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James Noake

@DrJN_SportsMed • 34,188 subscribers

Difficult stuff. Consultant in Sport, Exercise & Musculoskeletal Medicine

Shorts

Consent✅ - this is a beauty 🤓 Elite runner Crampy, aching lateral knee pain - onset at around 20-30 mins Seen multiple clinicians - had numerous injections including ITB plus extensive rehabilitation - refractory Almost 'claudicant' in nature - settles quickly on cessation of exercise - spreads both proximal & distal to lateral joint line No spinal symptoms & LSp assessment clear No lateral compartment pathology eg meniscal tear Had popliteus tendinopathy on US, but minimal response to my initial diagnostic injection POCUS video - The inferolateral genicular neurovascular bundle ('pepper pot' structure) is seen compressed under the distal ITB on active knee flexion : terminal extension Patient localises pain in this area with probe pressure Injection - hydrodissection (CSI, LA) - fluid seen separating plane just superficial to NV bundle 100% pain relief on extended treadmill test beyond 45 mins 👍 I wonder how many recalcitrant 'ITB' cases are actually neurovascular in aetiology? 🧐 Plan - considering angiography, MR neurography & possible distal ITB release at Gerdy's tubercle if not responsive to injection

Consent✅ - this is a beauty 🤓 Elite runner Crampy, aching lateral knee pain - onset at around 20-30 mins Seen multiple clinicians - had numerous injections including ITB plus extensive rehabilitation - refractory Almost 'claudicant' in nature - settles quickly on cessation of exercise - spreads both proximal & distal to lateral joint line No spinal symptoms & LSp assessment clear No lateral compartment pathology eg meniscal tear Had popliteus tendinopathy on US, but minimal response to my initial diagnostic injection POCUS video - The inferolateral genicular neurovascular bundle ('pepper pot' structure) is seen compressed under the distal ITB on active knee flexion : terminal extension Patient localises pain in this area with probe pressure Injection - hydrodissection (CSI, LA) - fluid seen separating plane just superficial to NV bundle 100% pain relief on extended treadmill test beyond 45 mins 👍 I wonder how many recalcitrant 'ITB' cases are actually neurovascular in aetiology? 🧐 Plan - considering angiography, MR neurography & possible distal ITB release at Gerdy's tubercle if not responsive to injection

49,561 views

Consent ✅ Late 40s female Referred as L ‘tight hip flexor’ Increased running volume to 120K /week for Ultramarathon See videos Diagnosis?

Consent ✅ Late 40s female Referred as L ‘tight hip flexor’ Increased running volume to 120K /week for Ultramarathon See videos Diagnosis?

89,478 views

Consent✅ Another personal trainer - Deep buttock pain with referred symptoms into hamstring & below the knee to pain - sitting, hinge based movements, yoga etc Lumbar spine & hip clear including imaging Typical symptoms brought on by - 1. Neural tension testing, seated piriformis stretch test & active contraction test 2. Palpation through deep gluteal space & on Tinel's test into sciatic nerve (SN) with US probe localisation....most provocative just inferior to piriformis Ultrasound image - annotated SN (longitudinal) as passes deep to piriformis - nerve calibre changes - can also see prominent adjacent vessels (fibrovascular adhesions a common cause of SN compression) US video - hydrodissection of SN longitudinally - can see inejctate pass along tissue plane proximally & distally (through piriformis) Immediate pain relief of typical sitting symptoms & under contractile load

Consent✅ Another personal trainer - Deep buttock pain with referred symptoms into hamstring & below the knee to pain - sitting, hinge based movements, yoga etc Lumbar spine & hip clear including imaging Typical symptoms brought on by - 1. Neural tension testing, seated piriformis stretch test & active contraction test 2. Palpation through deep gluteal space & on Tinel's test into sciatic nerve (SN) with US probe localisation....most provocative just inferior to piriformis Ultrasound image - annotated SN (longitudinal) as passes deep to piriformis - nerve calibre changes - can also see prominent adjacent vessels (fibrovascular adhesions a common cause of SN compression) US video - hydrodissection of SN longitudinally - can see inejctate pass along tissue plane proximally & distally (through piriformis) Immediate pain relief of typical sitting symptoms & under contractile load

25,041 views

Consent✅ Futsal Goalkeeper What is the injury?

Consent✅ Futsal Goalkeeper What is the injury?

13,080 views

Consent ✅ Bilateral arm pain & weakness This is his gait Diagnosis?

Consent ✅ Bilateral arm pain & weakness This is his gait Diagnosis?

35,806 views

Consent ✅ I've seen many rare cases in my time.... But never a pregnant medial gastrocnemius

Consent ✅ I've seen many rare cases in my time.... But never a pregnant medial gastrocnemius

21,236 views

Consent ✅ L ankle & lower leg pain & instability Diagnosis?

Consent ✅ L ankle & lower leg pain & instability Diagnosis?

