0:01

This one was the, uh, osteoporosis.

0:03

But, uh, also the, uh, the key

0:07

saline finding we were trying to share was the, uh,

0:11

subc chondral insufficiency fracture.

0:14

I don't know if you can, hopefully you can see

0:16

Ah, yes. Okay. My,

0:17

uh, yes, yes, yes. Cross hair

0:18

Here.

0:19

Yeah. Um, but the key that I wanted to just, uh,

0:23

highlight, um, yeah.

0:25

For this office office hours Yeah.

0:27

Was, um, a, a few, a few of the, uh,

0:32

reports that I saw, um, uh, perhaps did not notice,

0:38

uh, the, uh,

0:40

subc chondral insufficiency fracture here.

0:43

Uh, there was, uh, everyone mentions the, uh,

0:47

robust marrow edema in the femoral head.

0:50

Yes. Yep. But, uh, the key was probably this, uh, sort

0:54

of within this robust edema to notice this

1:00

hypo intense line paralleling the contour

1:04

of the femoral head diagnostic

1:06

of a subc chondral insufficiency fracture.

1:09

And there's even a little, is there a little step sort

1:11

of there on the Yeah. Sort

1:13

Of weird Crosses there. A little step,

1:15

Probably sort of maybe right here. Yeah. Yeah.

1:18

Which Some people would bring up the differential

1:21

of vascular necrosis, which certainly on the differential.

1:25

Um, okay. And a couple of things to try to help parse out

1:29

between the two is mm-hmm.

1:31

Uh, what I like to use is sometimes, um,

1:35

with ash necrosis, the hyperintense line will, in, instead

1:40

of paralleling the contour of the femoral head,

1:43

it'll be sort of, uh, concave Oh,

1:46

Yes. Towards

1:47

Versus, uh, paralleling

1:49

and sort of convex with the, uh, femoral head contour.

1:53

Yeah. So I

1:54

See, okay. But

1:55

in actuality, would, yeah.

1:56

When both start to collapse, it can be difficult

1:59

and probably, yeah.

2:01

You know, histology histologically sometimes I guess it

2:04

may be hard for Yeah.

2:06

Uh, our pathologists to, uh, figure out.

2:10

Yeah. Uh, yeah.

2:12

And probably on the spectrum at some point,

2:13

but the, you know,

2:15

those are definitely on the two differentials.

2:17

Gotcha. So, so essentially here, the, if,

2:20

if there's words more likely to be a VN, um, you would get

2:23

that, that concave sort of lower margin sort

2:26

of dipping down more into the femoral thing.

2:27

Yeah. Whereas this one is just running so parallel to it.

2:32

Yeah, exactly. Okay. Exactly. Yeah.

2:34

Nice. And,

2:35

and pathologically in terms of this one, this is,

2:39

this is basically occurring

2:41

because of the, you know,

2:43

the quite severe osteoarthritic changes present.

2:47

Yeah. That, that is, that is Mechanics

2:50

Frail bones.

2:52

Right. Gotcha.

2:55

Yeah. Typically seen in Yeah.

2:57

Older individuals, uh, and with frail bones

3:00

or, you know, perhaps someone that's just, uh, uh,

3:05

you know, nutritional deficient or, uh, perhaps, uh mm-hmm.

3:10

You know, overdoing it with, uh, right.

3:13

Uh, a combination of, uh, uh, perhaps,

3:18

uh, you know, uh, suboptimal nutrition

3:21

and maybe overdoing it with their workouts.

3:23

But I mean, either, either way, I guess. Yeah.

3:26

Obviously it's called, you know,

3:28

if it's a insufficiency fracture or a VN with fracture.

3:31

Yeah. You know, the, the edema, you know, w would be

3:36

in theory, uh, you know, robust with both.

3:40

But, uh, those are, yes.

3:42

That's one way I, I try to differentiate between the two.

3:45

Okay. Yeah. Okay. Um,

3:47

Yeah, and I sup I suppose also, you know, you may,

3:49

you may be lucky enough de depending on the referrer, um,

3:53

you may be lucky enough to get some, you know,

3:55

extra useful information, say like, you know, steroids

3:58

or some other things, um, in the background, um,

4:02

which I suppose is, is variable to, to help, to help sway,

4:06

um, sway things too.

4:07

Yeah. Okay. Yeah. Excellent.

4:09

Excellent. Yeah. And I guess too, the another point, uh,

4:14

I guess too would be to help if, if,

4:18

depending on protocols, um, where at my institution

4:21

where I'm at, we, on our hips, especially in older patients,

4:25

we'll get a large field of use stir, uh, yes.

4:28

And T one sometimes, uh, T one sometimes,

4:31

but most often at least a stir.

4:33

And obviously if it's AAV n

4:36

or systemic disease, you know, it, you know,

4:39

it can be bilateral.

4:40

So that's another thing that could help.

4:42

Um, oh, indeed. Yeah.

