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Medicine & Science in Sports & Exercise:
doi: 10.1249/01.mss.0000417527.38002.ed
Abstracts

Abst B-ClinicalSess

Free Access

A-26 Clinical Case Slide - Baseball/Softball

MAY 30, 2012 9:30 AM - 11:30 AM

ROOM: 2005

705 Chair: David L. Weldy, FACSM. University of Toledo, Toledo, OH.

(No relationships reported)

706 Discussant: Edwin E. Ryan. Adient Orthopedic Physical Therapy, Fairbanks, AK.

(No relationships reported)

707 Discussant: Alexis Ortiz. University of Puerto Rico, Trujillo Alto, PR.

(No relationships reported)

708 MAY 30 9:30 AM - 9:50 AM

Forearm Pain–Softball Player

Brian C. Liem, Ellen Casey. Rehabilitation Institute of Chicago/Northwestern University, Chicago, IL. (Sponsor: Joel Press, FACSM)

(No relationships reported)

HISTORY: A 14 year old right-handed varsity softball pitcher presented with 2 week history of right medial forearm pain. She first noticed pain while pitching during practice and denied any history of major trauma or recent changes in her training or technique. Pain occurred with throwing and was worse especially with curve ball pitches which required wrist flexion, pronation and bracing of her forearm against her hip at ball release. She also noted intermittent swelling in the medial forearm with extension into the medial hand and had experienced pain and tingling in her fourth and fifth digits. Despite her pain she had continued to play but noted that her performance was adversely affected. Ibuprofen and rest provided some relief. She denied any prior injuries to the neck, shoulder and elbow.

PHYSICAL EXAMINATION: Tenderness to palpation along middle third of the medial border of ulna and flexor carpi ulnaris myotendinous junction. Active range of motion at the elbow and wrist full and without pain. Some pain with resisted supination. Strength is 5/5 upper extremities bilaterally, sensation is normal and reflexes are symmetric. No ligamentous laxity. Negative Tinel’s at the elbow.

DIFFERENTIAL DIAGNOSIS:

1. Ulnar neuritis

2. Flexor carpi ulnaris tendinopathy

3. Flexor muscle strain

4. Ulnar periostitis

5. Ulnar stress injury

6. Soft tissue injury or bone contusion from repetitive bracing of forearm against hip

TEST AND RESULTS:

1) Right forearm X-ray: Normal. No fracture, cortical thickening or periosteal reaction

2) Left forearm X-ray: Normal. No fracture, cortical thickening or periosteal reaction

2) MRI right forearm: Bone narrow edema in the mid-shaft of the right ulna (on STIR and T2 weighted images)

FINAL WORKING DIAGNOSIS: Ulnar Stress Injury- Grade II

TREATMENT AND OUTCOMES:

1. Relative rest for 2 weeks (avoidance of pitching, throwing and all painful activities)

2. Physical therapy with focus on scapular stabilization, eccentric strengthening of wrist extensors and supinators, correction of posture and poor throwing biomechanics, and engagement of core muscles

3. Ice and Diclofenac topical gel PRN for pain

4. At one month follow up she reported 90% improvement after resting for 1.5 weeks and 2 sessions of PT but still had pain with pitching. MRI ordered as above.

5. At three months returned to pitching pain free.

709 MAY 30 9:50 AM - 10:10 AM

Osteochondritis Dessicans Of The Capitellum In A 16 Year-old Pitcher

Robert T. Hughes, Aaron Rubin, FACSM. Kaiser Fontana, Fontana, CA. (Sponsor: Robert Sallis, FACSM)

(No relationships reported)

HISTORY: 16 year old male referred by his pediatrician to sports medicine clinic for right elbow pain for 1 month. He is a right handed pitcher at his high school. The pain started after learning how to throw a splitter. It was described as a stretching sensation. He had no pain during the throwing motion. The elbow did hurt after throwing. He had been taking ibuprofen 800mg every eight hours without significant improvement. Icing and heat did not help either. The pain was located in the posterolateral elbow.

PHYSICAL EXAMINATION: Right elbow: No deformity or visible swelling. No significant tenderness to palpation. Normal range of motion with flexion, extension, pronation and supination. Strength was 5/5 with flexion, extension, pronation and supination. No pain or laxity with valgus stress. Negative milking maneuver. No pain with resisted long finger extension.

DIFFERENTIAL DIAGNOSIS: olecranon bursitis versus lateral epicondylitis versus triceps tendinitis versus osteochondritis dessicans of the capitellum versus Panner’s disease.

TEST AND RESULTS: Initial x-ray prior to consultation read by radiology as ill defined density in the antecubital fossa representing soft tissue injury. Review of x-ray by ourselves revealed irregular capitellum.

MRI: Initially read by radiology as mild increased intermediate signal and soft tissue prominence overlying the olecranon. Later addended with 9X5mm oval shaped focus of abnormal signal in the anterior aspect of the capitellum concerning for osteochondritis dessicans. No fluid signal deep to the fragment consistent with a grade 2 OCD.

FINAL WORKING DIAGNOSIS: Grade 2 osteochondritis dessicans lesion of the capitellum.

TREATMENT AND OUTCOMES: Consulted with orthopedic surgery and opted to manage conservatively with rest from all throwing for 6 weeks. Follow up is scheduled at that time. If pain free we may consider a return to throw program. We are concerned that this maybe a career ending injury.

710 MAY 30 10:10 AM - 10:30 AM

Humeral Injury in a Collegiate Baseball Outfielder: A Case Study

Scott E. Klass, Eric M. Yochem, Amy P. Powell, Patrick E. Greis, Charlie A. Hicks-Little. University of Utah, Salt Lake City, UT. (Sponsor: Patricia Eisenman, FACSM)

(No relationships reported)

HISTORY: A healthy 23-year-old Caucasian male in his third year as a NCAA Division 1 baseball outfielder reported to the athletic trainer, complaining of soreness and pain in his right distal humerus that he rated as 7-8/10, while throwing a baseball.

PHYSICAL EXAMINATION: Evaluation revealed no pain over the distal humerus with palpation, except after throwing. Athlete presented with full pain-free ROM and manual muscle strength testing (5/5) bilaterally at the wrist, elbow, and shoulder in all motions. He had slight discomfort with resisted horizontal external rotation. All special tests were negative for pain or excessive motion, including medial/lateral epicondylitis testing, varus/valgus stress testing, hawkins-kennedy, empty can, o’briens test, apprehension/relocation, load/shift, yergensons, and speeds. Interestingly, this athlete had just returned to play following a 2 year religious mission in which he did not throw at all. The athlete continued to participate in fall practices by ignoring prolonged soreness.

DIFFERENTIAL DIAGNOSIS:

1. Biceps brachii, brachialis or triceps brachii muscle strain

2. Periostitis

3. Bone tumor

4. Humeral fracture

TEST AND RESULTS: At the start of spring baseball the pain grew worse and the athlete was seen by the team physician and received radiographs, which were unremarkable for bone pathology. The athlete was prescribed an MRI that revealed an extensive bone edema in the distal portion of the right humerus that led to the physician’s diagnosis.

FINAL WORKING DIAGNOSIS: Humeral stress fracture.

TREATMENT AND OUTCOMES: This athlete was metabolically tested and found to have borderline calcium and vitamin D levels. His throwing mechanics were analyzed, as well as being treated with complete upper body rest, a bone stimulator, vitamin supplements (citrical), NSAID’s, ice, rehabilitation and a throwing progression. Pain returned while throwing and the athlete was forced to retire for the season. The team physician prescribed 5 months of rest, treatment, rehabilitation and a throwing progression. His participation was modified daily, as needed, based on soreness. To our knowledge, this is the first case reporting a collegiate baseball outfielder with a confirmed humeral stress fracture. Humeral stress fractures are more frequently seen in adolescents and pitchers.

711 MAY 30 10:30 AM - 10:50 AM

Wrist Injury - Baseball

Andrea L. Aagesen, Robert Kiningham, FACSM. University of Michigan, Ann Arbor, MI. (Sponsor: Bob Kiningham, FACSM)

(No relationships reported)

HISTORY: A 22-year-old right-hand-dominant collegiate baseball player sustained a left hand injury while batting during a scrimmage. He had chocked down on the bat placing the end of the bat in the palm of his left hand and developed sharp, throbbing pain in the palm of his hand at contact. He presented to the athletic training room within thirty minutes after injury for evaluation by the team physician.

PHYSICAL EXAMINATION: There is mild swelling about the thenar ememnece and dorsum of his hand with no ecchymosis. Sensation is intact to light touch. Radial pulses are 1+ at the wrist. Fingers are warm to touch with normal capillary refill. There are callus formations in the palms bilaterally. Skin is otherwise intact. There is significant tenderness over the left thenar ememence and mild tenderness over the third metacarpal. No anatomic snuff box tenderness. No wrist laxity. Full range of motion with wrist flexion, extension, radial and ulnar deviation. Full pain free finger active range of motion. Intact extensor pollicis longus, flexor digitorum profundus, flexor digitorum superficialis function. Strength is decreased to 4/5 with left grip, limited by pain. Otherwise strength is full.

