that we are going to get started here
I'm sure my peeps let me know if there's
a problem with regard to video or audio
streaming so first thanks so much for
being here we're going to focus today on
how to read an ankle MRI for
regenerative medicine this is really
just one part of a multi-part series as
you know I've been going through these
katarina lumbar MRI and shoulder me etc
and the real goal is trying to get
physicians to focus on how to do some of
these things themselves they can change
the lives of their patients using
precise regenerative medicine which is
what interventional orthopedics is all
about so we're going to start with an
unabashed on profit commercial this is a
presentation through interventional with
Phoenix foundation what is that it's a
501c3 focused on interventional
orthopedics and we're really looking to
create a new medical specialty that
bridges the gap between conservative
orthopedic care and days of surgery
really analogous to what happened in
interventional cardiology right in the
mid-1980s when I was in medical school
what we saw was pretty much every 57
year old guy who got a pretty early
bypass surgery eventually all of that
was replaced with the vast majority of
it via percutaneous procedures in
interventional cardiology so we really
see the same thing happening in repeat-x
and we need your help to build and shape
this medical specialty we need your help
as instructors for iof if you're so
inclined and you've got that skill level
we need your help with serving on
committees at ilf and determining what
it is we're going to teach houses we're
going to teach it etc so seeing
intervention
org for for more information and if you
join I laugh there are discounts on
courses obviously live webcasts like
this one
complimentary listing in the directory
of members opportunities serve on
committees and very important
participation in the patient registry
database that's really the largest
registry of its type right now there's
nothing even out there that's a close
second
we're tracking for instance ten thousand
stem cell treated patients going back to
2005 so for 12 years and the core skills
program is set up with level 1 2 & 3 so
in level 1 today we're going to be
focusing on ankle frit and then in April
this is coming up in just a couple weeks
here we'll have a level 1 ankle foot
hand wrist course and then there's a
level 2 course ankle foot which will be
in May and then obviously there's a
level 3 course that will be at a later
date so the level 2 course is basically
what you see here all of these different
areas will be covered as you can see
there's quite a bit to go over so this
is a very chock-full two-day course to
get all this stuff in and a lot of
common things that you would see in your
practice right you see a lot of plantar
fascia problems to see a lot of ankle
osteoarthritis these patients even if
you don't attract them will walk through
the door when they come in for their
knees and hips and shoulders
same thing with CMC arthritis which is a
big deal in a lot of patients it's
actually one of the most common types of
osteoarthritis out there and then
obviously a level 2 course focusing on
tendons on nerve blocks focusing on
ligaments as well so really kind of a
one-two punch of getting all the foot
and ankle stuff done including a bunch
of hand wrist stuff as well so
connor in the spring is very beautiful
so really consider coming out so why
give this lecture I see a lot of
practicing physicians who really rely on
the MRI report and they're missing many
findings that could help guide their
therapy and right now we're Greta bleah
we tend to have radiologists reading for
surgery and for conservative care but
not a lot for interventional orthopedics
there's not a lot of reading going on in
the middle there and that's a problem
because as I'll show you even the way we
describe some of these injuries don't
fit what we know about how we're gentle
innocent works so you need to be reading
all of your own films what does that
look like I use a radiologist obviously
for confirmation or rule out bad things
I do generally review the radiology
report but when it comes to everything
I'm focused on for region Med I reload
my own films I don't rely on what the
radiologist says not because I don't
trust the radiologist just because we're
looking for different things so my focus
with this let me go backwards here for a
second so I focus with this talk if not
to train you to be a radiologist I'm
going to skip over some of the pathology
and ankle for instance that a
radiologist might get all excited about
but because it's rare it's not something
that's generally treated with
regenerative medicine at this point I'm
going to focus on the things that I know
which I mostly works well for so how do
you get better at reading your own MRIs
well obviously it's reading patient MRIs
it's reading an MRI and looking at the
report and if you do this long enough
you're actually going to get better than
the radiologist and finding the things
that you're interested in seeing to
determine whether or not someone's a
candidate and you'll also have the
ability that the radiologist doesn't the
ability to correlate MRI findings with
an examination
so one of the first things you want to
do is get started with a standard DICOM
viewer and this is the one I use I don't
have any relationship to this company at
all I just think they make a great
product we have used a lot of different
standard daikon viewers what I mean by
that is that you know you open up this
the CD and the drive you a little crazy
you're looking at probably at least 10
to 20 common programs that you have to
master that's one of the reasons why I
think doctors don't like to read the MRI
in front of the patient because they're
afraid to look like an idiot they don't
know where this is where that is if you
use a standard daikon viewer like
radiance or something else you can
