A Practical Guide to Elbow Pathology

We get it, the elbow can be intimidating.

Lateral pain isn't always tennis elbow. Medial pain isn't always golfer's elbow. Numb fingers, snapping tendons, unstable ligaments, arthritis, stiffness, loose bodies, nerve compression—the differential diagnosis gets surprisingly long, surprisingly fast.

In this episode, Hannah and Beth break down one of orthopedics' most overlooked joints. We walk through our approach to evaluating elbow pain, discuss the anatomy that actually matters in clinic, and cover the conditions every orthopedic PA should recognize.

We'll discuss:

•  How to approach elbow pain without getting overwhelmed 
•  Lateral and medial elbow pain (and why it's often not what you think) 
•  Cubital tunnel syndrome, distal biceps tears, triceps pathology, instability, arthritis, nerve pathology, bursitis and throwing injuries 
•  When imaging helps—and when it doesn't 
•  Common treatment options from therapy and injections to surgery 
•  The mistakes we see providers make most often when evaluating elbow complaints 

Whether you're a new orthopedic PA trying to survive or a seasoned provider looking for a practical refresher, this episode will help make one of medicine's trickiest joints feel a little less intimidating.

Transcript

SPEAKER_01 0:00

Welcome to Joint Effort PAs, where two orthopedic surgery PAs get real about life in medicine. From tips and tricks to professional growth, work-life balance, and everything in between. We're here to share what we've learned and what we're still figuring out. Let's get into it. Okay, let's do it. Let's let's talk about the elbow. We're shifting years this week.

SPEAKER_02 0:27

We're getting right back on track.

SPEAKER_01 0:29

Yes, yes. Some clinically relevant topics, but very well-timed, like clinically relevant topics.

SPEAKER_02 0:37

Yeah. Um, yeah, today we're gonna talk about the elbow, um, which I think is a scary joint for a lot of people.

SPEAKER_01 0:43

It is, yeah. I feel like the elbow is really difficult. Like you think it's simple initially, right? And it's so not simple.

SPEAKER_02 0:50

Even the shoulder, too. I think shoulders like runner up.

SPEAKER_01 0:52

Yeah, yeah. Because you're like, oh, this is like this joint does this, and there's like these three things that it could possibly be that they teach about you about in school, but then there's so many more.

SPEAKER_02 1:02

Yeah, there's other, there's like 20 other things that it could be that you don't even know are clinical entities until you get into orthopedics.

SPEAKER_01 1:08

Yeah. Well, preface describe your week, Beth.

SPEAKER_02 1:12

Oh my god. This week was insane. Um the week started, the week started Monday. No, the week started Saturday when I SOS texted Hannah and I was like, Hey, I think my husband tore his biceps and you need to put him on the surgery schedule this week. She's like, Oh, great, can I see him? I'm like, no, he's he's away, he's away and he doesn't get home till Monday night. If he gets home because there's a massive forest fire where he is, whatever. But anyway, yeah, so he tore his bicep. He had surgery Tuesday. I maybe worked the entire day. Yes. Tuesday, because it was so unplanned. Um, but yeah, that um that I don't know, it's always weird when you have like this is what you do every day. Yeah. And then it like enters your home.

SPEAKER_01 1:56

Do you feel like it makes you more empathetic, less like more empathetic towards the process? Or do you feel like so detached? Like I almost feel like, I don't know, if my dad tore his biceps and had surgery, I'd be like, this is just like a regular day for me.

SPEAKER_02 2:11

Like it's not for them. No, it felt regular for me. And to give him credit, he also made it seem very regular. Like he seemed very okay with the fact that I like orchestrated, like, I need you to do this, I need you, like there was no conversation. In fact, when your surgeon talked to him beforehand, I was like, Oh, yeah, so we'll be down for eight weeks. And he was like, I'm I'm sorry, eight weeks. Like, I mean, we we didn't talk about that because my I was very much in like planning mode. Yeah. Um, so I don't know that he got all of the pre-operative info. I've been like slowly giving it to him.

SPEAKER_01 2:44

Well, that's obviously the last piece of information you give because it's the hardest to swallow.

SPEAKER_02 2:49

It is, but I mean, again, logistically, right? Yeah. So day of, you're like, hey, like, do you have a pharmacy? I'll send the meds. So when I had you send the meds, I didn't have time to get them. Like, I didn't get them because the day was what it was. You were still working. It was still working. So like I had after we finished our surgery day, I like went, you know, got the meds and came home. And oh my god, so I'll think. But anyway, that was just part of the week. Yeah. Um, and then, you know, the week itself went okay. We had, I did a cadaver lab on that same day. Same day. Oh my god. Yeah, that same, that was that morning of. And I tried to coordinate, I think I did. I coordinated everything to like get everything done and also get him to and from whatever. Um, so we did a cadaver lab, and that was on an orthoscopic uh later A type procedure. So I think we'll be able to do that. But it goes back to putting the shoulder in lateral to cubitus, which I hadn't done in like 10 years. So that'll be annoying. But I think I think we can do that. We've done these open, um, but now this is a good way to do it orthoscopically.

SPEAKER_01 3:48

What this is getting off topic. What like are you using for graft for that?

SPEAKER_02 3:52

It would still be the um uh uh uh distal tip. L gra graft, yeah. Okay, so you can use the like the coracoid, but we won't we use like a distal tip which we have to match into the whole thing, but normally it's like big open incision, you know, detach subscap, and the vi the visualization is just so poor to be honest.

SPEAKER_01 4:13

I think of this like the um hemi or the hemi hamate procedure that we did. Yeah. No, but we basically take a piece of the hamma and match that to fit the contour of like that's exactly a fixable feeling fracture.

SPEAKER_02 4:28

So you take the distal tip and you match the contour of the anterior glenoid. Yeah, it fits pretty well. Yeah, it fits pretty well. So it's all and there's no screws, it's all like a tightrope suture fixation, which is kind of crazy.

SPEAKER_01 4:41

And that's for recurrent stability.

SPEAKER_02 4:43

Recurrent anterior instability with more than 20% glenoid bone loss. So we have we have patients that we could do this for. Um, but anyway, so that was cool. Cadaver lab, then it was our surgery day, that was my husband's surgery day. But like when things go not planned like that, I I mean, I was telling you, I went home this weekend with like 76 open notes, which is I told you once upon a time, my number of like concern is 12.

SPEAKER_01 5:09

Yeah, so you like literally.

