Sonography of Common Shoulder and Elbow and Elbow Pathology - HD

Shoulder Pathology

I have no disclosures.

I will be covering tendinosis, impingement and rotator cuff tears in the shoulder, also biceps tendon pathology.

And then I will finish up with pathology in the elbow.

For the shoulder, the approach is patients usually come with a painful shoulder, and these are the top pathology that you may find.

I will not be covering joint effusions and other effusions.

Fluid on ultrasound is very easy to see.

We will focus on these first three topics here.

Normal Tendon Anatomy

The normal tendon, as shown earlier, a normal tendon is hyperechoic.

You may see these fibrillar pattern.

In the shoulder, because the tendon has a curved course, you will have a convex external contour and you'll have an underlying smooth bony margin.

For Dr. Needleman, this is the anatomy and for everybody else, when I look at the shoulder, I do a layer inventory.

There should be about four layers.

There's the skin and subcutaneous tissues.

Patients don't like it when you call it fat, but there is sometimes subcutaneous fat.

This person has none.

Then you have the deltoid.

You have the rotator cuff.

In this case, this is the supraspinatus tendon, and then you have the humeral head.

There's two other layers that you may see.

One is the articular cartilage, which is typically anechoic, and a potential space here between the deltoid and the rotator cuff.

That is the subacromial subdeltoid bursa.

And you won't always see that unless it is distended with fluid or thickened.

Skin or subcutaneous fat, deltoid rotator cuff, humeral head, four layers.

Tendinosis

Tendinosis as shown tendinosis will look the same no matter which tendon you look at.

As you build on your knowledge, you should recognize it from tendon to tendon or joint to joint.

Tendinosis is a chronic injury.

It's a degenerative process.

It's usually a response to repetitive activity or a lot of overhead or overhead reaching.

Patients will present with pain, typically burning pain over their deltoid or pain at night when they're lying on that side.

Here is an example of tendinosis in the rotator cuff.

In this case, we're looking at the infraspinatus tendon.

The tendon is thickened, it is heterogeneous.

You may see a nodular or spotty hypoechoic areas over time.

Calcification may develop in the tendon and even interstitial or intrasubstance tears.

Impingement

With impingement, what happens is as the arm is abducted, the structures in between the acromion and the tuberosity are pinched.

In this case, we're looking at the rotator cuff tendon, the supraspinatus and the bursa.

And these can get pinched.

The pinching may be between the acromion or acromial spur.

The space is decreased or because the tendon is increased in thickness with tendinosis, or when you have a thickened bursa, sometimes the compression can be in association with a coracoacromial ligament, which is right here.

And it stands off across the image here.

How do we test for that?

Ultrasound is great because of its dynamic nature, and we can have the patient abduct and look to see if there's impingement.

Here's the humeral head.

We have the rotator cuff, the deltoid, we see the acromion and view, and we can have the patient abduct.

As soon as you can see, the rotator cuff will glide normally or easily underneath that acromion.

This is a much older case, but we have the humeral head here.

The rotator cuff is this thickened structure here, and we have the acromion over here.

We're gonna have this go as the patient abduct.

There's difficulty with that tendon passing, and this is a calcification that's sitting within the tendon and it's blocking it from gliding underneath that acromion.

I am gonna let it play again because you can see here's the bone and then the calcification will come into view in a moment.

It's over here now.

That calcification just can't get underneath that acromion.

I'm gonna show static images to make it easier to see.

Here's the normal situation.

We have the humeral head, the rotator cuff, and the acromion.

And when the patient abducts, you can see that it glides right underneath that acromion.

But in this case, this patient has trouble sleeping at night, they had a thickened tendon.

There is a hyperechoic structure within the tendon.

This is tendinosis.

We have the acromion, and as the patient abducts, you can see that the tendon can't quite make its way under there, and it's blocked by this structure or the thickening itself of the tendon.

See the tendon bunching up over here.

Calcific Tendinosis

What is that hyperechoic structure?

There is another form of tendinosis, also known as calcific tendinosis.

And what happens is you have deposition of calcium hydroxyapatite crystals.

And this can be painful either due to resorption of the crystals or even due to a rupture of that intratendinous deposit, which can cause a bursitis.

Here's a patient who had really bad anterior shoulder pain, and it's actually all over shoulder pain.

He called me up on a Sunday and begged me to come in and help him out.

This is what it looks like on a radiograph and on an ultrasound you see a hyperechoic structure that may or may not shadow.