master that viewer and not use the
viewer that comes on the CD it really
makes you look like a superstar in front
of the patient you know where everything
is you know how to measure you know all
all the little parts and pieces are and
it really helps to get that patient
buy-in that you know what you're talking
about so let's just go over some very
simple MRI basics obviously we've got
the sagittal coronal and axial plane so
we have all three of those planes and
that's what they look like on an MRI
view and recognize that I'm a t2 image
we have muscles dark
satis dark water is bright and bonus
dark on a proton density or T 1 inch it
looks a little different and we use
these different images in order to be
able to identify with what these things
are so let's start with some anatomy and
we'll go simple and we'll get a little
bit more complex obviously we have the
big joint which is the tibia tailor
joint up in here so the main ankle joint
we've got the subtalar joint in here
we've got a tip fib joint over here so
we have three main joints just the
ankles some people would add in the tail
a navicular joint right here as well so
that's another
option to add in and we've also got the
sinus tarsi
right here which we're going to talk
about now if we look at ligaments you
know most people I think I've heard of
the 80s the anterior talofibular
ligament the PTF the posterior
talofibular the CF the calcaneofibular
ligament fewer people seem to be
familiar with the medial ligament which
is the deltoid one and I will tell you
that the deltoid one is a very important
ligament we see a lot of issues with it
but it seems to sell over the head of a
lot of providers so it really encourage
you as we go through this to learn how
to look at the deltoid looking at the
medial side ligaments as well as the
lateral side ligaments so if that is
tarsi sinus tarsi is really interesting
because if you're looking at ligament
stability it's a player but few of us
have been taught to look at it or care
about it so as you can see here there
are a load of different ligaments these
are just two different diagrams here
within the sign is Percy and we can see
that and obviously if there are
ligaments in there those ligaments can
get stretched and lacks so we should
likely be treating them as well so just
make sure that you understand that
obviously we're used to looking at the
medial and lateral ligaments but we have
the central ligaments that are this very
complex configuration that are probably
equally as important but often ignore it
so we have the lateral and medial side
here with regard to tendons if you look
at the lateral side we've got the
peroneal tendons and I'll talk to you
about those in a little bit we've
obviously got the medial side tendons as
well and then we've got anterior tendons
so those are the three different areas
now for the person for this talk I'm
going to talk about what's most commonly
Dean what's most commonly seen here are
issues with the medial lateral tendon so
that's where all our focus for the
purposes of this lecture because we
could spend an entire lecture just on
tendons so let's talk a little bit about
bone bone is the first thing you see
it's most of what you see and again
oftentimes it's ignored by physicians
because they're looking at cartilage but
bone is equally as important so one of
the things to recognize and I'll tell
you in any of these lectures that I do
on the musculoskeletal system is looking
at what's called a BML bone our lesion
or bone marrow edema is a big deal so
what does this mean this is a
fluid-filled and swollen area of the
bone that can have micro fractures and
literally it's these small little
fractures in the bone and it's believed
that that's what we're seeing here when
we see these bright spots on t2 these
dark spots on t1 or proton density and
treatment ortho biologics may be
appropriate we're treating many more DML
and viennese than we used to and I think
it's something to consider as a
treatment target obviously that's
something that requires a little bit
more finesse than injecting a joint but
in the ankle what we tend to see more
similar to the hip is that these B ml's
and B Emmys quickly turn into cysts and
obviously if left untreated you can get
this whole area of the talar dome
collapsing to just recognize that if you
see a B ml or DME it's probably a future
cyst and that future assist is probably
not a good thing for the overall health
of that ankle joint much more similar to
the hip where that's very common than
the knee where it happens but is less
common so there's an example here of a
Payless b ml treatment
that was that we performed this is a 15
gauge on control trocar dialed in to the
tailless and we have a level 3 course
available that looks at treating bone so
something to really consider so for
osteoarthritis we're going to switch
gears now and talk about the joint
obviously with regard to cartilage Ross
and regenerative medicine no ortho
biologics technology to date has shown
really widespread cartilage regeneration
the severely degenerated joint and
anyone that tells you any differently
doesn't know what they're talking about
I've been doing this long and anyone
else 12 years I've injected more joints
I think than anyone probably on earth
and you know we don't see this kind of
severe in this case subtalar away with
lateral displacement of the calcaneus
likely due to a torn up deltoid ligament
over here we don't see that kind of
joint regenerate using regenerative
medicine now we've seen small lesions
fill-in we were also seeing patients
like this respond without evidence of
regeneration sometimes their bone marrow
lesions will regress and there's lots of
different control lesion grading I would
say that I'm really more comfortable
with a simple score like this because I
very much doubt that we're going to see
this type of complex grading fit very
well into the regenerative medicine
pantheon already for instance we're
