0:00

So the first case, it was a 72 year old male with, uh,

0:05

anterior pain with squatting. Okay? And first off,

0:10

I actually probably spend the most time on localizer sequences. Uh,

0:15

I love anatomy, but as we all know,

0:17

the localizer sequences are typically larger field of view. And,

0:21

uh, I, you know, I catch some, some things sometimes, uh,

0:26

incidentals that may or may not be pertinent to, uh, the patient's presentation.

0:32

But, uh, sometimes we do catch a rare cancer. So I do like to, uh,

0:36

look at the localizers. And funny thing, I,

0:39

I tend to spend a little bit more time, uh, sometimes on that, especially on,

0:43

um, pelvises and what have you, or spines. Okay. But, um,

0:48

moving right along. Uh, I am a structural sort of person. Okay?

0:53

I, I did not grow up, uh, unfortunately, uh,

0:56

back in the day when we still hung films.

0:59

So the older staff I've noticed that I've worked with, they tend to, um,

1:04

look at the images by planes, and they, they, so,

1:07

so they look at all the structures on one plane.

1:10

So they'll work through from far posterior, far anterior on, on a coronal,

1:15

let's say, starting with the patella, and then work their ways all the way back.

1:19

Okay? But the way I do things, and I've been asked this before, and just,

1:24

just to get that, uh,

1:25

get this outta the way right from the start and for future, um,

1:29

discussions and, uh, office hours or my office hours, um,

1:33

I tend to divide all the joints into a few broad categories.

1:38

Okay? I do ligaments, tendons, joints,

1:43

ancillary stuff to the joint, okay? Uh, soft tissues, muscles,

1:49

and, uh, bone morphology and marrow signal. So that's my checklist.

1:52

So you can sort of get a sense that I'm a structural sort of person.

1:56

I like to look at each structure in each plane, be it, you know, uh, you know,

2:01

so, so for instance, to extrapolate that checklist out to a knee,

2:06

if I were dictating a stone cold, normal knee, my ligaments,

2:10

for lack of a better term, sorry, I, I start with the menisci, though,

2:14

obviously the medial and lateral menisci.

2:16

And then along with the ligaments I do next, the cruciate ligaments.

2:19

My next on the checklist is the medial and lateral supporting structures. Okay?

2:24

Those, those, uh, obviously are capsular ligaments. And as, as,

2:27

as some of you may know, medial, medial medially and laterally, the capsular,

2:32

uh, the, the ligaments about the knee are divided into about three layers. Okay?

2:37

Um, I noticed in some of your checklists, you use tibial collateral,

2:40

ligament fibular, collateral ligament, what have you. That's fine.

2:43

Lateral collateral, ligament, just stay.

2:45

I just ask that you stay consistent between your terminology, especially when,

2:49

when talking to your clinicians, you know, talk to your clinicians,

2:52

see what terms they use so that you're, you guys are communicating effectively.

2:56

Okay? Next on the, the, the checklist for the knee, I,

3:00

I go from media lateral supporting structures. I go to the, um,

3:05

extensor mechanism and fat pads, then sliding right into the joints.

3:09

I look at joint alignment, the amount of fusion, whether they're synovitis,

3:14

pase, particularly media superior pika, which are the most common. Okay?

3:19

Then I look at the cartilage, starting at the patella femoral compartment,

3:22

and then the median lateral femoral tubal compartments.

3:25

Then I check for popal cysts. Okay?

3:28

And then finally I wrap up with soft tissues, muscles, bone, morphology,

3:32

and marrow signal. Okay? So just before we get into the case,

3:36

just to fly through that real quick, okay? Um,

3:39

so if I were looking at this case, I'd look at the menisci, okay?

3:42

Just scrolling through real quick. Um, you know,

3:45

on the sagittals and coronals, that's gonna be key for me.

3:48

Then I look at the cruciate, okay? While I'm on my sagittal,

3:52

I will actually jump back to the coronals, okay?

3:55

And I also like the axials for the cruise ships as well, especially for the ACL,

3:59

because the ACL, uh, depending on who you read, okay,

4:03

is divided into two bundles, right? Uh, AMPL is the pneumonic.

4:07

I teach my trainees and your medium posterior lateral, uh, bundles, okay?

4:11

So I find that the axials are better to, uh, better, um,

4:17

show a partial terror, particularly of one, one or, or other of the bundles.

4:22

But mind you, mind you, okay, groups out of Pittsburgh,

4:25

they're actually doing fancy computer aided, um,

4:28

studies where they've actually identified up to 11 or 13 bundles.

