Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, we can do a quick sound check if you want lots of people join. Hello? Hello? Can you hear me? I can't hear you. Oh, great. Ok. How about now? Can you hear me now? Ok. One second. I can't hear you still. Just, how about now? Um, sometimes it depends what brows you're doing on. I can't remember which ones it's awkward on but I know it works on chrome. I'm using chrome. You're on chrome. Ok. Not sure what's going on then. Wait, let me just try this. How about now? So that's not worked either. Could you, um, leave and then rejoin again? Ok. How about now? No, still? No. Ok. One second. Ok. How about now? Is it working now? Um, just one second. How about now? Is it working now? No luck. That's not working finally. Y ok, cool. Ok, perfect. Um, if you could share a screen, that would be amazing. Yeah, just a second. So what I'll do thank you is sorry about that. That's ok. I'm just gonna pull up the, um, slides. Perfect. Where did I put them in? You wanted the sponsors up first, didn't you? Yeah, that's ok. If that's ok. Yeah, that's fine. Ok. Um So if I go back here, um sure. Entire screen. Well, can you see that like full screen? Uh it's just, it's on the powerpoint side. I don't know whether it's, it's on like the powerpoint um program. Ok. One second. Um, let me stop sharing. So if I do show window, oh, wait, it says don't share. Ok, fine. Hang on a minute. Entire screen. I think what I'll have to do is basically put this in powerpoint and then go on to here and then shirt and tie screen and then get the clip. There you go. Got it. Perfect. OK. Right. We'll leave it until 605 and I'll do an introduction and OK, just I'm just going to quickly flick through. Can you just let me know if it's working? Yeah, that's working. OK. Brilliant. Perfect. See you shortly. Thank you shortly. I think we might as well just get started. So, hello, everybody. Welcome to the week three. Now of sp teaching. Um today we are focusing on the upper limb with Faran. So hello, he's gonna be taking us through the talk. Um Just before we begin, I just wanna say a massive thank you to our partners. So the MDU teach me surgery, pass the MRC S medal and finally more than skin deep they've been supporting us. So we've been able to put on this teaching program for all of you guys. Um finally just make sure that you follow all of our socials. So you are made aware of when we are holding these talks. And also at the end, I will send a feedback form. If you fill it in, you'll have access to the slides and also you'll get some discount codes for fro from some of our sponsors. So make sure you keep an eye out and fill it out at the end. I will send it towards the end of the talk. So let's begin, I'll hand over. Let's go. Ok, so, hi everyone. My name is Farhan. Um I am 1/4 year medical student at Brighton and stuff medical school. I've just come back from installation. This is my fifth year and today we're gonna be looking at the shoulder joint and I believe there's gonna be a part that's gonna be on the elbow and wrist. So, um today we'll be looking at the anatomy of the shoulder, shoulder joint and the relevant conditions associated with it. So this is basically just an overview of what we're gonna cover today. So we're gonna start off with the bones of the shoulder, the bare basics. And then we're gonna go to the anterior and posterior shoulder compartments in terms of uh the anatomy of the muscles and then the different properties of each of the shoulder muscles. So their origin insertion, their neurovasculature and their function. Then we'll go on to some of the clinical applications of the anatomy. So, first of all, we're gonna look at examining the shoulder, what sort of things you should look out for and also some common pre shoulder presentations, both musculoskeletal and rheumatological. So let's get sorted. So start some of the bones of the shoulder, we're gonna er, work medially and go laterally. So we'll start with the sternoclavicular joint. Uh This is quite important because it can be um implicated in quite complex shoulder injury. So it can be affected in quite complex shoulder trauma. So, it's important to know about the sternoclavicular joint. And obviously, that joins the sternum to the clavicle over here. And the clavicle joins onto the acromion via the achromia cla clavicular joint, which forms the superior border of the shoulder joint, which is right here. Um The coracoid process is right here. You can actually feel it sometimes over here as well. So if you feel your clavicle and then drop just below it, you can feel your coracoid process, it's a little bit sore if you press it a bit too hard. Um and then just below that or, or just posterior, posterior inferior to that, even you have the glenoid cavity which joins onto the uh head of the humerus to make the glenohumeral joint. And this is effectively the shoulder joint. Uh It's more important to know that the gleno cavity, the coracoid process is all found on the scapula which is labeled over here. Um And then you have a head of the humerus over here and the lab room, which is uh basically the the border of the glenoid cavity. And then over here you have your humerus, which is your upper arm. So going on to the anterior compartment of the um of the muscles that are are that, that form parts of the shoulder. So the the key things that you should be aware of. So we've spoken about the goal joint being the main