Examining Hip Anatomy and Structure with POCUS: Posterior Hip |FUJIFILM Sonosite

Duration: 30 mins

Broadcast: December 18, 2020

Topics: Orthopedics, Physical Med & Rehab, Sports Medicine, and Sports Team

<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>

https://www.youtube.com/watch?v=A666VIJhqQ0

Learn diagnostic ultrasound of the hip utilizing point-of-care ultrasound during this expert-led, live webinar using the Sonosite PX. View techniques to visualize posterior hip structures, including the sacroiliac joint, piriformis, quadratus femoris, hamstring complex, and sciatic nerve and discuss diagnostic assessments using ultrasound. It concludes with scanning the proximal hamstring origin at the ischial tuberosity, recognizing the tendon components and nearby sciatic nerve, and discussing where myotendinous hamstring injuries are commonly seen, followed by Q&A and where to access the full webinar series recordings. You’ll have time at the end to ask questions.

This webinar is the fourth of a four-part series on the hip.

What You'll Learn

Visualization techniques for hip structures
Identify key structures on the ultrasound image
Pearls for diagnostic assessments

Daniel Shelton

Presenter: Daniel Shelton, RT(R)

Job title: Director, Musculoskeletal Market Development, FUJIFILM Sonosite

Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sonosite. He now leads musculoskeletal market development, where he works to spread the word about the benefits of point-of-care ultrasound.