SPEAKER_02 5:11

I just like I couldn't catch up because I well, I would come home and then he can't like do anything with his left arm, so like I'm making dinner and I'm trying to do all the things. Um, so I didn't have time to do the things I would normally do. Plus, my daughter's birthday was this week. I went down, drove two hours ago with my son who was with my parents.

SPEAKER_01 5:27

It was 4th of July. It was 4th of July. Dad just had surgery.

SPEAKER_02 5:30

Dad just had surgery. I did I interviewed two medical assistants this week. I interviewed a couple PAs, like there was just a lot of things. I did some training this week um with another PA. So I mean, yeah. The saddest part though is that Friday was yet another non-surgery day. I know. I missed it. I did, I did.

SPEAKER_01 5:50

And like to me, it was silly. I was like, wait, why are we off Friday? I mean, like, whatever I get. This is America's 250th birthday. Like, I'm not saying we shouldn't celebrate it, but like the fourth was on a Saturday. Could we have worked Friday? I I think we could have.

SPEAKER_02 6:02

It's the observed holiday. It's the observed holiday.

SPEAKER_01 6:06

Everybody observed it. So I don't know. This is just me being a crazy person.

SPEAKER_02 6:11

Yeah. Well, it it I wouldn't have minded if it was a Monday. Is that weird?

SPEAKER_01 6:16

No, I think Monday would have been better. Monday would have been. Well, actually, it would have been the same for me because our clinic, those are both full clinic days for me, so it would have affected me the same, I guess. Yeah. Um, I feel like it's hard though when a Monday is off because Tuesday is an OR day and jumping like without any of the prep from nothing to OR day is ugly, I don't like it.

SPEAKER_02 6:34

Yeah, I that too for us when we're off Monday and then Tuesday, like nobody there's no prep for Tuesday because you just dive into that. It's a little bit weird.

SPEAKER_01 6:42

Something always like goes awry.

SPEAKER_02 6:44

Yeah.

SPEAKER_01 6:44

Yeah. That was interesting Tuesday. Beth was literally like, you know, dressed out, like seeing probably your patients and pre-op and pack you, and then going into your husband's and be like, hey, well, you know what's funny?

SPEAKER_02 6:57

You know what's funny, not funny, is that your surgeon was like, Hey, once I get like all prepped, do you want to come in and like watch? And knee jerk, I was like, No.

SPEAKER_01 7:08

But but then in retrospect, you were like, I know.

SPEAKER_02 7:11

But my like, my like, I don't know, my family part of me was like, no, why would I do that? Like, I don't know. And then part of me afterwards was like, Why did I say no? That was weird. Because I just sat like you know sat outside the door. I sat outside, no, I didn't sat outside the door. I just sat like, I don't know, waiting. I was like, okay, they must have turned it up, okay. Like they must be making a decision. Okay, if they're struggling, they're struggling now. Like that's what I was thinking. But I didn't want to put pressure of like Delean. Like, yeah, nobody needs that. Yeah, nobody needs that.

SPEAKER_01 7:38

Like, if Beth had come in to watch me close or something, I would have like fucking died.

SPEAKER_02 7:42

Oh, so I I said no, and I thought that was the right thing to do, but um, I appreciate all the pictures afterwards. That was literally the best part. But yeah, so that that was that. And then the cases for the week, even though we lost the whole surgery day, um, they were good, and then clinic was good, and then again, all the other stuff that happened, but I I feel a different level of tired this weekend than I did last weekend. What about you? How was your week?

SPEAKER_01 8:06

Oh, it was something. I mean, Tuesday was the best day of all.

SPEAKER_02 8:10

Yeah.

SPEAKER_01 8:11

Because we got to fix the elbow.

SPEAKER_02 8:14

I know. And I actually know, but back up Monday. Remember, we had him come in and he rolled up his sleeve and all he did was soup in his forearm.

SPEAKER_01 8:21

We were both like, whoa my god, here it is. Isn't this like crazy? It was everybody looked at it at first glance, was like, whoa.

SPEAKER_02 8:29

I know, it was, it was.

SPEAKER_01 8:30

I mean, those initially Do you remember who else has a shocking bicep like that?

SPEAKER_02 8:34

Oh, yes. Yes, I do. Yeah, but that's the thing. I don't want him to live.

SPEAKER_01 8:38

You're like, I don't want you to fucking look like that.

SPEAKER_02 8:40

No, I know someone, I know someone who never got that fixed. It's terrible. I can't, I can't live looking at that or live looking at that. That's a deal breaker.

SPEAKER_01 8:49

But it did spawn our topic this week. It did elbow. It was helpful. So I'll give it that. Yeah. But other than that, you know, we had a good, good surgery week. It was kind of a lighter week because we missed out again on Friday. So those weeks I'm always like, I feel like I'm negative because, you know, everybody's like working hard and ready for the long weekend and like excited. And I'm like, guys, we suck this week. Just so you know, we're like, it's we're terrible.

SPEAKER_02 9:13

I don't have the feeling of like sucking. It's the feeling of like, what could have been? Yeah. You know, like this could have been this could have been. But I like, I'm at the point now in my career, like I know in holiday weekends what bad things are gonna happen. So on Thursday, which was our last like you know, day, we had our team meeting. I was like, all right, we have one patient on a wound vac this weekend. So I need someone to be like around and on call. And they were like, What are you talking about? Like, we just saw him yesterday. I'm like, I know, but something it's gonna be silly. So lo and behold, yesterday I got a picture. Hey, the guy with the wound vac, he took a shower, he thinks some water got into it. So he removed the whole thing. Oh god. Now, our urgent care is open till four yesterday. This was at 3 37.

SPEAKER_01 9:53

Oh my god.

SPEAKER_02 9:54

Which means no one is there to help him. So then I get a picture of the open wound that he decided to just expose nothing and said, Oh, hey, he put a band-aid on it. Any other instructions?

SPEAKER_01 10:04

Like at this point, no.

SPEAKER_02 10:05

No. So I had, well, I had one of the providers who was leaving one facility and driving by the second. She came to the second one to meet him because all of his stuff was here. And I said maybe we should, I said maybe we should take some of his stuff to the other location just in case. And everyone's like, no, no, no, no, no. And guess what? We could have used it. It's like without fail. That's always, always, always happens.

SPEAKER_01 10:25

Because of these three days that next week is going to be like it. Did you look ahead and see like um yeah, we're scheduled for 196 patients collectively this week. My team specifically.

SPEAKER_02 10:38

What is normal?