4:43

You know, um, could there be,

4:45

in theory one could raise a question, you know,

4:47

could there be bilateral insufficiency fractures, I guess.

4:51

Sure. You know, but I guess another thing that,

4:53

That's a lot less common Yeah.

4:55

Is insufficiency fractures in other, other locations

4:58

or history of, and, and that kind of goes to your Sure.

5:01

Um, point of, you know, additional history perhaps

5:05

around steroids or had radiation,

5:07

you know, in and around the hip.

5:09

You know, maybe like a, a prostate or,

5:11

or a, a ob gyn cancer perhaps, you know?

5:14

Sure. And look for other, you know, uh, acetabular

5:18

or, uh, pubic ray mi or,

5:20

or even like sacral

5:21

insufficiency fractures, things like that.

5:23

Maybe that'll help. Um, okay.

5:25

You know, parse out the differential sometimes too.

5:28

So I don't know if you're running large field of view stirs,

5:31

um, at your institution, you know, sometimes, um, you know,

5:35

go looking around at other joints

5:37

and, uh, maybe that'll help sometimes

5:38

to parse those out. Okay.

5:41

Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Very good. Very good.

5:45

Yeah. Well, I, I, I'll leave it to your discretion as

5:48

to the next case you, you wanna look at.

5:51

Oh, I think, I think that was the main one that, uh,

5:57

that, uh, was, was brought up.

6:00

And then the other, uh, I'll say the,

6:05

probably the hip one.

6:06

Yeah. Oh, yes.

6:08

So I, I did, um, I did see your, um,

6:12

your review of this one.

6:15

Yeah. Um, on laughter,

6:16

but yeah, very, very happy also to, to see in,

6:19

um, in real time.

6:21

I was, um, uh, my, I I actually thought

6:25

that this was just a, um,

6:26

a very large tear on the posterior labrum,

6:29

but in fact, it's, it's clearly more than that

6:31

because it's actually getting into the,

6:34

the bone itself, isn't it?

6:36

Yeah. So here we can probably better on the T twos

6:40

'cause it brings out not, uh, not just the, the, uh,

6:44

the dark T two signal of the, uh, you know,

6:48

fibrocartilage, uh, yeah.

6:50

Uh, uh, labrum.

6:51

But also you can see the similar, uh, sort of, uh,

6:56

osseous fragment and, uh,

6:57

Ah, the, the marrow,

6:59

The marrow signal with the, uh, acetabular limbus

7:01

or the posterior wall here.

7:03

Ah. So that's probably the key.

7:05

And, you know, the eyes just don't register it

7:09

'cause it's sort of blends in together with that, uh, lab.

7:13

Uh, you know, with that, uh, the labrum just runs along with

7:17

that, uh, OCI fragment

7:20

and hard to tell to, um, sometimes you don't, um,

7:25

get, as in this case, uh, there wasn't a

7:29

corresponding, um, fracture of the, uh,

7:34

femoral head to, uh, you know, to be, as a tip off

7:39

that there was a, a transient hip, uh,

7:41

subluxation or dislocation.

7:43

Um, but, uh, this robust edema within the posterior,

7:49

uh, muscles here.

7:50

Uh, yes. You know, the, uh, you know, you have like

7:54

edema outlining the, uh, Gail

7:57

and sort of, uh, piriformis,

8:01

You Ator, what have you.

8:03

Uh, yes. That's one thing to think about,

8:05

transient hip dislocation.

8:08

And then with that, you know, go looking

8:10

for the accompanying potential, um, femoral head, uh, in,

8:15

uh, osteochondral compaction fracture,

8:17

and sometimes you get a, uh, tear of the, uh, ligament

8:20

and terries and, and whatnot.

8:22

So that's sort of the, oh,

8:24

That's, that's, that's really this one.

8:27

Really nice and nuanced. Yeah.

8:28

'cause I suppose that's maybe, I mean, I've,

8:30

I've not seen this before

8:32

and, you know, as I was, you know, saying earlier,

8:34

it's like, you know, I've only, I only just started doing

8:36

some SK stuff, basically only needs about six months ago.

8:39

But that's a really nice nuanced, um,

8:43

sort of aspect of this one.

8:44

And that, yeah, there's nothing on that feral head

8:47

to tip off a, a rank such as myself

8:50

and say, oh, well that must have banged up against the

8:53

posterior, or, you know, lateral margin of

8:55

that fractured acid tablum.

8:57

Yeah. Um, and, uh, those axial, T two does show that

9:01

that little rim of residual, that arc of marrow,

9:04

if you wish, if you will Yeah.

9:06

At the base of the labrum, um,

9:08

it shows it really, really nicely.

9:09

Whereas the, the really heavily water weight one's not,

9:13

I think, sort of obscures it a bit relatively. Yeah.

9:16

Um, so like this T one Yeah.