DIFFERENTIAL DIAGNOSIS:

1. Metacarpal fracture

2. Hook of the hamate fracture

3. Finger flexor tendon reputure

TEST AND RESULTS:

Left hand radiographs (posterior anterior, lateral, oblique views):

- There is no definite fracture or dislocation.

Left wrist radiograph (posterior anterior, lateral, oblique views):

- No fracture or dislocation visualized.

Left wrist radiograph (carpal tunnel view):

- A focal linear lucency is noted in the hook of the hamate.

FINAL WORKING DIAGNOSIS: Nondisplaced hook of the hamate fracture.

TREATMENT AND OUTCOMES:

1. Customized thumb spica splint for immobilization.

2. Surgical exicion of hook of the hamate at 1 week post injury.

3. Post-op splint and non-weight bearing for 2 weeks following surgery.

4. Fabrication of custom hand based left thumb spica splint with padding over incision site.

5. Occupation therapy started at 2 weeks including active range of motion, scar massage, and desensitization.

6. Advanced to progressive strengthening at 4 weeks

7. Anticipate return to sport at 2 months when he has full, pain free range of motion, full strength, and able to meet demands of baseball.

712 MAY 30 10:50 AM - 11:10 AM

Lateral Ankle Sprain - Baseball

Katherine Susskind, Gretchen D. Oliver. University of Arkansas, Fayetteville, AR. (Sponsor: Heidi Kluess, FACSM)

(No relationships reported)

HISTORY: A 15 year-old baseball player, sustained an ankle injury while attempting to slide into second base feet first during practice.

PHYSICAL EXAMINATION: Evaluation revealed significant ecchymosis and edema about the lateral malleolus. Range of motion was limited and painful with inversion and dorsiflexion, and other movements were within normal limits. There was no numbness or tingling. The athlete was extremely point tender over the lateral malleolus and about one inch proximal to the lateral malleolus. Strength was within normal limits, although the athlete ambulated with an antalgic gait.

DIFFERENTIAL DIAGNOSIS:

Syndesmosis ankle sprain (high ankle sprain)

Contusion of the lateral ankle

Salter-Harris I fracture of the distal fibula

TEST AND RESULTS: Radiographs of the ankle revealed a stable fracture of the distal fibular growth plate, tibia and talus radiographs appeared normal

FINAL WORKING DIAGNOSIS: Salter-Harris I fracture of the left distal fibular growth plate

TREATMENT AND OUTCOMES: Once the injury was diagnosed as a fibular growth plate fracture, the following were completed:

Immobilization in walking boot for 4 weeks

Follow-up exam with orthopedist after 4 weeks immobilization completed

Non-weight bearing isometric and range of motion exercises started 3 days post injury and continued after correct fracture diagnosis

Weight bearing, functional activities started 4 weeks post fracture diagnosis

Athlete cleared by orthopedist to return to full sport participation 6 weeks post-diagnosis, with ankle bracing and taping, once able to weight bear fully without pain and limited range of motion, and fully meet the demands of his sport

713 MAY 30 11:10 AM - 11:30 AM

How Many Pitches Are Too Many? Shoulder pain- Baseball pitcher

Tracey A. Viola, Jeffrey Anderson, FACSM, Michael Joyce. University of Connecticut, Hartford, CT.

(No relationships reported)

HISTORY: 18 yo male right hand dominant pitcher with right shoulder pain since February 2011. No prior shoulder injuries or problems. He noted discomfort at the anterior and posterior aspect of the shoulder, was treated with ice, 10 days of rest, and physical therapy. He did well until the playoffs. He threw 150 pitches to a dead arm. Five days later he threw 90 pitches but felt as though it was not up to his normal throwing level. He shut down until the all-star game when he threw 20 pitches, but had very little strength in his arm. He has been unable to throw since.

PHYSICAL EXAMINATION: Normal contours, symmetric. A-C joint normal and nontender, trace pain at supraspinatus insertion, 1+ pain at posterior joint capsule, no pain at the bicipital groove or cervical spine.

ROM: flexion to 180°, 90° of abduction, 110° of external rotation in abducted position, internal rotation to T6. Strength is 4.5/5 IR, and 5/5 ER, abduction, flexion, biceps and triceps. 2+ positive lift off test.

Apprehension and relocation test: no instability, load shift is 2- anterior and 2- posterior, trace positive sulcus sign. O’Brien’s negative. Neer impingement test is moderately positive, provocative testing of bicipital tendinosis is negative and cross chest maneuver is negative.

DIFFERENTIAL DIAGNOSIS: Rotator cuff pathology, Internal impingement, Shoulder instability, Avascular necrosis of the humeral head, Biceps tendinopathy, Suprascapular nerve impingement, Thoracic Outlet syndrome, Brachial Plexus Neuropathy, Parsonage-Turner Syndrome

TEST AND RESULTS: MRI Arthrogram: no significant labral pathology, significant abnormality of the subscapularis, myofascial disruption with an associated 5 cm hematoma.

FINAL WORKING DIAGNOSIS: Subscapularis hematoma

TREATMENT AND OUTCOMES: This injury, although uncommon and not previously reported in the literature, was treated as a typical myofascial injury with prevention of contracture and limitation of muscle function until the injury had time to heal completely. This included a restricted regimen of rehabilitative exercises, with progression to include eccentric exercise, and return to interval throwing program. Five months after his injury, repeat MRI with improved but not resolved subscapularis hematoma. He has since been asymptomatic, and is currently throwing at 150 feet.

A-27 Clinical Case Slide - General Medicine I

MAY 30, 2012 9:30 AM - 11:30 AM

ROOM: 2007

714 Chair: Aaron Rubin, FACSM. Kaiser Permanente Sports Medicine Program, Fontana, CA.

(No relationships reported)

715 Discussant: Andrew Gregory, FACSM. Vanderbilt University, Nashville, TN.

(No relationships reported)

716 Discussant: Brian Babka. Cadence Physician Group Sports Medicine, Sugar Grove, IL.

(No relationships reported)

717 MAY 30 9:30 AM - 9:50 AM

General Medicine-Armed Forces

Nate Waibel. University of Minnesota - Family Medicine and Community Health, Minneapolis, MN. (Sponsor: William O. Roberts, FACSM)

(No relationships reported)

HISTORY: A 28-year-old G2P2 Army reservist presented with easy bruising , fatigue, and muscle aches that were exacerbated by her required physical training drills. Intermittent use of ibuprofen or naproxen did not relieve the pain. She had a six week episode of metrorrhagia five months ago after placement of a Mirena®, but otherwise menstrual history unremarkable. Previously diagnosed with iron deficiency anemia and supplemented with IV iron after oral replacement ineffective. Also vitamin D deficient and received supplement. ROS negative except for abdominal pain that worsened with crunches. She denied diarrhea, foul-smelling stools, or floating stools. No family history of blood dyscrasias and she denied the use of alcohol.

PHYSICAL EXAMINATION: Vital signs normal. BMI 19.3 and stable. Normal appearing, well-groomed female in no acute distress. HEENT, neck, pulmonary, cardiovascular, abdominal, GU, neurologic and psychiatric exams were all normal. No conjunctival pallor, glossitis, thyromegaly, abdominal tenderness, or skin rash noted. She had ecchymoses on both shins and left lateral thigh.

DIFFERENTIAL DIAGNOSIS:

1. Pernicious anemia

2. Hypothyroidism

3. Celiac disease

4. Alcoholism

5. Liver disease

6. Drug-induced macrocytosis

7. Myelodysplastic disorder

TESTS AND RESULTS: CBC

- Hemoglobin 12.9 g/dL

- RBC 3.72 mill/uL

- Hematocrit 39.3 %

- MCV 106 fL

- MCH 34.5 pg

- MCHC 32.7 g/dL

- RDW 17.1 %

- Platelets 382 thous/uL

TSH 0.7 uIU/mL

Folate 1.4 ng/mL

Vitamin B12 106 pg/mL

Vitamin D 34.2 ng/mL

Intrinsic Factor Antibody positive (false positive result secondary to B12 shots)

MMA 0.40 nmol/mL

Plasma homocysteine 13 umol/L

Tissue Transglutaminase IgA AB > 128.0 U/mL

Tissue Transglutaminase IgG AB 21.0 U/mL

Duodenal biopsy

RESULTS: changes compatible with celiac sprue - marked intraepithelial lymphocytes; marked villous atrophy and marked crypt hyperplasia (Marsh 3c lesion).

FINAL/WORKING DIAGNOSIS:

Celiac disease

TREATMENT AND OUTCOMES: 1. Strict gluten free diet. Referred for consultation with a skilled dietician. Provided with book, Web site and advocacy group recommendations.

2. Monthly B12 injections until repleted.

3. Oral iron, Vitamin D, a multivitamin and 1000 mg of calcium per day.

4. Patient is slowly regaining her strength as her counts begin to improve.

718 MAY 30 9:50 AM - 10:10 AM

An Unusual Cause Of Hemoptysis: A Case Report.

