Ultrasound of the Shoulder, Dr. Christopher Baker

The way that I got into ultrasound is I was sitting at our grand rounds and I was sitting next to a radiologist because we invited multidisciplinary grand rounds and he was telling me how he was just looking at his meniscus tear on an ultrasound and I was like This guy’s crazy, meniscus. You can’t take your meniscus with an ultrasound. And then he was telling me about yeah. He started doing it on his shoulder and then he got into that and I’m like You can’t look at a shoulder with an ultrasound for babies. You know I didn’t I didn’t really understand. And so I started looking into it and it just seems archaic. You know as you’re coming up and everything’s MRI and as I started to read the literature, I realized how good MRI ultrasounds are and how easy they were to perform. And so when I got to town it was a big part of my practice and I did a little bit of research in it and my training and it just kind of become a pet project of mine.
As far as discussions with this I don’t have any disclosures regarding this talk but I am looking for them. I’ve been talking with Sonosite for a long time about trying to pay me to do this but they don’t want to I don’t think I’m good enough. But if you do go into Sonosite first of all Sonosite donates all of this time to us and all this equipment for us we aren’t paying for it in any way they aren’t asking for anything from us but they are a great sponsor to education. OK. I’ve probably been a part of getting maybe 15 of these throughout my career whether it is in my fellowship training to get in for education. Again, I’m not a paid consultant with them but if I were buying us an ultrasound today it would be Sonosite because of the service. You get young ladies like Karen over here. Is Andrea here Andrea. Like these people are awesome. They will come to your office. They will walk you through it no matter how many times I said can you tell me how to do this again. And I forgot how to do it they’ll come and I’ll do it if there’s a problem with your machine your probe whatever it is they have a really good service program. They’ll overnight stuff to you and take care of you and it’s a really good device as well so that’s my plug on that.
All right ultrasound we’ll go over the basic terms and techniques of the ultrasound. We’ll talk about the benefits and limitations. We’ll go over thirteen-point shoulder exam that I learned from Don Buford who’s in Texas and then we’ll get you guys some time to do some hands-on practice as well. So the basics OK. You need you need two pieces in order to do an ultrasound.
You need a device you need your ultrasound base and you need a probe. OK. That’s the two most basic items you need if you’re going to invest in this whether it be a twenty-thousand-dollar device or a fifteen thousand dollar or refurbished one or eighty thousand-dollar mack daddy one. You want to protect that device. So I do recommend a cart. OK. So if you’re going to do something like this if you’re going to invest in IT spend the extra money on getting a cart to transport it from room to room OK. You’ll need some gel obviously. And then in order to get paid for this you have to have some way to save an image one single image in case you get audited that you can say look I did this here’s what it was and you need to create a note that says that I recorded my findings.
This is what it was. You can either do a printer and stick it in your chart. If you have DICOM you can push it to your EMR. All of those things are options. Now you can get really crazy and wild and do all kinds of stuff with it. Those are the basics that you need and that I’d recommend when you look at the knobs it can get very confusing and one of the good things about Sonosite is they’ve dumbed it down for orthopedic surgeons. So if we could figure it out you guys can figure it out. If you start getting into like the cardiology ones with all the buttons and wheels and whistles it can get crazy. There’s basically three knobs that I use. One is select. So if I’m trying to pick something I use that same with freeze. OK. The save button as well. The saves are over here.
So you’ve got to be able to select it, save it, and freeze it. Those are the three main. And then you want gain some form of gain auto gain is usually what I hit. Gain is just kind of dialing in the brightness and where you want it to hit. Now you can get very detailed in all these your girls. Sorry. I messed up your staff. I apologize. Your staff can program all the information that you need as far as you know their demographics and all that kind of stuff. You don’t ever have to touch that stuff. So how does it work. So you’re your base creates an electrical single deck the electrical signal goes to your probe which creates a sound wave. That sound wave then travels through your tissue and then bounces off that tissue and back to the probe the probe then takes that image of that that wavelength and then brings it back to the computer and it basically interprets based on how much signals coming back.