9:19

This T one sort of ru you see

9:22

that bony fragment running with the,

9:24

Uh, Uh, fragment of the, uh, posterior labrum there,

9:28

maybe better on the T twos here.

9:31

Yep. Right there.

9:33

Yeah. Like there Yeah. Where you see the arc of it. Yeah.

9:36

Or even like right here, that arc. That's correct.

9:38

The labrum running with the, uh, push your, your lip of the,

9:42

uh, as to have a wall there.

9:44

So something to think about.

9:45

I thought this was a, a nice case.

9:47

We, I'll probably see this, uh, maybe once or twice a year.

9:51

Um, typically like an athlete.

9:54

For, for us it's usually gonna be like a, uh,

9:58

like the last time I saw this was, uh,

10:00

was in a soccer player

10:01

and, uh, an American Oh, really? Football player. Yeah.

10:04

I was gonna say, I, it's the sort of thing I would expect.

10:06

I, I don't, uh, you know, I don't follow NFL,

10:09

but I, I would imagine it's the sort of thing

10:11

that if you've got a, you know, 350 pound guy jumping Yeah.

10:15

Back in certain spots, or I guess,

10:17

You know, you may see it with rugby

10:19

Players, guess that would surprise me.

10:20

Yeah. Rugby and a a FL, um, a FL players as well

10:24

as in Australian football.

10:26

Yeah. Yeah. But it's, um, yeah, it's,

10:29

it's quite a, it's quite an injury.

10:31

And the, the expense of sounding a bit, um, bit naive

10:35

or ignorant in terms of treatment for this, would they,

10:38

would the surgeon like tack that back on with a couple

10:40

of screws or something?

10:42

Or would they just leave it be and see how it healed?

10:45

I, I, I've seen, I mean, obviously, uh,

10:48

it's gonna be patient specific, but I've seen it couple

10:52

Ways. Yeah.

10:53

Right, right. Um, you know, especially larger fragments,

10:56

uh, where yeah, there's potential instability,

10:58

what have you, and, and to prevent that early osteoporosis.

11:02

Ah, yes, of course.

11:03

I, I've seen a, I've seen a couple cases where they'll go in

11:06

and, uh, you know, tack it down, sort

11:08

of treat it like a push your ask to have a wall fracture.

11:12

And I've seen another where, you know, they've just sort

11:14

of left it and, and, uh, with conservative management.

11:18

So yeah, I've seen it both ways.

11:20

Hmm. No, that's a, that is a, it's a really, really,

11:24

um, yeah. Really nice case.

11:27

Yeah. Um, It depends on, um, yeah,

11:30

what we have terms athletes, but you never, you never know.

11:33

I mean, sometimes things just turn up, you know,

11:35

you can have a, a, a kid playing something at high school

11:38

or doing something silly

11:39

and, you know, turn up with this kind of thing too.

11:42

I suppose it all depends on the, on the, on the, um,

11:45

the method of injury

11:47

and, um, you know, if the,

11:48

if the vector force is going in the right way,

11:51

well, this is what happens.

11:53

Yeah. I, I, yeah, obviously sort

11:55

of a posterier translation, so Yeah.

11:57

Yeah. Nifty one. Oh, that's great.

12:03

Yeah. Did you have any, uh, other questions

12:07

or concerns about the week seven cases, sir?

12:10

Um, those

12:11

Are the two major issues that I wanted to bring up.

12:13

Yeah, no, I think I'm just, um, just reading on here.

12:16

So, can impingement, pinch impingement? Oh yeah.

12:20

I suppose the only que I did have a,

12:23

I I do not think I picked the, um, the Piner thing at all.

12:26

And, um, a quick question about the, the pin impingement.

12:31

Is that mm-hmm. Sort of for the labor

12:34

and essentially there, are they, uh, for want

12:37

of a better word, are they sort of just elongated

12:39

or it's actually the, the margins of the acetabulum sort

12:43

of crimping in more as well?

12:46

Yeah. Uh, so, you know, as, as you know, I think it's,

12:49

it's also the, the margin, uh, right of, of the,

12:54

uh, acetate and sort of oss osteophytosis once the,

12:59

you know, labrum degenerates and whatnot.

13:01

And, and you can sort of appreciate not just the, uh,

13:05

the osteoporosis that's already present,

13:09

but, uh, sort of that creates a sort

13:11

of a lobster claw, if you will.

13:14

And, and that yes. Deformity

13:15

and that over coverage around the, uh, femoral head.

13:18

Um, but you know, this person's obviously,

13:21

as you can see here, especially sort of, uh, superiorly,

13:25

they've already started to loss lose cartilage. Um,

13:28

Yeah. Little bit of

13:29

subc chondral edema happening and, and,

13:31

and that, and then, um,

13:33

and the, the labrum doesn't look like a normal black signal.

13:36

Yeah.

13:38

Gray. Yeah. And then You could degener.