18,595 views

Consent ✅ The thing I enjoy most in my job is collaboration with expert physiotherapists on complex cases, especially in elite sportsmen & women It’s a symbiotic relationship – there is mutual learning & professional growth - and the patient gets the best of both worlds I had the privilege of assessing a professional ballet dancer who flew in from Budapest alongside the amazing Liz Bayley recently I thought I’d summarise our joint knee assessment for those interested (get a cup of tea! 😆) 2 months ago, sharp pain in the medial knee after sitting with legs crossed for 30 minutes ‘Instability’ during Swan Lake rehearsals, with pinching pain and fear of knee buckling – had one fall on stage during a performance One episode woke up one morning with local swelling, ‘pressure’ in the joint, and diffuse anteromedial knee pain - unable to walk or fully extend / flex the knee Currently experiencing sensation of pain, ‘swelling’ & fullness, particularly anteromedial patella - burning, prickly sensation Warms up with activity – latent post exercise pain Aggs - Grand plie in first position, squatting, bridges with hip adduction, transferring weight in turned-out position, down stairs Reviewed MRI in Hungary – Normal menisci, Hoffa's fat pad & articular cartilage – but report missed adductor magnus distal tendinopathy! (see sagittal image) – always check the images yourself Exam- Hip joint & lumbar spine clear Full squat sore especially with R leg bias Tender medial aspect of the knee, particularly in the region of the pes anserinus Fat pad compression test negative Mild awareness PFJ compression Knee flexion pain at end range but other meniscal tests negative Adductor loading / stretch tests (including adductor magnus bias) negative Prone knee bend neural tension test with saphenous nerve bias – minimally provocative DDs: · Patellofemoral pain – ‘common things are common’ · Pes anserine bursitis with associated infrapatella branch of saphenous nerve irritation? · Distal adductor magnus tendinopathy with associated saphenous nerve irritation? (AM forms floor of Hunter’s canal) POCUS in clinic – Great for tracing saphenous nerve & distal branches reliably; no nerve pathology seen or pain reproduction on systematic Tinel’s test using probe. Adductor magnus tendinopathy confirmed – but on further review of MRI, the inflamed adductor magnus tendon seems some distance from saphenous nerve (see axial image), so symptoms less convincing related to secondary nerve irritation However, pes anserine fluid noted vs contralateral side & correlates with her typical pain US guided local anaesthetic injection (video) significantly improves symptoms on comprehensive testing in gym & pilates studio P - Liz Bayley refined a Ballet specific rehabilitation plan now we have more diagnostic confidence - so cool watching her piece this together! Observe how symptoms respond over 6-8 weeks If no improvement, consider definitive injections to pes & / or PFJ – but need to exercise caution especially around tendons that are placed under huge athletic demand

Consent ✅ The thing I enjoy most in my job is collaboration with expert physiotherapists on complex cases, especially in elite sportsmen & women It’s a symbiotic relationship – there is mutual learning & professional growth - and the patient gets the best of both worlds I had the privilege of assessing a professional ballet dancer who flew in from Budapest alongside the amazing Liz Bayley recently I thought I’d summarise our joint knee assessment for those interested (get a cup of tea! 😆) 2 months ago, sharp pain in the medial knee after sitting with legs crossed for 30 minutes ‘Instability’ during Swan Lake rehearsals, with pinching pain and fear of knee buckling – had one fall on stage during a performance One episode woke up one morning with local swelling, ‘pressure’ in the joint, and diffuse anteromedial knee pain - unable to walk or fully extend / flex the knee Currently experiencing sensation of pain, ‘swelling’ & fullness, particularly anteromedial patella - burning, prickly sensation Warms up with activity – latent post exercise pain Aggs - Grand plie in first position, squatting, bridges with hip adduction, transferring weight in turned-out position, down stairs Reviewed MRI in Hungary – Normal menisci, Hoffa's fat pad & articular cartilage – but report missed adductor magnus distal tendinopathy! (see sagittal image) – always check the images yourself Exam- Hip joint & lumbar spine clear Full squat sore especially with R leg bias Tender medial aspect of the knee, particularly in the region of the pes anserinus Fat pad compression test negative Mild awareness PFJ compression Knee flexion pain at end range but other meniscal tests negative Adductor loading / stretch tests (including adductor magnus bias) negative Prone knee bend neural tension test with saphenous nerve bias – minimally provocative DDs: · Patellofemoral pain – ‘common things are common’ · Pes anserine bursitis with associated infrapatella branch of saphenous nerve irritation? · Distal adductor magnus tendinopathy with associated saphenous nerve irritation? (AM forms floor of Hunter’s canal) POCUS in clinic – Great for tracing saphenous nerve & distal branches reliably; no nerve pathology seen or pain reproduction on systematic Tinel’s test using probe. Adductor magnus tendinopathy confirmed – but on further review of MRI, the inflamed adductor magnus tendon seems some distance from saphenous nerve (see axial image), so symptoms less convincing related to secondary nerve irritation However, pes anserine fluid noted vs contralateral side & correlates with her typical pain US guided local anaesthetic injection (video) significantly improves symptoms on comprehensive testing in gym & pilates studio P - Liz Bayley refined a Ballet specific rehabilitation plan now we have more diagnostic confidence - so cool watching her piece this together! Observe how symptoms respond over 6-8 weeks If no improvement, consider definitive injections to pes & / or PFJ – but need to exercise caution especially around tendons that are placed under huge athletic demand

