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Just send the link to the uh. Mhm. Hi, everyone. Can you please put in chat if you can hear me? Hello? Mhm. Uh please, could you write to text in the chat if you can hear me? I don't, I'm not sure if you best can hear you or not. I can't see any messages. Hello? How are you? Oh, that's a familiar name. I, I think I remember you from our previous session. Hi. You're just going to wait for three more minutes or like a few more minutes and then we'll make a start. Just an introduction. You like the other uh presentations. We've got a few cases to go through and this is going to be our last session of MSK A series. Well, probably just to save time, we'll just go through the objectives quickly. So this session we're, we've got a bunch of cases of opera limp injuries. We've got a few nerve injuries and we're just gonna go through the presentation like the case like always and then you guys can help us reach diagnosis and doctor sorry will tell us about the medical management and investigation side of the things and add some clinical relevance to them. I've got some pictures to help you with the anatomy side of the things as well. In case if you guys have forgotten or you're not sure about the specific anatomy that you're talking about. Uh, it's gonna be the disclaimer page. So everything that we're going to cover today is basically just a supplement and we're going to supplement your medical education with this. This is not to replace your formal university teaching material. Um I'll just jump into the first case. Um, doctor, sorry, if you're happy, I'll start the first case. You know what kind of stuff. So for the first case, we've got a young gentleman presenting to the E T, uh he's got stabbed in the posterior thigh. Uh and uh we've managed to get an MRI of him, uh which is lucky and uh there it shows this tab track uh the nerve that we're going to discuss. In this case. This case is a bit obvious. This is the easy one to start with. And if you look at the symptoms, uh he's experiencing some numbness and weakness uh in the foot and uh he's got foot drop as well and weakness in the flexion and extension. So I'll just hand over to doctor, sorry to your take over this case. Okay. So this case is a quite obvious case, we will speak about sciatic nerve and the sciatic nerve course and what symptoms it's caused by injury So, in this case, it's quite over because of the start injury. And the star track, you can see an MRI creating closer the sciatic nerve. So what's the reason of the symptoms is I think it's because of sciatic nerve injury. And we can now start of speaking about sciatic nerve, sciatic nerve is the largest nerve in our body. It comes in the posterior side, it originates from the lumbosacra from L 523. It has motor and sensory function. Uh the, the nerve itself, it doesn't have any sensory uh side department. His sensory is indirect way by its branches, motor, the same thing, it will just apply for the muscles and the posterior toy and it will go in directly to the lower legs. So if we speak about it spot, it will enter from the thigh region, it will enter into the gluteal region by the greater side experiment. And then it will leave from below inferior and medially to the piriformis muscle. Uh If you can move to the second slide, they will see it. Yes. If you can see this muscle, this is the piriformis muscle. That's the entry. When he will go, when the nerve will enter the side, then the middle time he will go into the long head of the biceps, then it will end and the uh the apex of the popliteal fossa, that's when it will terminate it two branches which is the common fibula or common peroneal nerve and the other one was called the tibial nerve. So why the sciatic nerve is important? It has its injury can cause radicular pain, numbness over its course, uh like weakness, weakness in the plantar, under destruction of the foot. All of these are important. So we if we speak, where is the course of injury? It can be a direct trauma like we see in the special stuff injury or when I am injections. If you know that when we give the intramuscular injections in the buttocks area, we divide into four areas. The safest area is in the upper lateral area, upper lateral quadrant, because then there will be running in the medial, lower quadrant. That's one side of NJ the other side, which is we other thing that we are interested in is sciatica. Sciatica is not a disease, it's a symptom. So whenever the patient has a sciatica, which be the radicular pain, numbness and weakness, shooting pain in his leg, usually unilateral, that's called sciatica. Now, we need to find the cause. There are could be two causes of sciatica. One of them is the disc herniation at L4 L5 lumbar disc herniation would cause in accomplishing sciatic nerve causing the patient having the symptoms or because of the compression by the muscle, which is the piriformis muscle. They called us Piriformis syndrome. Usually with the uh with the people that do cycling a lot with bicycles, they will strengthen this muscle and they will cause compression or inflammation of this muscle. It will cause compression on the nerve. So you are an E D, you saw the patient will say like near the first thing you need to rule out is discrimination. And that's when we do an MRI, we rule there's no discrimination. Then by exclusion, we will say okay, this patient is having performance muscles. We can do some physical