13:40

Yeah. Yeah. Again, you can see that sort of, uh, uh,

13:44

you could even appreciate the irregularity

13:47

and sort of early remodeling that's going on undulation here

13:51

of the, uh, acet as subcon bone plate of the acet,

13:56

not just the, uh, over coverage by the osteophytes.

13:58

And you could also see here, you know, the femoral head, uh,

14:03

neck, sort of ossified collar here of the,

14:05

uh, at the femur as well.

14:07

This person's already, well on their way, unfortunately,

14:10

into, uh, osteoporosis and, and, uh, yeah.

14:13

Perhaps even ultimately a, a,

14:15

a hip replacement, but, you know.

14:17

Sure. Uh, and that the, the o the overgrowth there, the,

14:20

the s tablet degeneration, so does that then, uh, in a sense

14:24

of, I suppose, well, they're getting pain

14:26

for the osteoarthritis, but also the, the pinch effect that

14:29

what rubs on the, I suppose on the capsule

14:32

and the cartilage, the neck and so forth?

14:35

Yeah, I, I, I mean, most, most of the time, right.

14:37

It's gonna be, well, yeah, it's gonna be a,

14:40

a combination, right?

14:41

There's the two major flavors of cam and the pincer type,

14:45

but basically the, uh, incongruency between the femoral head

14:48

and the acetabulum.

14:50

So yes. You know, we can talk about, um, you know, like a,

14:54

a pincer type with either, you know, a, a sort

14:58

of a global over coverage of the ace haveum,

15:01

or even it could be like a, a focal, right, right.

15:04

Uh, a over coverage or a portion of the acet haveum

15:07

and, and whether mm-hmm.

15:09

It's, uh, a con incongruity between the acetabular,

15:14

uh, and or the femoral head, the cam that is.

15:18

But, uh, you know, most of the time people will say it's,

15:21

it's sort of a mix or a combination.

15:23

It's probably like a, I guess like a continuum,

15:25

but either yes.

15:26

Obviously can lead to that, uh, you know, uh,

15:31

lab degeneration and carre wear.

15:34

And then unfortunately, uh, early osteoporosis, you

15:37

Knows Yeah. Prevent

15:38

that early osteoporosis.

15:39

That's the name of the game. So, um, yeah. Yeah.

15:43

So hopefully that answers Yeah.

15:46

Uh, your question there

15:47

and also adds, uh, to what you were commenting.

15:50

And here too, as you can see, the,

15:52

the labrums not the most pristine, you know,

15:55

obviously likely torn Cys here Yeah.

15:59

With the cyst and the paralegal cysts

16:02

and the little degenerated sort

16:04

of tear ant superiorly quite commonly seen.

16:06

Yes. And as you noted too, the, uh, subcon edema not

16:10

as robust as Yeah.

16:12

The, uh, subcon sufficiency fresh

16:15

that we showed earlier, but Yeah.

16:17

You know, ultimately also Right.

16:19

With enough wear and perhaps Yes, uh,

16:22

superimposed frail bones.

16:23

This, this person's also not only, uh, at risk for,

16:28

uh, getting a hip replacement,

16:30

but, uh, obviously it potentially, uh,

16:33

insufficiency fracture one day as well as they Yeah.

16:36

Sort of, uh, unfortunately wear down the cartilage

16:40

and then the bone and,

16:42

and potentially, uh, form that fracture.

16:44

So not as robust edema,

16:46

and we don't see that hypo intense line now,

16:48

but, uh, also Yeah, sure.

16:49

At for that probably. Yeah. Yeah.

16:53

Oh, that's good. Yeah. I got, I got portions of this case.

16:56

I did not get this specific pin episode, so on.

16:58

But again, I, um, I'm actually glad in a sense,

17:03

I, um, I'd actually feel sort of a bit hard done

17:06

by if I was getting everything right,

17:07

because as I say to my trainees,

17:10

'cause I'm said in interventional and neuro,

17:13

and, uh, I say them, I wanna see you guys making mistakes,

17:16

because if you're not making mistakes, well, number one,

17:20

I become redundant.

17:21

And number two and number two, um, that's,

17:25

you know, that's when you learn.

17:27

Um, so that's why I've, I've found that you

17:30

and your colleagues review of all these cases, so Excellent.

17:32

'cause even if I'm getting, you know, some

17:35

of them mainly right or, or, or a little bit, right.

17:38

It's, um, again, there's a lot of that nuance and, uh,

17:41

and these smaller findings that, you know, sort

17:44

of bring it together much better.

17:46

So, um, no, great. No, no. Yeah.

17:48

Thank you for looking at that one. That's terrific.

17:50

Yeah. Glad, glad to, glad to help.

17:52

And, uh, good discussion. Yeah. Yeah, yeah. Yeah,

17:56

Indeed.

17:57

Um, yeah, so I think, I think that's probably it,

18:02

week seven.