SPEAKER_01 10:39

Um, I mean, I had had some weeks where I was over a hundred myself. So uh for reference, last week on our, you know, not busy week, it was like 130 or something because we missed a whole big day of clinic. But um usually like I would say 150, high 150s to like 170 or something is normal. So 196 is like verging on super busy, which is great. And I'm certain that somebody broke their wrist or a finger this weekend or something. Oh, somebody did, yeah. Yeah. And I will catch wind of it tomorrow, possibly.

SPEAKER_02 11:12

You definitely will.

SPEAKER_01 11:13

So it'll be good. Next week will be a great week.

SPEAKER_02 11:16

Okay.

SPEAKER_01 11:16

Um, so the elbow. The elbow can be the bane of our existence.

SPEAKER_02 11:21

Why do you think it's so scary for some people?

SPEAKER_01 11:23

Because it's a weird-looking joint. Like if you just like looked at a picture of an elbow, it's like, well is all this. Yeah.

SPEAKER_02 11:29

Like, like, why? I think though, also, if you have been doing this long enough, pediatric elbows. Oh, those are I won't even get into that.

SPEAKER_01 11:38

That's a whole whole separate friggin' thing. Yeah. My word of advice with pediatric elbows is just be cautious with everything. You have to. Yeah. Just everything's something. Everything is something. Yeah.

SPEAKER_02 11:49

Yeah. Um, so yeah, let's let's dive into it. So when you look at the elbow, I think it's um concerning because it's three bones making up a joint.

SPEAKER_01 11:59

Yeah.

SPEAKER_02 11:59

I mean, it's not two, right? Yeah. I mean, the kneecap's three. I'm sorry, the knee joint's three if you count the kneecap, but like, come on.

SPEAKER_01 12:04

But like, what is the kneecap? What is the kneecap?

SPEAKER_02 12:08

I think it's just it adds that extra element. Um, and when you add planes of motion, like again, the shoulder's scary because there's so many planes of motion, and then there's compound movements like abduction, external rotation with the elbow too, like you've got flexion extension, but what the hell is this pronation subination? Yeah, yeah. And where is that coming from? Where's that coming from? You gotta account for all the forces that allow for um, you know, that that um the range motion and the planes of motion.

SPEAKER_01 12:34

Yeah. You can think of it very simply, but you can, if you get into the weeds, you can really get into the weeds. So, stepwise approach to elbow pain. I guess the easiest way initially when you're looking at things is pain location. Like where is this coming from or what are the most likely? This is how you really should think about most things. What are the most likely causes based on where they're hurting? Yes. Um, so starting with lateral elbow pain, our good old tennis elbow, the cancer, uh a cancer of our lives.

SPEAKER_02 13:05

But I'll tell you what, not all lateral pain is tennis elbow. And I think it's very common for new providers to just group all lateral elbow pain into tennis elbow.

SPEAKER_01 13:16

Because it's a safety diagnosis, right? Like I feel like from an urgent care perspective, like nobody's really gonna fault you if somebody comes in with lateral elbow pain and you diagnose them and initially start treating them as tennis elbow, and it turns out to be something a little bit more intricate. Like you're not gonna be labeled as like an idiot, I think.

SPEAKER_02 13:34

Yeah, no, I don't think so either. Because I think also you can start with that as a diagnosis, treat it accordingly, because if it is or if it isn't, if you do immobilization injections, anti-inflammatory therapy, most things likely get better from that. So I don't think you're making a huge misdiagnosis, but I think if you want to be an expert of the elbow, you've got to really tease out like what are the other things that live there and what are the other things that can cause pain.

unknown 13:59

Yeah.

SPEAKER_01 13:59

So we also have radial tunnel syndrome to consider, which is like the stepchild to tennis elbow. Yeah. I only say that because it can coexist.

SPEAKER_02 14:08

Yeah, they cut they go together a lot, but not often enough, where you say that they always go together. Yeah. Um, but I think lateralitis is some, sorry, radial tunnel syndrome is sometimes grouped into lateralpochondylitis. And then once you go through this step treatment for lateral condylitis, then I think maybe on visit two or three, you're like, huh, that seems like it's more the nerve. It's a little bit more distal than I thought it was gonna be.

SPEAKER_01 14:31

A little bit, some extra symptoms, right? Yeah, classic tennis elbow, lateral elbow pain over the ECRB insertion, um, positive grip test. So if they like squeeze and make a tight fist with their elbow extended, that typically hurts pain with resisted wrist extension, um, because it's actually more pathology coming from like your wrist and forum extensors rather than like some pain that somebody feels when you're yeah, when your elbow moves, versus radial tunnel syndrome, you're gonna look more at um like more of a dorsal radial forearm pain. It can be kind of vague. They usually have point tenderness, a little bit more distal, um, sometimes a positive Tanel sign over the nerve, um, pain that radiates into their dorsal hands, sometimes parasesias with it.

SPEAKER_02 15:18

Um it's not gonna be textbook like radial nerve issue, wrist drop. It's not gonna be that. Yeah. Um, I do think the difference between the tennis elbow and the radial tunnel syndrome is how vague the radial tunnel syndrome symptoms are. Um, we do a lot of radial tunnel nerve blocks that we will send to you guys if positive. Um so when we do those, I actually do those, I've done them both in the forum, like distally, but I've also done them proximal to the elbow. Um, and again, a positive test would be if the patient's symptoms decrease for a very short period of time, AK lidocaine time, um, then that's usually radial tunnel syndrome. Now, EMG, if you're worried about radial tunnel syndrome, do you get an EMG on these people?

SPEAKER_01 16:04

Sometimes, very rarely. If there's like motor weakness issues, probably, but usually not, because an EMG isn't great at this.

SPEAKER_02 16:13

Like it is very inconclusive. So communicating with a patient, what you think the diagnosis is, and then working through like, you know, I need an MRI, like not for radial tunnel, I need an EMG. Well, guess what? It may come back normal. So I like the diagnostic nerve block as the test of choice.

SPEAKER_01 16:31

Yeah. Cause then you can actually just saw a patient of y'all's this week who had a positive diagnostic block. And radial tunnel is like so hard to definitively diagnose from imaging. So I always have the conversation like, hey, this is something I can't really like see on an MRI, not always see it on an EMG, but you responded positively to a block in that location. So theoretically, by treating this, by doing the release, you should get better.

SPEAKER_02 17:01

Now, what if they don't?

SPEAKER_01 17:03

If you don't, I mean, I don't know, we'll cross that bridge when we come to it, but you should.