21,470 views

Consent ✅ Female Cross fitter with bilateral quite focal anterior knee pain superolateral to patella Onset after ramp up in training volume & weight esp squats, cleans Function inhibiting catching symptoms at predictable knee flexion angle POCUS - thickened lateral quadriceps fat pad seen to impinge under quads expansion & over trochlea on active knee flexion ➡️ extension - correlates with palpable painful click felt under probe US guided injection today removed click & pain on squat testing

Consent ✅ Female Cross fitter with bilateral quite focal anterior knee pain superolateral to patella Onset after ramp up in training volume & weight esp squats, cleans Function inhibiting catching symptoms at predictable knee flexion angle POCUS - thickened lateral quadriceps fat pad seen to impinge under quads expansion & over trochlea on active knee flexion ➡️ extension - correlates with palpable painful click felt under probe US guided injection today removed click & pain on squat testing

30,434 views

Consent ✅ Footballer Preceding achilles tendon pain - then sudden pop & medial calf pain radiating into achilles last 5 mins of game POCUS - massive medial gastroc aponeurosis tear extending ('unzippered') all way through free gastroc aponeurosis into distal achilles tendon 28cm!! 3 months down the line, still struggling to load pain free & persistent strength deficits - poor hop power / spring.

Consent ✅ Footballer Preceding achilles tendon pain - then sudden pop & medial calf pain radiating into achilles last 5 mins of game POCUS - massive medial gastroc aponeurosis tear extending ('unzippered') all way through free gastroc aponeurosis into distal achilles tendon 28cm!! 3 months down the line, still struggling to load pain free & persistent strength deficits - poor hop power / spring.

22,288 views

THREAD ALERT 🚨🚨 Seen loads of interesting & 'left-field' foot & ankle cases over the last week so I thought I'd post them 🦶👣 1. Footballer Anterior ankle pain on powerful kick, sprint & inclines When very irritable, gets an uncomfortable 'flicking' sensation Pain reproduced on dynamic lunge & resisted dorsiflexion Tender over tibialis anterior & into anterior joint recess MRI shows inflammation anterior ankle joint line POCUS video - large dorsal talar ostophyte irritating TA tendon on active DF / PF So, 2 problems - 'footballers ankle' plus compression of TA tendon under load & through ROM US guided injection to anterior ankle impingement zone, podiatry & physio input before RTP

THREAD ALERT 🚨🚨 Seen loads of interesting & 'left-field' foot & ankle cases over the last week so I thought I'd post them 🦶👣 1. Footballer Anterior ankle pain on powerful kick, sprint & inclines When very irritable, gets an uncomfortable 'flicking' sensation Pain reproduced on dynamic lunge & resisted dorsiflexion Tender over tibialis anterior & into anterior joint recess MRI shows inflammation anterior ankle joint line POCUS video - large dorsal talar ostophyte irritating TA tendon on active DF / PF So, 2 problems - 'footballers ankle' plus compression of TA tendon under load & through ROM US guided injection to anterior ankle impingement zone, podiatry & physio input before RTP

14,179 views

Consent ✅ “Arthritis?? I was dreading you were going to tell me that. My mum has got it and she can’t do anything these days. That’s me done too I suppose” Not an uncommon chat in MSK and orthopaedic clinic But actually it’s amazing what some (motivated) people can do even with severe deforming OA This 80 yo old lady has a better squat than me and walks her dog everyday She does the exercises her osteopath gave her (who also refused to do any manipulative work and said there was little point her coming back for recurrent appts - I love this osteo already🤣) As an aside, interesting to see that the lateral compartment looks different on Rosenberg xray view vs standard AP, even in end stage OA

Consent ✅ “Arthritis?? I was dreading you were going to tell me that. My mum has got it and she can’t do anything these days. That’s me done too I suppose” Not an uncommon chat in MSK and orthopaedic clinic But actually it’s amazing what some (motivated) people can do even with severe deforming OA This 80 yo old lady has a better squat than me and walks her dog everyday She does the exercises her osteopath gave her (who also refused to do any manipulative work and said there was little point her coming back for recurrent appts - I love this osteo already🤣) As an aside, interesting to see that the lateral compartment looks different on Rosenberg xray view vs standard AP, even in end stage OA

16,514 views

Consent ✅ Badminton player Acute plantar heel pain 1 year ago lunging for drop shot POCUS - chronic high grade partial tear plantar fascia origin Pt wants intervention having not progressed with physiotherapy Shockwave therapy & CSI relatively contraindicated - PRP probably best option for this presentation

Consent ✅ Badminton player Acute plantar heel pain 1 year ago lunging for drop shot POCUS - chronic high grade partial tear plantar fascia origin Pt wants intervention having not progressed with physiotherapy Shockwave therapy & CSI relatively contraindicated - PRP probably best option for this presentation

19,456 views

Consent ✅ Female powerlifter Disabling retro / suprapatella knee pain, 'heat' - unable to tolerate even low load into squat, leg extension One episode of 'redness' above patella Low grade effusion No rheum risk factors Was expecting PFJ chondral injury, but the surfaces are pristine Rather she has a large serpentiginous inflamed plica

Consent ✅ Female powerlifter Disabling retro / suprapatella knee pain, 'heat' - unable to tolerate even low load into squat, leg extension One episode of 'redness' above patella Low grade effusion No rheum risk factors Was expecting PFJ chondral injury, but the surfaces are pristine Rather she has a large serpentiginous inflamed plica