shoulder joint and you also have the acromioclavicular joint over here and the shoulder bursa over here. Now, this is really important in one of the conditions that we will talk about later on. Um but the other things that you should be aware of is that you can see the um subscapularis attached onto the er er superior aspect of the um of the humerus. Er and we'll go into that a bit in, in a bit more detail of the rotator cuff muscles. Er but you can also see the supraspinatus that goes that runs across the superior border of the scapula, the teres minor that runs that runs below it and the infraspinatus, which is behind, it is not shown in this angle and you have the biceps muscle which originates from the supraglenoid tubercle of the, of the scapula and the coracoid process of the scapula. So, so sorry, cide, hum uh humeral cubicle, sorry. And then on the posterior compartment, you have the um you can see the er infraspinatus uh and the teres minor over here in terms of the rotator cuff muscles and the glenohumeral joint is just here. Um And then the subscapularis is now not shown behind. So the subscapularis actually goes in front of the humerus. Um and the um emperor Spinatus goes behind. Ok. So looking at the shoulder muscles in a bit more detail, I'm gonna start off with the deltoid, which is the main one and it's the the big one over here. Um So it originates in the lateral clavicle and the acromion process er and inserts into the deltoid tuberosity of the humerus. So it starts about over here and then inserts over here. So the neurovasculature, I'm talking, I'll talk specifically about the arterial supply and the nervous supply because uh the venous supply isn't as important in the er in medical school exams. It's more. So the arterial and nervous supply. So the arterial supply is a thoraco, a cranial branch of the axillary artery. So you'll probably just need to re re you probably just need to know the axillary artery and also the axillary nerve, which is C five to C six of the brachial plexus. So the function of the shoer, the deltoid is for shoulder abduction, flexion and extension. So flexion going up um front and upwards and an extension going back er backwards in the same plane. So the next one is a teres minor. So that is, originates in the postural lateral border of the scapula and inserts into the greater tubercle of the humerus. So, the greater tule of the humerus is um that um area of the humerus that I showed you earlier. So if I just go back a little bit, um it's this area here. Ok. Um So it's supplied by a couple of arteries of the subscapular, the circumflex scapular and the posterior circumflex humeral. Um This isn't tested on as much cos it's quite a high yield. So if you do know it great, but it's a good chance that it might not show up on exam. So it's not, don't stress too much if it doesn't show ii if you're not tested on it. Uh And it's also supplied by the axiliary er branching from C five to C six nerve roots. And the function is for glenohumeral stability. So it's the disability of the shoulder joint and also for lateral and external rotation. So, external rotation being this movement over here. The next is a supraspinatus. So that originates in the supraspinous fossa of the scapula. So that's what I was talking about in the superior border of the scapula. So there is a, there is a spinus process er if you will, that runs kind of about a third down of the scapula and that basically divides the supraspinatus and the infraspinatus. Um So the, the top bit of that is a supra supraspinous fossa and that's where the supraspinatus in originates and inserts into that same greater tubercle of the humerus. Um It is supplied by the suprascapular and dorsal scapular arteries and also the suprascapular, which again is a branch of C five to C six. The function of it is shoulder abduction. So again, lifting it up uh for rotator cuff stability and it prevents subluxation of the shoulder. So um the difference between the shoulder abduction within the supraspinatus and the deltoid is that the supraspinatus is responsible for the 1st 20 degrees of shoulder abduction. And after that, it's the deltoid and that can help you differentiate in shoulder examinations, um which is the injured, potentially injured muscle. The next is the infraspinous. So again, er originating in the infraspinous fossa of the scapula, what I explained earlier and again, inserts into the gratitude of the humerus. We're seeing a bit of a theme over here. Um And it's supplied by the suprascapular and the circumflex scapular um arteries and again supplied by the suprascapular nerves. Uh I will have slides er at the end which will have everything in black and not like highlighting specific things. So like if anyone wants to take a screenshot or wants to take, take it home for revision, that'll be absolutely fine. Um And then the function of the infraspinatus is external rotation. So, again, this movement um scaption, which is basically scapula plane elevation, which is basically just doing this um and er lateral rotation of the humerus and the last one is a subscapularis. This is er quite easily originates in the subscapular fossa, er and er inserts into the lesser tubercle of the humerus. So it's slightly so it's slightly below. Um, the neurovasculature is again, the axillary, the subscapular and the suprascapular arteries, er and the nerve supply is the upper and lower subscapular, which is from the C five to C six