SPEAKER_02 17:07

But diagnosis of exclusion, meaning you've treated them for latochondilitis, MRI shows that it's not, right? I mean, there's certain utility getting tests to show you what it isn't as you narrow down to what it is. But I don't like putting a lot of um faith in that EMG because that's disappointing, right? Especially if the words you say are it's a nerve, let's get a nerve test to see. Oh, wait, the nerve test is normal. Therefore, that implies that it's not a nerve issue. Not necessarily.

SPEAKER_01 17:32

Yeah. Um, but back to tennis elbows. So, like typical, I'll just like briefly go through the way we treat it, which is a little bit different than maybe some others might treat it or that I would have in the past. Um, therapy for sure. Sometimes those counterforce braces, eh.

SPEAKER_02 17:49

Yeah. Yeah. I do a wrist brace instead.

SPEAKER_01 17:51

Yeah, wrist brace, like a cock-up wrist splint, um, definitely therapy, steroid injections, plus or minus. They're one of the few steroid injections that I tell people like this truly is a band-aid and like it's probably gonna come back and get worse. Not great to repeatedly do. Um I'm a fan of PRP injections for this. People don't like them in the short term because they hurt, but they work pretty well, I think.

SPEAKER_02 18:17

Yeah.

SPEAKER_01 18:17

Um shockwave therapy, something that like we've semi-explored, but we don't have a shockwave unit here that we can like I don't know. Do you ever refer people for shockwave treatment?

SPEAKER_02 18:28

Um I have only if it gets brought up in conversation, but we will do MLS laser treatment for that, um, more so than we'll do shockwave. But shockwave, again, for patients who have like their chiropractor friend who does that, great. You know. Um, with lateral bocondy, I will tell patients if it's just inflammation, tendinopathic, partial tear, full tear, I find clinically they all present the same. Yeah. Like I don't think those that have severe pain equal full thickness tear. Sometimes it's just mild tendinopathic.

SPEAKER_01 19:01

Yeah. And I think honestly, and this is not like based on any research, tendinopathic tissue is probably more of a pain generator than any full thickness tear would be. Yeah. Um, so somebody with yeah, just purely tendinopathy and not necessarily any big tear, they probably have just as much, if not more, pain than somebody with a full thickness tear who's been living with this more chronically.

SPEAKER_02 19:24

Yeah. I will do initial treatment of like what you said, the anti-inflammatories, the wrist splint, physical therapy. Um, I will get to the point of MRI to see, quote, where they are on the spectrum of disease. But it doesn't necessarily matter because I mean, yes, full thing is tearing, we are going to recommend surgery, which is very effective. I love rehabbing these people because it just a textbook follows what it needs to. But those that are mild, you know, it's almost disappointing. They're like, well, it hurts so bad. Those are the ones I'll do an intraarticular injection as opposed to a tendon injection, but I will flip-flop back and forth.

SPEAKER_01 19:56

Why the intra-articular just so that you're just to not inject the tendon.

SPEAKER_02 20:00

Just to not inject the tendon. Um, and then to kind of leave the the playing field open for PRP if we need to. But um PRP hurts there. It hurts. People like they don't like that when I do it. Yeah, they do. It's that in the patellar tendon. It's like there's no place for it to go, but like right up in that, there's no burst of space, right? Like the shoulder. So they don't love that. But um, and then other like non-invasive procedures, 10x, um, do some percutaneous debreedment. Um, I don't love our 10x uh procedure because I feel like eventually they go on to need the repair. I don't know that we've had a 10x that has really gone away and disappeared.

SPEAKER_01 20:39

I it's it's so funny because I feel like we'll go through this is with everything, like time periods where 10x works great, like people are doing great with just 10x alone, fantastic. So we started doing more 10x, and then all of a sudden a time frame people that just like aren't getting better from it. So just recently had a stunt of people that were not like, you know, the 10x a little bit better, not great, PRP'd them afterwards. And sometimes that was very helpful to like combine the two of them. So I think that that is a good algorithm for partial tears and um uh even just tendinopathic issues. But I will tell you that agreement and inject it with PRP.

SPEAKER_02 21:15

We had um, we met with a vendor who has a 10x type procedure, 10jet. No, you guys do 10jet. It was something else.

SPEAKER_01 21:22

We do 10x, huh? But we did 10 jet in the past.

SPEAKER_02 21:24

It was something else. It wasn't 10x, it wasn't 10 jet, it was something else. But anyway, um you micro debreed and then you PRP. Like that's the secret sauce. But guess what? Insurance doesn't cover that. So that's like that I find very frustrating when we get into tennis level territory because all those that are tenopathic, mild this, moderate that, who don't want surgery, PRP is a great option and in the right setting works works really well. But you're asking patients to spend more money, the time it takes to recover when you could have just done it. It might not get better. Yeah, and you could have just done the surgery. Anyway. Yeah.

SPEAKER_01 22:00

And that's like I think that is a super frustrating thing with it too, because there's a ton of people that I do offer PRP to and I want to try PRP for them. But like they just I and I get it. Yeah. And we do, I think, relatively inexpensive PRP compared to what I see as market values out there. So but it's still like it's still expensive. So I get that people don't want to do it, but like, gosh, it's so frustrating that it's not something that is or will be anytime soon. Insurance covered. But yeah, that's a topic for another day. Um, so more lateral pathologies. Honestly, the rest of these that we kind of listed, I don't really again, either I don't see it a 10 or I miss it a 10. It's one of the two things. Uh lateral plaika. I don't even think of plaikas when I think elbow, like that's a knee issue. So I'm like, that's not even on my radar.

SPEAKER_02 22:52

No, and I think uh, I mean, I would inject an elbow if it looked okay and it was vague this, vague that, lateral elbow. I think you're safe doing the workout for lateral epochandolitis. Yeah.

SPEAKER_01 23:04

Yeah. Lateral elbow pain, I think those are the two biggest things. Like, sure, you can't have lateral pain from arthritis, you're gonna see that on an X-ray more than likely. And I don't think it'll necessarily be as uh localized as lateral elbow pain. I think if somebody presents with lateral elbow pain, but you notice they have severe arthritis on their x-rays, but still presenting like tennis elbow, it probably just is tennis elbow. Yeah. Umbow pain. Well, hold on. Wait, do you have another lateral?