18:03

Um, okay. From my perspective, I said having had a look at,

18:06

um, through the, um,

18:08

Let's, let's pull a couple of week eight cases then, oh,

18:11

is there a specific week eight? I know you, you

18:14

Mentioned Oh yeah, you had just so, um,

18:16

Drop dropped the man by Any Yeah.

18:18

Look, the, um, the, the, the, ah, yeah, the eu, um,

18:22

the EU one Peroneous, I think that was, yeah, that was,

18:25

that was a ripper case.

18:27

Um, because I mean, I thought that just,

18:32

you know, in terms of, I'll tell you what I sort

18:34

of just very quickly what I thought then that, you know,

18:36

they had long lamina tears in, um, the,

18:40

what I thought were both peroneous tendons,

18:42

but I see from your title there more peroneous brevis,

18:45

so gross thickening, gross, you know, tenino virus

18:49

per perino edema, ganglion cyst, et cetera.

18:52

Couple of specific questions mm-hmm. Please.

18:57

The, the marrow edema in the Alis,

19:00

I've been on the calcan, sorry.

19:02

Um, the, the Meema

19:03

and the Calcan, I was really taken with that.

19:06

Yeah. And is that all reactive to this process? Yeah,

19:10

Yeah. Yeah. Wow. Sometimes

19:11

you'll, you'll just sort of see it

19:12

and, and here you can even,

19:14

That was incredible.

19:15

You could even see here the, I mean,

19:17

the little spike from the Peral tubercle

19:20

and yeah, I believe it's an article out of, uh,

19:24

the Mass General, the Boston, the Boston group, they sort

19:28

of looked at sizes of the, uh, perineal tubercle.

19:31

Um, and I think the, the cutoff they found was if you,

19:35

if you sort of draw a line along the wall, lateral wall

19:39

of the, uh, calcan or calcaneus,

19:42

and then you, you drop a 90 degree to that, um,

19:47

to the wall essentially.

19:49

And if you measure out, I believe the cutoff was, uh, six

19:53

or seven millimeters, if you like, measurements.

19:57

Right. But what they found,

19:59

I don't think it made the threshold,

20:01

but sort of if you have a prominent peroneal tubercle, um,

20:06

you know, that can be a, a predisposing factor

20:10

to perineal tendon pathology

20:12

because the tubercle, as you can see here, forms, uh,

20:16

the border, um, for the, uh, brevis,

20:21

uh, superiorly or at its, uh, superior aspect.

20:25

And the long is at its inferior aspect.

20:27

But you could imagine too, that a large one could in theory,

20:30

crowd the area and sort of lead to, uh, uh,

20:34

perineal tendon pathology.

20:36

But yeah, every once in a while we'll see this sort

20:39

of robust edema related to the peroneal tendon tear.

20:43

And, and here, uh, just a nice case, uh, of, uh,

20:48

both tendons being tendon and sort of partially torn here.

20:52

And as you pointed out, sir, the, uh,

20:55

robust tenino synovitis, um, really a, uh, a nice example

21:00

of that here and

21:02

Sort of in, yeah, I thought that was,

21:05

Uh, along with that reactive edema.

21:07

So this is a great case here.

21:09

Yeah. And that's really, really iffy.

21:10

But yeah, I was, um, I must say I was, I was, I say put off,

21:14

but, um, it was more just, uh, you know, when I saw

21:17

that edema as well, I thought, wow, is this just, you know,

21:20

like prolonged really severe tenitis

21:24

with the tears and so on?

21:25

Because I didn't, uh, I wasn't sort of necessarily aware

21:28

that you could actually get such, um, you know,

21:30

reactive edema from it.

21:32

And you're pointing out

21:33

that peroneal tubical is not something I specifically picked

21:36

up on, but it does make such good sense

21:38

because, you know, without sticking out and rubbing on them

21:42

and so forth, some pretty, pretty significant forces across

21:46

that cubicle and that bone

21:48

and that, um, those tendon sheets there.

21:51

Um, yeah, that's really good.

21:53

So in terms of chronicity of this, this is something that,

21:56

this is not something this has just turned

21:58

up in a week or two.

21:59

So this has been going on for a prolonged length

22:03

of time, I assumes.

22:04

Yeah, I I, I would assume so. Yeah.

22:06

I would surmise this, uh, is not something acute. Yeah,

22:11

Yeah. Yeah.

22:12

Like, it may have, you know, it may have hit, um,

22:15

you know, it may have hit critical mass to the point where,

22:18

you know, there's just so sore

22:19

and painful they presented out.

22:20

But yeah, looking at that, that degree of that, you know,

22:24

fluoride Yeah.

22:25

Edema and soft tissue, tissue swelling, it's, um, yeah.

22:28

It's quite, quite a case.

22:31

Yeah. And,

22:32

and one, one thing to bring up too is, is, you know,

22:35

on the differential when you see this sort of, you know,

22:39

when I see this sort of tendon pathology too,

22:41

and sometimes tenosynovitis mm-hmm.