examination like state like test, we will stretch of an air or we can do uh flex it. And we do, we do internal rotation to do extra pressure on this uh by the piriformis muscle. We try to special but internally rotated the hip. It will cause a pressure on the nerve, it will retain the nerve and cause the patient. And that's when we know that this patient having Piriformis syndrome uh treatment for okay. We can suggest quickly for treatment if it was performance or sciatica. When we treat sciatica, we're treating the cause not sciatica. So there is a disc herniation. We're going to treat finance. It's an acute economy. We need surgery or we leave it conservative. If it's piriformis muscle, the same, we could just an essay, uh steroid injections. If these are failed, we can move to the surgery and we do a release performance maxillaries. Yes, we kind of, you know. All right. So the next case is a 40 year old male presenting to your clinic at yours. Really clinic and uh, they're having difficulty walking. And, uh, you do a Trendelenburg test and, um, and you find that the, uh, they've got not only the Trendelenburg Gate, but uh the Limburg test is positive as, as well for the patient and in the past medical history, they've had a surgery. So what do we think is going on? Look, I think, let me explain this. Uh, so trundle trundle Berg sign or Tranda, their tests, why we do it? We do it is just to assess the gate and the imbalance of the hip. So let's start from the origin of the story. Patient having these symptoms. You will think about what's causing the symptoms is usually by a near. So we have the lumbar sacral area. There is one important there that side it done. The other one is important is the superior gluteal near which also rise from the posterior horn of L4 L5 and S one. So the important of this muscle, it's uh this nerve, superior gluteal nerve that supplies three muscles. Two of them are the hip and hip abductors, which is the gluteus medius and gluteus minimus, gluteus medius muscle. It's the hip up just the main muscle that attacks the hip. So another one is the tensor fasciae latae. So you can see this uh okay, there is no for the gluteus me. So muscles, the gluteus medius, gluteus minimus, these two muscles, there are the hip abductors of our. So whenever there is injury or weakness in the near or in the muscles tender back would be positive. So let's start with trended birth sign. That's what tranter birth test. So usually it assessed the hip uh stability. So if the both hips are equal, not. So when we stand on both legs, we have our weight equal going into both legs equally, our weight is distributed. When you stand in one leg, let's see on the right leg. Usually if this muscle is function, it will abduct the hip to balance the weight. So you can see on the B image it is in the same. The both Elvis is in a straight. Elvis is not tilted, it's a straight way. That's the muscle is functioning because he's standing on his right leg, on his left foot. So all the way it is on the left book and with the help of help of the hip hop doctors, bloodiest Medius and gluteus minimus, he will have a spell the straight. However, if the patient has injury in the uh if the patient has injuring the muscles, muscle flashover is has uh tear in the in session of the gluteus medius muscle gluteus minimus, which they are inside in the greater for contract of the femur. So if they have enjoying these muscles in these areas, the rental back will be positive, which means you put the weight on your left leg. What will happen? The muscle is weak, it cannot, it cannot compensate for the weight and help with the patient weight. So what be patient pelvis will tilt away because they can, this muscle is not functioning. So it will not spread because you're putting weight on this one. Usually it goes this way because of this muscle is functioning, it will spread the pelvis. Now, this muscle left muscle is not functioning and putting weight on your left leg. What will happen is the pelvis will run away. We'll escape that will tilt to the right side. What will the body react because of the center of gravity? Now is moving and the patient, his pelvis is tilted, he will furl on his right side. So what the trunk will do is it will the patient will tilt his trunk to the left side. So you're having to movements, the pelvis will tilt away and the truck will tilt to the side of the injury. So on the image, a a you can see the patient standing on his left leg, putting most of the weight on his left leg has left gluteus medius. It's not functioning either because of current sensation either because superior beautiful nerve is not functioning, weakness of the muscle, whatever is that cause we have the deformity in that muscle. So the pelvis is tilted to the right pelvis is escaping the weight and the front is tilted to the side of injury, which is the left side. Uh everything is clear of trundle Burke test and why we do it as its importance with the muscles. Any questions so far? Okay. Uh Should I move to the next case where? Uh yeah, but that's my, I just wanted to make sure that you understand uh Kendall Burke and what were functioning and how something we can move to the next case. There's no questions. Uh So for the next case, it's a card kind of the similar presentation. Uh So we've got a patient this time complaining of uh difficulties, time being up from a seated position and climbing a stair due to weakness in his uh like and when you