4:33

And for those that are interested in knee and AACL reconstructions,

4:36

while you're studying, you may run into the what's been turned,

4:40

the double bundle technique where they take parts of where, wherever graft from,

4:45

wherever, and they loop it over, and they, they, they, they, uh,

4:48

double it over on itself.

4:50

So now what some people are doing are double and triple bundles, or even a,

4:55

um, uh,

4:57

increasing the number of bundles to make things more anatomic. But granted,

5:02

once you tear an ACL, you re you're really never gonna be the same. Okay?

5:07

So right after the ACL, obviously I go to the, the PCL. Okay?

5:12

Next, I, what I find, uh, is the medial and lateral supporting structures,

5:17

and the reason why I call it a medial and lateral supporting structures,

5:20

and what I've been trained by my mentor and now colleague, Dr. Resnick,

5:23

is because of the different layers, okay?

5:26

So walking probably the more important things, okay?

5:30

The second and third layers, okay?

5:31

That is gonna be the tibial collateral ligament, okay?

5:35

And the deep medial meniscal femoral,

5:37

and the deep medial meniscal tibial ligaments, or AKA, the coronary ligament,

5:42

walking a little bit more posteriorly, okay? Sorry,

5:47

my laptop is little, okay? We have the posteriorly ligament, okay?

5:51

And then obviously we have, you know, starting to get into the OPLL,

5:55

the semimembranosus tendon, and all of its arms, okay?

5:59

And obviously the posterior joint capsule,

6:01

walking around the posterior joint capsule and coming back from posterior to

6:06

anterior, okay? Looking at the lateral supporting structures, okay?

6:10

I look at the pop fib ligament, okay? Probably, uh,

6:15

apologies. So this right here,

6:19

okay? This little band right here, the pop lidio fibular ligament, okay?

6:24

Then we have the pop lius tendon, then obviously the biceps pems.

6:28

And if you read the literature, there's about three or four insertions. Um,

6:32

but the majority of them are going to happen, uh, at the, uh, the fibula,

6:36

obviously the, the lateral aspect of the proximal tibial epiphysis, okay?

6:41

Coming out more, uh, anally than now.

6:43

We have what's been termed in the popular literature,

6:46

the anterolateral ligament, okay? And that's what,

6:50

when that tears or pulls off a piece of bone that's been called the, uh,

6:55

sagon fracture, we know it better as a sagon fracture. Okay?

6:59

And then now mind you too, the, the proper term, uh,

7:02

even though the pop culture or the popular news has coined this as the

7:07

anterolateral ligament, it's,

7:08

it's better known as the mid third lateral capsular ligament. Okay?

7:13

That's the original term. But, uh,

7:15

people in the popular literature have been trying to, um,

7:19

show that this is a new ligament, but it's actually not.

7:22

And we've actually written about that for those that are interested.

7:25

Skeletal radiology a couple years back. Okay? And then finally,

7:28

obviously you have wisp of the, that biceps femme, but far anteriorly, okay?

7:34

The main insertion of the IT band or the ileal tibial band distally is gonna be

7:38

at gertie's tubercle, but recent literature, um, is, uh, and also review,

7:43

nice review article in skeletal radiology. Um, and please feel free, you can,

7:48

you can, um, uh, reach out to me via email, Olivia and the others can,

7:52

can direct you. But, and I'd be happy to share some of these PDFs or,

7:55

or citations with you. But, uh,

7:58

relatively recent literature has shown that the it band actually has five

8:01

insertions,

8:02

but the main important one is gonna be at the gerdes tubercle right here.

8:05

So that takes care of the medium lateral supporting structures, okay?

8:10

Moving right along and, and sort of going into our case and, and we'll go,

8:13

come back to the findings in a bit, but moving right along to my next c check.

8:17

Uh, next thing on the checklist is gonna be the extensor mechanism, okay?

8:20

And that's obviously gonna be the quadriceps, which consists of the VA triplets,

8:24

vass medias, intermediates and laterals,

8:26

and the rectus fous bar anteriorly inserting upon the patella and the

8:31

quadriceps, uh,

8:32

pre patella p plate or what some people also call the patella quadriceps

8:37

continuation written originally in the radiology literature by Dr. Resnick,

8:41

okay? And Dr. W back in, I think it was 2009 ish or something like that,

8:46

a nice cric study in AJR for those that are interested. And that, uh,

8:51

continuing on the patella tendon, obviously, which inserts upon the ligament.