What you’re dealing with. OK. When the tissues bounce off of softer tissues, you’re going to get less bounce back when you have a harder tissue, you’re going to get more bounce back so that’s going to be brighter. So the more dense that material is and the more perpendicular your probe is the more refraction you’re going to get back. So it’s very important that you understand the orientation of your probe. So if your probe is up and down against a flat surface you’re going to get almost 100 percent reverberation. You’re gonna get a really good sound wave. If you turn your hand to the side a little bit it’s going to bounce off and some of those waves are going to go the other direction and they’re not come back toward your probe. Similarly, if you’re doing a curve tissue and you’re on that thing even if you’re going straight on when you move over you have to go around the curve tissue.
OK. So it’s important to kind of have them in your mind’s eye what tissue you’re examining of how to do that. OK. Terms that you need to know the frequency is important the frequency is basically the size and wavelength of your measured megahertz of what is being emitted from your probe. OK. The higher the frequency the higher the image quality but the less dense penetration OK the lower the frequency the lower the quality image but the deeper the penetration. OK. So if you’re looking at you know the vole or forearm and you’re looking at tendons in the vole or forearm you want a very high frequency probe to get very high good definition in those superficial tissues. If you’re looking at the hip or the belly you want some that’s kind of a lower frequency wave that’s going to bounce deeper into the hip and give you a better example or better bounce back because those higher frequency waves won’t penetrate as deeply.
OK. The next thing you need to know is echogenicity and this is just kind of a descriptive term when you’re discussing with another person about an ultrasound. So hyperechoic is basically very brightly dense tissue that’s going to be calcium bone hardware. Those types of things. hypoechoic are going to have less exogenous meaning they’re less bright or dark like air or gas. OK. So if you were to look at this shoulder there’s a humorous down here somewhere. This is looking at the super seven eighths tendon in this patient has calcified tendonitis. So as you’re looking down through that shoulder you see the hyperechoic deltoid fascia you see the deltoid muscle which is hypoechoic to the hyperechoic fascia. Then you’re going to see ahyperechoic or more dense calcium phosphate and then your eye can see anything underneath that because the calcium deflects all those waves back. So you get a shadow beneath your calcium. OK so if you’re trying to look at a rotator cuff underneath the calcified lesion you’re never going to get there because the calcium bounces it all back. Same with bone you’re going to get the same kind of thing. If that calcium wasn’t there that bounce that signal would basically end that your bone. OK. That’ll make sense. I haven’t messed up ending my terms have I.
All right. So when you look at more sorry last slide of terms longitudinal means you’re basically examining the length of the of the anatomy being examined and then transverse through the short axis of the long axis which is the length of it transverse is a short axis. And those are the two descriptions that you need to describe your material your tissue and then anisotropy. This is the biggest risk I guess you could say to using an ultrasound. So ultrasounds are really good but they’re completely dependent on the person doing them which is why I don’t I don’t farm it out to my texts or my P.A. I want to have it in my hands because I’m making medical decisions based on that anisotropy is basically where you’re imaging a normal tissue but you’re thinking it’s abnormal. OK. And that generally occurs because your probe is at an angle and you’re bouncing off at the wrong angle and you’re looking at tissue that’s normal but it’s bouncing back to you looking abnormal because it’s not hyper a co-worker doesn’t have normal orientation because you’re not imaging it properly.
So whenever you image something and you think you have an injury go back and forth over it in each direction and make sure that it’s truly an injury and multiple planes. So if you can only see that injury in one plane and you turn it the other direction it’s not likely injured because if it’s torn or there’s fluid there it should be there in all forms it’s a three dimensional structure. Right. So anisotropy. This is a good example of that it doesn’t portray predict really well on the screen but this is a greater tuberosity. This is your human head and you have your supraspinatus tendon running on top. OK. Now what we should see is nice linear college and tissue and, on my screen, up top you can actually see there’s a black area here that looks like to me like could be a void of super spectators tendon but it’s not.
It’s the angle that this probe is coming in. So when I change my angle I can see these deeper tissues than it’s normal. So that’s an eye Satrapi. You don’t want to call something abnormal when it is in fact normal. When you hold the probe. You want to make sure like anything we do when we’re doing procedures you want to hold the probe that you can manipulate it correctly. OK. And most importantly you want to be based on something you want to have your hand stable there’s nothing that we do in the operating room there’s nothing that we do with a needle. There’s nothing that we do with an ultrasound where we’re not braced on something even when we operate sometimes you have multiple hands in the field all balance on my assistants hand sometimes to ground myself to be more stable. That’s. You should do that for injections for procedures and for ultrasounds. You don’t want to have it like I call this the Monkey Grip everyone so I’ll get a fellow resident that holds it like a monkey and you can’t control things you can’t have good accuracy if you’re holding it like a monkey. Use your thumbs but base the owner surface of your hand on whatever you’re doing and then go from there.