seeing in knee that even this outer
bridge classification or the caliber
Lauren's classification which is similar
doesn't really correlate to outcome
whereas in hips it may enables it may so
so here we
have purple condo lesion and something
to really be focused on in the tibia
tailor joint is that we will see the
small B MLS and you can see there's
bright spot in the bone and that bright
farm the bone is frequently adjacent to
a bright spot in the cartilage so you
see here we have gray cartilage out here
and the middle part of the joint and
then all of a sudden this area at the
corner of the joint gets a bit brighter
so one of the things you can really help
yourself with and reading this tibia
tailor joint MRI is looking for the
bright spot in the BML and then trying
to look at what's going on in the
cartilage and even more so in the knee
you tend to see these nice correlations
in addition in the tibia tailor joint
you tend to see these corner lesions so
they tend to accumulate in the corners
quite a bit and you know here something
to really be confident or to realize is
that often times will again see a corner
lesion like this where you can see a
very nice bone lesion right there is a
dark lesion on a proton density or t1
and what we see here on the opposite
side is a lacks calcaneofibular ligament
so again instability on this side and
the ankle related to a lesion on that
side so something to really consider
when you're treating these patients is
obviously you're going to perform some
sort of tibia tailored regenitive
medicine injection here but you're also
going to treat the opposite sized
ligament now there are stress ultrasound
procedures that you can do to really
sort this type of issue out but at the
same time you can also as I'll show you
look at the MRI to give you a sense of
whether or not that ligaments involved
so here the
other good example and something to
really consider looking at this coronal
MRI image here we can see off to the far
left that the calcaneus kind of lines up
with the tailless and that kind of lines
up with the tibia so we can see that the
force is coming from the ground here are
going to go up very nicely up into the
leg however look at this patient's MRI
in the right two images and we see
something different we see that the
calcaneus is flipped out that way and
what's over here the deltoid ligament
complex is right there so by definition
that deltoid ligament complex has to be
stretched and then on the opposite side
of the subtalar joint what do we see we
see a large bone marrow lesion right
there with some early cysts so again
laxity over here leading to in this case
a change of symmetry leading to
impingement on the opposite side so
treating this person's lesion on the
lateral side of the ankle which is over
here is not enough you've also got to
treat that deltoid ligament if you want
to make any long-term progress so here
we have a severe angle away associated
with mone changes and again as I said
the ankle is similar to the hip where
severe away is associated with cystic
changes and flattening of the tail is
known very similar to flattening of the
hip so we can see here
idml see here at BML we can see complete
loss of cartilage in this area over here
we can see some great cartilage but the
signal is not homogeneous which is
something else we're looking for we can
see that the signal on this side is kind
of modeled and if we look at the overall
shape of the tailor dome it's kind of a
mess we got a bump out here we got a
bump out there seems to be good there
then this part is expanded here so we've
lost the
normal ice-cream cone shape of the
tibial dome I'm sorry the tailor don't
apologize so this is more subtalar Oh a
and T Toa so you see again no cartilage
up here you can see the joint fluid
coming out the back of the joint here
and then again we have the tibia tailor
joint with the joint fluid coming out
the back right there now we have still
some gray cartilage present in the
subtalar joint but up in here we have no
cartilage and we obviously have a lot of
bone marrow lesion here and bone marrow
lesion there as well with a cyst located
here so if we look at treating off your
fried s by focusing on the joints inter
articular joint treatments are the
coming up level one course an ankle foot
that's in April and will also cover a
slew of different hand injections at
that time as well okay so let's look at
the ligaments now so for the purposes of
interventional orthopedics we have a
different metric that we're looking at
um hold on if you could I'm going to
hold out a quick second I just need to
deal with some local noise issues here
we're having some noise issues on our
side so let me just break for just a
second
okay so that there are circle noise
issues there but basically and this is
why I think the radiology reading system
probably needs to be changed for
regenerative medicine because as far as
your genitive medicine is concerned I
don't really care if it's a grade 1 2 or
3 all I care about
based on what I've seen in 12 years of
treating torn ligaments with stem cells
PRP and all sorts of other things is the
following do I have a partial tendon or
ligament tear in which case that's more
of a PRP patient do I have a complete
non retracted tenor ligament tear which
is where they're still fibers that are
attached to each other in which case
it's more of a same-day stem cell type
treatment or do I have a complete
retracted tender ligament tear like a
rubber band in which case if there's a
lot of gap there it's highly unlikely
that a stem cell injection procedure is
going to help so I would use for most
scenarios 1 centimeter as my gap here
and if it's smaller than 1 centimeter
that's something I can generally treat
if it's bigger than once I know that's
not something I'm probably going to be
able to treat using this type of
technology so let's look at some lateral
ankle ligaments and coronal is really