examine them, there's a bit of muscle HRV in the gluteal region. And uh they've had a hip surgery as well two years ago. Again, this is sort of uh same sort of problem. Can you guys guess what's going on? We have a patient who has difficulty standing up from sitting position, has difficulty climbing the stairs. He has obvious muscle atrophy on his right gluteal region and has history of injury surgery with or without any surgery. So these things will uh try to think there's something going on in the gluteal region. So I'll go start with it a few more feel. Secondly, this is an inferior beauty, inferior, beautiful nerve injury. Uh This is the inferior gluten, superior gluteal nerve. It will. So we have three nerves coming to important sciatic nerve, superior gluteal nerve and inferior gluteal nerve, superior gluteal nerve. We discuss it which is the hip abductors, which is the patient the way to balance the pelvis imbalance. That's the Trendelenburg fine Trendelenburg Gate, which the superior, which supplies the gluteus medius uti S minimus, that's superior gluteal nerve. The other one is the inferior gluteal near which supplies the biggest muscle in our bloody regions with the gluteus maximus, gluteus maximus, it's the muscle that's function would hit extension and hit up the external rotation and extension. So whenever he's trying, getting out of bed, whenever he tried to climb, getting complete position, that's the biggest muscle. She's the most superficial muscle, the bloodiest maximum. So the obvious atrophy of the muscle, it will be obvious because of the gluteus maximum, they will have a specific gate for them. They said the gluteus maximum gate, what will happen in the patient? He cannot extend his head because the muscle is after a fight, it got extended fully. So what he will do, his trunk will lean backward and he will try to flex all the way hip up and he will, he'll strike to the ground, then he will move. So he will take him. So whenever he's trying to move forward 30 on the right side, so I will get my leg up, I will lean my back like backwards. Micron going backwards, my foot going up and I will strike the ground with my here to move on because the function of the muscle that is responsible for exit extension and external rotation, which is our movement, it's gone. It's not functioning, which is the gluteus maximum. So we have two things either imbalance, left on sideways, right and left. That's the superior gluteal nerve, which is exactly the gluteus, medius and gluteus minimus or the patient. Whenever he's moving, he will lean backward, get his foot up and he will struggle a ground with his hip moving forward. That's like anterior, posterior position. That's because of the gluteus maximum, which is responsible for the hip extension and external rotation, which is our daily movement. Is it clear? Now, the difference between superior and inferior gluteal nerve and the two different gates, Trendelenburg and the gluteus maximum gate. So uh two years, it's not like huge way that happened. It's either like the same, the same causes for the three sciatic or superior diluted or inferior beauty, either at the disc herniation at the site that causes or direct injury like stopping injury or any diet injury. To this. This one, he has a hip, hip injury, hip surgeries and hip stages. They usually didn't miss by mistake, the injured, the nerves, they did stop tissue injuries, they did around the areas, the injured. So the special, he had a history of hip injuries in two years. Then they hit the nerves within these two years. He's having this difficulty, the muscle got atrop, I'd now he presented. So it's just showing you there is something injury happened. This is a traumatic cause that causes muscles to atrophy eye on the the innovation that's why he's presented now with us with this gate and the severe muscle atrophy because muscle atrophy, it will not happen quickly. It will take time to happen such as a big muscle as a beauty is maximum. It is the biggest muscle for this muscle to get a tra fight and it will be obvious it will need time. So that two years is in roughly, just to show that there is a hip, the hip surgery, there might be an injury to your okay, in that case. Uh So you've got another patient this time after a day, I understand the younger gentleman who was playing basketball, uh while playing, uh he put his foot in a bad position and turned basically twist, twisting his uh knee and he injured it. And uh he reports that he heard the popping sound when that happened. And uh when you can't see him, you see the joint, the joint is really swollen and it's very tender. Uh uh the medial. Uh Yeah, and there's, there's a medial uh swelling as well and you've got the MRI here as well to help. So this is a very common, you know, very common presentation. We say it patient playing either football, rugby, whatever sport he was playing, he stand on his knee, twisted his knee he hit a pop and after that, he can't wait with the pain. Yep. So they are quite right answered. Media, whatever ligaments, three of all three of them are kind of. So, uh most of you are right. There is an could be ACL tear, medial meniscal tear, medial ligament to uh meniscal uh torn meniscus. They are all right. The when you see the patient intake history, they usually they have uh severe meniscal good. The patient will pop sound, uh severe pain, he will be unable to wait where he fell down. The swelling start to develop for the minute