Benefits of the ultrasound immediate results for you and the patient. And this cannot be overstated. When I started my practice I had patients that I was the only guy in my small group that did this type of stuff. And right across the street from me was a giant multi-specialty group with lots of hungry orthopedic surgeons. And so if I was brand new to town and I sent that patient out for an MRI and expected them to come back from the two weeks it took them to get their MRI and come back they would talk to their friend who said oh I saw this doctor and they’d end up going to see that doctor on a second opinion. And I’d never see him again. That’s one problem. The second problem is that turnaround time. That patient is waiting now two weeks to go to the MRI get it.
Waiting on the report. The anxiety is building when you take this this ultrasound and you put that on their shoulder their knee their ankle whatever you’re examining and they walk out with a diagnosis they’re happy you’re happy. It’s a billable procedure so it can make you money in your office if you become proficient at it and it doesn’t slow you down. And it’s very important in that way when you look at patient satisfaction every study that’s ever been done when patients get ultrasounds, they’re happier you’re spending time with them you’re touching them. Those are the two things that patients want. Touch them on the shoulder while you’re examining it. Spend a little more time with them and discuss it. They’re happier when they leave your office. You can use it on the entire body. There’s not a lot of things that you can say that you can do that and you can do that at time zero. The ultrasound has really no contraindications.
So how many patients do we have every day that come in that have had a prior rotator cuff repair they have metal anchors or they’ve had a total shoulder or a replacement or reverse replacement. And when you go to put your ultrasound on there you can actually look at it whereas if you get an MRI you get all this scatter and it has all this artifact you really can’t get much out of it. Cost is obviously an issue. Ultrasound is ordered. Orders of magnitude cheaper than MRI or C.T. scan especially with a contrasted C.T. scan. So ultrasound significantly cheaper. All my patients it seems are claustrophobic. Seems like all of them have a pacemaker or a spinal stimulator. I just had I didn’t know they had this I had a lady yesterday who had a bladder stimulator. Did you know that was the thing so patients that are unable to have them are eyes ok if you can’t have an MRI you can have an ultrasound there’s no contraindications to ultrasound you can you image guide injections.
So if you’re that person that’s not real confident about doing your injections when you’re watching the needle go into the position that you want it to be and giving me a lot more comfortable knowing that that’s where you want it to be for the right reasons and not in the wrong tissues dynamic exams. This helps me because sometimes I’ll go back and look at my ultrasounds prior to surgery and sometimes I’m like What was that tear what it was like. I’m not really in the same spot when you’re doing it live. It means a lot more to you. So as you’re looking at it live and you’re moving in the patients moving you get a lot more out of that dynamic exam. There’s no radiation whatsoever so there’s again no contraindications for how many guys cover sports. You can use it for sideline sports.
You can diagnose fractures you can look at acute swelling or acute tendon ruptures with it. And again, it’s a billable procedure so once you become proficient in it it will make money for you. Limitations intraarticular anatomy you cannot see the superior labrum you cannot see the anterior labrum you cannot see much cartilage you cannot see the biceps anchor. The only really area within the joint that you can see is the posterior labrum which we’ll look at when we do our exam. The other negative to this is if you’re doing multiple spots, so if you’re doing hand and elbow and you’re doing shoulder and you’re doing hip you need multiple probes for that. Now the AFL 50 is pretty versatile You can get most of those exams with one probe but if you’re really going to be doing this a lot it can get costly with the probes those are the most expensive part it’ll definitely slow down your clinic times in the beginning so once you get proficient in this it really doesn’t.
But and again in the beginning it definitely will and it’s completely dependent on Examiner experience so the more you do the better you’re going to be when I got my first ultrasound I took it home and anybody that walked in my door they got examined I’m like Let me look at your shoulder and I went over everybody and basically every patient that came into my office I examined all their shoulders I didn’t charge them for that but it gave me that base of what I needed to learn and paper people who had pathology who had an MRI that was like the prime time to do it. So I would examine them then I’d look at their MRI and then examine them again. And then those pictures started to make sense in my mind. My hands started to get comfortable what I was looking at. And then I started to make decisions to the point that I don’t do MRI.