the best way to image the
calcaneofibular ligament so the
calcaneofibular ligament we can see well
on criminal kronole but we're also going
to need to come to the axial to see
other ones so if we look at
calcaneofibular ligament here we've got
the fibula here right we've got the
calcaneus here so we've got the
calcaneofibular down here on a coronal
if we look at the PPF ligament we've got
the tail is here we've got the fibula
here and the posterior talofibular
ligament right there now we can also see
these on the axial images and we have
our first axial image over here and we
can see this post Utila Fidler ligament
very nicely here and we can see kind of
a shredded anterior talofibular ligament
on the axial right there so you need to
use basically a combination of the
coronal in the axial to see all the
ligaments as well as you can now let's
look at the high ankle ligaments and
these are best viewed on axial generally
these tend to be ignored or the sports
medicine physicians know about these and
treat these but these I think they get
ignored so these are above those three
ligaments I've told you and they go you
know tib-fib and you can see here we've
got anterior right there and we've got
posterior right there now there's an
aquiline in here that you're not going
to see this is our fibula and this is
our tibia and you notice that obviously
if you just look at signal here this
should be dark so basically what I'm
looking at here should be a dark color
kind of like this right here and we're
seeing a right color and that light
color is throughout the ligament so
that's going to be more of a complete
non retracted tear now here we're seeing
dark in this ligament other than this
portion right here which is right where
it attaches to bone and again that goes
through it that signal change goes
through and through so I'm going to call
that a complete non retracted so both of
those would be really great ligaments to
try with likely bone marrow concentrate
but you might also consider trying PRP
to see if they might resolve because
ligaments again tend to be a little bit
easier to treat then then you might with
some other types of tissues like
cartilage so there is a good example of
something that I wouldn't use therapy on
that would definitely go straight to the
bone marrow concentrate this is a
complete non retracted calcaneofibular
ligament and you can see here that this
whole portion of the ligament is really
amorphous and gray and it looks
disorganized you don't see the street
discrete bands work so that's something
or I'm going to start with bone marrow
concentrate and I'm not even going to
think about using PRP on something like
that so let's look at the PT F here
so if we look at the actually this is a
PT F where we can see we've got this
portion of the PT F which is nice and
rich and dark but we've got this portion
of the PT F which is bright so we're
going to call that a partial PT f injury
and this is actually a pre and post PT f
ligament tear after the injection of
culture expand Tennessee is one of our
early very early cases but it's a good
example of a problem ligament right you
can see automatically that this ligament
should come across like that so you have
void here that's being filled by the
ankle effusion so we know that we have a
partial retracted tear and we also know
there's a problem because we see a V
sign here right that the the ligament is
bent and we know that the ligament
should go straight across and tight now
if you look at the right one here you
can see that most of that reconstituted
after the injection of culture expanded
mo-cedes when we were still doing that
here in the US and before that got moved
to a
seyton Grand Cayman this license so this
is more of a high ankle ligament injury
and you can see here that you do have a
posterior ligament that maybe you have
some bright areas in it but it's holding
together that you don't really see this
one in the same way and that is look at
the medial ankle ligament superficial
and deep so there's a lot going on in
the medial ankle you've got actually a
anterior component of the deltoids a
posterior component of the deltoid and
then you've got those are deep and then
you've got an anterior middle and
posterior superficial ligament as well
so if we look at the deltoid of the
medial side here you can see this
posterior tibial taylor ligament very
very clearly right here and it is
triangle-shaped so that's your deltoid
ligament there in addition you can see a
little bit to the flexor digitorum
longus is our longest and the peroneal
tendon there now this is the spring
ligament which is a very very important
component of all of this we've got the
ATT L which is that deep component the
anterior portion of the deltoid ligament
deep then we've got the tibial Spring
ligament of the TSL coming out this way
and then this is actually the flexor
retinaculum and this is the the
posterior tibialis tendon so again gives
you a sense of all the different
structures here now the spring ligament
is super important right because we've
got really three different things
holding up that arch we've got our point
of fashio way down here then we
a long plantar ligament down here and
then we've got the spring ligament there
so all three of those are holding up the
arch so if you've lost if you have
someone who slowly lost the spring in
their step and or have getting a flat
arch again all of these can be injection
targets so this is a dumpling ligament
sprain you can see here probably best on
this image right here that instead of
being nice and dark like the other one
we see a complete change in signal so
this would be a complete non retracted
again not a surgical case in my book
more bone marrow concentrate case so now
let's go over some ankle tendons so
sagittal is usually the easiest way to
see and follow these tendons so that's
really how you want to want to do this
and you can see here that we see a