Tanya Hagen, FACSM, Peter Wenger. UPMC Center for Sports Medicine, Pittsburgh, PA.

(No relationships reported)

INTRODUCTION: Hemoptysis is a common complaint in the fall/winter athlete. This case highlights an unusual cause of hemoptysis in a collegiate athlete, Ehlers Danlos syndrome.

CASE DESCRIPTION: A 19 year old female field hockey player presents to her team physician with complaints of blood in her sputum. The athlete states that she coughed up small amounts of blood for the last 3 days. She denies URI symptoms and has been feeling well besides the hemoptysis. The sputum is mostly saliva with dots of red blood. She remembers having frequent nose bleeds as a child but none recently. She has no allergies and takes only oral contraceptive pills.

PAST MEDICAL HISTORY: Ehlers Danlos syndrome type 2/3.

PHYSICAL EXAM: Hyper mobility- Beighton score 9; cutaneous laxity No source of bleeding identified on ENT exam Normal cardiac, GI, and pulmonary exams

DIFFERENTIAL DIAGNOSIS: Bronchitis, pneumonia, foreign body, pulmonary embolism, sinusitis, gastric/ esophageal source of blood, connective tissue disease

Course: Gentle nasal lavage with saline was instructed Humidifier used in dorm room at night-resolved after 3 days. Recurred approximately 4 weeks later, again resolving spontaneously.

Working Diagnosis: hemoptysis secondary vascular fragility

Discussion: Ehlers Danlos syndrome is a common problem, occurring in 1 in 5000 births, and presents a challenge to the sports medicine physician. The consequence of abnormal collagen and connective tissue is systemic. In addition to musculoskeletal pathologies, patients may have cardiac (valvular heart disease, fragile blood vessels, aneurysm), GI (functional bowel disorders, gastroparesis), systemic (chronic fatigue, myalgia), hematologic (easy bruising, inhibition of platelet aggregation), and neurologic (migraine) involvement. Familiarity with the sequela of this connective tissue disorder will help the sports physician to better care for their athlete.

719 MAY 30 10:10 AM - 10:30 AM

Hypoglycemia - Volleyball

Katherine M. Fox. Advocate Lutheran General Hospital, Park Ridge, IL. (Sponsor: William W Briner MD, FACSM)

(No relationships reported)

HISTORY: 19 y/o collegiate volleyball player presents to training room stating, “I think I’m having a hypoglycemia attack.” Before presenting to RN and team physician she had taken a glucose gel. Athlete states she feels “shaky” and “weak.” This was day 3 of volleyball practice. Pt had only had one meal the day of the event; and her last meal was five hours prior to practice

Athlete had been evaluated 5 days prior for her preparticipation physical. She reported her history of diabetes to evaluating physician. Patient reported an insulin regimen of:

1. NPH 11-14 units q am

2. Humalog TID sliding scale

3. Lantus 11 units qhs

She was told that she could participate based on conditions that she would follow up with her primary care provider and have her HgbA1C checked at the onset of the season.

PHYSICAL EXAMINATION: On exam in the training room, athlete was noted to be diaphoretic, skin cool to the touch. She was seated and eating candy and drinking gatorade. RN gave candy and did accucheck prior to evaluation by physician.

DIFFERENTIAL DIAGNOSIS:

1. Hypoglycemia

2. Hyperglycemia

3. Hyperventilation

TEST AND RESULTS:

1. Accuchecks: 80 (s/p candy), repeat in 15 minutes, 93.

2. Hemoglobin A1C: 8.5%

FINAL WORKING DIAGNOSIS: Hypoglycemia, type 1 DM, poorly controlled

TREATMENT AND OUTCOMES:

1. She was told she could not participate in volleyball until she had further education regarding management of diabetes in sport from a diabetes educator and followed up with a primary care physician. Adherence proved difficulty, partially because she did not have health insurance.

2. Her insulin regimen was adjusted to Lantus 12 units qhs and humalog 8 units TID with meals. She was instructed to check her blood sugar four times daily.

3. Team physician reviewed glucose log 1 week later and increased her lantus from 12 units qhs to 14 units qhs. Arrangements were made for her to meet with a diabetes nurse educator the following day. She was given a carbohydrate scale to follow before practice. At this time, she was allowed to participate if she continued to follow her detailed diabetes protocol and follow regularly with team physician and primary care provider. No sport participation if blood glucose <120 or >225.

4. Approximately 6 weeks after initial hypoglycemic episode, patient was seen by primary care physician at a local clinic for the uninsured. Repeat HgbA1C was 7.7%.

720 MAY 30 10:30 AM - 10:50 AM

Back and Left Leg Pain_Biking, Running

Kirk L. Scofield, Suzanne Hecht, Steven Stovitz, FACSM. University of Minnesota, Minneapolis, MN. (Sponsor: Steven Stovitz, FACSM)

(No relationships reported)

HISTORY: A 23 y/old female biker and marathon runner presented to our sports medicine clinic 9/2011 with a 5 day history of right low back pain and leg pain without injury. Onset mid run on asphalt. Pain with footfall while running or walking. Ran 85 miles the week prior to pain onset, a couple weeks after switching from biking to running. Admits a compulsion to exercise, denies intentional caloric restriction. Eats 2 meals, 3 snacks daily. Initially presented to PCP in 2008 one week after completing a marathon c/o fatigue, depression, dizziness, a 20# weight loss and 2 year history of amenorrhea. BMI was 21. LH and FSH were undetectable. Normal TSH but low FT4 and FT3 so started on synthroid 75 mcg daily and OCPs. BMI increased to 23.5, depression and fatigue improved and she continued daily intense exercise.

PMHx:

1. Osteoporosis by DXA 2/2011, Z-score -2.6 with 10.5% loss in BMD from prior DXA 10/2008

2. Atraumatic inferior pubic ramus fracture 6/2009

3. Bilateral tibial stress fractures 12/2009

4. Hx of altered body image and calorie restriction during teens.

FHx:

1. Obsessive Compulsive D/O_mother, brother

PHYSICAL EXAMINATION: BMI 23.3

Fit appearing, euthymic

Tender right SI joint with positive SI compression test. One leg standing lumbar extension test positive on right.

Tender anterior midshaft left tibia.

DIFFERENTIAL DIAGNOSIS:

1. Stress fractures

2. Spondylolysis

3. SI joint dysfunction

4. Osteoporosis

5. Low energy availability

6. Iatrogenic hyperthyroidism

7. Functional hypothalamic hypopituitarism

8. Exercise Obsession

TEST AND RESULTS:

Hemoglobin 12.5 g/dL

Ferritin 38 ng/ml

25OH Vit-D total 43 ug/L

Prolactin 5 ug/L

Free T4 1.14 ng/dl

Free T3 3.6 pg/ml

TSH <0.02 mU/L

Serum Calcium 9.2 mg/dl

Calcium Urine 0.22 g/24 hr

iPTH 71 pg/mL

Bone scan: Increased uptake in the right sacral ala, left distal tibia and right distal fibula consistent with stress fractures.

FINAL WORKING DIAGNOSIS:

1. Recurrent stress fractures

2. Iatrogenic hyperthyroidism, chronic

3. Osteoporosis

4. Exercise obsession

5. Low energy availability

TREATMENT AND OUTCOMES:

1. Synthroid reduced to 0.25mcg/day to be tapered off

2. Encouraged increased calories and evaluation by sports dietician

3. Calcium and Vitamin D supplementation

4. Long leg Air Cast, minimize walking

5. Reduce biking to shorter rides, lower intensity, avoiding back and tibial pain

721 MAY 30 10:50 AM - 11:10 AM

A Cheerleader with a Swollen Leg

bronson E. delasobera1, thomas howard, FACSM2. 1VCU, alexandria, VA. 2VCU, Fairfax, VA.

(No relationships reported)

HISTORY: 12 year old F cheerleader with a history of ADHD, presents to a sports medicine office complaining of left ankle swelling. The patient and her mother state this first happened one month ago and lasted for one day and then went away. However, 4 days prior to this visit her left leg started to become swollen again and this time it is persistent. When this first started they were out of town and they flew home to be evaluated. In addition to the swelling she is now complaining of mild leg pain which is hard to localize. She denies any known injury or trauma. She denies fevers, chills, weight loss, rashes, or other joint pains.