In this case, it is not shadowing.

You can see it's sitting on the surface of this tendon, which happens to be the subscapularis tendon.

Subscapularis tendon, humeral head deltoid skin, and this extra thing in here, this is that hyperechoic calcium hydroxyapatite.

And this is very painful, and many times when it starts causing a bursitis, patients are unable to raise their arms.

You can really help 'em out with ultrasound.

Here's another example where the deposit is shadowing, but it is still calcific tendinosis or tendonitis.

And what you can do is you can advance a needle into the center of this and you can lavage it with lidocaine or saline.

And then as the fluid comes back into the syringe, you can see that there is this backwash of the calcium hydroxyapatite into the syringe.

And you can actually remove this.

The remainder of it, you can repeatedly fenestrate or puncture, and then you can give them an injection into their bursa to treat the bursitis that is associated with this disease.

Rotator Cuff Tears

Moving on to rotator cuff tears.

With this chronic impingement, with a tendinosis, you can now get more and more degeneration and that can progress to tears.

Sometimes the tear can also be due to traumatic injury or even both a traumatic injury in someone that already has degeneration.

Patients may present with clicking, and this most commonly occurs in patients over 40, especially those with chronic impingement.

Rotator cuff tears can be divided into full thickness tears, meaning the affect the entire thickness from external to internal of the tendon or may be partial thickness.

If you're doing your tendon inventory or your layer inventory, you can see that there's gonna be a layer missing where you have that tear, the tear may be complete and you may see hypoechoic or anechoic fluid within that gap.

Here's an example showing normal and abnormal.

Normal is on this side.

If you look for the four layers, you have skin, subcutaneous, fat, deltoid, rotator cuff, and humeral head.

This is a long axis view.

We have the rotator cuff here, humeral head, deltoid and skin.

Now over here, when you're looking for layers, there is a layer missing right here.

See that?

And right here.

This is a supraspinatus tendon, full thickness tear.

In fact, this is the entire tendon.

It's a complete rupture, and you see that there's a missing layer.

Sometimes that layer, especially in the acute setting, can be filled with blood or fluid.

And in that case, it makes it very easy to see that there is a gap in that tendon.

And one pitfall is to not confuse this with a partial thickness tear because this is that articular cartilage that I showed you earlier.

There are other pitfalls some of these were shown yesterday in the plenary, but I'm gonna go over some examples.

The cartilage, typically you see this anechoic cartilage, but you don't see this hypoechoic surface of the cartilage.

And that is because the tendon is abutting the cartilage.

But when there is fluid overlying the cartilage, you can now see that surface as a specular reflector.

Many times that's easy to appreciate because you do see the fluid as well as the cartilage, but sometimes when the fluid is hypoechoic, there's blood.

You don't know if you're looking at cuff or fluid.

If you see the surface of the cartilage very well, then that might imply to you that you are looking at fluid rather than cuff.

These are more subtle cases of a rotator cuff tear and it's much easier to call it because you can see that the cartilage is showing up quite nicely there.

The cartilage interface.

Another thing to not confuse, we're doing inventory of the layers where you might see that layer that you expect to be the rotator cuff, but in fact, what you're looking at is the bursa that is just now thickened and abutting the humeral head.

What are you looking for?

You might try to angle your transducer, see if you can find some tendon fibers, perhaps trace back to see if you see a retracted tendon.

Be aware of this pitfall that you may be looking at a thickened bursa rather than residual rotator cuff.

Another thing, the cuff tear can, or the defect can be filled with blood or fluid that can look solid.

And how do I know whether I'm looking at an area of tendinosis or perhaps a defect in the tendon?

For one, as I mentioned earlier, the tendon should be, the cuff should have a convex outer contour.

And you can see there's a little dip in it here that contour.

And you can accentuate that contour by compressing on the tendon and bringing that deltoid to herniate into that defect.

This is an example of a rotator cuff tear where it was obscured originally by hypoechoic fluid.

Many times where the tendon tear is the underlying bone will also be irregular.

These are obvious tears here.

We're missing the entire layer of rotator cuff here.

We're missing the rotator cuff at its insertion site.

And the cuff or the tendon is retracted.

Another example of the same.

You can see that the underlying cortex is very irregular in all three cases.

Many times, especially in a chronic complete rupture, the absence of the tendon will be missed because you don't see any fluid in the defect.

It's very useful, again, to keep counting those layers.