nerve roots again. And the function of this is shoulder adduction. So, bringing the shoulder down and internal rotation. So when you put your hand behind your back and push out, that causes internal rotation of the shoulder, that's what the subscapularis is responsible for. Ok. So the key point is from this is that the greatest tubule of the humerus holds three of the five shoulder joint muscles. So, if someone has trauma to the greater tubercle of the humerus, you worry about the those three muscles that being the terres minor, the supraspinatus and the infraspinatus. The next is that the axillary artery is the most significant supply to the shoulder muscles. So if you have an axillary artery dissection or you have an axillary artery, aneurysm, you're worried about the shoulder quite a bit and also injury to C five to C six nerve roots in the brachial plexus can cause complete loss of shoulder function. As you notice in all of the neurovasculature, everything is applied by the nerve roots of C five to C six in the shoulder. Um, the rest of the brachial plexus may be spared in depending on the type of injury. But if C five to C six is injured, then they might, they, they will probably have complete loss of shoulder function and also wasting of the shoulder at that. So we're now gonna move on to the clinical side of things. So with any orthopedic examination, this goes for the shoulder, the wrist, the ankle, the foot, the knee, the hip, anything you wanna do four basic things. And the first thing you want to do is to look, you want to feel you want to move both actively and passively and you want to do your special tests. So in the shoulder specifically, you want to look for any kind of obvious dislocation. So if the shoulder is out of place, either it's dropping down or it's dropping to the side or it's dropping behind whatever it might be, you're looking for obvious dislocation. And the reason for that is that dislocation can be an emergency because you do have neurovascular compromise with uh depending on the type of er shoulder er dislocation that you have. You wanna look for erythema, you wanna look for swelling, bruising, um pallor as well because pallor can be a sign of arterial compression and therefore lack of arterial supply to the shoulder area. It's quite, it's not as common, but it is a good thing to look for because it can determine your management when you're feeling, you want to feel for swelling, any muscle tension, any tenderness when you palpate the area. So, uh what we were talking about with the glenohumeral joint, which is located just right here at the corner, you need to palpate that area, that area if you want to feel for any kind of swelling, any kind of tenderness as well, because that can determine certain shoulder pathologies when you're moving, you want to do all of the moving actions of the shoulder. So we've talked about flexion, we've talked about extension abduction, abduction, and internal and external rotation when it comes to ligament stability. And um so when it comes, when it comes to ligament stability and looking at rotator cuff muscles, that's where the special tests come in play. And also um just generally the mechanism of injury as well. Sometimes you can talk, sometimes you can discover l ligament laxity um through uh just palpating the shoulder itself or also just moving the shoulder under tension. Um But the main thing you want to be doing at this stage is just looking for the ma making sure that the flexion extension abduction adduction and internal external rotation is all. OK? And if that's impaired, what muscle might be involved and therefore what um mechanism, what was the mechanism of injury and also what the treatment might be, the special test that you should be aware of er in the shoulder is the job test, which is the empty can test. So what you do is that you literally put your arm out as if you're holding a can and then you tip the can over that actually tests for supraspinatus tendinopathy. Um and you have the wall push up test which checks for scapular winging. So you basically get the patient to stand against the wall and then push as hard as they can in front of it. And you want to have a look at their scapulae if they er wing medially. So if they go inwards towards the spine, um then that's a indi indicative erratus anterior pathology, which is a muscle that's located on your ribs over here around T four to T eight. And if it's lateral winging, so if it's pushing out away from the spine, then you're thinking about a trapezius or a rhomboid pathology. So the trapezius is the muscle that's on the back of your neck over here. And the r the rhomboid runs just parallel, uh like paraspinally, basically. Ok. So knowing how to examine the shoulder, uh it's good to know about what shoulder pathologies you might come across both in your placement or also in clinical practice. Uh It's really important that you are aware of these because um these are quite common and especially in er, the trauma, the orthopedics, rheumatological and also even the GP setting, you may come across a lot of these quite frequently. The first one I want to talk about is shoulder dislocation. So um any part of the shoulder may be injured in this area. Um But the things that are threatened are the axillary artery and nerve. Uh And this is why I was talking a little bit earlier about shoulder dislocation, neurovascular compromise. We want to relocate the shoulder as soon as we