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25-year-old with right shoulder pain and

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decreased range of motion for seven years.

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History of labral repair eight years ago.

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So a young and at 25 years of age.

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Okay, this time it's a little bit intimidating.

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All the images that we have, we have

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pre-contrast and post-contrast imaging.

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And, um, let's take a look at what we've got.

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I think we'll start with the axial this time.

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So the first thing I look at on the axial, and when I have

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a lot of images like this I usually will start with the

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axial just to get my feel for the shape of things, you know,

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does the humerus not only does it fit into the glenoid.

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And these are very simple but valuable things that

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you guys can extrapolate from CT and from radiography.

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How's the humeral head sitting in the cup.

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In other words, is the center of the humeral head right here,

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centered with the center of the glenoid, and it's primo.

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It's perfect.

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So then we scroll up and down, and I look at the shape.

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This happens to be a gradient echo, not particularly, um,

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effective for tendons, but I look at the tendons anyway.

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Um, why isn't it effective for tendons?

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It produces a lot of gray signal

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due to magic angle effect or the 55.

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4-degree artifact or the anisotropic

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phenomenon artifact with a short TE.

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So, but but I do use it for cartilage, and I

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can see the hyaline cartilage pretty well.

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In fact, this little gray slit here, you see cartilage

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on one side capsule collapsed, and then cartilage on the

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other side so you can really get into the joint space.

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joint mice, loose bodies.

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This is really the role.

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Articular surface evaluation for the GRE.

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What else does the GRE, uh, help you recognize?

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Well, first, what is, what, what does a GRE look like?

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Well, the muscles appear kind of shiny.

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The cartilage, and if there's fluid, is

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white, and the bones are typically gray.

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case all the fat will be black.

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So that's one way to identify a GRE.

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R.

2:27

E.

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Another way to identify a GRE.

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R.

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E.

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Is it says T2 star T2 asterisk and then it says G.

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E.

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Not for general electric for gradient echo.

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So that's another easy way to figure out it's a GRE.

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What else does G.

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R.

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E.

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Do it shows you calcium It shows you blood.

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It shows you ossification.

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It shows you metal.

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So let's scroll up and down and see if we have

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any blood ossification or metal or even iron.

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And we don't until we do.

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I'm gonna give you five seconds to identify it right there.

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There's something up there that doesn't belong.

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So right away, we haven't even looked at the case yet,

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and we have come up with a diagnosis in a 25-year-old.

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Now you might say, well, how do you have a diagnosis?

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Well, is it a hematoma?

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Well, why would it be a hematoma

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in a 25-year-old with that history?

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Plus there's no soft tissue swelling.

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Ossification, I suppose it's possible,

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but pretty rare to ossify spontaneously.

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Um, you know, you can get conditions that give you

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ossification, um, like heterotopic bone, often from trauma.

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So that wouldn't make a lot of sense.

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And, um, you're pretty much left with it being

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something common, so-called calcific tendonitis, which is

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really known as hydroxyapatite deposition disease or HADD.

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Now I don't want you to go off half-cocked and call

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this pseudo gout because this is not pseudo gout.

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This is just trophic calcification from impingement.

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And how do you get this kind of impingement.

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Swimming.

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When you're stroking, when you're overhead and you're

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in the finishing position of either freestyle or

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butterfly, you are in a position where the anterior

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shoulder comes in contact with the anterior acromion.

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Let's keep going, shall we?

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I have one coronal T1 and you can see somebody went to

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great lengths in this study, none of which was necessary.

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I don't do a lot of arthrography I do about five of them a day.

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That's five out of maybe 100.

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And the main reason I do it is to appease the clinician.

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I don't need it.

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So here's your T1.

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I'm going to put up a sagittal non-contrast.

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T2.

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So the T2 looks a lot like the GRE that you saw earlier, but

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the muscles are a little duller and the bones are also duller.

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And you can tell by looking at the parameters,

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the TR is very long and the TE is 60 or above.

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Whereas the TE in a gradient echo is very short and then

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you look up here and it says T2 FSE with fat suppression.