PHYSICAL EXAM: VS: T 98.8, HR 72, BP 108/64, RR 16 r/min

Gen: NAD, well appearing

MSK: moderate pitting edema of lower left leg to mid-calf, no pain to any palpation in foot, ankle, or lower leg, negative talar tilt, negative anterior drawer, negative tib-fib squeeze

Neuro: normal sensation and strength of lower extremities, normal gait

CV: 2+ DP pulse in left lower leg, no cords palpated

Skin: no redness or warmth

DIFFERENTIAL DIAGNOSIS:

Deep venous thrombosis (DVT)

Ankle sprain

Nephrotic syndrome

Cogestive heart failure

Liver disease

Lymphedema

Stress fracture

Lyme disease

Cellulitis/Abscess/Osteomyelitis

Autoimmune/rheumatologic arthritis

Tests & RESULTS:

1. Initial visit: Lower extremity ultrasound - negative for DVT

Xrays of left ankle/tib/fib - normal

Labs: CBC, ESR, CRP, Lyme titers, urine - all normal

2. Second visit (4 weeks later): Bone scan - increased activity all three phases at the distal left tibial growth plates at the ankle concerning for occult fracture (salter harris I/II); infection or primary bone lesion is felt less likely given the history

3. Third visit (6 weeks after second visit): MRI left ankle - no acute abnormalities, Lower extremity doppler repeated - normal

FINAL WORKING DIAGNOSIS: Lymphedema

Treatment: CAM walking boot for 4 weeks and PT for 8 weeks started after the bone scan reading came back. After the MRI was found to be normal and the patient was without any change in swelling, the boot and PT were discontinued. The patient was sent to a vascular surgeon and put in a compression stocking with the working diagnosis of lymphedema.

Outcome and Further Follow-Up: Patient is not having pain, only swelling currently. She is waiting to see the vascular surgeon, but she is back to cheerleading.

722 MAY 30 11:10 AM - 11:30 AM

Allergic Reaction During Exercise

Rick Morgan, Kyle Cassas. Steadman Hawkins Clinic of the Carolinas, Greenville, SC. (Sponsor: Dell Bolin, FACSM)

(No relationships reported)

HISTORY: 29 year old healthy male presents with four episodes of itchy rash during routine exercise.

The first episode occurred three years ago while on a treadmill after just ten minutes, he noticed the back of his head and neck started itching. He stopped running and felt over-heated, nauseated, dizzy, and vomited several times. His skin was bright red on his neck and upper chest but there was no swelling. It quickly resolved. The second episode occurred six months later just after hot yoga (RT 105 F), a few minutes into a raquetball game. His skin turned red again, but no n/v. The third episode occurred one year ago. After a regular meal 1-2 hours prior, he ran on the treadmill for 10 minutes and then went to lift weights. He started to get itchy head and neck so he quickly took a cool shower. During the shower he started to get redness again, but also swelling of his face and lips with hives on his neck and upper chest. His fourth episode occurred towards the end of August 2011, when he presented to me. After a brief workout, he started to itch again but this time the shower didn’t feel like it was helping. He still felt overheated and then started to feel like his breathing was restricted. He did not have any hives but was red and flushed. He took an ice bath and quickly felt better. Each episode was slightly different, separated by at least six months, and occurred in two drastically different geographic regions.

PHYSICAL EXAMINATION: Gen: NAD, lean muscular male. Skin: anicteric, no rashes or lesions. ENT:wnl, nares patent, mucosa pink CV: RRR no m/r/g Chest: CTA B Abd: S/NT/ND

DIFFERENTIAL DIAGNOSIS:

1. Food-dependent exercise-induced anaphylaxis (FDEIA)

2. Food allergy, IgE mediated

3. Cholinergic urticaria

4. Allergic response NOS

5.Familial exercise-induced anaphylaxis

6. Chronic idiopathic urticaria and angioedema

TEST AND RESULTS:

1. Food specific IgE testing

2. Open food challenge

3. Dietary journal and food elimination trial

4. CBC, TSH, thyroid auto antibodies, CMP, ANA, RF

5. Test for C1-esterase deficiency

6. Plasma histamine

7. Autologous skin test (ASST)

FINAL WORKING DIAGNOSIS: Food dependent exercise induced anaphylaxis

TREATMENT AND OUTCOMES:

1. Rx for self-injectable epinephrine

2. Oral antihistamines daily

3. Exercise with a partner at all times

4. Food identification and elimination

A-28 Clinical Case Slide - Lower Extremity I

MAY 30, 2012 9:30 AM - 11:30 AM

ROOM: 2016

723 Chair: Anthony C. Luke, FACSM. University of California-San Francisco, San Francisco, CA.

(No relationships reported)

724 Discussant: Laurie Donaldson. Ann Arbor, MI.

(No relationships reported)

725 Discussant: Lucien R. Ouellette. Orthopaedic Associates of Portland, PA, Saco, ME.

(No relationships reported)

726 MAY 30 9:30 AM - 9:50 AM

Knee Injury - Football

Robert Michael, Poonam Thaker. Resurrection Medical Center, Chicago, IL.

(No relationships reported)

HISTORY: A 19 year old football player sustained a right knee injury during a football game. During kick off to start of the second half of a game, the player reports he was hit from behind while simultaneously being clipped below the knee. He felt immediate pain in his right knee, but is uncertain if he felt a pop or tear with the injury. He was unable to stand.

PHYSICAL EXAM: Examination on the field revealed extreme pain in the right knee. The knee was flexed with the athlete unable to extend his knee. The joint line was abnormally palpable with a displaced patella. With knee extension, there was an audible pop. Shift of the tibia could be felt with extension. He was unable to move or bear weight on the leg.

Sideline exam: + Lachman test and + gapping with valgus stress with extreme laxity when compared to contralateral side. + medial and lateral joint line tenderness. Distally neuro/vascular intact.

Examination in the training room 3 days later revealed significant edema and ecchymosis, with swelling from just superior to his knee to the level of his ankle. The above findings were re-demonstrated. Additional findings at this time included inability to maintain or perform extension of knee. + patella alta when compared to left knee. Due to the amount of edema, palpation of the patellar tendon was not possible

DIFFERENTIAL DIAGNOSIS:

Sideline:

1. Patellar dislocation

2. Knee dislocation

3. ACL rupture

4. MCL tear

5. Medial meniscus injury

6. Fracture

Training room:

7. Patellar tendon rupture

TEST AND RESULTS:

X-ray from day of injury:

- No fracture or dislocation

- Joint compartment is maintained

MRI of right knee:

- Complete patellar tendon rupture at attachment to tibial tuberosity with 2.3 cm gap

- Anterior cruciate ligament rupture

- Medial collateral ligament sprain

- Tear of body of lateral meniscus

- Tear of medial meniscus

FINAL WORKING DIAGNOSIS:

1. Complete patellar tendon rupture

2. Complete ACL rupture

3. MCL sprain

4. Medial meniscus tear

5. Lateral Meniscus tear

TREATMENT/OUTCOME:

Initial primary repair of patellar tendon to restore extensor mechanism was performed. This will be followed by 4-6 weeks of immobilization with subsequent rehabilitation. After completing therapy he will undergo ACL reconstruction, using hamstring tendon autograft, contralateral bone-patellar tendon-bone autograft, or allograft.

727 MAY 30 9:50 AM - 10:10 AM

Knee Pain - Golf

Charlotte M. H. Moriarty, Robert J. Baker, FACSM. Michigan State University Kalamazoo Center for Medical Studies, Kalamazoo, MI. (Sponsor: Dilip R. Patel, FACSM)

(No relationships reported)

HISTORY: A 10-year-old golfer with increasing chronic left knee pain when running and walking up and down stairs. Injuries include a fall over one year ago with no obvious swelling, locking, or giving way. He has been treated conservatively with physical therapy for presumed hamstring tendonitis. Pain has increased significantly over the past two weeks, accompanied by turning his foot out and explicit pain and a limp with running.

PHYSICAL EXAM: Bright, alert male in no acute distress. Height 5 feet. Weight 100 lbs. Examination of the left knee significant for medial condylar tenderness. No effusion, lateral joint line tenderness, or lateral condylar tenderness, negative bounce home. Cartilage examination is negative, ligaments intact, good range of motion. Tight hamstrings. Left hip stable, non-tender, full range of motion, full strength. Slight antalgic gait. Right knee stable, non-tender, full range of motion, full strength. Negative patellar examinations bilaterally. Bilateral ankles are stable, non-tender, full range of motion, full strength.

DIFFERENTIAL DIAGNOSIS:

1. Osteochondritis dissecans lesion

2. Meniscal tear

3. Chondral fracture

4. Patellofemoral pain syndrome

5. Osgood-schlatter apophysitis

TEST AND RESULTS:

Left knee anterior-posterior, notch, lateral, and sunrise radiographs:

- irregularity along the lateral aspect of the medial femoral condyle

Left knee MRI:

- osteochondral lesion on the infero-lateral surface of the medial femoral condyle

- no loose fragments

- overlying cartilage maintained with no evidence of cartilage fracture

- normal medial and lateral menisci, no tears

FINAL/WORKING DIAGNOSIS:

Osteochondritis dissecans lesion

TREATMENT AND OUTCOMES:

1. Non-weight-bearing with crutches for 8-12 weeks.

2. Gradual return to weight bearing.

3. Assumed to return to full activity

728 MAY 30 10:10 AM - 10:30 AM

Thigh Pain - Cross Country Runner

Mark W. Peterson, Robert J. Baker, FACSM. KCMS-MSU, Kalamazoo, MI. (Sponsor: Dilip Patel, FACSM)

(No relationships reported)

HISTORY: 21-year-old college cross country runner who presented with a four week history of right thigh pain. He was playing sports with friends in the snow, when it started bothering him, with no injury at that time. He describes the pain as a constant ache. He has been working with his athletic trainer, and has felt like he was not improving. He experiences pain and discomfort when running on the leg. He has tried running in a pool and had no reported pain or discomfort. He has been doing deep muscle stimulation as well as ice for treatment. He is concerned because he has an important competition in one week and would like to participate.