tendon coming right around the fibula
and recognize that there are retinaculum
around all of these tendons so there are
pieces of duct tape if you will that
traverse a cross and hold them in place
so a snapping tendon actually need the
retinaculum tightened down via injection
and if you want to look in the lateral
side we see two major tendons we see
brevis to bone and longus
so literally if you look at the fibula
here the brevis is going to be the one
that's hugging the fibula so that's how
you tell it apart from the longus
so if you see them together on
ultrasound or an MRI the one that's to
bone is the brevis and so this is an
example of an inter substance tear with
hypertrophy so you can see here we've
got the peroneus longus tendon right
there peroneus longus tendon on the
other part of it right there and then we
have this split tear or inter substance
increased signal right there in addition
the tendon is generally bigger so it
per trophy this is a complete non
retracted two partial tear the peroneus
brevis so we can see here that we've got
the longest back here and then the
brevis to bone right up front there but
as you can see in part two this down and
here the entire tendon has high signal
so if it's still attached or there's
still fibers there this is more of a
bone marrow concentrate injection case
in my opinion and recognize that the
perineal is on the outside can be
impacted by ankle stability so if you
see someone with a peroneus brevis foot
tear for instance then that's something
that you want to look at that ankle and
stabilize that ankle before you really
consider treating that brevis or treat
them at the same time
I see a lot of these patients getting
surgery and I'm still scratching my head
because most of after surgery are
miserable they never really quite go
back to what they were doing before so I
stretch right after while getting the
surgery in the first place and they're
out for very long periods time and most
of the time the surgeon has not looked
at small amounts of instability within
the ankle it just goes right over their
head so here's an example does this
perennial tendon need surgery this is
actually a patient of mine who
regrettably got the surgery and she was
miserable she was much much worse after
this surgery so look at this tendon you
so let's first identify it right we got
the brevis over here we got the longest
right there so it's the longest and we
see in this circle from changes in
signal within the tendon but it's not
totally torn you might call this
complete in that you know it's not
completely dark so if you look at it
from here to there there's a change in
signal and there's obviously a little
torn piece there that's slightly
retracted but if we look overly down to
its insertion
or not seeing any type of complete tear
again complete change in signal here so
this is more of a bummer concentrate
injection case in my opinion I don't
think this patient is any business
getting surgery which is fighting a piss
off a lot of the surgeons but I don't
think this person in this day and age of
PRP and bone marrow concentrates should
be walking in and getting surgery at all
I think this needs to be treated via a
highly concentrated bone marrow stem
cell injection precisely placed in that
tendon and obviously if that fails they
might consider surgery but to me this is
an 80% likelihood of success case with
much less downtime and much less
morbidity than surgery so if we focus on
the medial ankle tendons and go medial
to lateral we've got the tibialis
posterior here we've got the FBL there
then we've got the posterior tibial
artery and then we've got the tibial
nerve so recognize that that's how it
goes so here we see a split tear of the
tibialis posterior tendon and you know
we can see some high signal in here so
you'd call a split there is also some
high signal here at the attachment so
again in general not a surgical case in
my opinion Achilles tendinopathy here we
see just a kill ease tendon that really
should be about this thick that's gotten
much wider here at this point a great
case for platelet-rich plasma injection
here we have an inter substance Achilles
tear where we can see that there's just
this thickening and high signal right in
here indicating a problem within the
tendon again a great PRP case
and then here we've got a complete
retracted tear and regrettably it's like
it's unlikely that a bone-marrow
concentrate injection is going to fix
this it's certainly worth a try and if
you were going to try it you might
consider paralyzing the gastroc soleus
complex up here with some mile block or
some Botox to bring these two pieces
together I mean they are a reasonably
approximated so you might also try to
approximate them with a boot but again
when you get into stuffing as sniffing
it retraction you're talking more
surgical at least until someone invents
the right device to treat this
percutaneously so this is more level to
ankle foot stuff that we're talking
about which is of course again that
we're holding in May okay so now let's
do some MRI readings and for those
people who probably got the time
translation wrong and they're just
logging on now this will be available
the recording so you can watch it at
your leisure so I'm going to start these
videos here and that way you can have to
do this just to be able to keep the
patient's name out of it so I'm gonna
let this video run by itself and I'm
going to bump up my sound here just to
make sure you can hear it all and you're
not going to see me for a few minutes
here and you're probably going to see
this thing jumping all over the place so
just recognize that that's technical
difficulty which of those just trying to
make this so you can hear everything
appropriately I'll start this video
which will run a little bit and go over
some actual live MRI reads okay
ii am i read it was really a horse of a
different color this is a more much more
severe on your products first thing i