SPEAKER_02 23:33

Yeah, I have I have a little like snake in the grass. So lateral ulnar collateral ligament instability. We have had, and I can name them because when you treat them postoperatively, you have to splint slash cast them in full pronation. Okay. So anyway, so lateral ulnar collateral ligament instability, the ligament that stabilizes the radial head. When you when you twist something, push-pull, and you feel a pop, and there's like an instability pop in the elbow, you can see that. Like if you take the forearm surgically and you pronate, supinate, you can see the radial head almost dislocate. So that is a diagnosis of exclusion. That one is really, really hard to diagnose. You treat these ones for lateral conilitis, but they just have like a weird popping sensation, I guess. Um, and then your physical exam essentially is the finding. So what you do is you repair the ligament, and then in order to not have them stress that, you have to splint them in full pronation, which is ridiculous. Because then your hand bases down for four weeks, but it works. The last couple we've done it on, it works. You so you repair it and then splint them for four weeks and then just tighten it up, and then you really slowly have them work on um uh supinating their hand.

SPEAKER_00 24:45

Okay.

SPEAKER_02 24:45

Yeah. So that one, that one, put it in your brain somewhere when it's just not fitting the diagnosis. We've seen a couple later chondylar repairs that they come back, like, hey, I still have my same problem.

SPEAKER_01 24:56

Yeah. You know, and is it popping specifically?

SPEAKER_02 24:59

It's popping with rotation. Okay. Yeah. It's popping with like persistent pain still. Yeah.

SPEAKER_01 25:03

Okay.

SPEAKER_02 25:04

And when you go to, you know, grip and lift something, it's like it gives out on you. Yeah.

SPEAKER_01 25:08

And you're not like, this isn't something easy to catch on in MRI. Yes. Not at all.

SPEAKER_02 25:12

Not at all. More physical exam findings. But again, that's why when you work with someone experienced, they are bold enough to be like, no, I know this is what it is. You know what I mean? Yeah. And I just think that's not even on like urgent care new grad radar, because that's just not something that you learn about.

SPEAKER_01 25:27

And it's also not something you're really going to change what you're doing in your in that specific practice setting. Um, will I? Yes.

SPEAKER_02 25:37

Well, I'm telling you, we yeah. I mean, we've done over the past 10 years, probably maybe like one or two a year. It's that rare, but it is that not rare where we fix it. I like that. Yeah. All right. All right. Now we can move on safely. Safely move on.

SPEAKER_01 25:53

Safe to move on to golfers elbow, the less common twin of tennis elbow.

SPEAKER_02 26:00

Yeah. And uh does this occur just in golfers, Hannah?

SPEAKER_01 26:03

I don't think it really have I seen it in a golfer. I don't know.

SPEAKER_02 26:07

I I definitely have, but is it always from golfers? No. And that's, you know, you will spend some time speaking with the patient, but I don't golf. Yeah. You don't have to to get this.

SPEAKER_01 26:17

So basically the same pathology as tennis elbow. It's just on the medial side where the flexors insert. Um, so I treat it the same way, essentially, but it's a lot more rare.

SPEAKER_02 26:27

Like, how often are you guys fixing like one to every three laterals? Yeah. Yeah. Yeah. So I'd think definitely more rare. And when just like with the radial tunnel, when you're looking at medial elbow pain, that ulnar nerve. Yeah. Especially in throwers, like that ulnar nerve is is sometimes tricky in getting involved in the pathology. Yeah.

SPEAKER_01 26:48

I think you need to go through your exam with this because I feel like medial elbow pain, you guys see a lot more like athletes than throw like specific throwing and overhead athletes. Yes, we treat cubital tunnel, um, but there's a lot more that goes into this for like your overhead throwing athletes in younger population than just golfer's elbow or cubital tunnel.

SPEAKER_02 27:09

Yeah. And I think that um a lot of urgent care providers have seen it, that ulnar nerve can be unstable too when they complain of like a popping or like a snapping sensation on the inside of the elbow. I mean, my head first, rule out medial condylitis. Second, make sure that ulnar nerve is not subluxing because that can, in full flexion, sublux right out of that ulnar groove. Um, and when we see that, sometimes that is by itself, but sometimes that is also in the setting of mediocondylitis. I will not, sorry, I have, I don't make a routine of it to do an ulnar nerve block because I feel like that one's so much easier to diagnose. It's so less vague than the radial tunnel. Yeah. Like my two fingers go numb sometimes. Okay. Well, that's your ulnar nerve.

SPEAKER_01 27:53

And you can pick up, I'm on an EMG. Yes, the EMG.

SPEAKER_02 27:56

Yeah, I wonder why that is. But yeah. Yeah, you see it more in EMG, definitely.

SPEAKER_01 28:00

Yeah. So I mean, for exam-wise, for this, I obviously golfer's elbow like tenderness on the medial epicondyle, pain with resisted flexion. Um, and then looking at cubital tunnel, positive tunnels. You can typically, if they have subluxation, you can feel that when you take them into full flexion extension. You can feel it popping. Um, you want to definitely look for like true nerve weakness. Um, so distally, that's gonna be the intrinsic muscles of the hand. Um, so I'll check typically always uh like their index finger abduction, right? Abduction, yeah. Um so that's important because if there's true weakness with cubital tunnel syndrome, that's definitely more of a surgical indication for us.

SPEAKER_02 28:51

And when you miss that, that's a bad one to miss.

SPEAKER_01 28:53

Yeah, yeah. Yeah. Um now for your athletes, you also have the uh the ulnar collateral ligament stuff to worry about.

SPEAKER_02 29:02

Oh yeah, and um that's a tough one because well, let's back up. Baseball players are tough. Baseball players are gonna be able to get to the top baseball players are tough, baseball players' parents are tough. Specifically that, yeah. Yes. So there's you know a whole other side conversation of those athletes that are pitching on immature elbows and those athletes that are doing too many pitch counts in a game or a week or whatever. Um, and you can just beat down the UCL. And it it starts with partial tearing, um, and then it can progress with full thickness tearing, but I would say the majority of the UCLs we fix are just recalstrent partial thickness tearing that just will not get better with the shutdown, with the PRP, with physical therapy, with um throwing analysis. And when we do um UCL repair for partial tear, we do the repair with internal brace. Okay. Um, we will not do recons unless they have a full thickness tear or unless it's like multiple partial tears and the whole ligament is garbage. Um but I like the UCL repair, they get back to throwing like at you know, competition level within six months, as long as they do everything well. Yeah. Yeah, then that's not, you know, that's not the same for um Tommy Don UCL reconsor a year if they ever get back. Yeah. You know, so that's that's a tough um we don't jump there first. We will usually PRP them, but we will usually get them after they've had a year or two years of continued symptoms. Yeah, and they've tried, they usually have tried all the things. Yeah. Um, but you know, the parent always wants them to get back to things. Yeah, always, yeah. Um, but more so you will see the valgus extension overload syndrome where they stress the elbow and it's that constant valgus stress on the elbow that gives them that posterior elbow pain. So that again, if you see a lot of you know, sports med elbows, that's something you should be able to see and diagnose. You'll see medial elbow pain on um exam. If you put them in valgus stress, specifically ABER shoulder valgus stress, they don't like that. Pinching in the back of the elbow, MRI will show that you've got like a bone bruise pattern um back there. So um, if you can shut them down at that phase, then generally you don't get to the UCL injury phase.