Ninety nine percent of the time I do an ultrasound on the shoulder I diagnose the problem and we move on it and I’m comfortable booking them for surgery and all that kind of stuff with that ultrasound. So to the exam any questions on the basics of that. Hopefully it wasn’t too boring. Looking at the basic kind of thirteen-point exam you have to have some algorithm for how you’re going to go through this. Otherwise it’s gonna become kind of a mess of exam. So the first place and the place to always come back to kind of the lighthouse of the shoulder is the bicipital groove. OK that’s one place that today hopefully all of you guys will be able to identify and say yep there’s my biceps I know where I’m at so obviously that would be point number one. So what we do is we have the patient seated here. You’re standing next to the patient. You have the probe trans virtually oriented across the front of the shoulder.
So we look on this cartoon model we’re looking across the a little groove in the short axis or the or the transverse plane. And we’re looking at the Greater tuberosity, the groove, and the luster tuberosity. With the biceps right between them. OK. When you look here here’s our sub scapula is our greater curiosity excuse me our lesser two prosody and then our greater tuberosity. and then between them is the bicep it’ll groove with that little tiny biceps just sitting in there OK.
Now if you look at that it’s basically a zoomed in image of an MRI. But look how much sharper and how much more detail I see here versus that MRI. I basically have to take that MRI and zoom in to try to find all the detail that I can find by looking at that on an MRI. So that’s our first point each point’s going to have a 90 degree opposite. OK. So the second point is also our biceps what we’re just going to rotate that probe 90 degrees. So we were transverse to the biceps. Now we’re going to rotate rotated 90 degrees and we’re to look at the long axis of the biceps.
Again, looking at that that’s now looking down this direction up and down the bicycle groove and you’ll basically see the depth of the groove and then you’ll see parallel college and fibers running through with a with a factual layer over top.
And you can see there’s the fashion layer or the are the biceps all over him and then the bicep tendon runs within that layer. OK very straightforward no one transverse number two long axis. Number three is just like number one we’re just going to slide medial so when you’re actually doing these I would just do one in three at the same time and then luckily five ends up being at the same time to just stick it in the same position that I run right across and I’ll show you live how quickly we can do this basic all you’re doing is taking that same position from point 1 if you want you can rotate the arm out a little bit and what we’re trying to do is look at the long axis of the supscap. So we’re taking our view right here. The biceps tendon runs in this little blue groove right here and we’re looking at the long axis of the supscap.
OK what you see here is the lesser tuberosity the deltoid fascia all the tissue in between is the sub’s gap so that is the area that we’re really trying to look at on the sub scapula is again it’s a zoomed in version of this view but look at all the detail I can get in that OK when you look at an experienced ultrasound Examiner versus an MRI there at least as good and usually the ultrasound is actually better. OK. Point 4 again I said it always goes 90 degrees. So we were short X or long axis supscap transverse. Now we’re going to turn it vertically and we’re look at the short axis of the sub’s gap and we’re basically cutting it this direction and we’re gonna be zooming in like we’re looking at this piece right here but now it’s been turned around into a 90-degree version of that.
So now we’re looking at the human head the fashion of the deltoid the biceps groove is over here and then we’re looking at all these college and fibers. So rather than longitudinal college and fibers we’re seeing the axis of those college and fibers. Point five is as the first kind of start point five is an extension of one in three. Basically, we’re starting at the biceps here we then moved over to the supscap now we’re looking at the anterior joint line and in the coracoid process. So what we see here is the humerus head. We see the sub scapula. And then the core quite process so point one point three and point five or basically all the same thing just moving more medial and looking at that anatomy. So if you know that anatomy and it makes sense then it’s easy to see this is another good spot where you can look at Dynamic exams you can watch the tendon move underneath the coracoid it’s an interesting look when you’ve never done it before.
Point Six is probably where our real money comes in this is this is the first time are actually usually finding pathology and this is the first time, you’re really moving the patient. So in this patient in this example you put the hand on the patient’s hip they’re gonna put their elbow back as best they can and then you’re gonna parallel from their shoulder to their opposite hip OK and that’s gonna be sorry. Other way around. So you’re going to go opposite shoulder to hips you’re going be looking in this direction. OK. So you’re going to be paralleling in this direction because we’re uncovering the supraspinatus from underneath the chromium. So we’re putting it at a goofy angle by putting the hand here to get it out from underneath the chromium and you’re going to parallel control lateral shoulder Tip’s lateral hip.