want you to look out here is on the
chrome because there's missing things go
on basically we have collapse of the
Kami and an ankle that's really no
longer aligned so if we draw some lines
of force we've got forcing down this way
from the top and when we go this way and
then we go that way
so basically not a healthy ankle we're
going to have an engine in here which we
can see evidence of them get rid of this
little anyway which we can see evidence
Evan this corner where we have fabulous
on the lateral side maybe ml here and if
we look at the side you'll we can see on
the so we remove that over there this is
precise I'm working on that so we're now
single side when we can key the tibialis
posterior tendon which has by this one
which we imagine it would simply because
the stress that's going to be under
because of this whole are this whole
need a collapse and we're also seeing
again quite a bit of bone marrow lesion
of the subtalar joint with cystic
changes and recognize that we have to
the contended on the side we've got
tipping our special fel FDL is going to
be the second one you see and then we've
got the nerve artery vein complex back
here to be a tubular and we can see here
that the TT joint really has severe
arthritis with no nil kondal surface at
all to speak out a little bit of
cartilage left right there on the white
be aware
the middle she's actually had at this
point at least 2/4 expanded MSC
treatment so that could be where that
came from because I was very much a
student either but it's also one of the
probably lower load weight here in the
areas because of this arrangement here
and we also see a small bead osteophyte
in the part of the tiki joining we see a
subcarrier effusion back here which is
pretty significant and we see this is
the flexor digitorum longus coming down
this way a canister device there
obviously front which not the purpose of
this lecture we're seeing multiple
joints and impacted by this ankle she
also has her pain this was placed here
for her pain more medially and shortly
after this we hundred I set about the
tibial nerve to try to help her and
something else that you can see T on
this lateral here as we move laterally
on the sagittal is that the signal is
move posteriorly because of this
arrangement it over the fibula would be
about right here so something
interesting can milk we can also see
here that the terminus probably longus
is torn you can see that it's probably
torn down here and get the circuitous
course and then the brevis we can see
from this purpose we can see some change
in signal here so Oscar nod in this
ankle the kind of severe issues now if
you take a look at ligament here we'll
try to cue those up because they're very
difficult to even see in this patient
this is PTF ligament here that you can
see the deltoid ligaments with p2
a little bit right here I signal in
those and hardly even make out some of
the other ligaments because of the
partitions in this ankle okay this is
our last time I read it's going to throw
a curveball okay let's go to our first
MRI reading here as you can see here I
have the teaching sagittal and the t2
axial up now as you scroll through is t2
sagittal you can certainly see right in
here that we have quite a bright bone
marrow lesion or BML or bone marrow
edema run here and you contain
brightness in the kondal surface right
here in fact in front of that probably
loss of cartilage so certainly a
cartilage lesion right there and
recognize that in MRI of the ankle
really following this bone marrow edema
is important in addition if this is left
as if it's probably going to turn cystic
over time fact you can see I believe in
a small system the cartilage there then
also do this there's quite a bit of a
Dima here within the Sun is Percy and
work used to be some possible
disorganization of those ligaments with
some cystic changes here where they
attach so that might be an old subtalar
injury and in fact more to that point is
that you have spurring the back of the
subtalar joint here with localized edema
localized Dima continues through
multiple slices here with regard to the
Achilles tendon let's look at that
Achilles tendon right back here you can
see that there's some small chain
signal within the achilles tendon so
that might be a target to take a look at
clinically and what else here we're not
seeing the traditional beak-like
osteophyte that usually see anterior in
the tibia killer joint so this may
represent a newer injury of the tibia
camera joint now in the axial you know
there's only a few things we're going to
really look at in the axial one is going
to be for a high ankle ligament sprain
and you can see here that there's
increased signal antistick changes
around back in here the high ankle
ligament so this is the fibula and these
are the high ankle ligaments here and
here so probably a high ankle ligament
claim has occurred here addition if they
come further down I'm going to be
looking at truly here for the 80s
ligament and everyone will queue the 80s
ligament you expect this complete Taylor
right here of the nto 800 fibula
ligament and we tend see some of the
posterior Taylor or charitable ignant
here which will actually be better
appreciated on the coronal image so on
the coronal image here this is really
going to be our ligament image and it's
also known as that that tells us a lot
here as I as I said in a lecture when
you see these medial corner cartilage
injuries as we see right here we see the
brightness here we see changes in the
cartilage signal there you really need
to start looking at the lateral side for
chronic laxity here causing compression
there so as we try to line this up here
we see the kaki November or CF ligament
which does have changes in signal within
it as we this part looks more normal
this part looks more abnormal here and
then we also start to pick up the
posterior talofibular ligament here
which was highly abnormal signal
a complete through-and-through signal