13,005 views

Consent ✅ Runner Lateral knee pain longer runs & with multi-direction movements in football MRI - marked ITB inflammation - but zero response from diagnsotic injection after extensive rehabilitation Re-assessment today on POCUS shows popliteus tendinopathy evaluating the lateral joint line & hiatus Pain on resisted knee flexion from EROM extension in prone, and on resisted rotation Popliteus tendinopathy can masquerade as ITBFS, so have it on your radar

Consent ✅ Runner Lateral knee pain longer runs & with multi-direction movements in football MRI - marked ITB inflammation - but zero response from diagnsotic injection after extensive rehabilitation Re-assessment today on POCUS shows popliteus tendinopathy evaluating the lateral joint line & hiatus Pain on resisted knee flexion from EROM extension in prone, and on resisted rotation Popliteus tendinopathy can masquerade as ITBFS, so have it on your radar

10,646 views

Consent✅ Love VIBE MRI sequences for assessing & monitoring pars stress fracture recovery Images are 😍 Death of CT in assessing this injury?

Consent✅ Love VIBE MRI sequences for assessing & monitoring pars stress fracture recovery Images are 😍 Death of CT in assessing this injury?

14,768 views

Consent ✅ Ballet dancer - deep seated R buttock pain on single leg activities, attitude derriere (see pic), arabesque, pigeon stretch Positive ischiofemoral impingement test (side lying hip ext & adduction) MRI - oedema in quadratus femoris Not improving despite offload & rehab - therefore US guided CSI & LA both diagnostically & therapeutically (see video - avoiding sciatic nerve on central / left of screen adjacent to the ischial tuberosity) I've inverted the MRI image so marries up with injection video orientation.....

Consent ✅ Ballet dancer - deep seated R buttock pain on single leg activities, attitude derriere (see pic), arabesque, pigeon stretch Positive ischiofemoral impingement test (side lying hip ext & adduction) MRI - oedema in quadratus femoris Not improving despite offload & rehab - therefore US guided CSI & LA both diagnostically & therapeutically (see video - avoiding sciatic nerve on central / left of screen adjacent to the ischial tuberosity) I've inverted the MRI image so marries up with injection video orientation.....

10,295 views

Consent ✅ L anterior elbow pain in bodybuilder POCUS - shows distal biceps tendinopathy & paratendinitis with fluid in sheath US guided injection - seems there is an occult intra-substance tear that is only visualised with the injectate in-situ Lateral to medial approach to avoid vessels medial to tendon - also be wary of radial nerve / branches bottom right of screen Injection can also be done in cobra position - here paratendinitis an easy target so injection undertaken proximally

Consent ✅ L anterior elbow pain in bodybuilder POCUS - shows distal biceps tendinopathy & paratendinitis with fluid in sheath US guided injection - seems there is an occult intra-substance tear that is only visualised with the injectate in-situ Lateral to medial approach to avoid vessels medial to tendon - also be wary of radial nerve / branches bottom right of screen Injection can also be done in cobra position - here paratendinitis an easy target so injection undertaken proximally

10,635 views

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Consent ✅ Retired nurse, 60s Decade of flank / loin pain - perceived around thoracolumbar junction (blue cross) Extensive MSK, renal and GI investigations - no diagnosis forthcoming CT and MRI of spine reported normal On systematic palpation / PA glide in prone, her pain is actually provoked more inferiorly (green cross) POCUS video - calcific changes at 12 rib interface with spine, correlating with her pain - there is no true costotransverse joint at this level, rather ligamentous attachments- so this represents an enthesopathy / 'ligamentopathy' US guided LA & CSI - complete abolition of pain after 10 years! (see enthusiastic gyrating - sound on)
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Consent ✅ Retired nurse, 60s Decade of flank / loin pain - perceived around thoracolumbar junction (blue cross) Extensive MSK, renal and GI investigations - no diagnosis forthcoming CT and MRI of spine reported normal On systematic palpation / PA glide in prone, her pain is actually provoked more inferiorly (green cross) POCUS video - calcific changes at 12 rib interface with spine, correlating with her pain - there is no true costotransverse joint at this level, rather ligamentous attachments- so this represents an enthesopathy / 'ligamentopathy' US guided LA & CSI - complete abolition of pain after 10 years! (see enthusiastic gyrating - sound on)