and it will come to an E D. So you see him, you do physical examination and uh and Roberta, Roberta, they will be positive. Uh You do the valgus and varus stress to see the SSD ligament, they will be positive. And then you can do X rays to check if there is any fractures. Then you do an MRI which is the absolute 12 diagnostic, all the standard diagnosis. So this presentation, this station has all three. We have a C L injury, uh medial collateral ligament injury and medial minister injury. So imagine this patient, this patient has a huge Pulga's trust that it will put a lot of pressure on the media side. So we had first of all media collateral ligament tour, then we put extra pressure on the medial meniscus because all that stress on the ligament is plastic destroyed. The ligament and there's extra pressure on the meniscus, medial meniscus also that cause uh pressure on that as well. Cause it medium methods here. Then the ACL is like 90% of MCL tear. It will have an ACL tear. So the patient, there is a name, there is a name that we call. The patient presents all these torn off ACL, MCL and medium because we said that unhappy try. Uh as we said, and there's an a triad, like we said in the terrible triad and the elbow and then the there's an unhappy triad. Well, the patient has all three ligaments torn out because of the huge strong valgus trust. Usually with the patient's uh playing rugby, patient's playing uh football, any kind of game they will have this and an injury. This is a quite serious injury. So usually if it's only a CL or a meniscus tear or MCL, we can go depending on the tiers that create partial sometimes will conservative and see this one probably will need surgery. He need uh meniscus tear surgery. You might also need an ACL grass need uh cll repair. So whenever we have all these three together, we call it as an unhappy triad. And with any knee injury, you need like this unhappy, try it or there's any dislocation, we'll discuss it earlier. Uh Any new fractures, you need to check for Safina's Venner, you need to check the artery popliteal artery around there. Neurovascular tea, okay. You can move to the other countries. We'll move to the next case. Uh So at this time, you've got a 35 year old gentleman uh coming with pain in the anterior part of their near and uh there's a bit of swelling as well. Uh He said that he was kneeling uh for a long time and we, we get an X ray and on the X ray, this is what you can see. Um Do you guys want to because we've been through a lot of x rays. Do you guys want to take over this one and describe what you see? Imagine yourself. You are the sexual on call and us in this case with this, with this history and they, you ask them for images, they did images, they send you these images. What you are thinking of when you go to this case, what are you going to do? Anyone want to join the stage? Anyone wants to type in the chat. I'm happy with whatever you want. If you've got any brave volunteers, you can just uh say, and I can bring you invite you to a stage so you can just go through this and tell us I want to know what you're thinking, what your differentiations. We discussed something similar. Wonderful previous. Someone took them with knee pain, sweating, he came to reduced range of motion. There is something emergent you need to think of when you're going to see this patient. Yeah, always concert septic arthritis. So you have this patient, knee pain, swelling. The first thing is septic arthritis. You will be the, that's such a phone call. You will tell the doctor don't keep the patient antibiotics, giving the patient not by month, send for bloods and do an X ray is we are coming. That's the things you need. Uh tell the E D send for uric acid. It could be the result or gout. So you send all the your blood if your X rays don't give the patient antibody because if they give antibiotic and you took the blood culture, which will be useless because you can't see the bug that's causing the infection. It is infected. So don't give antibiotics. Keep the patient know by mouth if you went there. And so it's a tick bite. You might cause theaters. Now these things you need to give it for all deep pain, swelling. Then you go to see the patient, we went there to see the patient huge German on see the swelling hubs, the swelling, uh tenderness on the joint line. That's very important. Septic outside is they will have severe tenderness, unbearable tenderness. Like when you touch it, it was cream of pain. Others they will be there is slight tenders but slightly bearable. They can OK. That's fine. The swelling will not be red case, uh septic arthritis will not be that red. So we less red. So the station had pain, swelling produce a range of motion, all the things they were thinking okay. Which one could be? You went there, you saw the patient, the swelling was over the super Patil er, area, localized that area, okay. Uh slight tenderness over the joint area like hotness. Okay. I'm thinking this could not be a skeptical that is smaller than the other thing that bursitis. You do a aspiration, you send it for the last test to check in. Once you do the aspiration, the patient will improve symptomatically, it will be okay. That's fine. Okay. This is not subject bursitis. So as we said, what is birth uh versus the fluid that for the traction over the nick up against the skin, it can happen over different areas to patella, patella. You have low bursitis, suprapatellar, pre patellar, infrapatellar