PHYSICAL EXAMINATION: A bright, alert male in no acute distress. There is no point tenderness with palpation of his right leg on examination. In supine position, he does have discomfort and pain with passive right hip extension. He has slight discomfort with labral stress and FABER (Flexion, Abduction, & External Rotation) and FADIR (Flexion, Adduction & Internal Rotation) positions. The right hip is stable with no weakness in the leg. Back is non-tender, no step-off, good strenght and ROM.

DIFFERENTIAL DIAGNOSIS:

1. Labral tear

2. Stress fracture of femur

3. Quadriceps muscle strain

4. Femoroacetabular Impingement (FAI)

5. Adductor strain

6. Sacral stress fracture

TEST AND RESULTS:

Radiographs of right hip, AP and frog leg views

- No acute fractures or abnormalities, normal views. No evidence of FAI

Magnetic resonance imaging of right hip

- Grade 2 stress fracture, with cortical breaking, in the proximal femur.

- Superior labrum tear in the femoral head-neck junction. Suggestive of FAI.

FINAL WORKING DIAGNOSIS: Stress fracture of right proximal femur and FAI.

TREATMENT AND OUTCOMES:

1. Initial recommendation of no running.

2. With permission, will advise his athletic trainer of his restrictions of no running.

3. Limited weight bearing, if he is having pain with walking, crutches might be needed.

4. Continue with low impact, “water” running in pool with range of motion stretches, as tolerated.

5. When pain-free with walking, he can start a gradual strength training exercises, including bike and treadmill, and progress to full weight bearing.

6. Anticipate return to running in 4-8 weeks, as tolerated.

7. Recommend that he not participate in his upcoming competition.

729 MAY 30 10:30 AM - 10:50 AM

Bilateral Lower Leg Pain in a Runner

Eric P. Wilson, Carol Frey, Keith Feder. West Coast Sports Medicine Foundation, Manhattan Beach, CA. (Sponsor: Aaron Rubin, FACSM)

(No relationships reported)

HISTORY: A 39-year-old female military officer presented with two years of leg pain with activity. It began insidiously during her daily runs and regular marches with a 40-lb backpack. She localized the pain to her bilateral shins and described it as sharp, non-radiating, occasionally associated with numbness and tingling in her feet and ankles that was relieved with rest. It worsened to the point that it would be provoked by only minimal activity. It failed to resolve with rest, ice, celecoxib, diclofenac patches, and tall cam walkers.

PHYSICAL EXAMINATION: She appeared as a well-nourished, well-developed, overweight female, 5’4”, 155 lbs (BMI 26.6). She had a normal gait, plantigrade feet, and normal arch dynamics. Bony alignment was normal. Her calves were large and tight. She was tender to palpation bilaterally just lateral to the tibia along the middle and distal thirds. There was no swelling, ecchymosis, erythema, or warmth; however there was drum-like tension over the area of tenderness following her run. She demonstrated full and painless range of motion about the feet, ankles, and knees bilaterally, which were all ligamentously stable. She demonstrated full strength without pain with resistance testing. Distal pulses were present and full. Sensation was intact.

DIFFERENTIAL DIAGNOSIS:

1. Periostitis/Medial Tibia Stress Syndrome

2. Bilateral stress fractures

3. Peroneal neuropathy

4. Anterior tibialis tendonitis

5. Exertional compartment syndrome

TEST AND RESULTS:

1. Normal plain radiographs

2. Normal bone scan

3. MRI demonstrated minimal periosteal edema along the middle and distal thirds of the tibia bilaterally

4. Nerve conduction studies demonstrated normal latencies and velocities over the tibial, sural, and peroneal nerves bilaterally.

5. Compartment pressure testing following a 30-minute run:

a. Left lateral compartment: 28 mmHg

b. Left posterior compartment: 26 mmHg

c. Left anterior compartment: 55 mmHg

d. Right lateral compartment: 28 mmHg

e. Right posterior compartment: 29 mmHg

f. Right anterior compartment: 55 mmHg

FINAL WORKING DIAGNOSIS: Bilateral, chronic exertional compartment syndrome

TREATMENT AND OUTCOMES: After failing conservative management, the patient has opted to undergo bilateral fasciotomies.

730 MAY 30 10:50 AM - 11:10 AM

Knee Effusion-football

Tom W. Bartsokas, FACSM. Summa Physicians, Inc,, Streetsboro, OH.

(No relationships reported)

HISTORY: 11 yo male presented for evaluation of right knee pain/swelling that developed acutely after tackling another player. MOI was landing on anterior aspect of knee. Able to continue playing. Swelling developed within 1 hour over anteromedial aspect of knee and was mild at first. He related several re-injuries to same knee (usually from falling or tackling), with each new injury causing advance in swelling. At initial encounter, he was being forced to run with right knee in almost full extension due to pain/swelling. Rest Hx was negative.

PHYSICAL EXAMINATION: Gait was not antalgic. Large suprapatellar effusion was noted extending to medial compartment without discoloration/increased warmth. 3+ TTP at medial joint line, just superior to this (over medial femoral condyle), and at medial aspect of distal femoral physeal plate. No ligamentous laxity on varus and valgus stress. Positive McMurray’s test. Negative bounce test. Limited on passive flexion secondary to pain in medial compartment. Negative anterior drawer and Lachman’s tests. Negative patellar apprehension and grind tests. No TTP of patellofemoral joint surfaces. No TTP at tibial tuberosity and infrapatellar tendon.

DIFFERENTIAL DIAGNOSIS:

*Muscle contusion with hematoma

*Ligamentous injury (MCL, ACL, PCL)

*Bone injury (patellar, Salter-Harris, or other fracture)

*Pre-patellar bursitis

TEST AND RESULTS:

*4-view x-rays of right knee showed abnormal soft tissue swelling and suspected suprapatellar bursal joint effusion. No evidence of acute fracture.

*MRI scan of right knee showed thin heterogeneous fluid collection within subcutaneous tissues about anteromedial aspect of knee. This collection was much smaller than the degree of soft tissue swelling present on radiographs 5 days prior. This likely represents a resolving hemorrhagic degloving soft tissue injury (Morel Lavallee Lesion). Minimal bone contusion involving anteromedial aspect of medial femoral condyle was suggested.

FINAL WORKING DIAGNOSIS: Morel Lavallee Lesion of Knee

TREATMENT AND OUTCOMES:

1. Initial plan: No running, jumping, or kicking until MRI scan AND

Apply ice to involved area for 20 minutes, 3-4 times/day

2. Effusion resolved within 2-3 days

3. Knee was no longer tender, full PROM, and he had returned to full play activity upon follow-up (at 4 weeks after initial injury)

731 MAY 30 11:10 AM - 11:30 AM

Knee Injury in Football

Peter Cronin. Medical College of Wisconsin, Milwaukee, WI. (Sponsor: Craig Young, FACSM)

(No relationships reported)

Knee Injury in Football

HISTORY: 17 year old high school cornerback hurt his knee after getting his legs tangled up with the an opponent. He fell striking his flexed knee on the turf with immediate pain over the medial knee that resolved quickly. He denied any feelings of dislocation, numbness or inability to flex the knee. He was able to walk without pain but unable to jog.

Physical: Examination on the sideline showed a mild joint effusion with vague mid-patellar tenderness with direct palpation only. There was no peri-patellar, joint line, MCL, LCL or patellar tendon tenderness. He had painless, full ROM with strength of 5/5 on flexion & 4/5 on extension. Ligamentous testing was normal. Apprehension & McMurray’s testing were negative. The swelling progressively increased during the rest of the game despite ice & rest.