James Noake

50,092 views • 1 month ago

Consent ✅ Professional race driver - FIA endurance / LeMans R upper limb heaviness, weakness, headaches and facial pain with very high sustained effort in car over 3-4 hours - specifically repetitive shoulder abduction, forward flexion, rotation Pre-dated by high energy 'whip lash' injury in crash Numerous cervical spine investigations abroad - all normal Most telling exam sign - Roo's test - (see video reel) Forearm and hand cyanosis with vein dilatation Highly suggestive of vascular (venous thoracic outlet syndrome) End of reel - duplex ultrasound shows flow occlusion taking patient into functional driving position (FF, lateral raise 60 deg max) Awaiting MRI TOS protocol with contrast and arms up / down vTOS can be caused by myriad anatomical variants - anomalous muscle slips, ligaments, accessory rib, and also post trauma Pearls - listen to the patient, the story's the pattern, and the sporting MOI
0:27
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Consent ✅ Professional race driver - FIA endurance / LeMans R upper limb heaviness, weakness, headaches and facial pain with very high sustained effort in car over 3-4 hours - specifically repetitive shoulder abduction, forward flexion, rotation Pre-dated by high energy 'whip lash' injury in crash Numerous cervical spine investigations abroad - all normal Most telling exam sign - Roo's test - (see video reel) Forearm and hand cyanosis with vein dilatation Highly suggestive of vascular (venous thoracic outlet syndrome) End of reel - duplex ultrasound shows flow occlusion taking patient into functional driving position (FF, lateral raise 60 deg max) Awaiting MRI TOS protocol with contrast and arms up / down vTOS can be caused by myriad anatomical variants - anomalous muscle slips, ligaments, accessory rib, and also post trauma Pearls - listen to the patient, the story's the pattern, and the sporting MOI

James Noake

20,918 views • 29 days ago

Consent✅ So - how many times do I have to say this? This is close to my 200th case - medial neck of femur stress injury, in a runner who is over-training, misdiagnosed as a 'hip flexor' problem 🤮🤢 Look at the video & appreciate why the 'hip flexor' might be implicated
0:28
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Consent✅ So - how many times do I have to say this? This is close to my 200th case - medial neck of femur stress injury, in a runner who is over-training, misdiagnosed as a 'hip flexor' problem 🤮🤢 Look at the video & appreciate why the 'hip flexor' might be implicated

James Noake

65,933 views • 6 months ago

Consent ✅ Some things are sent to test us 😕 You build momentum, then the obstacles appear It feels so unjust - I don't feel I deserve this - but we go on It's how you deal with it that defines you as a person & your character #meanstoanend
0:30

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Consent ✅ Some things are sent to test us 😕 You build momentum, then the obstacles appear It feels so unjust - I don't feel I deserve this - but we go on It's how you deal with it that defines you as a person & your character #meanstoanend

James Noake

81,300 views • 11 months ago

Consent✅ Female, 20s L upper abdominal pain since lockdown - on back of increased home work outs including ab & core work Now pain lying supine, prone, trunk rotation, being hugged, deep inspiration.... Hugely impactful on QoL Seen multiple specialists - GI, gynae (!), respiratory - utterly frustrated Referred as possible ACNE syndrome - but not in the right place anatomically (ACNE is peri-umbilical semilunaris border) OE - hypermobile ? EDS Focal pain on gentle palpation into immediate L inferior costal margin EROM thoracic rotation painful, plus trunk flexion / extension POCUS video - L 'floating rib' - possibly 11th - seen subluxed superficially over adjacent rib, vs normal side sat 'flush' On deep inspiration, pain reproduced with probe pressure maintained as irritable over-lying soft tissue 'tents' Diagnosis - 'Floating rib' or 'rib tip' syndrome Outcome - symptoms validated - no more medical 'rabbit holes' - surgical resection
0:29
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Consent✅ Female, 20s L upper abdominal pain since lockdown - on back of increased home work outs including ab & core work Now pain lying supine, prone, trunk rotation, being hugged, deep inspiration.... Hugely impactful on QoL Seen multiple specialists - GI, gynae (!), respiratory - utterly frustrated Referred as possible ACNE syndrome - but not in the right place anatomically (ACNE is peri-umbilical semilunaris border) OE - hypermobile ? EDS Focal pain on gentle palpation into immediate L inferior costal margin EROM thoracic rotation painful, plus trunk flexion / extension POCUS video - L 'floating rib' - possibly 11th - seen subluxed superficially over adjacent rib, vs normal side sat 'flush' On deep inspiration, pain reproduced with probe pressure maintained as irritable over-lying soft tissue 'tents' Diagnosis - 'Floating rib' or 'rib tip' syndrome Outcome - symptoms validated - no more medical 'rabbit holes' - surgical resection

James Noake

24,571 views • 5 months ago

Documented consent ✅✅ Super fit male 70s Extreme skiing, climbing Previous lumbar fusion, then discectomy L4/5 Lost sporting confidence, with insidious drop off in functional power & coordination in R > L legs Dragging foot Leg doesn’t “feel like my own & it spasms unpredictably” Can’t heel or tip toe walk - no lower motor neurone signs as one might expect in context of previous surgery… Rather, marked UPPER motor neurone signs (see video - clonus +++ and hypertonicity) Whilst examining lower limbs supine on bed - “What are these abdominal scars?” “I had an appendicectomy” “What about these ones? (port scars - look closer) “Oh yes, i had a radical prostatectomy for cancer several years ago” MCC (cord compression) now top of the differential diagnosis list. Tips: 1. Always expose the patient as fully as is appropriate 2. Don’t automatically assume patients will report all the relevant medical stuff even if you ask “any other medical conditions I need to know about?”
0:26
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Documented consent ✅✅ Super fit male 70s Extreme skiing, climbing Previous lumbar fusion, then discectomy L4/5 Lost sporting confidence, with insidious drop off in functional power & coordination in R > L legs Dragging foot Leg doesn’t “feel like my own & it spasms unpredictably” Can’t heel or tip toe walk - no lower motor neurone signs as one might expect in context of previous surgery… Rather, marked UPPER motor neurone signs (see video - clonus +++ and hypertonicity) Whilst examining lower limbs supine on bed - “What are these abdominal scars?” “I had an appendicectomy” “What about these ones? (port scars - look closer) “Oh yes, i had a radical prostatectomy for cancer several years ago” MCC (cord compression) now top of the differential diagnosis list. Tips: 1. Always expose the patient as fully as is appropriate 2. Don’t automatically assume patients will report all the relevant medical stuff even if you ask “any other medical conditions I need to know about?”

