begin="00:52:10.130" end="00:52:11.420">- That's another one of those bursa</p>
<p begin="00:52:11.420" end="00:52:12.740">that we're really not gonna see it</p>
<p begin="00:52:12.740" end="00:52:14.390">unless there's some pathology there,</p>
<p begin="00:52:14.390" end="00:52:15.390">- Right?</p>
<p begin="00:52:15.390" end="00:52:18.050">- But if you want, if you wanted<br />to see that interface, it,</p>
<p begin="00:52:18.050" end="00:52:20.630">it's not a bad idea to add<br />a little dynamic component</p>
<p begin="00:52:20.630" end="00:52:22.760">to your exam and just kind of roll,</p>
<p begin="00:52:24.050" end="00:52:28.430">roll the glute max a little<br />bit by getting the femur</p>
<p begin="00:52:28.430" end="00:52:31.670">to rotate so you could at least<br />delineate, hey, where does,</p>
<p begin="00:52:32.720" end="00:52:36.170">where do all of these<br />connective tissue layers</p>
<p begin="00:52:36.170" end="00:52:37.520">begin and end?</p>
<p begin="00:52:37.520" end="00:52:38.870">And, and the answer to that,</p>
<p begin="00:52:38.870" end="00:52:41.390">sometimes depending on the<br />patient's body habitus,</p>
<p begin="00:52:41.390" end="00:52:43.730">which we don't have a problem with today,</p>
<p begin="00:52:43.730" end="00:52:45.980">but when you're out in the,<br />out in the real clinical world,</p>
<p begin="00:52:45.980" end="00:52:50.120">sometimes these tissue<br />interfaces are not so obvious.</p>
<p begin="00:52:51.320" end="00:52:53.870">So what I'm doing is just<br />causing an external rotation</p>
<p begin="00:52:53.870" end="00:52:56.300">by moving the leg</p>
<p begin="00:52:56.300" end="00:53:00.320">and I'm isolating that<br />glute max superficially</p>
<p begin="00:53:01.610" end="00:53:06.320">over the ischial tuberosity<br />in a, in a, in the hamstrings.</p>
<p begin="00:53:06.320" end="00:53:09.320">And I'd be looking for a bursa<br />right up in that spot that</p>
<p begin="00:53:09.320" end="00:53:10.825">- Was so similar to what we do with the,</p>
<p begin="00:53:10.825" end="00:53:13.220">with the trocanter bursa.</p>
<p begin="00:53:13.220" end="00:53:15.770">- Absolutely. You know, this<br />is ultrasound, make it move.</p>
<p begin="00:53:15.770" end="00:53:18.020">You know, static images are not going</p>
<p begin="00:53:18.020" end="00:53:20.120">to help you answer a lot of questions.</p>
<p begin="00:53:20.120" end="00:53:22.490">So anytime you get a chance, you need</p>
<p begin="00:53:22.490" end="00:53:24.170">to make these structures move</p>
<p begin="00:53:24.170" end="00:53:26.760">and oppose each other as<br />frequently as you can.</p>
<p begin="00:53:26.760" end="00:53:28.860">And then, and sometimes you're<br />gonna expose some additional</p>
<p begin="00:53:28.860" end="00:53:31.740">pathology like adhesions that are not</p>
<p begin="00:53:31.740" end="00:53:33.570">so obvious on a static image.</p>
<p begin="00:53:34.950" end="00:53:39.390">- Daniel, one other question we had was to</p>
<p begin="00:53:40.950" end="00:53:44.550">revisit the where, where it's common</p>
<p begin="00:53:44.550" end="00:53:48.660">to see a myo tendonous<br />tear of the hamstrings.</p>
<p begin="00:53:48.660" end="00:53:50.400">So maybe down, start</p>
<p begin="00:53:50.400" end="00:53:55.400">with the conjoin tendon<br />at the Mercedes-Benz sign</p>
<p begin="00:53:55.500" end="00:53:57.420">level and Sure.</p>
<p begin="00:53:57.420" end="00:53:59.670">Just follow that central tendon.</p>
<p begin="00:53:59.670" end="00:54:02.640">And that's basically what<br />we're doing as we're following</p>
<p begin="00:54:02.640" end="00:54:04.050">that central tendon there</p>
<p begin="00:54:04.050" end="00:54:09.050">and we're looking right<br />adjacent to it for any change in</p>
<p begin="00:54:09.120" end="00:54:13.410">what is normal echo<br />architecture where the my,</p>