22:43

I'll just, uh, run the bones real quick too and,

22:46

and then also correlate with the patient history and,

22:50

and, uh, the, their medical records.

22:53

But, uh, one to one, right.

22:54

One potential thing to think about is perhaps someone with,

22:58

uh, like an inflammatory arthropathy, right? So, oh,

23:02

I see, okay. You know, I'm

23:03

looking for potential like erosions

23:05

of the bones or, and synovitis.

23:08

So just glancing real quick, making sure

23:11

that this is not just, uh, you know, teno synovitis

23:14

and tendon tear, uh mm-hmm.

23:16

Simple one, but perhaps one

23:17

that's also could be related in theory to, uh, uh,

23:20

underlying inflammatory arthropathy.

23:22

So Right. Like in this case, you know, I'll,

23:25

I'll look glance real quickly at some common area, you know,

23:28

look at quickly at the joints,

23:30

make sure there's no robust synovitis or mm-hmm.

23:32

You know, sort of joint erosions

23:34

or even like perhaps a retrocalcaneal, uh, bursitis.

23:39

So just to clear those real quick along

23:41

with such a t synovitis.

23:44

And when you say arthro,

23:47

you mean like essentially a primary, you know,

23:50

primary arthropathic conditions

23:51

or things like say connective tissue disease,

23:54

Such as Yeah, like a rheumatoid arthritis.

23:56

A rheumatoid, yeah. Gotcha. Okay. Okay. Yeah,

23:59

Yeah, exactly. Yeah.

24:00

Okay. Yeah. Yeah. Very good.

24:04

That's, and then, and then other things too, like,

24:06

you know, Tino, if, if there was such a robust t synovitis,

24:10

uh, you know, other things like, you know,

24:11

perhaps like a crystals, uh, yeah.

24:14

You know, I guess worst case scenario, uh, you know, uh,

24:19

I guess, you know, with such robust t synovitis, you know,

24:22

you wanna make sure you're not also missing a septic teno

24:25

synovitis, you know, perhaps if there's like, yeah.

24:28

Marrow edema by the fifth metatarsal or,

24:30

or nearby, make sure there's no overlying wound, things like

24:34

that to also contribute to such, you know, yep.

24:37

Uh, tenin. But, uh, we don't see such, uh, uh, any

24:42

of those findings or, or led with the history.

24:44

And this just likely all just related to the

24:47

perineal tendinopathy.

24:49

Yeah. Okay. Yeah. Well, that was the, the, the infection

24:53

option did come to mind when I was looking at this

24:55

because I was so unfamiliar with that, that fact

24:57

that you can get that, you know, edema,

25:00

and so that marrow edema in relation

25:02

to tenino cell superior.

25:04

And, um, but yeah, I think I sort of did dismiss that.

25:07

'cause assuming that, you know, the clinical history with,

25:10

there was no mention of say, you know, fevers

25:12

or raised white cell count or anything.

25:13

But, um, yeah, that's a very good thought

25:17

to also in the background always,

25:19

always rule out the infection, eh,

25:21

because, um, you know, not, I suppose including

25:24

that if there was a history suspicious that, um,

25:27

wouldn't necessarily be a good outcome.

25:29

Yeah. Yeah. Okay.

25:31

Oh, that's a, that is a really, really good case.

25:34

Yeah. That's really, really nice. Nice classic case there.

25:39

Any other, any other ones

25:41

communicate you'd like to go over, sir?

25:43

Um, I think I was pretty comfortable

25:46

with the osteomyelitis.

25:47

Um, and I think the navicular stress

25:51

factor, I thought that was fine.

25:52

Oh, the case three here, complex regional pain syndrome.

25:57

Oh, yes. It's, now that I, I mean,

26:01

I got some findings on this, um,

26:05

but in terms of, you know, that I'll, you know,

26:09

be bluntly honest, I was never gonna come out

26:11

and say, you know, cr

26:16

CRPS slash reflex sympathetic dystrophy or whatever.

26:19

To me, there's more, more like say a, um, a neuropathic foot

26:24

with sort of some collapse of the longitudinal arch.

26:27

Yeah. Uh, to some degree and all this meed and so forth.

26:30

So, yeah, I suppose as if I could,

26:33

if I could mine you on the, the nuance of this as to

26:38

why this is, you know, the crps, um,

26:41

Yeah. So

26:41

Rather than say the neuropathic,

26:44

I think, I think neuropathic, I, I, uh, in all honestly,

26:49

I think, uh, I definitely would have raised the possibility

26:53

of a, uh, neuropathic joint here.

26:56

Mm-hmm. Um, you know, not just, um,

27:00

because of the marrow edema, but here mm-hmm.

27:05

On this, uh, T one, you know,

27:08

I think the T one brought it out best.