SPEAKER_01 31:09

Shutting down is hard. Why not? Like I feel like every time I have that conversation with a parent, they're like, okay, but like But like can they hit? Yeah, like can they hit? And in isolated instances, yes. I feel like a lot of them just still hit because that's not putting the same stresses on it that uh throwing is. Yeah. Um but but yeah, it's always like there's some competition coming up, there's some thing showcase, I don't know, like we'll just rest it after this, but then we have this, so can we do this in between? And like, I don't know, this coach is traveling from wherever, and he's gonna look at Johnny and Johnny.

SPEAKER_02 31:44

Well, Johnny's the next best thing. Johnny's Johnny's gonna get a scholarship. He's the best honest team.

SPEAKER_01 31:50

His coach is really gonna be disappointed at you. Also, Johnny's 14. Yeah. So Johnny's over here like crying. Yeah.

SPEAKER_02 31:58

Yeah, the throwing athletes and their parents and their medial elbow pain, that's so tough. It's so, so tough.

SPEAKER_01 32:04

Psychologically traumatizing for me.

SPEAKER_02 32:05

But I will tell you, if you have the immature, and again, I don't want to go into pediatric elbow because I hate that, but if you do have the skeletal immature patient who is a thrower with medial elbow pain, they can get a um needle apophysitis injury, and that very quickly can turn into a nice little avulsion fracture. Yeah. Guess what? Johnny shut down after that.

SPEAKER_01 32:25

Johnny shut down, yeah. I actually saw that an old um, I feel like I don't see a ton of baseball players, but I I had one maybe two or three weeks ago, and I get contralateral x-rays because there's widening, but you don't know how much widening until you see.

SPEAKER_02 32:37

Some white is good, some white is abnormal. Yeah.

SPEAKER_01 32:39

And, you know, I show them the x-rays. I'm like, this is your throwing arm. It is clearly wider than your other one, which it's going to be any throwing athlete that does as much as you do, but like this is obviously a sign that your growth plate is very irritated. And I mean, you got to stop throwing for a period of time, or you're gonna pop that shit right off there. I mean, and Johnny doesn't like that. Yeah, yeah. Yeah, yeah. So um, shut those down real quick. Sometimes I cast them, sometimes not.

SPEAKER_02 33:04

I do, I will cast them. Yeah, um, I had a um like a pitcher who was also like a quarterback, so the throwing, like the repetitive throwing of that arm, I'm like, you know, buddy, yeah, you gotta shut it down. Especially because when you say the things to them like you can't throw, and they're like, Oh, I thought you just meant a baseball.

SPEAKER_01 33:21

Like I thought if I was throwing a football, I didn't think that's what you meant.

SPEAKER_02 33:25

You know, like I'll have those conversations and I'm like, how about we just cast you just to like Yeah, keep protecting from yourself. Um, so but yeah, immediate elbow pain, golf golfer's elbow in the non-throwing athletes, pay attention to the ulnar nerve because sometimes it is, and you're throwing athletes, you gotta understand UCL injury, what type of stress will injure the UCL, get them with the right therapist because again, run of the mill, returning them to throwing, you gotta get someone who is experienced with return to throwing program. Um, flexor pronator strain, best case scenario. That's when it's not the UCL. But again, shut them down, throwing mechanics, um specific baseball rehab person, yeah, best friend.

SPEAKER_01 34:07

Sometimes. Sometimes, sometimes not. Um, okay, posterior elbow pain. A couple things going on here. I mean, we briefly mentioned VEO. Say easy. Posterior elbow pain easy. For the most part, I feel like it is. Now, how to manage some of these things? I'll go with the biggest two that that we see. So uh brief triceps tears. I think we touched on this a couple of weeks ago. Um, a distal triceps avulsion tear fell on it, weakness with extension, or can't actively extend their elbow. Those need to be surgically fixed, ASAP. So there's your treatment for that. Now you can also get like tendinopathic, partial triceps tendon tears, and we'll PRP those and um rehab them, and most of them do fine. Let's talk about elecrinomborsitis, though. I feel like that's super common and sometimes mismanaged. And this explained. I kind of hate alecrinon bursitis.

SPEAKER_02 34:57

Um, I don't hate it. I hate it in that, like, I will see someone, and you can see someone that has that. And I think urgent care providers that will send that over to us, if they have a really decent electrion spur, there will be a deformity there, but it's not always bursitis. Right.

SPEAKER_01 35:14

And that's hard to explain to the patient. Like I've had a couple of patients that are like, this side's bigger than this side, and I'm like, there's nothing for me to drain. Like, that is your bone.

SPEAKER_02 35:21

That is your, yeah, that is your contour. Yeah. Um, when it's bursitis and it's just, let's say, you know, I don't know, it's the older guy that just does a lot of work, even he works at his desk and just leans on his elbow all the time. Then you talk about draining it, right? Do you want me to aspirate it? If I aspirate it, do you or do you not do a steroid injection? I know Hannah's um I know Hannah's standpoint on this because Hannah has seen if you do a steroid injection and the patient's diabetic or they're not, that goes downhill pretty quickly.

SPEAKER_01 35:50

Yeah, I will not ever inject them with steroids. Yeah. Ever, ever, ever. Um, I saw one person come back from having, I didn't inject it, but they came back from having a steroid injection like a month later, and they were like, Oh, it's just like this something's happening to it. And literally the nastiest shit I've ever seen in my life is just like coming out of it. Yeah. Um, and yeah.

SPEAKER_02 36:12

Yeah, I I compare this to prepatillar bursitis.

SPEAKER_01 36:16

Do you get infected prepatillar bursitis like that?

SPEAKER_02 36:18

I will drain it, but I won't inject it. Yeah. Because they'll come back like super angry and infected.