You have the skin, you have the deltoid, and you have the humeral head and possibly with this cartilage or bursa, but you don't see a rotator cuff.

And this is a complete rupture of the supra and infraspinatus tendons.

And the same rule will apply to patients with total shoulder replacements.

Many times I have trouble scanning them.

These replacements are very tricky.

But if I see deltoid touching humeral head, then I know that the rotator cuff has got to be missing.

We're missing a layer in all three.

A lot of referrers will ask me, did you look at the muscles?

Are they atrophied?

Because that can impact on their management because if the muscle is completely fatty replaced, those patients have a different outcome.

Sometimes if I'm not sure if there's a tear, I will start looking at the muscles first, because if you know the muscle looks abnormal, then there's something going on in the tendon.

In this case, we're looking at the infraspinatus muscle.

This is the scapula.

And this muscle right here is the infraspinatus muscle is typically hypoechoic on ultrasound.

And when you compare it to the affected side, you can see that this muscle is atrophied.

It's smaller, asymmetrically smaller, and it's also increased in echogenicity.

This is fatty atrophy of that infraspinatus muscle.

Not all increased echogenicity within the muscle may be fatty atrophy.

Here's an example.

We're looking at the supraspinatus muscle.

Here's the scapula again, here's the scapular spine.

It's long axis view.

We're looking at the supraspinatus muscle on the right and the supraspinatus muscle on the left, you can see that this one is asymmetrically increased in echogenicity, but it is not decreased in size.

A couple of things that can be edema within the muscle or reaction to a tendon tear, but that can also be a retracted tendon if there is a tendon rupture.

Just be aware that it's not always fatty atrophy.

Partial Thickness Tears

Partial thickness tears can be divided into or can be classified based on their location.

They may be either on the bursal side or on the articular side.

And when you describe them, you want to see where they are and the measurement of their size.

Here are bursal surface tears.

The bursal surface tears are abutting the bursa.

This is where the subacromial subdeltoid bursa lies.

And you can see that there's a defect in the tendon that doesn't go all the way through.

Here's another bursal surface tear with fluid in it.

And another one here.

If you are scanning and with a lot of pressure, you may obliterate that.

And sometimes as you're lifting up the transducer, you may see fluid enter that site and it will clue you in that there is a bursal surface tear.

Articular surface tears are on the articular side.

Here you can see a defect in the rotator cuff tendon here, supraspinatus and the underlying bone is irregular.

You have to be careful to not confuse this with anisotropy, which is an artifact.

When the tendon fibers are not parallel to or perpendicular to the transducer beam, they can appear hypoechoic.

If you're not sure, you can re-angle or rock your transducer and try to see if you can bring increased echogenicity into this area.

If this decreased or hypoechoic area persists, then you know you're looking at either tendinosis or a tear, in this case a tear here, the tear is more subtle, but you are seeing that cartilage interface sign.

You know that there is a undersurface or articular surface tear.

With chronic tendinosis, you may also get intrasubstance tears, which look like linear hypoechoic or anechoic defects within a tendon or cystic appearance to cystic spaces within a thickened rotator cuff.

Biceps Tendon Pathology

Moving on to the biceps.

With the biceps, as the name implies, there are two heads.

We have the long head, which comes down through a bicipital groove.

This is the long head and the long head muscle.

And then we have the short head which comes up and attaches to the coracoid.

What we're looking at with ultrasound is actually the long head.

Here we are looking at transverse view.

We have the lesser tuberosity, which is here, and then the greater tuberosity here and the biceps sitting within the bicipital groove.

Tendons are bright on ultrasound, so there are hyperechoic here.

And then in the long axis, when you turn on it, you can see the fibers and it's bright, it's linear, and you tend to lose that echogenicity as the tendon dives and is no longer perpendicular to the sound.

Biceps tendons can also be affected with tendinosis.

They can rupture and they can dislocate.

As shown earlier, tendinosis manifests as hypoechoic thickening of the tendon.

You may have nodular areas or diffusely hypoechoic and may appear heterogeneous.

And again, these can predispose to tendon tears or tendon ruptures.

One thing to mention is that you can also get tenosynovitis, which is inflammation of the surrounding biceps tendon sheath.

You may see fluid, it may be entirely anechoic, but may also be complicated.

You may see increased vascularity on power doppler.

The nice thing is you can also inject these under ultrasound guidance.

Here's a patient who has anterior shoulder pain.

You can see that this biceps tendon is very thickened.

