Stephen Bird

1: When I see roof lne dipping /collapse I think it is absolutely diagnostic of collagen loss and this may be chronic and attractive in nature or represent a more acute injury. When I see it I am very suspicious of a full thickness tear and will stress the tendon with full Crass positioning as well as looking at in modified Crass and relaxed position trying to demonstrate the full thickness defect. Most times I can and I call it full thickness. If I can’t I say there is significant volume loss and it represents at least a high grade partial thickness tear. Dynamic movement while you scan can also force some peri-bursal fat or fluid into the defect making the diagnosis.

2: I tend to use the tern sub-periosteal cyst but we are all talking about the same thing. They occur at the enthesis part of the skeleton only. It is what we see on a plain radiograph where the enthesis changes from looking smooth to looking more like a close up photo of the moon surface with many small craters. It is what we see on ultrasound as enthesis irregularity as we only see the surface of them. They are strongly associated with tendon tears and attrition so when you see it you must look at the tendon adjacent to it really carefully. So the sub-periosteal cyst relates to a bony enthesis change not a tendon tear but they are strongly associated with an adjacent tendon tear.

3: For me the axillary recess which I see deep to the trees minor insertion is all about joint fluid to make a diagnosis of joint effusion. It is the best place (along with the long head of biceps sheath)

4: Nup, not really, just tell them to toughen up and externally rotate them (with empathy!)
You can try them supine, but I think with encouragement patients can give you enough external rotation to see the important part of the tendon.

5: Doesn’t matter, but I find holding onto the belt area of the lateral hip is comfortable and effective

6: probably doesn’t matter much to the tension on the supra but I think it is more comfortable to have the back (dorsum) of your hand on the small of your back rather than the palm. Try it and see what I mean. Or am I just getting old and inflexible !


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