0:00

Thank you, Don.

0:01

As we get started, this, uh, phenomenon of epicondylitis,

0:05

especially lateral epicondylitis, is incredibly annoying.

0:10

And, uh, as somebody that, that sees patients

0:13

and does a little primary care, orthopedics,

0:16

mashing it throughout the day with your good hand

0:19

is a very effective, inexpensive way to treat it.

0:22

And if you go on Amazon,

0:23

they make a lateral epicondylitis roller for, for $50,

0:28

which is a lot cheaper than having

0:30

a lateral epicondyle release.

0:33

Let me turn your attention now to our first case.

0:37

Um, this is a 37-year-old with posterior elbow pain

0:42

for six to seven months.

0:43

It said rule out triceps tear. So there's no secret here.

0:48

Um, we've got some, uh, examples of the lovely anatomy

0:53

that you've already seen, the anterior capsule

0:57

and the, uh, biceps long head with.

1:00

Its, its fan shaped insertion on the radial tuberosity.

1:04

And I'll show you an example, uh,

1:05

of a biceps injury in a moment.

1:08

And, uh, we also see the brachialis, uh,

1:11

both the insertion its terminal, uh, sort of round

1:15

like insertion on the ulnar shaft.

1:18

And then we can barely, barely, uh, make out the, um,

1:22

insertion of the brachialis on the coronoid, uh, process.

1:27

But we're focused on the triceps, which you've just heard,

1:31

uh, quite a bit about.

1:33

And, uh, one of my tenets is that the, um,

1:38

triceps medial head, which inserts about the mid slight,

1:42

certainly more distal than the, um, than the lateral head

1:48

off the back of the humerus, is a fat, stubby,

1:52

strong, powerful structure with a very short tendon.

1:57

So in my experience, uh, taking down this deep layer

2:03

is if not uncommon, rare, um, it is rather the middle

2:08

and superficial layers that are affected.

2:11

And sometimes it's hard to tell which

2:13

of those two layers are affected,

2:15

or the lateral head, which arises from the upper third

2:19

of the back of the humerus

2:21

and the long head, which arises from the inferior cubicle

2:24

of the glenoid, kind

2:25

of squished themselves together and merge.

2:28

So it, it's very difficult to pick out,

2:30

uh, one of the two of those.

2:32

And then superficially we have the central tendon

2:35

with the lateral expansion more laterally.

2:38

And here we're almost smack dab in the middle.

2:41

I, I think this is the central portion.

2:44

Uh, it's, it's fairly superficial

2:47

and you've got a, a separation here

2:50

of fibers from the posterior footprint, uh, of the,

2:54

with a few of these fibers hanging out posteriorly

2:57

and some secondary swelling.

2:59

So just a quick example of a more superficially located,

3:05

uh, partial depth, uh, non full width tear.

3:09

You can see it does not involve the entire tendon from side

3:12

to side of the triceps.

3:13

And I think the big challenge here

3:15

is not in making the diagnosis in coming up

3:18

with the right descriptors.

3:20

Uh, Don do you have any comments on this one?

3:22

Yeah, I just wonder if we're seeing, I,

3:24

and I think we are seeing there in this case

3:26

that the tendon, uh, of the medial head, is

3:30

that structure just in front of, uh, this one?

3:34

The one, right? I think it's this, this one, yeah.

3:37

And I think that this is the, the, the central

3:39

or common tendon, and it's torn as you go more posteriorly.

3:43

But that was the point I was trying to make that, you know,

3:47

everybody points to the muscular attachment,

3:49

which is certainly deep,

3:52

but that it's that tenderness attachment sometimes.

3:55

It's a very broad tendon that really confuses the issue.

3:59

And I told the truth, I went, I three times

4:02

I went back on this anatomy and we, we, you know,

4:05

and wrote three articles on this.

4:07

'cause I, I just couldn't figure out the layered anatomy

4:11

and I'm still not a hundred percent sure of it.

4:13

Yeah, I do find this one confusion confusing

4:16

because it looks like this tendon is coming out

4:18

of the medial head right

4:20

Here. Yeah. I think that's what that

4:21

is.

4:21

And, and I think the one

4:22

behind it based on what we're seeing.

4:24

Yeah. Yeah. Okay. Yeah.

4:26

I think, but I think it is torn more posteriorly is you're

4:29

pointing out as you go back.

4:30

Yeah. So, but I, but it, you know, as they say, I struggle

4:33

with these, I, I really do.

4:36

Yeah. So this would be medial long, right.

4:39

And then lateral,

4:41

That's probably what we're seeing.

4:43

Okay.