Differential:

1. Patellar dislocation

2. Patellar fracture

3. Tibial plateau fracture

4. Traumatic bone bruise

5. Synovitis

Testing and RESULTS:

1. Left Knee X-ray:

a. Large joint effusion

b. Possible inferior patellar pole fracture

2. Left Knee MRI

a. Comminuted fracture of the inferomedial aspect of the patella

b. Torn medial patellar retinaculum

c. Bone contusions of the inferomedial aspect of the patella and anterolateral aspect of the lateral femoral condyle

Final Diagnosis:

1. Comminuted patellar fracture

2. Subluxation of the patella

TREATMENT AND OUTCOMES:

1. Knee immobilizer brace for 4 weeks to allow ambulation without knee flexion

2. Passive knee flexion exercises in therapy to 30 degrees

3. Repeat x-rays at 4.5 weeks showed healing

4. Range of motion, patellar stabilization and strength exercises were started

5. Returned to sports 6 weeks after the injury while wearing a patellar stabilization brace for comfort

B-20 Clinical Case Slide - Expect the Unexpected

MAY 30, 2012 1:00 PM - 2:40 PM

ROOM: 2007

732 Chair: Constance M. Lebrun, FACSM. Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, AB, Canada.

(No relationships reported)

733 Discussant: Lauren M. Simon, FACSM. Loma Linda University Medical Center, Loma Linda, CA.

(No relationships reported)

734 Discussant: Dennis F. Borna. Kaiser Permanente Fontana, Colton, CA.

(No relationships reported)

735 MAY 30 1:00 PM - 1:20 PM

Congenital Absence of the Anterior Cruciate Ligament

Jothi Murali1, Paul Fadale1, Keith Monchik2. 1Brown University/Rhode Island Hospital, Providence, RI. 2Foundry Orthopaedics, Providence, RI.

(No relationships reported)

HISTORY: A 20-year-old female volleyball player presented for orthopaedic evaluation because of worsening medial left knee pain. Four years prior to evaluation, she injured her knee while jumping during a volleyball match. She had knee pain while walking around her college campus, especially while walking on uneven ground or up and down stairs. Her pain lasted 1-2 days and would intermittently come and go, with episodes about every 1-2 months. She denied any feelings of buckling, catching, locking, or instability.

PHYSICAL EXAMINATION: Notable for overall valgus alignment of the left lower extremity, minimally decreased motion, trace effusion, positive medial joint line tenderness, positive McMurray sign, and one plus Lachman with guarding on pivot shift testing. Knee stable to varus, valgus, and posteriorly applied stress. No global ligamentous laxity.

DIFFERENTIAL DIAGNOSIS:

1. Medial meniscus tear

2. ACL tear

3. Prior patellar dislocation

TEST AND RESULTS:

Plain films:

-valgus alignment

- narrowing of the lateral compartment, narrow notch, and hypoplasia of the tibial spines and the lateral femoral condyle

MRI:

-large tear in the posterior horn of the medial meniscus

- absent visualization of the anterior cruciate ligament

-hypertrophy of the meniscofemoral ligament

-anterior translation of the medial aspect of the tibia

KT-1000 testing:

9.5 mm of translation compared to the uninjured right side

FINAL/WORKING DIAGNOSIS: Posterior horn medial meniscus tear and congenital absence of the ACL

TREATMENT AND OUTCOMES: Arthroscopy showed complete absence of fibers of the anterior cruciate ligament with accompanying hypertrophy of the meniscofemoral ligament and the medial meniscal tear seen on MRI. A partial medial meniscectomy was performed. Postoperatively the patient was started on a standard rehab protocol for meniscectomy. At this time she is over two years post-op from her meniscectomy. She is clinically doing very well and is playing volleyball without difficulty. She reports no hindrance in her activities and denies any pain or instability in her knee.

736 MAY 30 1:20 PM - 1:40 PM

Neck Injury - Concussed Football Player

Greg Canty. Children’s Mercy Hospitals & Clinics, Kansas City, MO.

(No relationships reported)

HISTORY: 14 yo football player presents after head-head collision during football game 13 days prior. He does not recall exact mechanism during tackle but noted the prompt onset of headache, nausea, dizziness, and neck pain. He denied any neurologic symptoms, weakness, or paresthesias. He was seen by his primary care provider and diagnosed with a concussion prior to his referral to Sports Medicine for further consultation because he had a prior concussion last year. His PCP also ordered a CT scan of his head in the interim. His symptoms of headache are much improved and his dizziness, difficulty concentrating, and difficulty sleeping that developed have now all resolved. He denies any persistent neck pain.

PHYSICAL EXAM: Office exam reveals an alert, cooperative 14 yo young man. Answers questions appropriately, does successful recall, months in reverse order. Cervical spine reveals full flexion, extension, and lateral bend but may have slight decrease of 10 degrees bilaterally with terminal ranges of rotary motion. No cervical spine tenderness. Negative Spurlings. No skull or facial bone tenderness. CN 2-12 intact. Normal fundoscopic exam. Strength 5/5 in all extremities. DTR’s of patella, triceps, and Achilles normoreflexive. Heel-toe walk. Cerebellar function intact with rapid alternating movements, finger to nose, and heel shin maneuvers. BESS normal.

DIFFERENTIAL DIAGNOSIS: 1. Concussion 2. Cervical Neuropraxia 3. Cervical injury/Anomaly

TEST AND RESULTS: 1. Outside CT of head reveals congenital fusion of C2- C3 vertebrae 2. Subsequent MRI confirms fusion of C2-C3 vertebral body and posterior elements. Vertebral canal from C5-C7 is also noted to be lower in AP diameter. The vertebrae and discs are otherwise within normal limits. Torg rations are lower normal.

FINAL DIAGNOSIS: Klippel-Feil cervical anomaly of C2-C3

TREATMENT AND OUTCOMES: 1. Multidisciplinary consultation because patient adamant about continuing to play football and sports. 2. Multidisciplinary opinion was definitively no participation in collision sports. 3. The risks associated with other contact sports such as basketball are real and potentially catastrophic, but they much less than with collision sports. 4. Family was willing to accept risks and patient remains active in basketball and baseball without symptoms or further injury.

737 MAY 30 1:40 PM - 2:00 PM

Acute Swan Neck Deformities of the Fingers and Upper Extremity Spasms - Tae Kwon Do

Stacy A. Frye. Geisinger Medical Center, Danville, PA. (Sponsor: Cynthia R. LaBella, FACSM)

(No relationships reported)

HISTORY: A 10-year-old female presented with acute swan neck deformities of her right 4th and 5th fingers; this occurred while practicing a kata routine in tae kwon do. Episodes progressed to include all fingers and paroxysmal spasms of bilateral elbows and shoulders. Triggers included cold and anxiety. Episodes were painful; upper extremities “locked” for several minutes. No neurologic symptoms, swelling or acute injury. No family history of rheumatologic, neurologic, autoimmune or endocrine disorders.

PHYSICAL EXAMINATION: Overweight, BMI 25.8 (>95%ile for age). Rigid swan-neck deformities of right 4th and 5th fingers. No discoloration or swelling. Tenderness at the DIP > PIP joints and finger flexors. Beighton hypermobility score: 9. Blood pressure cuff on arm and hyperventilation triggered finger spasms & elbow flexor posturing. Trousseau sign positive. Percussion over thenar eminence produced myotonia. Appropriate strength and sensation to light touch, temperature in the upper extremities. Reflexes 2+ throughout. Symmetric radial pulses.

DIFFERENTIAL DIAGNOSIS:

1. Tetany

2. Autoimmune continuous muscle fiber activity syndrome

3. Hypermobility syndrome

TEST AND RESULTS:

Labs: Ionized calcium, magnesium, thyroid functions, PTH, metabolic panel, anti-GAD antibodies, IgA, vitamin D profile, anti-ganglioside antibody, paraneoplastic panel, RF, CRP, CBC, ESR, ANA, C3, C4

- All normal

EMG:

- Continuous muscle fiber activity during episodes

FINAL/WORKING DIAGNOSIS: Continuous muscle fiber activity syndrome

TREATMENT AND OUTCOMES: - Initial visit: Immobilization with splinting in DIP and PIP flexion. Warm compresses and non-steroidal anti-inflammatory medications as needed.

- Neurology consult: Admitted for tetany. Intravenous immunoglobulin 1 g/kg given over 2 days; tetany improved. Started carbamazepine 100 mg daily - increased to BID after 1 week.

- 10 day follow-up (F/U): Only finger spasms.

- 4 week F/U: Reported 1 episode affecting all digits after prolonged swimming. Began medication taper.

- 6 week F/U: Recurrence of digit/shoulder spasms during swim class. Carbamazepine increased to 200 mg twice daily.

- 7 week F/U: Frequency and intensity of episodes decreased.

- 8 week F/U: Episodes flared again with return to tae kwon do and school. Considering long-term immunomodulating therapy.

738 MAY 30 2:00 PM - 2:20 PM

Wrist Pain-gymnastics

Phuong Huynh, Susannah M. Briskin, Amanda K. Weiss Kelly. Rainbow Babies & Children’s Hospital / University Hospitals Case Medical Center, Cleveland, OH.

(No relationships reported)

HISTORY: A 4 year old female recreational gymnast presents with L wrist pain for 2-3 months. During gymnastics, she repeatedly landed with her wrists in ulnar deviation. There was a questionable FOOSH injury. A wrist splint relieved her pain for ADLS, but taping did not help in gymnastics. By choice, she avoided wrist extension.

No significant PMH, PSH, PFH.