It's extending beyond the margin of that bicipital groove.

It is hypoechoic and we can advance a needle and avoid the tendon and inject into the tendon sheath.

If there's fluid in the tendon sheath, it's much easier target.

And just in case you're worrying that I went through the tendon here, this hyperechoic material is actually the steroid as it was being injected.

If there's no fluid, then you can actually advance the needle and try to park it next to that biceps tendon and inject.

If the tendon is missing, it can either be ruptured or dislocated.

What you're looking for is an empty groove.

And many times the muscle will be retracted and balled up.

You'll get this Popeye appearance in the anterior forearm.

And this is rarely associated with weakness because the long head of the biceps tendon does not account much for the strength around that elbow.

Here's a patient who presented with acute pop, ran over to see me, we're looking at the biceps groove, bicipital groove, and there's a missing tendon here.

All we see is kind of this collapsed sheath with a little bit of fluid in it.

And as we scan distally, we find this thickened tendon because it is retracted.

And if I follow it in long axis, the muscle here is balled up and here's that tendon and it's kind of pulled back.

Patients will also confirm that that's where they're feeling their pain.

Another thing that can happen is instead of rupturing the tendon may dislocate or sublux.

And when that happens, it subluxes medially.

It's easier to look if you have the patient externally rotate the groove.

Beware may be filled with scar tissue, which may be hyperechoic.

You really wanna follow that down and see if you see those fibers.

And sometimes the tendon may be perched onto the tuberosity and can mimic the subscapularis tendon.

Here's another patient with anterior shoulder pain.

And I could not find the biceps tendon at first in the groove.

I scanned distally, I looked for it distally, I can see the tendon here, and you can see that it is surrounded by fluid in the tendon sheath.

He said, that's where I hurt.

But as I traced it upward, I see that the tendon is actually perched medially.

Here's that bicipital groove.

There's echogenic tissue in there, which is not tendon.

The tendon is actually displaced medially and into the substance of the subscapularis tendon.

Elbow Pathology

Moving on to the elbow, the elbow and like the shoulder, the pain or where the pain is localized will correlate directly with the structures that you are scanning.

You can actually do a targeted examination of the elbow if you want, and only examine the side that hurts.

We divide it into compartments, anterior, posterior, medial and lateral.

There are several structures in the anterior compartment, but it'll be focusing on the distal biceps tendons.

The distal biceps tendon comes down and inserts onto the radial tuberosity.

Here it is coming down here and inserting onto the radial tuberosity.

It sometimes does not appear hyperechoic because the tendon now has does not have that perpendicular orientation to the transducer.

As it's diving down, it can normally appear more hypoechoic.

You can either rock your transducer or dig or heel the transducer to bring it into a more transverse orientation.

Or what you can do is you can scan through the brachial artery and get a better visualization of that distal biceps tendon as it's attaching onto the radial tuberosity.

Here's a patient who presented with tearing sensation at the gym working out.

You can see as you follow that biceps tendon down, there's this kind of hypoechoic defect in the tendon or fluid.

And the tendon is no longer attaching into the radial tuberosity.

Many times you may, it may not completely retract as expected, but when it does, it's much easier to diagnose.

Here's a normal comparison.

Patient presented with sudden pop, or we're looking at a normal biceps tendon here and here in this patient you can see that the tendon is no longer have that tension on it.

It's retracted and as shown yesterday, you can get these refractive or shadowing areas when the tendon is retracted and that can clue you in that you're looking at a tear.

But in this case, you can see the free edge of the tendon.

There's a little bit of blood perhaps, or fluid, and then you don't see the tendon extending distally to attach on its attachment site.

When you see fluid around this tendon, many times when you see fluid around the tendon, you're calling it tenosynovitis, but the distal biceps tendon does not have a synovial sheath.

And in fact, when you see fluid around the distal biceps tendon, what we're looking at is a bursa.

This is a bursal effusion, bicipitoradial bursitis.

Medial Elbow

Medial and lateral elbow pain, very similar approach.

What we're looking at are tendons and ligaments.

We're gonna be talking about in this case these three structures, ulnar collateral ligament, the common flexor tendon, and the ulnar nerve.

We're focusing here on the medial elbow, the flexors come together and form a common flexor tendon.

And that's what it looks like here.

Tendons are bright on ultrasound.

You see this fibrillar structure.

Here's that muscle myotendinous junction.

This is the common flexor tendon.

