0:00

A few words, and we'll finish up

0:02

by looking at the external rotators.

0:05

Not a lot happens to these.

0:07

We have our piriformis, which is the largest located

0:11

in the sciatic notch,

0:13

and then the smaller tendons of the gamian ator internists.

0:17

This is often referred to as a triceps,

0:22

triceps coa,

0:24

and then the large flat quadratus femoral below.

0:27

Again, these are deep

0:29

and not easily palpable by the clinician.

0:33

I want to show this case, which is not a traumatic case.

0:36

This patient had rhabdomyolysis of multiple muscles,

0:41

but it nicely illustrates the anatomy of the muscles

0:44

because they're swollen.

0:46

And you can see the sciatic nerve here located right

0:49

behind the external rotators between the external rotators

0:52

and the gluteus maximus.

0:54

So sometimes these patients who have pathology

0:57

and the external rotators will present with sciatica.

1:01

We all know about the rather vague, uh, syndrome of, um,

1:05

piriformis syndrome.

1:07

I'm not exactly sure what that is.

1:09

I don't usually see anything in those patients.

1:11

Uh, but, uh, we do have this, uh, sciatic nerve

1:15

that you should look at carefully

1:17

whenever you see pathology involving any of the external,

1:20

uh, rotator group.

1:23

This is a patient with a trocanter fracture similar

1:26

to one I showed you, uh, previously here.

1:30

The gluteus minimus, uh, sorry, the gluteus medias is,

1:33

is intact.

1:35

And you can see here the tendons

1:37

of the external rotators coming across to insert along

1:41

The inner margin Of the trocanter.

1:44

These will frequently displace

1:46

and rotate the trocanter, uh, fragment, uh, medially.

1:50

So rotational at the fragments, uh, is an important finding,

1:55

uh, resulting from these.

1:57

The main thing that we look for

1:59

for the external rotators in more chronic cases is isco

2:02

femoral impingement.

2:04

This is strongly associated with hamstring pathology,

2:07

so it's convenient after you've done looking at the

2:10

hamstring to move to the external rotator group.

2:14

And when you're at the hamstrings,

2:15

you're gonna be at the level of the quadratus,

2:17

which is the lowest of the external rotators,

2:20

and you could look at it, uh, for impingement and bursitis.

2:25

This is taken from an article by Ani and they

2:28

provided normal measurements for distances

2:31

between the trocanter and Isum and between the trocanter

2:35

and the, uh, hamstring tendons.

2:37

I actually never really measure this.

2:39

I don't think the measurements are really reliable

2:42

'cause they change with hip positioning.

2:44

And I pay more attention

2:45

to whether there's any edema in this region

2:48

or whether there's focal compression

2:50

and atrophy of the quadratus femur.

2:53

So the soft tissue findings in, in my opinion,

2:56

are really more important, uh, than measuring these.

2:59

These, uh, type of impingement is, uh, most common

3:03

in females thought to be due

3:05

to the broader inter ischial distance, uh,

3:08

in, in the female.

3:10

Remember, narrowing is often, uh, asymptomatic.

3:13

So again, look for the secondary findings.

3:16

Here's a patient where the numbers look fine,

3:19

but we have symptomatic is trocanter impingement.

3:22

Notice the extensive atrophy of the quadratus femes as well

3:27

as all of this soft tissue, uh, edema in that region.

3:31

There is some tendinosis,

3:33

low grade partial tearing here in the hamstring tendons.

3:37

Very common, uh, association, uh,

3:40

with the is trocanter, uh, impingement In this patient.

3:44

We have frank bursitis, a more discreet fluid collection,

3:49

again, associated with hamstring, uh, pathology.

3:52

So I always like to just move from the hamstrings right into

3:56

that area and look for signs of isotropic,

3:59

enteric impingement, and then work my way up into the

4:02

smaller external rotators where I rarely see, uh,

4:06

any, uh, pathology.

4:08

I.