change or complete non retracted care so
it's um ATF with a complete protracted
care a PCF with a complete number
traffic care and then portions of
partial tear with the only contain a
similar ligament now if we go and look
at the deltoid Lego the deltoid ligament
doesn't look great either this is the
PTT portion of the deltoid ligament and
you can see it's right here on this t2
so that's that's an issue so in general
we're seeing an ankle with multiple
ligament injuries with an ankle with a
tubular tailor probably more acute type
injury or chronic subtalar injuries in
that joint okay this is our last time on
I read comm it's going to throw a curve
ball or to demonstrate some interesting
things so first off here we start on the
sagittal we can see that we have fusion
in the posterior part of the tip of your
tail or joint I don't really see any BML
and there's more facts at an image so
really not much there other there there
is some posterior spur here to be noted
and also note that there is a loose body
in the back of an effusion at the
subtalar joint and the subtalar joint
actually looks a little bit more beat up
here we can see that we have a bone spur
right here we can see that we have some
caramel candies you can see we have some
thickening of the cortex here so
circular joint of these two things have
more osteoarthritis and given that also
seems to have a smallest body probably
more going on there and we also see this
few responded here and this effusion and
was a traffic and gone back and forth
back and forth actually seems to be
coming
to tell in the book you're joining here
so interesting now even more interesting
than a see a whole bunch of things here
on this guy's Colonel the first thing
you'll notice is that there is a
necessity obstacle here that has its own
made its own joints that's really at the
bottom part of the fibula more
anteriorly and so that's something and
that's kind of right where he has cane
there some increasing on that accessory
obstacle seems like there's some condo
loss here but we're not sure if there
ever was cartilage there and also
noticed this - parsley here this is a
really great example in another one is
active healthy person what somebody's
bringing their foot lengths you can see
this ligament doing in this direction
and the sinus tarsi another one there
another one here all of them are not
great we've got how signal these are
more low signal so quite a bit going on
and the sinus tarsi
and as we look at the tibialis posterior
terror it's got high signal it's still
there mostly through introduced oh that
would be a complete high signal possible
care in the non retracted in the
tibialis posterior tendon and then we
can see again we should see this dark
ligament here and we're not in the
calcaneal fibula ligament portion so
again a candidate to look potatoes my
most radiologists would not even call
that the fact the radiologists that read
this didn't call this but i can tell you
from a region web standpoint and if you
look at this under stress ultrasound
this is likely to be relaxed under
stress ultrasound image if you don't
know these results time imaging again
take these courses also to the deltoid
ligament the PTT portion of the deltoid
ligament again doesn't work dark like it
should in this type of image and the
more superficial parts but what they've
got changes in signal here the deltoid
ligament so something else that's going
to need to be looked at in this in this
gentleman
as we go over here we can see something
to note I always think this is so
interesting that it all works out as you
can see here that this is his Achilles
now it doesn't have a very robust
Achilles but you know I know this
patient either call very thin patient
that's probably why but also far the
achilles are we then you can see fibers
that connect into two prior fashio
so again we have one fascial plane
that's going all the way from the
Achilles to the plantar fascia you're
not separate structures there are
definitely fibers there you can see
those fibers under ultrasound at much
higher magnification than this MRI will
allow so if you want to look at them
some tendency to start with a lateral
peroneal tendons we see some split hairs
here so we see here we're going to
identify these brothers two bones
this is brevis it's got a high signal
laterally as well or a more posteriorly
you can see a split care or high signal
interception in the longest so issues
going on there and then as we go to the
other side remember how all this is
going to work so we have here a tibialis
posterior which again has high signal
interception and then we have FDL coming
all the way down which has some high
signal down here and then we have in
there harder than complex bacteria that
we're seeing but lots of definition was
going on in the support ankle complex
that may be treated obviously depending
on exam
again an MRI as I did with that exam
that's where the ridiculous concepts I
think about having the primary provider
that reads these images not being
involved in the actual health care
because memorize only helpful I just
combined with an exam by itself it can
tell us some things but sometimes it's
fairly useless by itself so it's an
important concept here of everything we
work there is going to need to be
confirmed on stress ultrasound exam
whether or not you guys tend to there
etcetera etcetera so interesting
okay let me set this all back up here
and we'll take some questions because I
think we've gotten to the end here so
again upcoming iOS foot and ankle hand
risk course number one but this is one
heck of a level one course there's all
going on in this course as you can see
many different elbow hand injections and
ankle foot very very common to see
obviously patients with pointer
fasciitis MTP issues tibia tailor
osteoarthritis CMC osteoarthritis I mean
these are all super common problems that
we all see day in day out
even if you don't start with these