8:55

Now, some of you, I've noticed, have called this a, um,

8:59

a patellar ligament or even a quadriceps ligament. That's fine, right?

9:03

It's bone, bone to bone, you know, it's gonna be a ligament. So again,

9:07

I just ask, you know, just know what your clinicians are using,

9:11

and I kind of just dictate to what the clinician is, is used to hearing.

9:15

I'm fine either way, calling it tendon or ligament,

9:18

especially when obviously it was between bone and bone. Next, I check the, the,

9:22

the fat pads, okay?

9:24

And the three or four fat pads that I like to check on a knee are gonna be the

9:27

pre femoral fat pad, which is right here, the super patellar, uh, fat pad,

9:32

the hoffa fat pad, and then the paraship fat pad. Okay?

9:36

Depending on who you read the super patellar fat pad,

9:39

when EMS can be problematic, some people believe in it, some people don't. Okay?

9:43

Pre femoral fat pad, you really don't see any problems here.

9:46

Usually the ones that I really pay attention to are Haas fat pad,

9:50

where you see the, uh, the edema,

9:52

particularly sup laterally with patella mal tracking,

9:56

but you can also see it in things with Haitis, okay? Uh,

9:59

originally described by our group back in the, uh, I think the two thousands,

10:04

or maybe late nineties, especially with HIV patients, they can get haitis.

10:09

Okay?

10:10

The other thing that they can get and more recently written about is PeriShip

10:13

fat pad edema, okay? And then th this,

10:16

basically this fat pad right here in between the tendons, or sorry,

10:20

the ligaments here, it is an intraarticular, extra synovial structure,

10:25

okay? Can get inflamed, particularly with patients that like to bend the knee.

10:29

So a lot of, we get this in a lot of soccer players, okay?

10:34

So peri cruciate, fat pad edema. All right? So that's my, uh,

10:39

so just to backtrack real quick, so menisci cruciate ligaments,

10:43

medium lateral poring structures, extensor mechanism, fat pads.

10:48

Now the joint, I look at the joint, I look at the alignment, okay? Granted,

10:52

it is a static image, okay? We're not gonna, you know,

10:54

we're not doing the physical exam, but sometimes, especially with a, uh,

10:58

anterior cruciate ligament tears,

10:59

we're obviously gonna see that anterior translation of the tib with respect to

11:02

the femur, with uncovering of the menisci. Right? Next I check the, uh,

11:07

cartilage, starting with the patella femoral compartment, then using, uh,

11:11

and I evaluate that with axials and sagittals, that compartment.

11:16

And for the coronal, uh, sorry for the, um, for the, uh,

11:20

medial and lateral femoral tubal compartments, I like to obviously use the, um,

11:24

the sagittals and coronals. I will, however, use the axials,

11:28

especially for these far posterior, uh, con or lesions, you know, um,

11:33

sometimes, you know, we miss a little far, uh, posterior lesion.

11:37

And some of my, um, some orthopedic literature will say, you know,

11:42

if we don't mention it, they will miss it,

11:44

because they won't get the scope all the ways back there,

11:47

or entirely flex the knee to try to get back there. Okay? Next,

11:51

along with the joint, I look for the Popal cyst, and I harp,

11:55

I harp on my trainees here at UCSD to make sure that the neck comes out between

12:00

the m and m muscles, that is the medial gastroc anemia, and the semimembranosus,

12:05

uh, muscle or tendon. And that is the direct arm here, okay?

12:09

Depending on who you read, there are actually about six or seven attachments,

12:13

okay? Or arms of these emin ss tendon. But here, for this purposes,

12:18

I'm talking about the direct arm, which inserts upon the, uh,

12:21

posterior aspect of the, uh, uh,

12:25

medial tibial, uh, pip proximal, medial tibial pips right here. So this as,

12:30

in this case,

12:31

this is where you want to see the neck of the Pope cyst arising from,

12:35

from the medial gastroc anus,

12:37

from in between the medial gastro anus and the semimembranosus muscle,

12:41

or the m and m muscles, kind of like the candy. Okay?

12:44

If you don't see that neck there, then you gotta worry about something else. Um,

12:48

uses neoplasm, a ganglion cyst, what have you, something like that. Okay?

12:52

Something more, potentially more ominous,

12:54

especially with the mus neoplasms or potentially, let's say a synovial sarcoma,

12:59

right? All right. So finally,

13:01

the last few checks I have are for any incidentals.