And what we’re looking at here is greater to porosity human head deltoid fascia and a nice linear college into of the supraspinatus tendon. And again, it’s a zoomed in version of this MRI and this is a one point five tests like good MRI and look at the detail that you’re going to see on the ultrasound versus that MRI. OK. It’s a very good exam. Exam finding and again on the cartoon version we’re looking right here. Point seven is the one time where we’re not going automatically to 90 degrees or just sliding backwards. This is really one point it’s a dynamic process so I’m just sliding from the front of this supraspinatus to the back and I’ll show you this dynamically so I haven’t moved my probe I’m just going from back to front here scanning to look at the entire length of the supraspinatus. OK points eight and nine are also the same but we’re rotating 90 degrees now so we’re looking at the short axis or rotating from the lateral shoulder to the control lateral hip and now we’re again it looks like that sub’s Gap View where we’re taking the short axis of the supraspinatus tendon.
So we’re now coming this direction across the super seven eight is ten point nine is the same thing just moving more posterior. Point ten is the first time we’re going to the back of the shoulder so now we’re gonna do the short axis of the back of the shoulder so basically this is almost like our biceps view but we’re doing it from the back now and we see the greater tuberosity humeral head deltoid fascia and in between is the infraspinatus. You’ll notice it’s a lot smaller the supscap has the largest tendon the supraspinatus has the next and then in front and it’s smaller and smaller under tendons and as you go distal on this you’re gonna lose all ten altogether because you’re gonna get down to the muscular belly. Point eleven again we switch ninety degrees which is looking at the orientation of that infraspinatus now and the short axis and we’re seeing now the muscular tendon ah sorry the tenderness portion and as we get more inferior you see the muscular portion of the enforcement at this.
Point twelve is the only point where we see the joint so far really and what you’re looking at on this cartoon view we’re looking in the back of the shoulder we’re looking at the glenoid labrum the capsule here and then the human will head OK. So we’re looking at the infraspinatus here humeral head labrum glenoid and that’s that same view as here and when we outline it humeral head, labrum, glenoid, and then all of infraspinatus. And then 13 is pretty easy it’s a C joint you’re just looking at it across the joint you can see here the edge of the chromium the edge of the clavicle you can see that fascia the S.A. ligaments and then this patient has a little bit of an infusion in there so you can see fluid within this AC joint which is pretty common.
So clinical images this is just point six and seven. So basically looking at the greater tuberosity humeral head. we have our deltoid Fascia. We have relatively good-looking tendon it’s not very organized but it is intact right behind that when we go back from point six point seven where to sliding our pro backwards you can easily see the greater tuberosity humeral head. This is our retracted tendon tear deltoid tuberosity and then a big area full of fluid. This is our tear. OK so that’s the space in an MRI you’re usually looking at the torn tendon in an ultrasound you’re looking at the space and the fluid that’s void of the tendon OK. So fluid really helps you out when you look at points eight and nine which are the 90 degree views of this the short axis views you’re going to see normal tendon with a big hole here and again it doesn’t it doesn’t project real well on this but you’ll see I’m very well on the on the ultrasounds.
If you guys are into this and you want to learn more about it this is a very good book it’s very straightforward and basic the fundamentals of musculoskeletal ultrasound by John Jacobsen. I own this I scan through it if I’m gonna do some new body part I do that Don Buford who is not a personal friend of mine but I’ve met him and learned this through him has is very good he does courses in Vegas there are courses in Orlando there’s courses in St. Pete, Clearwater you can really get a lot I’m doing a full course on this and then Sonosite has a great Web sites on a site dot.com you can go in there basically search whatever you want they’ll do a video of how to do it and then you can get some experience doing it that way as well. Any questions on ultrasound.
So right now there is not any accreditation requirement. OK. There is a push to try to get it right. Orthopedic surgeons and specialists and musculoskeletal care are probably gonna be exempt from that but there is currently no requirement of that. But I don’t think that it’s going to be an onerous certification process. If and when it does occur you just need to show some competency and you know that the issue is that when something makes money people overdo it. Right. So when I moved to Florida I guess there was probably maybe 2010 where it was just rampant every injection was being done under ultrasound guidance and I think back then you got like two hundred dollars for the ultrasound another like 50 or 70 for the injection.