27:10

Like you just have an absent PTT tendon, you know,

27:14

so I would've, I would've, uh, worried,

27:17

and here obviously you, you know, you're,

27:19

we're missing the PTT, the postage to be tendon

27:22

where it should be at the medial retro maal groove.

27:25

So obviously completely torn.

27:27

So I would've worried that this person is a diabetic

27:30

with a charcot foot.

27:32

Um, um, and, but, uh, and,

27:35

and also I, I personally, and,

27:39

and anecdotally the way I was trained was to

27:43

shy away from sort of, uh,

27:46

complex regional pain syndrome, um mm-hmm.

27:49

Being, because it, it, it sort of has, uh, to some people,

27:55

uh, especially like insurance companies here in the states,

27:59

uh, a stigmata of Yes.

28:01

Uh, you know, being a difficult, uh, sort

28:04

of patient to, to manage it.

28:06

Yeah. Yeah. And I don't want absolutely that

28:08

to affect their, uh, sort of coverage, if you will, sir.

28:12

Indeed. So indeed, I, I, I hardly diagnose, uh,

28:17

um, complex regional pain syndrome

28:20

or, you know, sude atrophy or whatever terms you use.

28:23

Um, yes. But the key here to potentially raise

28:27

that diagnosis is, um, classically some

28:31

of the stuff you see on this case is the robust soft tissue

28:35

edema, and then Right.

28:36

The sort of, uh, um, splotchy, uh, marrow edema.

28:41

But you can sort of appreciate

28:43

that it's more based sort of Yeah.

28:46

Um, but you can also see this sort of, uh,

28:49

marrow edema pattern, certainly with the charco joint.

28:52

So the charco I would've probably, uh, put on, um,

28:58

on the higher on the differential, but obviously I think,

29:01

and then we could sort of get into the academics

29:04

and semantics of it too.

29:06

And, and, you know, one could perhaps even argue it sort of

29:09

the two are probably maybe even, uh, uh,

29:13

on a continuum if you, if we wanna think about it too.

29:16

Right. So, yeah. Um, and I suppose,

29:18

but I, I would've certainly added Charcot in,

29:20

in my differential here.

29:22

Uh, okay, good. With that possibility.

29:24

Well, I'm very sure. Well, well, that's, that's good.

29:26

Yeah. It's, um, uh, I, I like your description of

29:30

that splotchy marrow Yeah.

29:32

Signal change. Yeah. Because that the, when you sort

29:35

of think about that is Yeah, that is indeed what it,

29:38

what it looks like, um, yeah.

29:41

And the soft tissue edema. Um, yeah.

29:44

I suppose that's not necessarily the case with your,

29:47

your typical charcot one maybe. Um,

29:49

Yeah, no, but like an acute charcot right.

29:51

Can, can present with the

29:53

cellulitis sort of picture. Oh, indeed,

29:55

Indeed. So

29:56

for sure. So before you get all the collapse

29:58

and, you know, disorganization, dislocation

30:01

of the bones and, and yes.

30:03

And what have you. So certainly I think Charcot is,

30:06

is a great differential if not diagnosis for this case.

30:10

You know, and, and as you pointed out earlier through, uh,

30:14

you know, with the, the pt, the Postier, tbi, oin

30:18

and tear, we're losing that dynamic stabilizer of the, uh,

30:22

the, of the longitudinal arch.

30:23

So some of this mar edema could also, uh, one can argue,

30:28

you know, that it's, um, you know, related

30:31

to altered biomechanics, right?

30:33

Yeah, for sure. Sort stress changes

30:34

and we're just not seeing, you know, fractures

30:37

yet or what have you.

30:38

Right. So again, that sort of points out to maybe it's all,

30:42

it is all perhaps tied together,

30:44

but I mean, Charcot, you know, along with, uh, you know,

30:49

PTT tendon sort of, uh, dysfunction

30:52

and ultra biomechanics, certainly on, uh,

30:55

all on the differential with, uh,

30:57

this complex regional pain syndrome diagnosis

31:00

for sure. In, in my opinion.

31:02

Okay. Excellent. Yeah. Excellent. Yeah.

31:05

Well, that's another, uh, another ICE case,

31:07

but you know, I'll let, I'll let you in on a secret.

31:09

I didn't actually even pick up that the PTT was torn.

31:12

I did, I did pick up on that,

31:14

but hey, that's, that's why I'm doing,

31:16

that's why I'm doing this relationship course,

31:20

but, um, at least there's good enough

31:22

to pick up the collapse of the arch and so on.

31:24

But you see now, I'll never look at one

31:25

of these again without going straight to look at the PVT and

31:30

Yeah, no, no, the, the Key, it's intact, you know?

31:33

Yeah. So the key to remember also,

31:35

right, and, and what I, yeah.

31:36

What I try to, what, what Dr.

31:38

Resnick, my mentor and,

31:39

and now, uh, uh, co c colleague, uh,

31:43

always teaches me is yeah, learn

31:45

to count the tendons in the, on, in the back of the, uh,

31:48

of the back of the ankle and ankle, right?