patients and you don't attract them
you're just seeing someone for a knee
problem these other issues walk in all
the time so it should be a good course
out here in Colorado in April and
obviously the level tuned for that
focusing just on ankle and foot there's
an awful lot to go over we'll also cover
many of these same structures that we've
seen a TF CF PTF the high lateral ankle
ligaments the perineal the tibialis the
Achilles how to do a tibial nerve block
how to inject many of these same tendons
that we just talked about and and soft
how to deal with a pie plate issue
I've had several player plate patients
that we've been able to treat where they
have failed surgeries telling the Vic
Euler Calcagno cuboid all of those
things so lot going on in April and name
and really encourage you to come out to
these courses so let's see if we can go
to some questions see if we have any
right here also I want to bring up
before we go to question before you
forget the I think I had stated in one
of those videos it's kind of funny to
sit and watch yourself give the video
because I just played those videos to
make
I got the the patient's name out of the
field of view those are things I
recorded over the weekend and I honestly
called the PPF ligament the tibialis
posterior tendon and one of those so
just to let you know that was just doing
too much too much that week let's see
here so John what percentage of ankle
injuries do you see treat that our ATF
plus CF injuries versus all others yeah
John it's a great question you know I
see you know it's really interesting I
think there's a tremendous amount of sub
clinical or not diagnosed ankle
ligaments issues we see it all the time
and literally it goes over the heads of
the surgeons because they look at it as
a binary issue if it's a complete
retracted tear great I'm going to
operate on that but anything else I'm
not interested it'll get better but if
you look at these under stress
ultrasound which will show you how to do
during the course because in this April
course there's actually a big hands-on
component of doing diagnosis and one of
those things we'll cover is truss
ultrasound you'll see that there's an
awful lot of ligamentous laxity out
there that doesn't get diagnosed but
needs to be treated that eventually
affects the knee and the hip etcetera
second question so a very high
percentage done when treating high ankle
sprains do you treat just superficially
at the ligaments or deeper in the
retinaculum yeah not in certain actually
but I think you're talking about the
osseous ligament so yes I try to get
both in those ligament structures that
we talked about the tip fit the inter
and posterior component but also attempt
to dive deep into the interosseous as
well and that's one of the real
advantages I think of having both
ultrasound and floor right because you
can dive in there very accurately under
ultrasound and then you can check under
floor a little bit of contrast to make
sure you're getting interosseous
ligament before
you then chase that with your biologic
so I think that answers that question
guys we have a question session now if
you'd like to off on the right there
you'll see a space to ask questions
please feel free to type any questions
you have there and I'm happy to take
five or ten minutes of questions if any
have come up in the meantime while we're
waiting for that to happen let's see
what else can I tell you about foot and
ankle yeah something else you might want
to consider anywhere else that's
watching is there's a fantastic book
called Anatomy trains if you've never
seen it by Tom Mayer it's really a
game-changing book because it talks
about how all these things are connected
I think I the last MRI read there tried
to show you it's very clear that they
were connecting fibers for instance
between the Achilles in the plantar
fascial and it would make sense that
there would be connecting fibers between
those two areas but it's not what we've
been taught and we've been taught the
beauties of separate areas and they're
really not they're connected and you can
see it very clearly under ultrasound in
a gym but you can even see it on that
very nice clear MRI that there were
fibers that seemed to connect those two
and that's really talked about quite a
bit in Anatomy trains
okay guys what looks like we don't have
too many more questions today so I
didn't want to let you know that this
has been recorded so if you arrived late
then you can get the recording from
Nancy Hope and she'll be sending out
something to do that and then no we got
another question here or we go home a
slew of questions all of a sudden Tony
one how do you combine these biological
research intervention for severe issues
such as this bodies yeah Tony it's a
good example so loose bodies are one of
those scenarios where you may want to
have the patient pursue an arthroscopic
debridement before they consider doing
stem-cell treatment and normally I will
place some time between those two so
basically about a week I think is
optimal because you're still in that
inflammatory healing phase I don't know
that would give it too much more than a
week because you want to be in that
inflammatory healing phase from the
surgery when you put a biologic in there
let's see Tom can you do a stem cell
regeneration procedure for the plantar
fat Pat yes I'm looking interesting
question we have done a fat graft there
on at least one patient who did quite
well and so yes so you're talking about
fat pad atrophy that's something that
you could certainly consider doing a fat
graft on let's see I think that's it on
questions okay guys well Nancy we'll
have this for you we're on this
wonderful to see we're lettuces working
with us and in Brussels so so wonderful
to see that it's probably very very late
in Brussels right now so Rolando so I'm
glad you're up so late and thank you for
watching so guys thanks so much for
watching and have a great day