So it’s like tripled the cost of an injection. Now what they’ve done is they combined the ultrasound and the injection into one code. So a normal code is 2 0 6 1 0 for an injection 2 0 6 1 1 is now injection with ultrasound and it’s not that much more it’s like what 40 dollars more so. So it almost doubles your injection CPD payment but it’s not so lucrative that they’re coming after it anymore. Any other questions or.
Is it HDMI. So just to show you that it’s really not that tough. I know I used a lot of words there. Yeah. Thanks Rob. Now. In the foot pedal if you do a lot of these the foot pedal is absolutely helpful.
Yes. So normally we’re doing this standing it’s a little bit awkward. So normally the patient is just like on my exam they’re sitting on the edge of the table and I’m standing doing it. You want to be at that about the same height as the patient. You want to be reaching and doing all this stuff you want to be comfortable with. We’ll talk about the next. Talk about injections. Comfort is the key to this. So basically my right arm is going to be the probe Holder during a right hand exam. And if I was on the left side my left arm would do it. Lot of people aren’t as comfortable doing that you can do it the other way but it’s just easier because usually you have your machine here if you’re messing with it. Plus, you can manipulate the patient’s arm with that arm. It’s more difficult if you’re kind of reaching this way. So I always find that whatever examined whatever arm you’re examining use that arm to examine with if you can because then this thing can you know your remaining arm can move it.
All right. So the first thing we’re gonna do. And again, it does not project as well here when you guys do this it’s a lot better in your machine. So the first thing I did was look at point one and point one is the biceps. OK so Karen’s is gonna show us the biceps right there. That’s the bicycle groove to the right is the lesser two prosody. And the sub scapula is. OK to the left is our greater to porosity. OK. So is everybody oriented to that. OK point 1. Super hard right. So this is your lighthouse when you get lost which you will. That’s OK. Go straight to this and start over. All right. What tends to happen is you start moving around and you start getting lost at where your hands are. And before you know it you’re off the map. OK. So just always go back to this position.
Now the interesting thing is a shoulder surgeon for me, it’s super variable where that biceps is some patients. I’m out here and my hand is in the same spot to find the biceps other patients their arm is way across their belly to find the biceps.
It is not in one spot. So I have a lot of people that tell me that they can do biceps injections without ultrasound. This is actually the one time I almost always use it because the position is so variable and patients’ pain does not indicate where their biceps is. Sometimes in a thin person like Andre here you can feel it but not everybody and actually find that most people so point one short ahead of the biceps point two. We’re gonna go long axis of the biceps so you can see the long college and fibers there. That’s the biceps tendon. If I go medial to that you’re gonna see the bone is gonna go up. That’s lesser two porosity. I’m going to drop down into the groove. That’s the biceps and I’m a go lateral now I’m in the greater tuberosity so I see all the backbone goes up down and then up again. That’s how you know we’re in the groove. And then if you see just fluid there it’s gonna be a biceps tendon tear or rupture or something to that degree. So that’s points one into. Point three is again to the biceps we’re just going to rotate out. And we’re gonna find this subscapularis and you can see nice linear college and fibers there. And you can see the deltoid fascia. Which is the White line above it. And then the great the letter to prosody below it.
So if you see this nice area and it’s filled with tissue you’ve got a good looking supscap no tear. OK that’s point three point forward is rotating ninety degrees I just rotated my hand up 90 degrees so up is to my left and down as to the right and I’m just looking at that same sub’s captain and it’s the same as this I’m just rotating my a 90 degrees and so we’re not gonna see linear college anymore we’re gonna see dots of college and mostly and that’s just the subscapularis is not very helpful but just for memory of what we’re doing. Point five again against so we’re gonna go back to point one. Point two point three is the supscap and then point five is going to involve the core quite as well so now we can watch the supscap move underneath the core quite. Some patients are diagnosed with core quit impingement This is a good way to see it and diagnose it and you can inject it if you want to. So that’s one good way to look at that point five.
Point Six is the first time Andrew is going to change her position she’s gonna put her hand on her hip and she’s going to touch her elbow back best she can. Patients with a tear this can be difficult to do. If you guys can’t see feel free to walk up here and what we’re going to do is we’re gonna look at that again we’re going to parall