James Noake

50,128 views • 1 year ago

Consent✅ Another - possible - genicular nerve case Runner, bilateral lateral knee pain Treated as ITB overload; exhausted all non-surgical options so reasonably proceeded to targeted partial ITB release Unfortunately symptoms persisted but changed in nature - 'burning' now (L more than R), slightly more diffuse & symptoms with sitting, not just on exercise POCUS video - Scarred thickened ITB (typical post-surgical legacy) seen, with superolateral genicular NV bundle sat just deep to it Injection - hydrodissection of scar tissue around the NV bundle, freeing up the fascial plane systematically - hard work because of the density of the tissue Post procedure (volume up) - patient essentially pain free on the treadmill - R side (not injected) still painful
1:10
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Consent✅ Another - possible - genicular nerve case Runner, bilateral lateral knee pain Treated as ITB overload; exhausted all non-surgical options so reasonably proceeded to targeted partial ITB release Unfortunately symptoms persisted but changed in nature - 'burning' now (L more than R), slightly more diffuse & symptoms with sitting, not just on exercise POCUS video - Scarred thickened ITB (typical post-surgical legacy) seen, with superolateral genicular NV bundle sat just deep to it Injection - hydrodissection of scar tissue around the NV bundle, freeing up the fascial plane systematically - hard work because of the density of the tissue Post procedure (volume up) - patient essentially pain free on the treadmill - R side (not injected) still painful

James Noake

19,269 views • 5 months ago

Consent✅ Runner, HIIT Deep left buttock pain Occasionally travels down posterior thigh with intermittent parasthesia & numbness lower leg & foot Brought on with pigeon stretching, yoga, as well 4 point kneeling core hip extension / adduction work 🤷‍♂️ Sitting main aggravating factor - isometric single leg bridging as well Clinical exam difficult to reproduce pain but discomfort on palpation through deep gluteal space MRI: Lumbar spine - normal Pelvis - mildly reduced ischiofemoral interval L side - subtle oedema in quadratus femoris (QF) POCUS video: With passive hip external rotation (closing down the ischiofemoral space) can see bunching of QF and tenting of sciatic nerve (SN) - 'Eruption Sign' - maintaining probe pressure on this soft tissue during the manoeuvre reproduces typical pain US guided injection (lateral to medial to avoid SN) to QF and ischiofemoral space - immediate reduction in sitting pain post procedure
0:54
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Consent✅ Runner, HIIT Deep left buttock pain Occasionally travels down posterior thigh with intermittent parasthesia & numbness lower leg & foot Brought on with pigeon stretching, yoga, as well 4 point kneeling core hip extension / adduction work 🤷‍♂️ Sitting main aggravating factor - isometric single leg bridging as well Clinical exam difficult to reproduce pain but discomfort on palpation through deep gluteal space MRI: Lumbar spine - normal Pelvis - mildly reduced ischiofemoral interval L side - subtle oedema in quadratus femoris (QF) POCUS video: With passive hip external rotation (closing down the ischiofemoral space) can see bunching of QF and tenting of sciatic nerve (SN) - 'Eruption Sign' - maintaining probe pressure on this soft tissue during the manoeuvre reproduces typical pain US guided injection (lateral to medial to avoid SN) to QF and ischiofemoral space - immediate reduction in sitting pain post procedure

James Noake

16,258 views • 4 months ago

Consent✅ Hip osteoarthritis can be readily seen on POCUS Use internal and external rotation to view a surprisingly wide area of femoral head cartilage
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Consent✅ Hip osteoarthritis can be readily seen on POCUS Use internal and external rotation to view a surprisingly wide area of femoral head cartilage

James Noake

12,141 views • 3 months ago

Consent ✅ Footballer - ACL recon & MCL tear 12 months ago Uneventful rehab process & RTP ...... but then developed focal pain over medial joint line & restricted flexion Sore on side passing & cutting / change of direction drills OE - Palpation pain at proximal MCL Stiff & painful into EROM flexion MRI - no medial pathology reported - but on closer inspection, subtle medium signal focal change in deep MCL on T1 & T2 (always check the scan yourself) POCUS - obvious large heterotopic calcific deposit in previously injured proximal MCL fibres - Pelligrini-Stieda lesion Video - needle barbotage / fenestration of deposit, finished with a soupçon of CSI 🫰 Post procedure, complete abolition of pain in gym & typical provocative movements ✅ Ultrasound is much better than MRI in identifying calcific pathology (as is plain x-ray)
0:33
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Consent ✅ Footballer - ACL recon & MCL tear 12 months ago Uneventful rehab process & RTP ...... but then developed focal pain over medial joint line & restricted flexion Sore on side passing & cutting / change of direction drills OE - Palpation pain at proximal MCL Stiff & painful into EROM flexion MRI - no medial pathology reported - but on closer inspection, subtle medium signal focal change in deep MCL on T1 & T2 (always check the scan yourself) POCUS - obvious large heterotopic calcific deposit in previously injured proximal MCL fibres - Pelligrini-Stieda lesion Video - needle barbotage / fenestration of deposit, finished with a soupçon of CSI 🫰 Post procedure, complete abolition of pain in gym & typical provocative movements ✅ Ultrasound is much better than MRI in identifying calcific pathology (as is plain x-ray)

