0:01

<v ->I have an extra case.

0:03

The last extra case.

0:05

So talking about the Milwaukee shoulder,

0:10

this is a...

0:13

case that we have a lot of...

0:15

signs of OA.

0:18

Osteoarthritis.

0:20

That the space is quite reduced.

0:22

Large osteophytes.

0:25

And...

0:27

with MRI,

0:28

we can see...

0:32

that the tendons, they are not very compromised.

0:35

So we have a case of isolated OA with...

0:40

preservation of the tendons.

0:44

So...

0:46

The space is narrow.

0:49

We have sclerosis.

0:50

We have this focal sclerosis here at humeral head.

0:56

Some synovial fluid.

1:00

But we don't...

1:02

We have a preservation of the tendons.

1:06

And also...

1:09

of the muscle valleys.

1:11

They don't have any atrophy.

1:13

So this is a case of OA...

1:17

without...

1:20

tendon problem.

1:24

So, I think...

1:27

Don, I think I...

1:30

already showed my cases here.

1:33

So, if you wanna go ahead.

1:37

I wanna make a couple comments

1:39

and ask you a couple of questions.

1:43

Like you, I've been impressed...

1:47

particularly with regards to the greater tuberosity

1:50

and to the lesser tuberosity,

1:52

that we do see examples of calcium migrating into the bone.

1:57

I've seen that also where the gluteus maximus

2:01

attaches to the femur with migration of calcification.

2:06

But have you seen that same intraosseous penetration

2:10

at other sites of tendonitis?

2:14

I know you showed the disc,

2:16

but is there another site where you see it that often?

2:27

<v ->No.

2:29

Mainly is the humeral heads.

2:35

And some spine case also.

2:37

But...

2:39

I'm not recalling to see that on other joints, Don.

2:44

Have you?

2:45

<v ->No.

2:46

Well, it may relate of course,

2:47

to the frequency of calcification in the shoulder area,

2:51

but I always wondered why.

2:54

I don't think I've seen it in other sites of calcification.

2:58

Other than one like you showed of a disc calcification

3:02

with a Schmorl's node.

3:04

I've seen that.

3:05

But there may be something unique

3:07

about the architecture of the greater and lesser tuberosity.

3:12

I'm gonna get into that in a little bit,

3:14

when we talk about cyst formation in OA.

3:17

The next comment, just quickly,

3:19

do you have any understanding

3:22

of why the popliteus tendon is involved in gout?

3:27

We got a lot of tendons.

3:29

You know, I showed some examples

3:31

of, you know, rotator cuff, et cetera.

3:33

But clearly the popliteus.

3:36

I don't know why.

3:37

I just wondered if maybe you came up with a theory.

3:42

<v ->And the popliteus is...

3:44

the difference from the other tendons.

3:48

It's like, I think I can remember,

3:50

the long hand of the biceps,

3:52

because it's a place where the tendon...

3:56

goes inside the articulation...

4:00

and penetrates.

4:03

So, there is a transition

4:06

between the extra-capsular, extra-synovial tendon.

4:10

And the intra-capsular and intra-articular tendon.

4:14

I think...

4:16

<v ->Yeah, the Intra-capsular, extra-synovial.

4:20

Yeah, I had mention that early on.

4:23

But anyway, and the final comment I would ask is,

4:27

you know, just to show how things have changed.

4:29

When I trained in radiology as a resident,

4:33

I was told to never accept the diagnosis of osteoarthritis

4:38

of the glenohumeral joint.

4:39

That whenever we saw that,

4:41

we had to start think of rare things like ochronosis,

4:45

acromegaly, epiphyseal dysplasias, primary AVN.

4:50

But clearly people have become more active

4:53

through the years.

4:54

So we clearly do see examples of significant osteoarthritis

4:59

of the glenohumeral joint.

5:01

And as you showed,

5:03

even without massive tears of the rotator cuff.

5:08

So I do think it is a site of OA,

5:10

and you don't have to start looking for weird diseases

5:13

to explain why the joint looks so bad.