or pop. Yes. With the history of kneeling, they will give you a d they will not tell you history of needing any refills. They have no history. That's why you will dig up in the history. And uh for previous history of any infection that could be gout, pseudogout to be an acute care of God's. You ask for occupation, especially in the leg. It has another name for good side of it of the house made me patient with occupational has a lot of need uh needing on his knees that will cause traction, that will cause inflammation could be uh infection like a bacteria infection coming on the Procida causing this inflammation treatment. You can just leave it and I say I always can do aspire ation aspire. Asian Sense for gram stain and culture. Whenever you aspire, it just send it. However, if you are thinking of septic arthritis or you're not sure. Uh and there's a swelling on the skin, do not put the needle in there because you don't want to introduce the infection, the bug into the joint. If there is no infection, the joints not septic arthritis and you went and put the needle in the joint and you aspire it, you are risking losing the joint because you introduce the infection on the bug in the joint. That's why you consider speaking to the seniors. So this is bursitis. That's what we do. That transection usually uh self limiting with an estate, antinflammatory eyes, putting eyes innovate uh and it will heal. Usually we do aspiration just for pain relief and they will improve symptomatic graft but the aspiration. Okay. Print. Um uh huh. We've got the real case scenario here. One of them uh Katrina mentioned active, okay. Uh We're going to the next case if you're all happy. Yeah, I don't think they're any question. Uh Case number six. Yeah, next case. Uh we've got a lady coming to our clinic to uh to be the clinic and uh she's got a mass behind her left knee that's been getting bigger and she just, she's worried about that. That's correct. Complete. It'll system you guys are amazing. Should be all orthopedic. Okay. Uh Yeah, publicly assist. So what is this? We know it's a fluid filled. Uh It is all the usual. It is their their it has a connection while connection to the joint usual. It is on the posture of the medial condyle media, female condom. It is there whenever there is a pathology in the need. So uh the arthritis, uh meniscal tear, usually medial meniscal tear, uh any inflammation around the knee, it will cause this fluid to increasing amount and it will go through the vault because of the pressure and there is increased. So it will push the fluid through the vault. So one way vault into the system, this is the start to get bigger. So the patient will come to doctor, I'm having this uh system on my back. It is painful uh is bothering me. I can't say so whenever you see the cyst, okay, put one of the DBS in your head. That could be a tumor. It's not always that could be a a pretty assist. So you see the patient, you examine you best way to see the sisters to fully extend the knee. You put the patient on his belly and examine the knee from back to back. What fully extended me, you will see the system there. So whenever you are sure that is assist, you do an MRI, why we do an MRI, we need to check the intra articular astrology. If they're connected to the intraarticular, not connect the joint. If it is connected to the joint, does confirm my diagnosis. There's a possibility and it's just all you can do an ultrasound. Ultrasound is also helpful. If it's not connected on there is a mass going there, you need to investigate more. Other said it could be a tumor, it could be something else going on. The a test, usually conservative treatment. If you're gonna say either I give some exercise for the patient. If not improving, emphasis is big in size, we go there on a spirit basis. But aspiration is, it only will treat symptomatically because we are just leaving the pressure that main pathology, which is whatever going inside any information, arthritis, meniscal tear, it will keep building up the fluid, it will keep forming and uses. That's why we need to treat the mink of this, uh which is the main cause causing it. It's just there will be in the knee arthritis or anything causing it. So, aspiration is just a temporary relief. Okay. Okay. Can, yeah, almost to the next case. Um, this time we've got another athlete and at our clinic, uh this time, uh 24 year old female uh runs a lot presents with four week history of worsening pain along uh the inner part of her left shin. And uh this is started after she increased the running distance, she's pushing uh harder and harder and the pain is described as a dull uh that started during running and when she rests, it gets better and she denies any sort of trauma or anything like that. Oh, also she's got a flat feet and her footwear are not good just to make things worse. Okay. Stress structure transplant. Okay. So given this history, giving this presentation for education, usually they present with pain. Uh she's a runner. She increases the distance here on the shin bone. Okay. All of you are correct. It is like what we said as the medial uh TBL stress syndrome, which is a process it as a Shinbone ocean explained. So what's the mechanism of this why this thing happens with the patient? So the patient will, it usually happen because of overuse of repetitive injury, positive board of that leg. So they will come with resistance, they'll achy pain. Uh usually it will be on the distant