13:04

I look for any muscle anatomy, uh, variance,

13:07

particularly third head of the gastric anemia muscles,

13:10

which typically will arise right here, can, can, uh, uh, uh,

13:14

lead to popliteal artery entrapment syndrome if you believe in that.

13:18

Other things I look for are, uh, accessory plant terrace,

13:22

which is thought to contribute potentially to it band prien syndrome.

13:25

And another thing I also look for, especially if someone's going for, let's say,

13:29

a high tib osteotomy, or they have really overt degenerative changes,

13:33

I look for an abberant, anterior TBIs artery, okay?

13:37

Which is depending on who you read, seen in, in the knee,

13:40

about 2.1% of the time, that's according to an article from the,

13:45

the American Journal of Sports Medicine.

13:46

And basically it's a little early takeoff of the angio tibialis artery that

13:51

interposes itself between the posterior aspect of the tibia and the populous

13:56

muscle right here. So you would see it right here.

13:59

Why is that important to mention?

14:00

I've actually been involved in a couple of cases right now, not me personally,

14:04

but testifying that, uh, the, that artery was missed.

14:09

Surgeon went in, it was Nick,

14:11

and the patient later went on to bleed out and got compartment syndrome.

14:15

And obviously the, the problems with that. So if you do see, uh,

14:19

an anterior an an aberrant anterior anterior TBIs artery, I would,

14:24

I would highly suggest, uh, uh, mentioning it in your, uh,

14:28

in your findings at least, if not in the impression, especially,

14:31

especially if the patient is planning to go for, you know, uh, surgery, um,

14:36

a high tibial osteotomy, knee replacement, what have you.

14:40

So something to be aware of. And finally, lastly, I like to look at the,

14:45

uh, bones, uh, bone, uh, bone morphology and marrow signal,

14:49

and obviously I like a nice T one for that. Okay, so going back to our case.

14:54

Okay. Uh, sorry,

14:55

any questions on how I kind of approach a knee before we jump into the

15:00

actual case or the first case?

15:04

Well, you, you talk about the complexity of structures,

15:06

especially in the postal lateral corner in the EM prognosis,

15:09

having multiple attachments.

15:12

Is it crucial to identify each of these attachments and structures,

15:15

these small structures?

15:18

I would say not, not really, sir. Uh, great question. I, I,

15:21

I think that was coming from Hari. Great question. Uh,

15:24

I'm happy to provide that, uh,

15:25

literature for literature to you if you're interested. But really, I would say,

15:30

uh, in my experience, the big things are going to be identifying the, the, uh,

15:36

the, uh, direct head. Okay? This one right here, okay.

15:41

Or sorry, the direct arm of the semiosis, which obvious, uh, oftentimes,

15:46

uh, gets, uh, degenerated tendon otic or partially torn.

15:50

And I would say the other arm that I would, uh,

15:53

like to know about is the, uh, anterior arm,

15:57

which is this arm right here,

15:59

which inserts upon the lateral aspect of the proximal tibial epiphysis. Okay?

16:04

And if you view it on a sagittal, it's actually been likened to, uh,

16:08

a hockey stick. Okay? And why is that important? This,

16:12

this arm is important. It's right here, okay? And going back to our coronal,

16:17

it's right sort of, uh, here, this sort of thin structure right here,

16:22

it, it can become tendon otic, and sometimes people will come in,

16:27

say, uh, with a rule out mass, and it just turns out to be a really tendon otic,

16:32

uh, long, uh, sorry, anterior arm of the semimembranosus tendon. And,

16:37

uh, it is been confused for, um, a mass, for instance, like, uh, you know,

16:41

tens synovial, giant cell tumor, focal type intraarticular,

16:45

or even like gout or something like that. So those,

16:49

those are in my experience, are probably the two more important arms to,

16:53

to think about for the, uh, the posterior medial corner here.

16:58

So it's interesting to, to,

16:59

to find out that it's actually 11 bundles within the ACL.

17:03

Yeah, yeah, yeah. There's, there's up to 11 or 13 now and stuff like that. And,

17:08

and as you'll see during my office hours, and I'll point out the, the more,

17:13

the more I study, at least the more I find out I, I, I, I have more to learn.

17:17

So, but that's why, that's why we do this, right?

17:21

And the

17:23

Anterior posterior bundles of the, um, ACL,

17:27

how do you identify that?

