0:00

It is possible to be very athletic

0:02

and be 55 years old as this lady is.

0:06

Her chief complaint was pain in the anterior aspect

0:09

of both shoulders, right, greater than left, kind of a weird

0:13

rear weird history

0:14

after being strapped down for a surgery, uh,

0:17

about a year ago.

0:18

Now, she's a former volleyball player.

0:21

Um, and I do have quite a, a cadre

0:24

of volleyball, volleyball players.

0:25

It appears that it's my specialty to attract them.

0:29

And here is her axial.

0:31

Let me pull up, uh, a couple of coronal images

0:35

and scroll those.

0:38

She's got a few things going on.

0:39

Now, remember on day one I said one of the first things I do

0:43

is I look at the overall shape

0:44

and conformity of the humeral head and the cup.

0:47

I take a 10,000 foot view.

0:49

I look to see that the,

0:51

that the humeral head is not the centered.

0:53

And, and I also look at the, the shape of the humeral head.

0:56

'cause a lot of these overhead athletes, e even ones

0:59

that are in their fifties, you know, they will remodel.

1:02

And this remodeling often contributes to problems when they,

1:06

when they have their arm up over their head when they're

1:08

abducted and external rotation, the so-called Aber position

1:12

and look, look at her humeral head.

1:14

She's got this very curious looking bump.

1:18

And I have innumerable cases where the,

1:20

where the rotator cuff

1:22

and these throwing athletes just gets crushed

1:24

between two skeletal structures, the acromion,

1:27

and either a bump or, or more focal spur.

1:29

Let's look at her sagittal.

1:31

Where I, where I think this, this curious elevation

1:35

that I see so frequently, um, it,

1:38

it looks like a button spur.

1:40

You know, it's very broad,

1:41

but a little broader than a button, a big button.

1:43

And you can imagine that with the arm over the head, uh,

1:47

this bossing

1:49

or proud appearance of the bone is, you know,

1:51

has the potential to impact the, the subacromial space.

1:56

She does have some undersurface disease in the rotator cuff

1:59

right there as well.

2:01

Cuff's a little bit thickened,

2:03

but I'm, I'm showing it not

2:05

for the accompanying AC joint fluid,

2:06

which every 55-year-old is gonna have on a fat suppression

2:10

sequence, but rather for the labrum.

2:12

Uh, as Don talked about, slap lesions occur

2:15

with some frequency in, in volleyball players,

2:19

baseball pitchers, tennis players, overhead athletes.

2:22

And this one you can follow forward.

2:24

It becomes a little bit cystic. Let's go back.

2:27

Remember, it should go away as you go from A to P

2:31

and it doesn't go away at all.

2:32

In fact, it gets bigger. That violates a cardinal rule.

2:35

And as we come forward, not only does it persist,

2:39

it persists as a cyst.

2:41

Now, if we look at that cyst, I know we're not, not keenly,

2:45

uh, we're not too keen on Roman numeral these,

2:49

but rather describing them, um, a slap 10 would be one

2:53

that dis dissects into the superior Glen humoral ligament.

2:56

I showed you a tear of one in a dislocate earlier.

2:59

This SGHL is intact

3:02

and this pseudocyst, which is very gang

3:04

and like if you gave it to a pathologist,

3:07

they would call it a ganglion.

3:08

Every time it's,

3:09

it's not epithelial line fills the rotator interval.

3:12

So this is an overhead athlete with some of the changes

3:16

of impingement, these large pseudocysts in the back

3:19

remodeling of the humeral head, some rotator cuff pathology,

3:23

and a slap two with an anterior pseudocyst.

3:26

Any comments about this one? Don,

3:28

With this case really interests me

3:30

and mainly for this outgrowth

3:32

because, uh, I haven't seen it.

3:35

It may have seen me and I simply, you know, overlooked it,

3:39

but this outgrowth has bone marrow in it.

3:42

So this would be properly called an osteophyte. Okay?

3:46

It's not just due to thick subc, chondral bone plate

3:50

and osteophytes, whether they're marginal or central.

3:52

You mentioned button like,

3:54

which are typically the central ones they form

3:57

because of cartilage laying down bone,

4:00

endochondral, bone formation.

4:02

So you have to have cartilage.

4:04

So the thing I don't understand, I, first of all,

4:06

I'm not sure there is cartilage here.

4:08

And second, if it was contact with the acromium,

4:11

it would seem like the cartilage would've been

4:13

first worn away.

4:15

So I, I don't know how this develops.

4:17

I'm gonna start looking for it,

4:19

but, uh, if it looks like the picture's mound in the wrong

4:24

bone, you know,

4:25

and, uh, so I, it's kind of really interesting to me.

4:29

I, I don't recall a case where this was apparent,

4:34

You know, I'm not sure how it developed either.

4:36

Um, what I am sure of is if you pick your arm up over the,

4:40

over your head though, and you've got that thing in the way

4:42

that you're certainly more prone if you're a performance

4:45

athlete, uh, to problems in that location.

4:47

So maybe this is a patient,

4:49

'cause I'm looking the cartilage elsewhere.

4:51

It does look abnormal.

4:52

Maybe there was osteoarthritis

4:54

and this is a osteophyte that related to one area

4:58

where the cartilage was left behind.

5:01

And then because of it there would be impingement, nowing

5:04

of the cortical humeral distance. I,

5:06

I, I like that theory.

5:07

It's a weird looking spur for

5:08

Sure. It, it, it's,

5:09

it's

5:11

Now one other finding here that I, I mentioned to you, uh,

5:15

prior to, uh, us coming online

5:18

is I'm always looking at the entire shoulder

5:20

and I'm looking at the lungs.

5:21

You don't wanna miss a lung cancer.

5:23

Uh, this isn't why I showed the case,

5:26

but I don't mind nodes, you know,

5:28

everybody has nodes in the axilla.

5:30

I like them to have a fatty hilum.

5:33

Um, I like them not to be numerous, but when they're plump

5:35

and I see no fatty hilum, especially when they're deep,

5:39

really deep to the pectoralis minor,

5:41

I get concerned in a woman.

5:43

And this woman did have as a result of this study of

5:46

mammography and she did have breast cancer.

5:49

Um, let's move on, shall we? Any other comments on this one?

5:52

No. Remember if it's on the

5:57

image, we're all responsible for it.