Deep to that you have the ulnar collateral ligament, which comes down and bridges this joint, 'cause ligaments connect bone to bone.

This is the ulnar collateral ligament and the common flexor tendon can appear fan shaped as well.

Medial epicondylitis, that's a misnomer.

It's not an itis, it's not an inflammation, it is again, a degeneration.

We're looking at tendinosis, just like we saw on the shoulder.

It's a thickening, it's decreased in echogenicity.

And you may see increased vascularity, which is not inflammatory.

That's that angiofibroblastic response or the healing process.

And patients will say that they hurt when you scan them there.

It's very satisfying and it will correlate with your scan.

Here's another example we're scanning here.

Here's the normal and here's the abnormal.

You can see hypoechoic thickened nodular and increased vascularity.

This is common flexor tendinosis or also known as medial epicondylitis, also known as golfer's elbow, which doesn't always occur in golfers.

The ulnar collateral ligament, which is deep to that can also be injured.

And normally we think of this as that Tommy John ligament.

This is the affected in pitchers.

But can also, as you can see in this picture, javelin throwers can get ulnar collateral ligament injuries.

You can see that stress on that medial elbow.

This is that normal ulnar collateral ligament.

We're looking at this anterior band right here, connecting bone to bone.

And you can see in this example there's this partial defect in that ligament with fluid filling the defect.

This is an ulnar collateral ligament tear.

I have to mention the ulnar nerve because many patients who present with medial elbow pain will come with a diagnosis, rule out golfer's elbow.

And you look at the common flexor tendon and it looks quite normal and they're saying, you're not quite on the area that hurts.

It's actually a little bit back here.

If you feel your medial epicondyle and let your fingers fall into a groove, right behind that, you're falling into the groove that houses this ulnar nerve.

This is the ulnar nerve back here, ulnar.

The nerves on ultrasound are less hyperechoic when compared to tendons, but they also have this kind of band like or striped appearance.

This is a fascicular appearance.

This is the long axis view of the ulnar nerve.

Here is the short axis honeycomb appearance of a nerve.

In this case the ulnar nerve.

The ulnar nerve is here.

We're looking at the medial epicondyle here and the triceps muscle here.

Cubital tunnel syndrome is like when you think of carpal tunnel and median nerve, you can have cubital tunnel which houses the ulnar nerve.

And these patients will present with medial elbow pain.

It's like their funny bone, which is not a bone and it's not funny, but this is what you're getting.

You're getting entrapment or irritation of that ulnar nerve.

And it can be entrapped at the level of the elbow at two sites, either at the entrance to the cubital tunnel, which is right at the medial epicondyle or as it pierces the muscles distally, which is the flexor pronator muscles.

There's a size criteria, but what I like to look for is a difference in size between the affected portion of the nerve and the normal by about two.

This is an enlarged ulnar nerve.

We're scanning here adjacent to the medial epicondyle.

You can compare it with the other side if you want to, but this is definitely very enlarged.

And you can see here that when you turn on this, you can see that the nerve is definitely thickened proximal to this normal distal segment.

When you look at nerves, think about a garden hose.

When you pinch a garden hose, above the pinch fluid is collecting.

Water is collecting and that's the same thing with a nerve.

When a nerve is pinched proximal to that, that nerve will appear thickened kind of called axonal damming, but that's another way to find that area of entrapment within the nerve.

The nerve can also sublux.

Here's static images showing that the nerve can sublux.

What happens is these patients present with a snapping elbow sometimes with pain and a snapping occurs with flexion and extension.

This is a extension image.

We're looking at the medial epicondyle and the ulnar nerve.

The nerve will snap as you flex.

Now you can see that the ulnar nerve is sitting here on the medial epicondyle.

It may even snap anterior.

Dynamic is great because you can actually watch what happens with the ulnar nerve as you have the patient recreate that snapping.

Here's the ulnar nerve and snap.

Can you see that?

It's snapping.

Sometimes snapping elbow may be related to a snapping triceps.

The triceps over here, I want you to watch the video again because there is a second snapping structure when the patient snaps and then second, see that, do it again.

This patient has a snapping ulnar nerve and snapping medial head of triceps.

Patients with ulnar nerve irritation, we can also perform injection, we can inject with steroid to help them with the inflammation in that nerve.

But another part of that injection is getting fluid to dissect around on the outside of the nerve called hydrodissection because you can sometimes free that up from the overlying structures that are causing the entrapment.

Here's a needle advancing and injecting around this ulnar nerve.