17:28

Uh, just where they insert, right? So the anter medial is just,

17:32

is just gonna be more anterior and medially located,

17:35

and the posterior lateral is just gonna be post, uh, insert, uh,

17:37

sort of post more posterior and lateral. And if you think about it, right,

17:41

the cruciate ligaments and pretty much everything, even the meniscal,

17:46

meniscal ligaments right,

17:47

are named for its insertion upon the tibia more anteriorly,

17:52

if you want to think of it that way. Okay?

17:56

So going right to the case. Okay? So,

17:59

so now that I've shown you how I kind of approach a case, that being said,

18:04

okay, besides looking at the localizer and the, uh,

18:08

my sequence or structural analysis,

18:12

I do initially open up every study, um,

18:16

looking at, uh, usually AT one and a fluid sensitive sequence. Okay?

18:21

And that just gives me a flavor of the case, okay?

18:23

Just where to direct my eyes and where I,

18:26

I figure I'm gonna direct most of my intention, okay? And in this case,

18:30

in our 72 year old male with problems squatting, what we see here, okay,

18:35

we will go from proximal to distal, okay? The quadriceps tendon, uh,

18:39

some of you may have called, um, some tendonosis, that's fine,

18:43

maybe even a little bit tearing.

18:45

But what I wanna highlight is the quadriceps can look quite striated,

18:49

sort of almost like a step celery stock that we see with the ACL. Okay?

18:53

I like to see a lot of edema. I like to hear that,

18:56

that history of anterior knee pain if possible too as well. Okay?

19:00

But continuing distally part of the extensor mechanism or the heart of the

19:04

extensor me mechanism, what we see here is a really emus okay,

19:08

or patella with osteo, right?

19:11

Without any good history and any other good, uh, other findings to corroborate.

19:16

Yeah, you can think of contusion if there's an ulcer, you know, you could,

19:19

you could start thinking about osteomyelitis,

19:22

septic arthritis with pre patellar bursitis, what have you.

19:25

But going more distally, we've noticed that the quadr, uh,

19:29

pre patellar quadriceps, uh,

19:31

continuation or what some of you have termed the, the pre patellar plate,

19:36

okay? We, uh, know this, okay,

19:38

as basically a chondro,

19:41

a pope zone, okay? And I kind of think of it like,

19:46

um, I love sweets, okay? And I love baklava. Okay?

19:51

I don't know if you guys have baklava before or like, uh,

19:53

croissants or fine pastries. It's, it's multiple,

19:56

it's actually multiple layers and bursa overlying this, uh,

20:01

anterior patella, and I always have to look it up.

20:04

There's like a subcutaneous bursa, a subfascial bursa,

20:08

and a three or four more, more bursa. But you can look it up in the literature.

20:13

But what can happen is with injuries, this is, this can actually tear,

20:16

or as in our case, okay,

20:18

we have a little bit of enthesopathy perhaps from the tugging,

20:22

the pre patella quadriceps.

20:24

This entire plate is sort of dispersing or helping to disperse the force

20:29

of that quadriceps and patella tendon across the Accenture mechanism, right?

20:33

Think of this patella as basically a pulley, right?

20:36

Providing more mechanical advantage to our extensor mechanism,

20:41

allowing us readily ready or easier extension, okay?

20:45

Between the, uh, of the lower extremity, obviously. But in this case,

20:49

this patient obviously has osteitis or reactive edema,

20:53

some enthesopathy, some stripping,

20:55

and some arguably low grade or some partial tearing of that pre patellar plate

21:00

or the quadriceps continuation. And then more distally,

21:03

it cuts into the sort of interstitial deamination delaminating sort of

21:08

tear of the proximal teller tendon superimposed upon, um,

21:12

tendinopathy. I used to grade tendinopathy and sort of,

21:16

sort of differentiate tendinopathy, but after talking to a lot of my surgeons,

21:20

they don't mind if I don't, uh, sort of, uh,

21:25

better classify or come down hard on the typical, the,

21:28

the exact type of tendinopathy you may hear terms of such,

21:31

such as hypertrophic, uh, degenerated, fatty,

21:35

replaced calcific ossific, you know, sometimes even, you know,

21:39

you can have crystal deposition or fatty deposition in, in some tendons,

21:43

what have you. Um, but I just say tendinosis. Some, some of my surgeons, yes,

21:48

they like measurements. So in this case, I would maybe measure the,

21:53

not only the AP thickness,

21:55

but the cranial coddle thickness as well and just really try to be specific.