PHYSICAL EXAMINATION: GEN: Well appearing 4 year old, in NAD. Favored the L wrist when getting on the exam table

WRIST:

Inspection/Palpation: No swelling, erythema or warmth. Tender L distal radius and anatomic snuffbox

ROM: 80 degrees flexion, 0 degrees extension, radial / ulnar deviation. Passive ROM painful with extension, radial / ulnar deviation

Strength: Limited by pain

Special Tests: Negative Watson’s, Finkelstein’s and TFCC grind. Refused lift off test

SKIN: No rashes

NV: Intact

DIFFERENTIAL DIAGNOSIS:

1.Distal radial physis injury

2.Scaphoid fracture

3.Dorsal impingement syndrome

4.Juvenile idiopathic arthritis

5.Carpal tunnel syndrome

6.DeQuervain’s tenosynovitis

7.Kienbock’s disease

TESTS AND RESULTS: Wrist X-Rays: Normal

Wrist MRI:

Extensive pan carpal synovial edema and enhancement with associated effusion enhancement within the 3rd and 4th MCP joints. Consistent with juvenile idiopathic arthritis.

Labs negative, except for ESR of 23 (normal range 0-13)

FINAL / WORKING DIAGNOSIS:

Juvenile Idiopathic Arthritis

TREATMENT AND OUTCOMES: Subsequent visits to sports med clinic:

- After 3 weeks in a thumb spica cast, her snuffbox tenderness resolved. She had decreased ROM and persistent mild tenderness of the dorsum of the distal radius.

-After 3 weeks in a wrist splint, she was nontender with persistent ROM deficits. Recommended active ROM home exercises were not done.

-After 2 weeks of OT, her extension was 72 degrees and her parents witnessed a fall on her head because she would not use her wrist to brace her fall. She was then scheduled for an MRI under sedation.

After MRI results available:

-Referral to pediatric rheumatology

-Further joint involvement: L elbow, 3rd and 4th MCPs, R 2nd MCP, 3rd toe IP, and 5th toe

-Meloxicam and methotrexate initiated

-Steroid wrist injection under sedation

-Meloxicam discontinued due to transaminitis

-No active arthritis at her 3 month follow up visit with rheumatology

739 MAY 30 2:20 PM - 2:40 PM

Bilateral Knee Pain_Multi-sport Athlete

Eric Bowman, Richard Rodenberg. Nationwide Children’s Hospital, Westerville, OH.

(No relationships reported)

HISTORY: A 13-year-old male multi-sport athlete presents with bilateral medial knee pain for approximately 3-4 years without a specific mechanism of injury. He reports that the pain has been mostly on the medial side of both knees and that the pain is worse with running activity-specifically basketball and soccer and shortly after those activities. Dad reports that he used to run with a normal looking stride, but over the past few years, his stride is getting worse. He has been pre-medicating before games with ibuprofen, but it isn’t taking away all of the pain. He has had no pain with ADL’s, and no limping noted except with games. He denies swelling, catching, locking of the knees.

PHYSICAL EXAMINATION: Healthy appearing young man with a normal walking gait. A full examination of the left and right knee reveals no swelling, erythema, ecchymosis. No tenderness to palpation anywhere. Range of motion is full in flexion and extension. His strength demonstrates 5/5 in flexion and extension with the extensor mechanism intact. All ligament tests are negative. No pain with deep knee squat. His proprioception is intact. He has mild to moderate valgus alignment with single leg deep knee bend.

DIFFERENTIAL DIAGNOSIS:

1.Osgood-Schlatter Disease

2.Patellofemoral Pain Syndrome

3.Osteochondritis Dissecans (OCD)

4.Meniscus injury related to discoid meniscus

5.Juvenile Idiopathic Arthritis

TESTS AND RESULTS: AP/lateral, Sunrise, and Notch radiographs of both knees:

- Irregularity suggestive of osteochondral defect at all 4 of the femoral condyles. Also irregularity noted at the lateral aspect of the left tibial plateau consistent with possible osteochondral defect.

MRI of both knees: -OCD lesion involving the medial and lateral femoral condyle of both knees with subchondral cyst formation in all but the right medial femoral condyle. There is an unusual OCD lesion within the left lateral tibial plateau along its medial aspect with no cyst formation.

FINAL/WORKING DIAGNOSIS: Osteochondritis dissecans of all 4 femoral condyles and the left lateral tibial plateau

TREATMENT AND OUTCOMES:

1.Rest from all physical activity

2.Orthopedic referral for plans to complete staged knee scopes with in situ drilling and possible screw fixation

3.Plans for 4-6 weeks non-weight bearing with progression to full activity as tolerated at 4-6 months

B-21 Clinical Case Slide - Lower Extremity II

MAY 30, 2012 1:00 PM - 2:40 PM

ROOM: 2016

740 Chair: Carrie A. Jaworski, FACSM. Chicago, IL.

(No relationships reported)

741 Discussant: Jeffrey A. Ross, FACSM. Baylor College of Medicine, Houston, TX.

(No relationships reported)

742 Discussant: Marci Goolsby. University of California Los Angeles, Los Angeles, CA.

(No relationships reported)

743 MAY 30 1:00 PM - 1:20 PM

Rapid Failure Of Open Fasciotomy For Treatment Of Exercise Induced Compartment Syndrome: A Case Report.

Peter Wenger, Tanya Hagen, FACSM. UPMC Center for Sports Medicine, Pittsburgh, PA.

(No relationships reported)

INTRODUCTION: Chronic exertional compartment syndrome (CECS) is a common cause of exercise induced leg pain. Of patients who have disease recurrence after surgery, time to symptoms was at least 8 months and up to 54 months. This case highlights failure of the index procedure, which used a minimally invasive incision, after symptom-free period of 2 weeks.

HISTORY: A 20 year-old male collegiate runner presents to his team physician with complaints of lower extremity pain and swelling made worse with exercise. He presents 3 months after fasciotomy for exertional compartment syndrome. Operative report indicated he had bilateral complete anterior and lateral compartment fasciotomies using single 5cm proximal-based incisions. Post-operative course- intense pain and swelling below incisions. He progressed poorly through strength/proprioception therapy secondary to pain. 6 weeks post-op he had a symptom-free period of two weeks. 2 months post-operatively he began running. Pain and swelling returned shortly after each run began.

PHYSICAL EXAM: Tenderness and fullness of the anterior compartments bilaterally below incisions Weakness in dorsiflexion and eversion bilaterally

DIFFERENTIAL DIAGNOSIS: Failure of index procedure/ recurrence, stress fracture, deconditioning, tendinopathy, indolent infection, DVT, neuropathy

Course: Persistent symptoms despite therapy Diagnosed with recurrent exertional compartment syndrome -Repeat anterior compartment pressures- 35 on left, 32 on right (resting)

Discussion: A treatment for exertional compartment syndrome with good cosmetic results has been sought with a variety of surgical techniques described in the literature. In this case our athlete had small proximal-based incisions, a common technique. Causes for recurrence include failure of index surgery and more commonly, prolific scar formation. Hematoma secondary to post-operative bleeding has been implicated in excessive scar formation. Likely cause of recurrence in our athlete was hematoma formation early in the post-operative period and subsequent scar proliferation. In theory, adequate visualization of the distal fascia with the overlying skin off-tension could be more difficult using a smaller single incision.

744 MAY 30 1:20 PM - 1:40 PM

Leg Pain In A 45 Year Old Female Soccer Player

Nathan Holmes, David Webner, Dan Miles, FACSM, Steven Collina. Crozer Keystone Health System, Springfield, PA.

(No relationships reported)

HISTORY: A 45-year-old female presents with two days of right anterior lower leg pain and an inability to dorsiflex her ankle. She was kicking a soccer ball and struck the ground with her foot over the area of the metatarsal heads. She noticed an immediate sharp pain over the anterior leg with associated tingling over the dorsum of her foot. She presented to the emergency room that evening where she had x rays of her tibia and fibula and was placed on crutches for comfort. Later that night she noticed some mild swelling and bruising over the anterior leg and a decreased ability to dorsiflex her ankle. When we saw the patient she noted improving pain but continued lack of dorsiflexion of the ankle. She stated the tingling in her foot had resolved the day prior to presentation.

PHYSICAL EXAMINATION: Initial examination of the right lower extremity revealed no ankle swelling, , mild ecchymosis over the anterior shin, and no erythema. Passive dorsiflexion, plantarflexion, inversion, and eversion of the ankle were all preserved. She was non tender over the ATF, CF, PTF, and deltoid ligaments and had no boney tenderness. She had negative anterior drawer and talar tilt testing. Motor tests revealed : 1/5 on Dorsiflexion and 5/5 on plantarflexion, inversion and eversion of the ankle. She had no great toe extension (0/5 strength). She had intact sensation to light tough and pin prick over the entire foot and normal Dorsal Pedis and Posterior Tibial pulses with normal capillary refill.

DIFFERENTIAL DIAGNOSIS:

1.Extensor Hallux Longus Rupture

2.Anterior Tibialis Rupture

3. Peroneal nerve damage

TEST AND RESULTS:

1.Right tibia - fibula x ray from the ER - no osseous changes

2.Right Foot and ankle x rays- no osseous changes

3.Right Lower Extremity MRI - partial tear of the anterior tibialis, extensor hallucis longus and extensor digitorum longus . No evidence of peroneal nerve compression

4.Right lower extremity EMG 4 weeks post-injury: severe incomplete peroneal neuropathy of the deep peroneal nerve branch with axonal loss.