SPEAKER_01 36:24

Yeah. That is the biggest issue with electro non bursitis. Okay. So if somebody comes in, they have a giant golf ball sitting on the back of their elbow, um, palpable effusion. Like, it's pretty obvious. Google a picture of alecrinombarsitis, uh, most people can't miss it. So um there is aseptic and septic. Um, and then there's also traumatic. So you can have just purely like normal yellow-colored fluid that fills it. Um, you can have an infectious alecrinomborsitis typically from like a puncture wound, or maybe they scrape their elbow and some bacteria got in and then it's filled with nasty stuff, or you land it on your elbow and fill with blood. Yeah. Um, so let's say they come in non-septic, atraumatic alecrinombositis. They want it drained because their elbow looks weird, and maybe it's like painful or uncomfortable from pressure. Um, you can drain them. You have to be super careful. I'm like swab these with like five beta dynasts and alcohol. Super sterile technique for these because I've seen them get infected a lot. The issue comes when they recur and they will sometimes like I put a compression wrap on it, sometimes sling them or even sniff them to try to prevent recurrence, but that burstal sac can fill right back up. So then the patient has an you know a recurrent effusion, they go to another urgent care the next week and they're like, hey, I got my elbow drained and it came back. And then this other urgent care drains it again. And then four weeks later, it came back again. They go to another urgent care and get it drained again. Now they're definitely infected. Yeah, they're definitely infected.

SPEAKER_02 37:59

Yeah. Um, it's one of those things that I would tell the patient, if we it's like a beaker cyst, right? If I aspirate this, there's a chance it may come back. And it may come back when you get to the parking lot.

SPEAKER_00 38:09

Yeah.

SPEAKER_02 38:09

That does not mean I'm gonna drain it again. Yeah. Right. Um, but I will wrap them and I will tell them over time it should get smaller. Yeah. But, you know, if you've got, you know, the guy or the the female that's super happy, they just wanted to know what it was, and you tell them it wasn't cancer. Sometimes they can walk out and they're like, oh my god, thanks. I will coexist happily with this lump on my elbow.

SPEAKER_01 38:28

Yeah, yeah. And I'm like, give it time, like it'll probably go down on its own. If it doesn't, it's bothering you, you know, significantly a while from now. Like, we can surgically excise the bursa. You may have a big bone spur on the back of your elbow, we can take off. People get fixated on like the bone spurs cause, you know, the association between the two, and they're like, oh, I have to have surgery for this because I just need the bone spur removed. And sure, if it's uncomfortable when you rest your arm, like, yeah, that's a a reasonable thing to do. Um, but just jumping straight to surgery for these or even straight to repeated injections is I hate more.

SPEAKER_02 39:01

Have you ever done doxycycline sclerotherapy on these?

SPEAKER_01 39:05

No, but um, one of the docs I used to work with does them for prepatellar bursitis? Oh, was it? It was something uh morale of L lesion. Yes, that.

SPEAKER_02 39:15

So I've done I've done doxycycline sclerotherapy on all those. Yeah. Um, and when you do that, you're supposed to inject doxycycline into the aseptic, atraumatic uh elbow bursa, and then you pancake the patient. Right, you like make them turn on their side. So it's 15 minutes, let's say they're prone, 50 minutes on the left side, 15 minutes supine, 15 minutes on the right side, and then I mean it's an hour, right? They're in your exam room for an hour, and then after that time, you aspirate, and it should, it's supposed to kind of um deliquefy the bursa. I would say, I don't know, maybe 75% effective enough where I would do it again.

SPEAKER_01 39:53

Yeah, like that's a good thing to try. Yeah. What I I would be curious, like, how does the doxycycline affect the triceps tendon or like I would think you'd be superficial enough, but I mean, at the time, doxycycline was on back order and I couldn't order it.

SPEAKER_02 40:11

So like I feel like there's always a reason. Yeah, we don't know a ton of that. But I would say probably 75% effective, um, recurrent, atraumatic electroumber cycle.

SPEAKER_01 40:21

Yeah, because I was actually thinking of that like four or five years ago, we had a patient that had a cyst and it was 10-inch heath from a like a recurrent trigger finger cyst, and it just kept coming back, like kept draining it, huge problem. Um, I think we like went in two or three times to remove this, and he just kept coming back. That's super annoying. Yeah. So I'm like, do we doxycycline this? But like, how does that affect the flexor tendon? Like, is flexor tendon gonna scars up there? Like the whole or yeah, like will it work on its tendon.

SPEAKER_02 40:52

It's supposed to scar the tissue. So if you think if it's just clear-cut bursa, clear cut cyst, the cyst or the bursa walls will scar to each other. Yeah. So let's say, in an attempt to get rid of the cyst, you now scar up the tendon. That's not an ideal. Now you're off. Yeah. Um but again, they don't teach that in school. Like that's something like on the job.

SPEAKER_01 41:12

You're like, oh, that's what we're talking about right now. We don't yeah. Um, let's end on anterior elbow pain, something near and dear to our hearts. Very near and dear. To our weeks.

SPEAKER_02 41:23

And there's not a lot of stuff that lives in the annual fossa. So like it should be easy. It should. I think what is confusing sometimes is when you think it's a distal biceps injury or not injury, but it's really brachialis, you know. Yeah, because everybody's yeah, everybody thinks that that biceps will is your main flexor of the elbow. It's not, yeah, right. I mean, that's um, I've seen a lot of um radial head, distal biceps bersitis. And in the ultrasound course that I've taken in the past, like, oh my god, yeah, you can inject that. Hello? Like, yeah, it's so deep. Yeah. First of all, second of all, radial nerve is kind of right there, and all your vasculature is very much right there. I don't know that I've ever done that. I've ultrasounded it and seen, like, you know, like the textbook shows you if you have them pronate supinate, you can see that bursa rotate. Yeah. But that's like that's ballsy. Yeah. It's ballsy. I did it once.

SPEAKER_01 42:14

Um it was ballsy, and I was like, it's just and they said it helped a little bit afterwards. I don't actually, I I don't know that that was what was contributing to this person's issue as much as some other confounding things. But um, yeah, I used ultrasound and have to. I mean, I basically just I I mean, yes, I used ultrasound to localize it in, but more importantly than anything, it was more like, are you feeling any shooting nerve pain while I'm doing this? Maybe you sure amount around that. And like, let me aspirate before I do it. And like that, those are the things that made me feel safer about it than the ultrasound alone. But yeah, so distal biceps ruptures. I think you're always safe if you're concerned at all. Just get an MRI. Yeah.