one third of the tibia. Uh Usually it's on the medial, posterior, medial and there's an interior lateral uh which is our attachment of the tibia list muscle, anterior and posterior tibial is muscle. So the patient presents with these symptoms, they will tell you this pain, you go there and take history. It will be a new something changed in his uh the way that you do the sports like this runner, she increases her distance. She puts more stress on her like she presented to you. So what you will see in the history, you took history, then you go for examination. Usually they will be tenderness on the distal one third of the tibia, it will be exercising to induce. So whenever she exercise, she will have this pain and whenever she rests, her pain cause better and she will be fine. I have no pain. There will be tenderness over the area. However, this tenderness must be more than five centimeters. If it is less than five centimeters, you're thinking there will be a stress structure causing this pain. It is more than five centimeters. We all think about this could be a TPL stress syndrome investigations. First, I'm going to order X rays to check if there is any press structures. We can do bone scans, we can do Mri's to check whether any pathology going on. Whenever we ruled out any fractures, any stress structures, we will come to the stress syndrome. It could be another thing you need to think of might be a chronic compartment syndrome. So you might have a compartment but is a chronic causing this special gradually to increase. You need to keep it at the back of your head. It could be a compartment from that delayed. Okay. I need to think about it. So what's the mechanism why the things happen? So the patient is patient will have doing exercise, we will do more and more running more and more load. Then that will lead to muscle weakness, which is usually the solis and gastrocnemius muscles which we run on them. So usually what we do, which is the wrong way of running. We threat with our, here's should be in the middle of our foot sole. That's the way we should uh fall on drawn. What we do is on the hill all the time. That's the wrong way of running. So the patient will keep running an incorrect way. He will overuse his gastrocnemius solis, muscle will have muscle weakness which lead to muscle fatigue. Then they will be changing the running mechanism. He will use his anterior and posterior tibial is small. He will depend on this small uh putting extra pressure on anterior tibial list. And for 30 pills will cause irritation of the periosteum that to these two muscles are originated from. So, from their origin, you'll have more pressure causing on them. So from the origin, uh they will have extra pressure, causing extra pressure, irritation on the periosteum. That's what will cause uh periostitis, which is an inflammation of the periosteum. And that's the main cause of the media TBS stress syndrome. So, what's the media TV. A stress syndrome? Actually, it is an periosteum inflammation, periostitis. It's caused by the repetitive and the muscle fatigue at the origin of the two muscles, anterior or posterior tibial list, which has happened usually either posterior, medial or anterior lateral sides, commonly by the posterior media site. So now we know how is the mechanism of this injury mechanism office. That's how it's happened. There is a classification for it. The classification, it's just follow the progression of the disease. So we can soon great one. It will be just uh edema to the periosteum edema. Then the edema will go inside the bone uh in the bone marrow which can see in the grade 203 inside the bone, there is an edema so that it's progressed inside the bone for there will be a start of structure. So the end results, if it's not left, that is keeping putting more pressure on that, it will cause a stress structures and the bone. How are we going to treat it? We start with conservative. We need to do some activity modification. We need to reduce the running distance. We need to change how the patient run. We need to avoid running an uneven surface, avoid running in the uphill anything running uphill, uneven surface, try to avoid it. We also give some shoes, shoes, try to distribute the weight, but the patient is striking and the foot, all this is not helpful. We may go to surgery. Give it at lost. Any questions is the mechanism of the TBS stress syndrome. Clear. Mhm. Okay. All right. Uh Let's move to the next case then. All right. This time we got the 35 year old gentleman presenting to clinic with problems with weakness and difficulty lifting. The foot while walking. So basically he's got a foot drop and he reports that his foot is catching the things on the ground when he's walking. So, what do you think is happening? You've covered similar presentations? Never damage. Okay. That's correct answer. Which now common fibula peroneal nerve. Yep, that's correct. So, we spoke earlier about sciatic nerve, sciatic nerve as the popliteal, it will divide into two peroneal, which is the same common Peroneal or common fibula owners. Another one is the tibial nerve. Now we will speak about the common uh fibular nerve of the common Peroneal nerve. So when it entered the latter compartment of the leg, as you can see, it is the traps around the similar neck. And after that, it will divide into superficial and deep fibula or the peroneal nerve. So at that area, any injury, any fractures happen to the fibula neck, it will injure