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So now let's scroll around and see if we can spot our

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calcific tendonitis or hydroxyapatite deposition and we can.

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It's right there on the coronal T1 and

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right there on the sagittal, sagittal T2.

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So Now, some of you are wondering why this

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coronal T1 doesn't look like this coronal T1.

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And that's because many people will choose on their

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arthrographically injected studies to fat suppress.

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So this is a fat-suppressed T1-weighted

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image, which makes the fluid look white.

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It also brings forth hydroxyapatite deposition.

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I like to perform a pre-injection

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image and a post-injection image.

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The reason this is only a post

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injection image is economics and time.

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When you get really sophisticated and you've done a lot of

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these, you can probably omit the pre-contrast injection.

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I've been doing this a long time.

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And the reason that I still hold on to that is because after you

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inject, you cannot tell what is swollen and what is not swollen.

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So if you have 10 or 15 different findings, And

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you're trying to figure out what is the critical

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finding, doing a post-arthrographic injection

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only can obscure where the real swelling is.

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So now, another comment that was made by one of

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your colleagues, is that there was loss of bulk of

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the anterior inferior labrum let's check that out.

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we've got an answer, an appropriate

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answer in a swimmer and a 25-year-old.

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And I don't mind if the anterior labrum is a little flat.

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That's a normal variation.

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The labrum can be flat, the labrum can

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be round, the labrum can be pointed.

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So this is not evidentiary of any type of labral pathology.

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You can see the inferior glenohumeral

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ligament right on top of it.

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Beautifully.

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And as we get down low, it becomes

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the labral ligamentous complex.

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Yes, there is a paucity of labral tissue down low.

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That is normal when you get into the axillary space.

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As you come up, it gets strong in the anterior quadrant.

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Look to the right here.

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You can see where you are in the humerus.

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You're in the inferior quadrant.

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And now you're about at the equator.

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Maybe a little bit above the equator.

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Um, actually you're at the equator and

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still a strong labrum still very strong.

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And then as you get up high sulcus, and

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then you're back to the superior labor.

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Now another way to tell that that is not

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pathologic is no contrast is going into the labor.

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None whatsoever.

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There might be a little scar right here, but

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that's probably all you could say about the labrum.

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Let's look at the labrum coronally.

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As you come forward, you got a pretty big sulcus in the front.

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And as you go back, I would say at the sex a little

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bit so I would not object to someone calling

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this some minor fraying of the superior labrum.

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And some of you might be saying well how do you know,

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there are exceptional times when the only answer is

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going to be to look in there and see if there is.

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hemorrhage or inflammation.

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Otherwise, it can be very hard to tell if you are in the mid

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coronal plane and you still see this little bit of fissuring.

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Now, I'll tell you that in swimmers, it's very common to see this

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kind of minor fissuring along the undersurface of the labrum.

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And as long as there isn't clicking and you

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have another answer, then you can play it down.

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This patient did not have arthroscopy for this.

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She had, um, barbitage for her calcific

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tendonitis or had, and she did just fine.

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She was asymptomatic thereafter.

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Um, let's see the rest of the comments on this case.

10:14

Moderate AC joint arthrosis.

10:18

That is way too strong.

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I will say that no person over the

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age of 30 has a normal AC joint.

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It just wasn't meant to last that long.

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But I think for the patient's age and their

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activity level, this is a normal AC joint.

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There's nothing wrong with it whatsoever.

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And somebody read subacromial bursitis.

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We'll have to look at our water-weighted image for that.

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Here's the sagittal water-weighted image.

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There is a little bit of fluid there, so I, I

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wouldn't dispute that there's some minor bursal

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swelling right around the coracoacromial ligament.

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So I'm okay with that particular statement.

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This is just normal wear and tear.

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I don't really get excited

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about the AC joint unless the patient has erosions, capsular

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distension, edema of bone, or it's the only thing on

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the image that explains the patient's clinical syndrome.

11:20

For a repetitive overhead athlete, this is a normal AC joint.