can just so that we don't risk that neurovascular compromise. The mechanism is usually trauma or also just joint instability. Some people might just have really lax ligaments that don't really hold the shoulder in place properly. And therefore, they can actually suffer from recurrent shoulder dislocation. The clinical findings associated with shoulder dislocation is the inability to abduct flex or extend their shoulder. Um So the, it's basically like a deltoid dysfunction because the deltoid covers the glenohumeral joint. Um And they might have an extreme shooting pain down their arm if they have um the axillary nerve compromise. Uh and they might just be in just extreme tender pain in the shoulder area itself if there's no neurovascular compromise, but it's just a dislocated shoulder because that knob itself is very, very painful. So the management of a dislocated shoulder is physical relocation. So there are different maneuvers for this. Um I'll be completely honest, I don't know what the specific maneuvers are, but it's physical relocation. Uh Surgery may be indicated, for example, in a ligament, tear or ligament laxity, physiotherapy will be required after the original relocation of the shoulder. So to make sure that either they can build the strength of the ligaments, the muscles around it, or perhaps even to just make sure that the mobility of the shoulder is still doing ok. After the um shoulder dislocation and during this entire process, they'll be in a lot of pain. So you all need to give them analgesia. Typically, you want to work up the who analgesic ladder, which starts off with paracetamol NSAID S and then it works up to things like weak opioids like codeine cocodamol, things like that. So, shoulder impingement. So this is where you have an injured rotator cuff tendon around the greatest triple of the humerus. Uh The mechanism is also trauma, but this is more of an achy pain and it's worse on internal or external rotation of the shoulder. So if they do this or they put their hand behind their back and push out and so their, their shoulder is internally irritating and it hurts. And that could be indicative of a shoulder impingement. And again, the management is physiotherapy and analgesia to make sure that the there is no um to further rotator cuff injury. The next is a rotator cuff tear. So this is any rotator cuff muscle. It could be uh Taras minor, it could be the supraspinatus insp soar, it could be any of the rotator cuff muscles. So, um this is again an achy pain. Uh it can be sharp as well though. So it's, it's good to be aware of. Sometimes you can have complete tears, which can be quite sharp. Er, and it's worse on the different actions of the rotator cuff muscles. So that's internal, external rotation and shoulder abduction up to about 20 degrees. Um, and uh this, they may not be able to do that if, if they have a complete tear, they may not be able to do one of those movements at all. So the first thing we need to do is rest because with any tear, you need to rest the area and make sure you're not moving it too much. So it can reattach properly. You want to give them analgesia because again, it is very painful, there will be a lot of pain and you want to give them physio as well in the long term and if it's severe. So for example, a complete tear, they may require surgery. The next stuff is about fractures. So the one of the quite common ones is fracture of the clavicle. So what's injured is the clavicle and what's threatened is a subclavian artery which can actually lead to the axillary artery. So this is more of an indication in more severe clavicular fractures. So those are kind of diminutive or complete displacement fractures that can um compromise those arteries again, caused by trauma and it's severe pain, localized to the clavicular area. There may be swelling, there may be erythema, there may be contusion or just bruising, but they may have an absence of these things as well. So just be aware. So, always order, or always order a shoulder X ray. Um but the passive shoulder function is usually preserved because there's no muscle compromise. So, if you were to move the arm on its own, um the er muscular function sh you shouldn't feel any muscular wasting. I wouldn't recommend it though because if they have a fractured clavicle, then you risk displacing it and that's really bad. So don't do that. Um And in terms of management, it's usually conservative. So you use a sling, uh you also use analgesia because it's um a fracture, there'll be a lot of pain. And again, if there's neurovascular compromise or it's severe, you give them, uh you perform surgery and lastly, it's a fracture of the humerus. Now, this is the most tested in medical school because it really is testing your anatomy and um like testing your location of like, you know, nerves as they uh travel through bones. So obviously the injured aspect of the humerus, but it d whatever is threatened, it depends on where the fracture of the humerus is. So common medical school questions are, if someone comes in with a fracture of the surgical neck, what nerve is compromised? And that will be, um that will likely be the axillary nerve because the axillary nerve runs through the surgical neck of the humerus, uh and also the uh mid shaft of the humerus, that's where the radial nerve runs through. So if someone presents with um a mid shaft fracture of the humerus, then you are thinking of radial nerve palsy. It's also good