<p begin="00:54:13.410" end="00:54:18.270">where the muscle comes<br />into the tendon right</p>
<p begin="00:54:18.270" end="00:54:19.270">- There.</p>
<p begin="00:54:19.270" end="00:54:21.000">Yeah. This nice little<br />interface right here.</p>
<p begin="00:54:24.960" end="00:54:26.940">And now I'm tenderness Yeah,</p>
<p begin="00:54:26.940" end="00:54:29.760">I've left the myo tendus portion and now</p>
<p begin="00:54:29.760" end="00:54:31.770">- I'm as, as you proximally.</p>
<p begin="00:54:31.770" end="00:54:36.510">- That's correct.<br />- So it's just</p>
<p begin="00:54:36.510" end="00:54:39.750">that myotendinous location<br />kind like what we see</p>
<p begin="00:54:39.750" end="00:54:44.040">with gastro tears right<br />up against the tendon</p>
<p begin="00:54:44.040" end="00:54:47.010">and you're looking for<br />fluid defect, you're looking</p>
<p begin="00:54:47.010" end="00:54:50.430">for a change in that normal penate pattern</p>
<p begin="00:54:50.430" end="00:54:51.870">or starry eye appearance.</p>
<p begin="00:54:51.870" end="00:54:55.800">If you're short axis to<br />the course of muscle,</p>
<p begin="00:54:55.800" end="00:54:58.710">you're just looking for a change in that.</p>
<p begin="00:54:59.730" end="00:55:01.920">What otherwise is a typical</p>
<p begin="00:55:02.850" end="00:55:07.440">echo architectural appearance right there.</p>
<p begin="00:55:07.440" end="00:55:09.030">Beautiful. See how you follow, see</p>
<p begin="00:55:09.030" end="00:55:11.040">how he's following that down.</p>
<p begin="00:55:11.040" end="00:55:12.480">So anywhere along</p>
<p begin="00:55:13.440" end="00:55:16.710">and adjacent to that central<br />tendon is where you're going</p>
<p begin="00:55:16.710" end="00:55:21.420">to see changes, appearance change there,</p>
<p begin="00:55:21.420" end="00:55:24.510">you see the semimembranosus<br />tendon deep to it.</p>
<p begin="00:55:27.390" end="00:55:29.730">See that tadpole looking structure there.</p>
<p begin="00:55:33.000" end="00:55:34.620">Hope that answers the question.</p>
<p begin="00:55:35.550" end="00:55:37.710">Are there any other<br />questions that we have?</p>
<p begin="00:55:39.030" end="00:55:43.380">I'm not seeing any, Laura.</p>
<p begin="00:55:43.380" end="00:55:45.540">I think with that we'll<br />turn it back over to you.</p>
<p begin="00:55:46.440" end="00:55:48.180">- Great. Bill, by any chance, do you have</p>
<p begin="00:55:48.180" end="00:55:50.400">that last slide that<br />you can show? Or do you</p>
<p begin="00:55:50.400" end="00:55:51.690">- Want Oh yes, I, I do.</p>
<p begin="00:55:51.690" end="00:55:52.690">Thank you.</p>
<p begin="00:55:53.610" end="00:55:57.540">- Just so everyone knows, we<br />will be posting the recordings</p>
<p begin="00:55:57.540" end="00:55:59.910">of all these webinars at this<br />website that you see here,</p>
<p begin="00:55:59.910" end="00:56:03.810">secure dot sona<br />site.com/behind theskin webinar</p>
<p begin="00:56:03.810" end="00:56:08.340">and look forward to some new<br />webinars posting in January.</p>
<p begin="00:56:08.340" end="00:56:10.680">We'll have a few on in the MSK market</p>
<p begin="00:56:11.700" end="00:56:13.800">on dorsal wrist and carpal tunnel.</p>
<p begin="00:56:13.800" end="00:56:15.180">So I just wanted to let everyone know</p>
<p begin="00:56:15.180" end="00:56:16.260">that those are coming soon.</p>
<p begin="00:56:17.730" end="00:56:20.225">- Great. And we wish you<br />all a happy holidays.</p>
<p begin="00:56:20.225" end="00:56:22.290">- Absolutely. And thank you<br />all for joining us today</p>
<p begin="00:56:22.290" end="00:56:23.850">and thank you Bill and Daniel again</p>
<p begin="00:56:23.850" end="00:56:26.970">for an exceptional<br />presentation and demonstration.</p>
<p begin="00:56:26.970" end="00:56:27.970">Very well done.</p>
<p begin="00:56:29.250" end="00:56:29.850">- Thanks everybody.</p>