James Noake

20,118 views • 7 months ago

Consent✅ Lots to think about here Male, 40s- super fit - skiing, running, weights Always had stiff hips and tight 'hip flexors' 👀 hmmmm Recalls aggressive breaststroke kick right side (ie minimal trauma) - sudden catching pain right groin Remained intrusive with mechanical symptoms - pain at rest, sitting, rolling over, deep squat Exam - both hips reduced ROM especially into FADDIR -right particularly irritable Video - AP Xray pelvis - bilateral dysplasia R > L, plus cam bumps.... a hip pain 'perfect storm' POCUS - extensive R sided delamination labral tear (use passive hip rotation to manipulate & 'milk' effusion fluid into tear to highlight it) MRI images (surrogate markers of dysplasia) 1. 'Saturn Sign' (I made this up) - anterior to posterior labral tear 2. Cystic change in ligaments teres 3. Hypertrophic cystic labral changes It's not just women that have dysplastic hips This needs experienced surgical input rather than 'kicking the can down the road'
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Consent✅ Lots to think about here Male, 40s- super fit - skiing, running, weights Always had stiff hips and tight 'hip flexors' 👀 hmmmm Recalls aggressive breaststroke kick right side (ie minimal trauma) - sudden catching pain right groin Remained intrusive with mechanical symptoms - pain at rest, sitting, rolling over, deep squat Exam - both hips reduced ROM especially into FADDIR -right particularly irritable Video - AP Xray pelvis - bilateral dysplasia R > L, plus cam bumps.... a hip pain 'perfect storm' POCUS - extensive R sided delamination labral tear (use passive hip rotation to manipulate & 'milk' effusion fluid into tear to highlight it) MRI images (surrogate markers of dysplasia) 1. 'Saturn Sign' (I made this up) - anterior to posterior labral tear 2. Cystic change in ligaments teres 3. Hypertrophic cystic labral changes It's not just women that have dysplastic hips This needs experienced surgical input rather than 'kicking the can down the road'

James Noake

14,275 views • 4 months ago

14 day post op Maia implant update Basically looks & moves like a normal thumb
0:26
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14 day post op Maia implant update Basically looks & moves like a normal thumb

James Noake

42,544 views • 2 years ago

5 days post discectomy feeling comfortable to do boring ‘tick over’ stuff, not least to keep me borderline sane 🤪
0:21
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5 days post discectomy feeling comfortable to do boring ‘tick over’ stuff, not least to keep me borderline sane 🤪

James Noake

19,735 views • 11 months ago

Consent ✅ Teen runner & footballer - mid thigh pain after intense Sport's Day culminating in hard 800m couldn’t recall acute pop / tear then recurrence during 'Duke of Edinburgh' award hiking with back pack Kicking & sprinting provocative ++ POCUS - rectus femoris tear adjacent to posterior aponeurosis (BAMIC 2A?) - small haematoma Central tendon not involved - but given recurrent nature, I'd tend to be conservative with RTP timescales eg 6 weeks plus Interested in others thoughts... carlespedret
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Consent ✅ Teen runner & footballer - mid thigh pain after intense Sport's Day culminating in hard 800m couldn’t recall acute pop / tear then recurrence during 'Duke of Edinburgh' award hiking with back pack Kicking & sprinting provocative ++ POCUS - rectus femoris tear adjacent to posterior aponeurosis (BAMIC 2A?) - small haematoma Central tendon not involved - but given recurrent nature, I'd tend to be conservative with RTP timescales eg 6 weeks plus Interested in others thoughts... carlespedret

James Noake

39,723 views • 3 years ago

Consent✅ ACL reconstuction with lateral tenodesis 9 months ago Persistent lateral pain 'sliding / catching' sensation over tenodesis site on predictable knee flexion squat angle Tenodesis screw looks ok on x-ray POCUS - fluid / inflammation seen around graft as passes under LCL (graft = circle.... then narrow slip as US turns longitudinal) @orthotwitter - do you see graft / tenodesis soft tissue irritation - impingement? - in any of your cases?
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Consent✅ ACL reconstuction with lateral tenodesis 9 months ago Persistent lateral pain 'sliding / catching' sensation over tenodesis site on predictable knee flexion squat angle Tenodesis screw looks ok on x-ray POCUS - fluid / inflammation seen around graft as passes under LCL (graft = circle.... then narrow slip as US turns longitudinal) @orthotwitter - do you see graft / tenodesis soft tissue irritation - impingement? - in any of your cases?