31:50

So count the tendon, just make sure you have five, right?

31:53

So three medially, two laterally, okay.

31:56

And then that, that will always help you

31:58

to pick up obviously the, uh, the, all the accessory muscles

32:01

that you can have back here.

32:03

Mm-hmm. That's, that's probably the

32:04

main reason that I do it now.

32:06

Uh, gotcha. But, you know, uh, and,

32:08

and you should be calling, you know, uh, if,

32:11

if you're a a numbers person,

32:13

you should be calling a per peroneous corus every about

32:16

every fourth MRI of the ankle that you read, right?

32:19

Oh, okay. So apparently the incidence is about, uh,

32:23

you know, out there in the world is about, uh, 4, 4 20 5%,

32:27

depending on if you read about 25% of people have, uh,

32:31

prunus cordes muscles.

32:32

So every, every fourth Mr.

32:35

In theory, you should be expect

32:37

to see perhaps a a per a per peroneous cortis.

32:40

And, and that, with that, with that present that, you know,

32:44

I'll, I'll mention the report, the Peroneous Cortis

32:47

for instance, but kind of going back

32:48

to the perineal tendon tear case, you know, that could lead

32:52

to crowding, uh, of the, uh, uh, of the

32:57

lateral aspect of the ankle, along with other things such

32:59

as the low lying brevis

33:00

and the prominent peroneal tubercle

33:03

that we were talking about and lead to, uh,

33:05

peroneal tendinopathy or tearing as well.

33:08

So, Hmm. You should, you should be saying that.

33:10

So yeah, learn to count

33:12

1, 2, 3, 4, 5.

33:13

Yeah, just, just, I just do a quick checklist.

33:16

So, so my checklist is I go ligaments, ankle, uh,

33:20

then the ankle tendons,

33:21

and I'll, I'll work the anterior anterior extensors,

33:23

then I'll go to the Achilles,

33:25

and then I'll go medial and then lateral.

33:28

So that's, that's my eyes.

33:30

So I'll just sort of, as I'm scrolling, I'll,

33:33

I'll go cranial to coddle on the anterior extensors,

33:37

then I'll come back up the Achilles,

33:39

and then I'll walk back down the medial flexors

33:42

and then back up the peroneals.

33:44

So in like, you know, two, four scrolls, I'm, you know,

33:48

I'm done with the, uh, the tendons

33:49

and that's, that's my, but that's my search pattern.

33:52

Okay, great. Yeah. Yeah. Thanks. That's excellence.

33:57

That's, that, that's, that's the, um, that's,

34:00

that's gold as they say.

34:02

Um, no, that's great

34:04

because, um, I said, you look at a case like this, say,

34:08

okay, tenants missing, always look for that count

34:12

for five tendons. Fantastic.

34:13

Yeah. Um, and then,

34:15

and then to go along with the tendon counting too, right?

34:18

So the Perus quarters, the next, uh, type of tendon, uh,

34:22

that I typically see will, will be a flexor digitor axis,

34:27

long muscle, and it'll just be a little muscle

34:30

and tendon right over typically the, the, uh, tibial, uh,

34:34

neurovascular bundle right here coming off the, uh, the, uh,

34:38

the flexor retina aum right here.

34:40

So it'll be sitting mm-hmm. Like right there.

34:42

And then the third I'll look for is the accessory solia.

34:44

So that'll be so superficial to the retina ulu,

34:47

and then it'll, it'll sit like right here.

34:50

So yeah, so that's, those are the three major accessory.

34:55

Then you, then we could start getting fancy

34:57

and, you know, looking for things like, uh, you know,

35:00

perineal, calcan internus and,

35:03

and other, you know, rare ones that you may see.

35:06

But, um, but those are the three major

35:08

ones that I look for in the back.

35:10

So the cortis, the FDL, and then the accessory soleus.

35:15

So, okay. Yeah.

35:17

Very good. Sure.

35:19

Yeah. Very good. Okay. Awesome.

35:22

Yeah. Well, thank you. Any other ones on this case?

35:26

No, no, that was great.

35:27

I think that was, that they were the, um, yeah,

35:30

they were the main ones, the titis, I was happy with that.

35:33

Um, the stress fracture, happy and the osteomyelitis.

35:36

So, um, yeah. But no, those, those two were, um, the,

35:39

the perone and that and that one, um, were, that's terrific.

35:44

Got a lot of, a lot of nuance out of that.

35:46

So much appreciated.

35:48

Of course, of course. Happy to help. Cool. Happy to help.

35:52

Awesome. Well, um, thank you.

35:56

I think, um, I think that's the specific

36:00

queries I have for those.

36:01

Um, I feel very lucky it was a one-on-one,

36:06

but, uh, that's very nice. Very nice.

36:08

Happy to assist. Happy to assist. Yeah.