that next. Any uh sometimes even up injuries in the hip dislocations injuries, it can threaten uh command Peroneal nerve because what we believe is sciatic nerve that is two nerves that crashed together with the same sheet. It will be common Peroneal on TPN years. They are running together. That's why it is a thickness, the largest nation, our bodies sidedness because composed of tuners. So either had dislocations, it can affect the common parental pressure on the macaroni in there. So either hip dislocation need dislocations, any fibular neck fractures, it will injure the common common peroneal near compartment syndrome also kind of threatened uh common peroneal nerve. So common peroneal near what it will innovate, especially the deep branch, the deep branch, it will innovate all the interior compartment of the leg, which is the compartment that are responsible for the dorset flexion of our foot and extensor pollicis that which is the Victo extension. So dorsiflexion and the victor extension, it is caused by the deep peroneal near which is coming from the common Peroneal nerve. So any injury of that, we have dysfunction of this. So we will have foot drop. Food drop is very important. You can't imagine how our walking, it will be affected if you have foot drop because think of it when you walk, how you're, we're, we're walking, you lift your leg and you go down with your hair. That's how you work. If you have lifted drop, you will lift it, then you're going down. You can't, you can't put it should keep tripping, the patient, keep dripping. So what they do they will lift. So the usual there is a usual called step it gate, they will do, they will extend how they will fix their high, how high up and then they will step their foot on the ground. So they will put tie up and then it will drop it on the ground. They have like a separate gate. That's what they usually the gate of the common Peroneal of the foot drop. Patient's are we going to treat it? Usually treat the cause. However, it's causing fractures because this fractures will cause irritation and the pressure compartment, relieve the pressure. Help dislocation, try to relocate and treat it if it's a high up and there may be a disc herniation and L5 L for also can cause common peroneal foot drop. Whatever is the cause, try to treat it. If there is injury to the nerve, we can go on surgery and try to explain air board as we do. And nervous studies, that's when we decide the surgery. So if we find there's no cause is causing this uh weakness of the nerve injury of the nerve, we do nerve studies, then we can plan for surgery for the nerve uh station. So this is common throwing up. That's one of the two important nerves in the leg. Okay. There is no questions. We can move to the other one. Any questions? I think the uh the next question, the next case, uh we've got a 35 year old uh presenting with a complaint of burning and tingling sensation in her left foot for the past two weeks. She reports the the sensation mainly on the sole of her foot and toes. Uh And uh she sometimes feels occasional sharp pain that really radiates of her leg about the nerve distribution, which now this is a lot. Now tarsal tunnel syndrome, which is which you have. It's affecting it's that TVN. Okay. So the other important is the TV net, which is the second uh posterior tibial okay, which is the second dose of the tibial nerve. As you also gives motor and sensory motor mainly to the posterior compartment and the muscles of the foot. And so give sensory to the posterior lateral of the leg and the lateral of the food and the sole of the foot, sole of the foot. Latter and posterior latter. It's all sensory by the posterior, by the tibial nerve. The important as one of you mentioned is the tarsal tunnel. So there isn't can happen, injury anywhere to the truck. One of the common uh sites of the injury or compression is that tough sell tunnel, what started? So when the nerve entered the feet and the volunteer of the foot, it will go posterior and inferior to the medial malleolus. So this is the media, let's imagine this is micro, this is the medial malleolus, posterior and inferior to that, it will go into a canal that cannot call the tarsal tunnel which is covered by uh Flexeril tenaculum, she the same as uh CTS. So this flex uh netflix here whenever it's sticking one of the new claims, of course, compression on the TBL nurse who will have the same presentation, you will have numbness on the left uh soul under uh transit muscles. Uh So this is one of the important syndromes or the important places that this could be compressed, which is the tunnel, castle tunnel as one of you measured uh castle tunnel syndrome. So when this one, this nerve got compressed, you will have weak uh plant reflection. He has week toast flexion, he has week inversion because all of them, they're innovated by the TV. And there the same thing for the treatment. Uh We do nervous studies. If you think there is a nerve injury, we need to do nerve surgery and repair all we can treat the cause. So if it is a tarsal tunnel syndrome, we can do and do fasciotomy to the uh to the tunnel to release the nerve or if there is a disc and there's any fractures up, we're going to treat that okay. I think we will move to the next case. And uh in the next case, you've got a 28 year old female presenting to the E T after twisting her ankle, this one is going to be a bit easy because it's kind of stays what it is. And uh she reports pain