Lateral Elbow

Lateral elbow where there are several structures, I'll be focusing on the common extensor tendon.

Which is right here.

And then the deeper structure, which is the radial collateral ligament.

Lateral epicondylitis, same as medial epicondylitis is not an inflammatory condition, it is a degenerative condition.

It's tendinosis.

Here's normal, here's abnormal, it's thickened.

It's heterogeneous, there are hypoechoic areas, and you can sometimes get intrasubstance tearing.

You can have increased power doppler flow.

Here's another example with cystic spaces in the tendon or hypoechoic nodules in the tendon and increased vascularity.

Sometimes it's very hard to tell, it does not, it's not as nodular or as obvious.

I scanned this patient.

Originally I thought that they did not have anything going on it, kind of normal to me, but he said, it really, really hurts there.

And when I turned on the doppler, you can see that there's a lot of vascularity in that area.

I also gave this patient a diagnosis of tendinosis.

Sometimes it's not tendinosis, but it's actually also rupture or something involving that underlying ligament.

This is a patient who presented with lateral elbow pain.

You can see that the overlying common extensor tendon is normal.

It's hyperechoic, it's intact, it's extending across and attaching onto the lateral epicondyle.

But deep to it you have this free edge of a retracted ligament and fluid in that defect.

This is a radial collateral ligament tear.

I have to mention the posterior interosseous nerve because that can mimic lateral epicondylitis because the nerve is also lateral.

The radial nerve will come down and divide into a sensory and a motor branch.

The motor branch is the posterior interosseous nerve.

This is what it looks like in transverse and long.

The nerve comes down and pierces into the supinator muscle.

And this is a normal posterior interosseous nerve in this patient who has lateral elbow pain, but normal, not normal for lateral epicondylitis.

You can see that their posterior interosseous nerve is thickened and it is thickened proximal to the area where it is compressed.

Just like I showed you where that pinch is, that hose.

In comparison with this nice gradual and normal appearance here, hypoechoic and thickened transverse, it's thickened here compared to this little tiny nerve right here.

Posterior Elbow

Last talking about the posterior elbow, we're looking at the triceps tendon.

The triceps tendon is right here.

We have three parts.

We have the medial and lateral, and then a deeper part that we don't see on this image.

We're looking at this tendon over here.

If you see one tendon, you've seen it all, they all have the same appearance.

And if you've seen tendinosis in one tendon, you can recognize it in another.

What are we looking for?

We're looking for decreased echogenicity within the tendon, possibly with calcific deposits and even an associated osteophytes.

This is a patient with an enthesopathy or tendinosis at the insertion of the triceps.

And we're scanning right here.

Last the bursa, the olecranon bursa can fill with fluid.

I show this because you can see that there's, you really don't see much here.

You see the olecranon, which is the bone right here, and then the bursa, which is kind of a potential space at the moment.

All you see is skin and bone.

Literally, if this fills with fluid and there's very little fluid, if you press on this, you may actually obliterate that fluid and miss the diagnosis if they're feeling pain right there.

What you would hope though is it would be something obvious like this.

Here's the normal, here's where we're scanning, here's that olecranon.

You can see this is a patient with gout.

It is distended with fluid, but this is the olecranon bursa and this is a patient with olecranon bursitis.

The triceps tendon is up here.

Closing Remarks

I know I flew through that.

30 minutes to do two joints is really quite a challenge.

My final comments are that in the shoulder the symptoms are really pretty vague.

Patients will say it hurts here, they'll point in front.

In fact, you'll scan it, you'll scan your routine, you'll look at all the tendon and say, no, no, no, it's back here.

And you can't really poo poo them because I kind of just look back there and say, no, it's really your rotator cuff.

The symptoms can be pretty vague.

We do a complete examination of the shoulder when patients present with shoulder pain, whereas in the elbow, if they have medial elbow pain, you know that you can focus on the common flexor tendon, the ulnar collateral ligament, and the ulnar nerve.

And many times you'll find the diagnosis in one of those three structures.

You can very much focus in the elbow into compartments when patients present with pain.

Dynamic scan is very useful.

You can look for impingement.

You can look for a dislocating biceps tendon, which I didn't go over, or you can look for a snapping ulnar nerve or triceps.

And what's nice about ultrasound is that you can actually provide guidance for needle placement if you want to perform a diagnostic injection or even a therapeutic injection.

And that's it for today.

I thank you for your attention and I welcome any questions.