James Noake

25,782 views • 2 years ago

Consent ✅ Middla aged Ironman Months of L inferior gluteal pain that radiates into posterior thigh to knee - burning / throbbing Recent 'pop' in gluteal region with sudden hip & lumbar flexion Worse on - running / fast walking, sitting, cough / sneeze +ive proximal hamstring tendinopathy tests +ive adductor magnus bias tests +ive SLR neural tension Pain LSp flexion, limited POCUS & MRI - interface tear (peel away lesion) of proximal hamstring but remaining tendons intact, so no retraction LSp MRI - L sided disc bulge irritating L S1 nerve root So - concurrent pain drivers? Or one injury mimicking the other? PHT pain can refer pain distally into hamstring. What next after 3 months rehab / load mods & no change? 🧐 Patient will return with symptoms provoked - then US guided LA only injection to proximal hamstring tendon - then re-test - easier & safer to rule out / in tendon driven symptoms first before considering spinal options.
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Consent ✅ Middla aged Ironman Months of L inferior gluteal pain that radiates into posterior thigh to knee - burning / throbbing Recent 'pop' in gluteal region with sudden hip & lumbar flexion Worse on - running / fast walking, sitting, cough / sneeze +ive proximal hamstring tendinopathy tests +ive adductor magnus bias tests +ive SLR neural tension Pain LSp flexion, limited POCUS & MRI - interface tear (peel away lesion) of proximal hamstring but remaining tendons intact, so no retraction LSp MRI - L sided disc bulge irritating L S1 nerve root So - concurrent pain drivers? Or one injury mimicking the other? PHT pain can refer pain distally into hamstring. What next after 3 months rehab / load mods & no change? 🧐 Patient will return with symptoms provoked - then US guided LA only injection to proximal hamstring tendon - then re-test - easier & safer to rule out / in tendon driven symptoms first before considering spinal options.

James Noake

19,428 views • 1 year ago

Consent ✅ Female early 20s - overweight Started running for weight loss Bilateral cramps medial gaiter area & ankle pain Complains of 'swelling' in the region Pain settles quickly post exercise after 30-60mins More recently P&N spreading into plantar aspect of foot Video slide show - MRI shows hypertrophied FHL muscle belly & very low lying, down to level of sub-talar joint Now causing tarsal tunnel symptoms - tibial nerve (with high signal / mild oedema) immediately adjacent to FHL muscle belly Low lying / accessory soleus can also behave like this Consider gait re-training, optimising triceps surae capacity to 'offset' FHL, botox, US guided targeted tarsal tunnel hydrodissection injection, de-bulking of muscle as last resort if conservative measures fail
0:29
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Consent ✅ Female early 20s - overweight Started running for weight loss Bilateral cramps medial gaiter area & ankle pain Complains of 'swelling' in the region Pain settles quickly post exercise after 30-60mins More recently P&N spreading into plantar aspect of foot Video slide show - MRI shows hypertrophied FHL muscle belly & very low lying, down to level of sub-talar joint Now causing tarsal tunnel symptoms - tibial nerve (with high signal / mild oedema) immediately adjacent to FHL muscle belly Low lying / accessory soleus can also behave like this Consider gait re-training, optimising triceps surae capacity to 'offset' FHL, botox, US guided targeted tarsal tunnel hydrodissection injection, de-bulking of muscle as last resort if conservative measures fail

James Noake

12,853 views • 1 year ago

Consent ✅ Very interesting case!! 🤓🤓🤓 Young teenager - laparoscopic cholecystectomy months ago Persistent debilitating R upper quadrant pain around port scar site Burning, stabbing - provoked by minimal activity eg sitting up, bracing in car turning corners 4 weeks as in-patient in hospital, having further general surgical work up .... MRI, US, CT, bloods normal Off school Examination - +ive Carnett's sign, pain / inhibition on sit up, clearly abdo wall issue POCUS - can appreciate subtle port site hypoechoeic channel through rectus abdominus - this has injured the anterior cutaneous nerve at this level (T9 / T10 - see ACN schematic) Video - US guided nerve block / hydrodissection..... immediate pain relief 🥳 So at least the potential (harmful) hunt for a non MSK / gastroenterological cause can stop now Only one other case report of this in 2022 - but not a typical laparoscopic complication or tick box form. If the block fails to improve pain beyond short term, RF ablation might be helpful - then last resort surgical neurolysis.
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Consent ✅ Very interesting case!! 🤓🤓🤓 Young teenager - laparoscopic cholecystectomy months ago Persistent debilitating R upper quadrant pain around port scar site Burning, stabbing - provoked by minimal activity eg sitting up, bracing in car turning corners 4 weeks as in-patient in hospital, having further general surgical work up .... MRI, US, CT, bloods normal Off school Examination - +ive Carnett's sign, pain / inhibition on sit up, clearly abdo wall issue POCUS - can appreciate subtle port site hypoechoeic channel through rectus abdominus - this has injured the anterior cutaneous nerve at this level (T9 / T10 - see ACN schematic) Video - US guided nerve block / hydrodissection..... immediate pain relief 🥳 So at least the potential (harmful) hunt for a non MSK / gastroenterological cause can stop now Only one other case report of this in 2022 - but not a typical laparoscopic complication or tick box form. If the block fails to improve pain beyond short term, RF ablation might be helpful - then last resort surgical neurolysis.

James Noake

15,550 views • 1 year ago

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