and swelling on the lateral side of her ankle. So what, what do, what do we think this is? This is also quite common. It happens to all of us to happen to me. Yep, ankle sprain, ankle sprain. The same thing the patient will have in virgin falling, gonna Plantarflex would go ankle sprint have two sides, either going to be a high ankle sprain or going to be a low ankle sprain if it is a high ankle sprain. So we're thinking that injury would be other indus Morse's injury uh which is like the thing that connect that the some of the same discourses on the idea and Ulna, there is a responsible government connect the tibia and fibula. So there, there is an high end uh sprain. It will be at the center asthmatic and we'll usually it will need surgery to repair it. We'll do a CT to evaluate the intra articular uh fractures or intra articular. I think going on there and it's soft tissue injury, then we're gonna prepare it by surgery or it's gonna be a low ankle sprain, which is the ligament, Cynthia tibia fibular ligament or the Calcaneal fibular ligament. Both of that could be a tear or it could be just uh irritation because of the spring. Usually we treat it with conservative leave, it will here by itself, just leave it and say it's rest and elevate ice. However, within 6 to 8 weeks, if it's not healed, we're going to do an MRI to evaluate the need of surgery to evaluate the surgery. So, what we're going to do is x rays. So first of all, second story, we do x rays to rule out any fractures to see if it's high or low. We start treating, put conservative 6 to 8 weeks. If it's not healed, we're going to do um a Roy to evaluate all the uncle, evaluate all the soft tissue there's, and the other injuries going on and then we can start planning for surgery. Okay. Okay. This is going to be our last case. So if you're happy I'll just move to the next one. So, uh, yeah, you can stop. Yeah, first five year old female patient complaining with sharp heel pain and, uh, it gets worse when she's doing weight bearing activities. And, uh for example, when she's getting up from the bed standing up or like uh those positions that she's putting pressure on her leg, uh it is under the hill and it feels like a stabbing sensation. Uh they report uh okay, we've got over the differential coming in mail order be of dance on our own, right? Plantar fasciitis. Okay. The patient with prostatitis plantar. Yeah, a key list tendonitis. Okay. Sure. Okay. So this case from the presentation patient having uh painful here, the uh food is out this tenderness, what we think of the plantar fasciitis. So plantar fascia, it is a thin layer of connective tissue. It will happen on the arch of the food. So whenever this got inflamed, especially at the site of its origin, which is around the calcaneum. Uh because this tenderness, this pain, the patient will have uh we'll say okay, doctor, I'm having a sharp heel pain from his severe pain. Whenever I stand on my heel, he will be usually standing on his toes. To avoid the standing of putting pressure on his. Uh he'll usually they will tell this is happening worse at the end, end of the day, because of the moving under, moving around, putting extra pressure at the end of the day, he will have severe pain. Uh It happens because overused because of preventative damage uh to the plantar fascia. Usually it is by clinical diagnosis when you see the eye examination, by the history. Uh okay. This is the plantar fasciitis. We don't need images. You can alter extra a plantar x rays that checked for anything else going on, any fractures going on. It's not, this is uh we don't usually do um allow it unless we think. Okay, we need surgical planning, that's not healing. We give it a time usually six months, it's not healing. We need to start to think about uh surgeries, which is going to be a surgical release and the plantar fascia. To me, all the first line is conservative, pancreas, corticosteroid. We refer to also uh food or tosis food orthotics to get some special boots or some special cast, walking cast to invitation and we do some stretching exercise. It's quite an easy on common presentation and in front of her shatters any questions so far with any of the scenarios that we presented? Okay. Yeah, it was our last case. Uh So as I mentioned at the beginning, this was our last uh lecture of R M S K series and I hope you guys have enjoyed it. And if, if there were any conditions that we didn't cover, you could also tell us in the feedback form. So in the future, if you're going to deliver this and like make improvements in the, this series for next year or years, uh, that's hard to come. Uh, we could, uh, work on their feedback. Thank you, everyone for attending. I hope you already found helpful the sports sessions and uh we really appreciate your feedback. We can work harder on the next uh I'm not sessions. Next series we can prove can put more cases you would like so feel free to provide your feedback but whatever you want for them next questions and if you've missed on any of the sessions, uh the first two sessions catch up with the content are already available. Uh By the end of this week, I'm just going to make sure that everything all the catch up content are uploaded properly and you guys can have access to them. All right. Thank you everyone. Um I think we will just mark this at the end. Uh Thank you, doctor. Uh Sorry. All right. Thank you having for everything, organizing all this thing. My pleasure. Thank you. Bye.