to know the functions of these nerves further down the arm as well. So for example, the radial nerve is responsible for the complete posterior compartment of the arm. So if someone presents with a uh midshaft fracture of humerus and they've got wrist drop, then they probably have a radial nerve palsy as well. Mechanism is again, trauma and the clinical findings is similar to the fracture of the clavicle. Um but the passive shoulder function is usually affected because of the fact that you may have axillary nerve or radial nerve involvement and there also may be neurovascular compromise. So, just be very worried that again, it's conservative management. So you can use a brace if there's no neurovascular compromise. And again, analgesia. Um but if there is neurovascular compromise and you do surgery and that's basically the m main musculoskeletal conditions that you should be aware of as a medical student. Um but I'm gonna go on to some of the rheumatological things now. So it's three main um shoulder pathologies that you should be aware of. Er, and they're the both both types of arthritis and adhesive capsulitis. So, starting with osteoarthritis of the shoulder. So that's basically a one sided joint pain that's isolated to the shoulder joint and this is usually your wear and tear. So it's typically asso associated with old age. The pain is worse after exercise and better with rest and it's worse in the evening and better in the morning. Um So on a shoulder X ray or any x-ray of any joint, we're suspecting arthritis. This is a really good acronym, loss. Um because you have loss of joint space is the biggest thing. But the other factors of osteophyte margins, subchondral cysts and subchondral sclerosis. These are other things that you notice in osteoarthritic joints on an X ray. But the biggest thing is a loss of joint space and the management first is topical nsaids. So that's topical Ibuprofen gels or diclofenac do. So, voltarol basically, um you can use oral analgesia as well if it's quite severe. Um If, for example, there is a lot of degradation of the shoulder space to the point where they're losing function, then you may have to consider a shoulder replacement surgery. If there's extensive uh degeneration, it's also good to be aware that patients with sickle cell disease also often get osteoarthritic shoulders because when they have sickle cell crises, um they actually have avascular necrosis of the um glenohumeral joint basically, and they'll basically mimic an osteoarthritic shoulder and therefore, they'll also need a shoulder replacement. The next is rheumatoid arthritis of the shoulder. So this is a bilateral arthralgia and there may be some extra articular involvement, so they might have it in their fingers as well. Um, but again, it's symmetrical, um, and it's always symmetrical unless it's a psoriatic arthritis. But I won't get, that's all you need to know about. I won't get too much into too much detail about that. Um, it's basically the opposite of osteoarthritis. So it's actually better after exercise and worse with the rest. It's better in the evening and worse in the morning and it actually can present at any age. So you may get juvenile arthritis that originates in the shoulder. Uh, you may have patients who are also 60 that might have both osteoarthritis and rheumatoid arthritis. Um, so your shoulder x-ray may actually be normal because you don't have a loss of joint space and it's not as apparent. So you need to do, you may need to do things like an MRI or a CT scan, but they're not routinely done as far as I'm aware. Uh, according to the latest guidelines, um, but the investigations that you want to do are an anti CCP and a rheumatoid factor. So, um, in the acute setting, so if they have an acute flare up of their rheumatoid arthritis, steroids all the way. If you do any rheumatology question, I promise you. If you say steroids, you're probably not wrong. Um, but generally for long term treatment, it's your disease, modifying anti rheumatic drugs. So that's your methotrexate, your hydroxychloroquine, um, your leflunomide things like that. And then your second line is your biologic agent. So your anti TNF alpha agents such as Infliximab or um antiinterleukin six, for example, Te Eliz. Um So you may see patients on this on placement as well. And lastly, of the three rheumatological conditions, you have adhesive capsulitis, uh which is basically also known as frozen shoulder. So this is inflammation of the shoulder bursa. So I showed you a diagram of that earlier. Um If you have inflammation of that bursa, that's basically inflammation of the entire glenohumeral joint which causes pain and stiffness. Um and it reduces movements um in flexion extension and abduction of the shoulder with, with internal and external rotation, involvement as well. I forgot to write rotation there, but it it affects internal and external rotation. Um So basically, they'll have a really stiff shoulder. You can't do anything with it. It's really, really painful and it's really stiff as well. So they can't raise their shoulder more than about here or over here. It's quite bad. Um So the first line is that sometimes it can go away. So you just need to give analgesia and physio. But if it is recurrent, then you can give intraarticular steroid injections. So that can be either methylprednisolone or triamcinolone. The third line is hydrodilation which is basically just injecting fluid into the joint space to