21:59

But this does fall in the realm, okay, of, uh,

22:03

arguably attraction apophysis. Okay? And someone older, if, sorry,

22:08

if it was a very young patient, uh, uh, a,

22:11

a little kiddo where the patellar, uh, um,

22:14

the epiphyseal cartilage is not yet mature,

22:16

you get the patellar sleeve evulsion fractures, okay?

22:20

But as they get older, and at the proximal uh, end,

22:24

we're gonna worry about jumper's knee,

22:26

but basically you can think of them as traction of pope or traction sort of

22:30

injuries across the Accenture mechanism. If you have it happening more distally,

22:35

then that's gonna be that classic SLJ or syn larsson johanson, uh,

22:40

syndrome for those that like eponyms, okay? And,

22:42

and obviously a little bit younger, you're gonna have, especially when you have,

22:46

uh, typical tubercle edema and uh,

22:49

oif osci fragmentation of the tibial tubercle,

22:52

then that's gonna fall in the realm of os Oscar slaughter's disease.

22:55

But I sort of think of these, uh, injuries as a continuum,

22:59

much older patients, especially if they have bilateral disease.

23:03

I'm gonna start thinking of systemic disease processes, right?

23:06

Whether it is renal failure, diabetes, what have you, uh, maybe, you know,

23:12

rare medications, but as we know, medications,

23:14

especially fluoroquinolones has typically been described with your achilles

23:18

tendon tears. But that, uh,

23:19

and that we may see that in another course if you guys are with us. Okay?

23:24

So this just a, just a nice case within the realm of jumper's knee,

23:28

but also some nice, uh, tearing or stripping of the, uh, uh,

23:32

patellar quadriceps continuation. Okay?

23:35

And you can see that obviously too nicely on our axial sequences.

23:40

Again, coming from proximal to distal, we see some of that quadriceps, uh,

23:45

tendinosis, maybe even little foci of tearing out medially there,

23:50

going out, uh, more distally, we see that abnormality,

23:53

that enthesopathy and osteitis underneath that patella's quadriceps

23:57

continuation,

23:58

we see some of that uplifting of the three or four layers of the bursa anterior

24:03

to the patella bone and more distally, we see that, uh,

24:06

partial mainly intrasubstance hearing of the patellar tendon. Okay.

24:12

Questions on this case.

24:15

Is this commonly seen in racket spots, uh, particularly with tennis players?

24:20

Uh, I, I have seen it. I have, yeah, I have seen it. But here in, uh,

24:25

San Diego, I typically see it more with, uh,

24:28

basketball players and volleyball players.

24:31

So what are the treatment adjuncts for that?

24:34

You know, I i, I don't know the, the, uh,

24:38

treatment adjuncts for that. Um, but um,

24:44

I think I,

24:46

I have been asked at times to like inject, um, you know,

24:51

steroids if, you know,

24:52

to see if that's like a pain generator or lidocaine at times under ultrasound.

24:57

But more often than not, I, I would say, um,

25:03

I would say definitely repaired when the rest of the, uh,

25:07

other components of the extensor mechanism are involved.

25:10

But I have not in my, uh,

25:13

experience or anecdotally seen a surgeon go in just to fix that, uh,

25:18

quadriceps continuation.

25:21

And certainly there's some controversy with, uh,

25:23

corticosteroid injections because they tend to cause weakening and possibly even

25:28

tears in the future.

25:29

Yeah, I, I think I, and, and depending on who you read too, um,

25:36

a long term, and there's a, there's a couple recent articles.

25:41

Longer term,

25:42

if you follow some patients out tendon tears at the hips and or

25:47

tendonosis and tendinopathy, long-term, um,

25:51

what they found is long-term steroids may be detrimental.

25:57

'cause it does, as you had mentioned,

25:59

lead ultimately to tears and what have you.

26:02

And it sort of accelerates the process, some of my colleagues and,

26:07

and listening to authors at various, um, meetings.

26:11

Some people believe that, um, you know, we are just treating friction with,

26:16

you know, saline, lidocaine or steroids. But, um,

26:20

I have not heard of a good, uh, prospective study. Uh,

26:25

I, I, that would be a nice thing to do. Just, you know,

26:28

in do a sham injection where someone's getting, um,

26:32

no injection, uh, maybe lidocaine, um,

26:37

uh, maybe lidocaine saline or just saline injections and then, you know,

26:42

steroid injections and just see longer term what, uh, um,

26:47

how these patients do in the various, um, uh, you know,

26:51

in with these various injections in, in various locations. I, I'd,

26:55

I'd really be interested to, to see that. Yeah.