SPEAKER_02 42:54

Stat MRI for distal biceps, and you'll see a defect most of the time if it's like an acute full thickness. But the tricky ones, like the tennis elbow, is the partials, like someone who's had pain for a long time or someone that felt a pop, but there's no deformity, but all the tests are positive. So, what do you how do you educate those patients? And I remember how we used to do it because we send most of them to you guys now, but like when they have a di when they have a partial tear, hey, we can go in and fix this, aka detach what is there, which is probably bad tissue, debreed it, and then repair it. And then now you're you're like a you know, post-op repair. Or if it you leave it alone, if it fully pops, you call this immediately.

SPEAKER_01 43:35

Like I mean, that's pretty much the same thing. It's like a ticking time bomb. It is, yeah. And so either I think of these as just non urgent surgical patients. You know, most of them, if they have had a chronic enough issue for a while that it's bothering them, they do want to fix it, but it just doesn't have to be at the same level of urgency unless they feel that last little pop that gives, and then it becomes a little bit more urgent. Um but yeah, I mean it's Basically, just telling them, like, hey, at some point it's probably gonna give on you. We need to fix it. If it does, if you want us to just take care of it now because it's a more convenient time for you, we just do it.

SPEAKER_02 44:11

Um, and then distal biceps, if you're worried about it, regular MRI. Uh UCL, if you're worried about it, arthogram. Yeah. That's that's a a good um definitive test because if you send them for a normal MRI and we have to send them back for an orthogram, that's never a pleasant conversation. Pronator syndrome, anterior pain. Yeah, pronator syndrome. Yep. Um, back to distal biceps because I'm living this life right now. Do you fix all of them?

SPEAKER_01 44:38

Uh, you don't have to. I feel like we fix the vast majority of them. My conversation with people is typically like, hey, this isn't gonna kill you, obviously, right? Most orthopedic things will not in our elective procedures, but you can very much live without your distal biceps being attached. You only have one tenon insertion there, so like you will not have function of it afterwards. Will not be attached if it's not attached. So you will have some loss of function with it. Now, will that level of loss of function affect you? It that varies person to person. So, like, if you are not super active, an older patient, you know, non-dominant arm, all these things, like you really don't have to get it fixed. Um, I don't even know if I tore mine, which it's not super common in women. Uh that's another thing.

SPEAKER_02 45:28

Yeah, I had an I had an um urgent care provider come up to me the other day and she's like, Oh, this lady, you can very clearly see it's her distal bicep. I'm like, it's not.

SPEAKER_01 45:35

Yeah. Yeah. It's just I've never seen I've never seen it. I've never seen it. I don't know why. But if I were to be um, and I'm sure I wouldn't be the first, but if I were to be the first woman to tear their distal bicep. I fully support you. Would I fix it? I don't know that I would personally need to if it were my non-dominant arm. Would I fix my dominant arm? Like, I don't know. It depends on how old you are. If you ever have to be able to do it. If I was like now.

SPEAKER_02 45:59

And you're still lifting. The answer is yes, you would.

SPEAKER_01 46:01

Yeah, I guess. But like it's more that supination, repetitive motion than elbow flexion. Like, will you still be able to bend and straighten your arm without a biceps? Yeah, absolutely. Will I look like I have a beefier, more jacked bicep if I just left it alone? Also, yes. So, like, could that be a reason to not fix it? Maybe. Maybe, yeah. Maybe I just want to like look like I'm super like Popeye. You may enter that point in your life where that matters. I'm like, yeah, this is aesthetically a better option for me. Yeah.

SPEAKER_02 46:28

What if somebody like went in and surgically had their distal bicep tendons cut just to have so I I have had patients who have torn one and they literally cannot wait to tear the other one so they look like similar.

SPEAKER_01 46:39

They're like, It's like proximal too.

SPEAKER_02 46:41

When they tear the proximal one, they're like, oh man, I can't wait to tear this other one so they look like equally jacked.

SPEAKER_01 46:45

So this is something to keep in mind though when you're thinking about biceps tears, distal versus proximal. Um, if you tear your proximal bicep tendon, obviously you would typically have more shoulder pain, more bruising around that area. Um, it's painful maybe in the moment, but then it typically resolves. Think about like which direction it would retract based on what your level of concern. Typically, the patient is gonna tell you, I felt something happen in my shoulder versus I felt it happen in my elbow. But if you're unclear because of that, if your distal biceps tendon uh retracts, the muscle is gonna roll up more proximal. If it happens the opposite way, it's gonna roll more distally, it's gonna go towards the point of attachment.

SPEAKER_02 47:26

Uh but it but I mean, we say it like that, and you're like, oh my God, yeah, that's easy. It's not though. Sometimes you see it in person and you're like, what am I looking at? Yeah. But yeah, elbow, I mean, when we talk about it now, like I feel pretty good about it.

SPEAKER_01 47:38

I I yeah, I think that the elbow doesn't need to be as complicated as we make it sometimes.

SPEAKER_02 47:41

I think um missing the diagnosis is bad. I think if you think the only things that exist in the elbow are mitochondylitis, lateralchandylitus, lacronbritis, and your triceps, you're missing all the other things. So many other things. So many other things. So I think on the list of things you guys should look up if you're like, wait, what? Um uh radial head instability, the lateral ulnar collateral ligament, um, pleca syndrome, capitellar OCD. My daughter had that, very rare. Um, and she ended up having surgery. Um referred cervical pain presenting as a lateral bocundilitis. Yeah. I see that a lot. Yeah. Um, especially in our shoulders that are stiff shoulders, when they're trying to get the range of motion back, they are limited by their lateral elbow pain, which is usually some manifestation of some sort of mechanical thing. It's like a mechanical overload thing. Interesting. Um, inflammatory arthritis. I will see that enough where they present with an effusion out of nowhere. Um, so that's another one of them. Rheumatoid type thing. Yeah. Running blood work on those patients.

SPEAKER_01 48:36

Um but yeah, I think we did a pretty good thing. I think so. This was very insightful for me and hopefully for you as well. Yes, all of you. All right. All right, until next time. Bye.

SPEAKER_02 48:56

Thanks for tuning in to Joint Effort PAs. If you enjoyed this episode, be sure to subscribe, leave a review, and share it with a fellow PA or med-minded friend. You can also follow us on Instagram at Joint EffortPAs for updates and extra content. See you next time.