make it more move well. And then the fourth is manual manipulation under anesthesia. So, because of the idea of a frozen shoulder, the more you move it, the more it kind of melts the joint space a little bit. So the more you move it physically, the more it will free up the space and should be able to help with the symptoms of an adhesive capsulitis. This can be unilateral or bilateral, but it depends on the patient and often is associated with other comorbidities such as uh either rheumatoid arthritis, any other autoimmune conditions such as um SL E or even uh polymyalgia, rheumatica, but that in effect is the shoulder. Um So this is the, so socials over here, these are the sponsors again and that concludes my presentation um the Sowa exercise I'll show shortly. But does anyone have any questions at the moment? If you guys just stick the questions in the chart, I can pass them on as well. Here we go. I mean, II can't see the main screen. So if you wanted to read them out, that'd be great. Yeah, I will do if you've got some, but in the meantime, I have sent the feedback form on the chat. So if you guys fill in the feedback form, you can request the cap content and also you get the slides and recording and you also um will get access to those discount codes on your certificate as well for attendance. Um Also, I just wanna say a massive thank you. Those tables are so useful and I definitely needed them when I was in first year learning anatomy. You've had. Awesome. Thanks a lot doctor. Thank you. But yeah, I'll show these up for a couple of minutes. If anyone wants to take screenshots or pictures of it to put in their notes or whatever, I'm more than happy for you guys to have that in your notes. It's always good to kind of look at this, but then also reflect it onto a diagram. So you'll get the cation when you'll have the diagrams of the posterior and anterior of the shoulder and also the bones of it. So if you map it, I find it really helpful if you map your muscles to the anatomy and kind of visualize it in your mind and also even just doing the actions of the shoulder on yourself. OK. So the deltoid the shoulder abduction and flexion and extension, like that's what I found really useful when revising muscles and stuff. And that's why it makes so much sense to me in that sense. And I don't know if that might be helpful to some people. It might not be, I don't know, but um thought I throw it out there. No, that's really really useful advice. So thank you so much for sharing as well. No worries, maybe go on to the next one just so people have a chance I am DFO using these. These are so sure good friend. But yeah, emphasis on the fracture of the humerus one over here. I've seen so many questions on passed and SMED and all these, all these other med med question platforms they always ask about these. So please, please, please learn this. We've been asked to go back a slide. I'll go back a slide. OK. Fine. OK. We'll give a minute on this one and then we'll go to the next one. Yeah, that's fine. Sorry. Making you go back and forward. No, no, it's fine. It's fine. You guys will get the slides as well. So like, uh if you, if you don't manage to get like a screenshot or you don't manage to write them down, then don't worry. My lack of my upper limb knowledge is seriously lacking. I'm a very much a lower limb TN O type of person. You've actually taught me a lot of stuff. It's good today. It's good today. OK? A couple more seconds and then we'll go over to the other one. OK. Next one, let's go. We're done. OK. Next one is the Musco skinny, tall stuff in the shoulder. Again, please emphasis on this like 50,000 times. Please learn it. It is honestly so high yield. Is there another one after this? If I remember there is one that's for the rheumatological stuff, but I'll, I'll stay for like 15 seconds on this one, then we'll go to the next one. Um When you have filled in the feedback form, you will get an email saying that the catch up content is available. So it will prompt you to literally click on the link and you can get it to everyone listening. OK? And the rheumatological ones just a quick note now that I've remembered on Odesa capsulitis, internal external rotation will likely be affected as well, but it may also be normal. So it's just that some patients might have it normal, some patients might have it affected. So it's just something to kind of be aware of when you, when you examine patients. But if they have flexion extension and abduction being completely restricted, it's pretty much an ads of capsulitis and they often offend women more than men. I think I'll just wrap up whilst you've got that slide up. But thank you so much for everybody coming and a massive thank you for actually doing the talk and providing those such amazing um tables which I am definitely stealing. Um The next talk is on Thursday and it is also on upper limb. So please do come along for that. The links are on our socials and you can also find it on our medal page. So make sure you register for that. Um I've said thank you to our sponsors again and make sure you follow us on Instagram, Facebook and on metal just so you are um alerted to all of our talks coming up. So a massive thank you to everybody and thank you again. For such an amazing talk. Have a nice evening. Ok. Your certificate was up to you shortly, by the way. Ok, cool. So keep an eye out for that. Um Thank you so much. Have a nice evening. Ok. Have a nice evening. Bye.