FINAL/WORKING DIAGNOSIS:

Deep Peroneal neuropathy

TREATMENT AND OUTCOMES:

1. Patient placed in an ankle-foot orthosis and physical therapy was initiated

2. At most recent follow up five months after the injury the patient was noted to have 3/5 strength with great toe extension and 4+/5 strength on dorsiflexion of the ankle.

745 MAY 30 1:40 PM - 2:00 PM

Knee Pain - Basketball Player

Trasey D. Falcone, Gary P. Chimes. University of Pittsburgh Medical Center, Pittsburgh, PA.

(No relationships reported)

HISTORY: A 15-year-old female basketball player presents with worsening bilateral knee pain over 1½ years that was first noted during the early spring, and by fall prevented play. Pain was in the anterior knee, without associated redness, inflammation, or swelling. She had 3 courses of physical therapy with marginal benefit. Female athlete triad screen significant for menstrual irregularity and multiple stress fractures.

PHYSICAL EXAMINATION: Appropriate muscle bulk. Single leg balance > than 5 seconds. Single leg squat- decreased gluteal activation and increased internal rotation. Double-leg squats with infrapatellar arch support exacerbated pain. No knee effusion or erythema. Plica palpation non-tender. Maximal tenderness palpated at the junction of the proximal 1/3 and distal 2/3 of the patellar tendon bilaterally.

DIFFERENTIAL DIAGNOSIS:

1. Bilateral knee patellar tendonopathy

2. Sinding-Larsen-Johansson syndrome

3. Patellofemoral syndrome

4. Female athlete triad

TESTS AND RESULTS: MSK US

- Consistent with patellar tendinosis

MRI

- Edema in the distal femoral metaphysis and epiphysis of the left knee

- Normal patellar ligaments

X-ray

- Slight lateral displacement of bilateral patellae

Blood

- 1, 25 Dihydroxyvitamin D - 25 ng/mL

FINAL/WORKING DIAGNOSIS:

- Bilateral Patellofemoral Pain Syndrome

- Vitamin D deficiency

TREATMENT AND OUTCOMES:

1. Vitamin D3 50,000 units per week for 8 weeks

2. Calcium, vitamin D, fish oil, DHEA, and essential amino acid

3. Resistance training regimen

4. Conservative management of her knee pain had provided minimal improvement. A diagnostic infrapatellar nerve block was performed, using 5 mL of 1% lidocaine administered to each knee via medial approach

5. At 2 weeks and 2 months following the infrapatellar nerve block the patient reported 100% pain relief with no recurrence. She was participating in gymnastics and cheerleading without difficulty, and had expressed interest in returning to competitive basketball.

746 MAY 30 2:00 PM - 2:20 PM

Persistent Knee Pain in a High School Athlete

Kristen A. Scopaz1, Lucien Ouellette2. 1Maine Medical Center, Portland, ME. 2Orthopedics Associates, Portland, ME. (Sponsor: William Dexter, FACSM)

(No relationships reported)

HISTORY: A 17 y.o. male high school athlete presents with intermittent right knee pain for 2 months. He first noticed the pain playing basketball. He went to pick up a loose ball and felt as if his knee “locked” but was able to continue playing. Since then he has had posterolateral knee pain that shoots anteriorly. The pain is worse with activity and interferes with sports. The knee feels less stable but has not given out. He has stiffness with squats but no swelling. Prior history includes right knee pain 8 months ago after an opposing wrestler landed on his distal thigh. He was diagnosed with a quadriceps contusion, and his pain resolved with conservative treatment.

PHYSICAL EXAMINATION: His gait is nonantalgic. Right single leg stance and squat show decreased proprioception with poor gluteal activation. On palpation there is a tender firm growth on the medial distal femur. He also has tenderness along the distal lateral hamstrings that more closely simulates his pain. There is no joint line tenderness, effusion, or skin changes. ROM and neurovascular exams are normal. Ligamentous and meniscal tests are negative.

DIFFERENTIAL DIAGNOSIS:

Hamstring strain

Meniscal pathology/discoid meniscus

Osteochondroma

Surface bone tumor including parosteal and periosteal osteosarcoma

Traumatic periosteal reaction

Myositis ossificans

TEST AND RESULTS:

Right knee radiographs:

- Irregular round growth at distal medial femur on AP view with only mild prominence of periosteum on lateral view

Right knee MRI with gadolinium:

- 1×3×3cm abnormality protruding medially from the distal femoral cortex that does not communicate with the medullary cavity

- Mixed signal intensity: intermediate and high T2 intensity and intermediate and low T1 intensity

- Impression: post-traumatic changes versus neoplasm such as parosteal osteosarcoma

Consultation with orthopedic oncology:

- Likely periosteal bone formation from wrestling injury with little risk for neoplasm

FINAL/WORKING DIAGNOSIS:

Hamstring strain and traumatic periosteal bone formation

TREATMENT AND OUTCOMES:

1. Physical therapy with therapeutic exercise to improve lower extremity biomechanics, strength and proprioception.

2. 2 months after presentation his symptoms and function are improved; he feels ready to start his wrestling season.

3. Follow-up in 6 months for repeat x-rays.

747 MAY 30 2:20 PM - 2:40 PM

Thigh Pain - Football

Adam Abdulally, FACSM, Jeanne Doperak. University of Pittsburgh Medical Center, Pittsburgh, PA.

(No relationships reported)

HISTORY: 23 year old NFL rookie football player complains of acute worsening thigh pain hours after practice. He recalls “locking legs” with another player and a trivial twisting injury. His pain was minimal and finished practice without difficulty. Eight hours later he reports 10/10 pressure-like, non radiating pain in his distal anterior lateral thigh that has been getting progressively worse. He is currently unable to weight bear and is in moderate distress. He has no numbness and tingling; no fever, chills or sweats; and no previous injuries.

PHYSICAL EXAM:

Left lower extremity exam showed no ecchymosis or erythema on skin. There was a large bulging in the anterior lateral thigh. There was tenderness to palpation over anterior lateral distal thigh which was firm to touch. He could only actively flex 10 degrees. Sensation was intact. 2+ symmetric femoral, popleteal, DP, PT pulses. No lumbar pain and negative straight leg raise bilaterally.

DIFFERENTAIL DIAGNOSIS:

1. Acute Compartment Syndrome

2. Hematoma

3. Fracture

4. Quad Contusion

5. DVT

TEST AND RESULTS:

CBC - normal

PTP- 44

PT- 11.3

VWF ag - 0.4

Ristoetin Cofactor Activity - 0.29

FINAL/WORKING DIAGNOSIS: Acute Compartment Syndrome complicated by Von Willebrand’s Disease

TREATMENT AND OUTCOMES: Based on appearance he was taken to the operating room with a presumptive diagnosis of acute compartment syndrome. Incision from mid-thigh to distal thigh over IT band was preformed. 3 × 3 cm tear in his vastus lateralis over the distal portion of his intramuscular tear. No evidence of expanding hematoma.

Had significant bleeding post-operatively (likely caused because of newly diagnosed VWD) and required multiple debridements and skin grafting. He had gotten DDAVP during his hospital stay. Further hematological work up was consistent with von Willebrand’s. He will undergo repeat VWD testing in several months.

B-22 Clinical Case Slide - Sports Trauma

MAY 30, 2012 1:00 PM - 3:00 PM

ROOM: 2020

748 Chair: Mark L. Stovak, FACSM. Wichita, KS.

(No relationships reported)

749 Discussant: Bryan Wiley. Rancho Cucamonga, CA.

(No relationships reported)

750 Discussant: Kyle J. Cassas, FACSM. Steadman Hawkins Clinic of the Carolinas, Greenville, SC.

(No relationships reported)

751 MAY 30 1:00 PM - 1:20 PM

Neck Injury - Ultimate Frisbee

Chad S. Beattie, FACSM, John Herbert Stevenson, MD. University of Massachusetts, Fitchburg, MA.

(No relationships reported)

HISTORY: HISTORY: 16yo high school soccer player was playing in an Ultimate Frisbee game where he reports that he and an opponent both went up to make a catch when he was inadvertently struck in the right-anterior neck by the opponent’s elbow. He immediately felt pain and swelling in the area. Negative LOC or difficulty breathing but + pain upon swallowing. He then presented to the TR. He was observed for ∼ 20-30 minutes by the ATC but the swelling was increasing. Pt sent to ED. Upon presentation, +pain over the anterior neck with increased swelling but denied any resp distress/cough/change in voice.

PHYSICAL EXAMINATION: VS- wnl

Gen: - Resp distress

Head: NC/AT

Neck: + TTP over tracheal cartilage and R SCM. ∼ Trachea with ? shift to the Left. No c-spine tenderness/crepitus

HEENT: MMM, oropharynx clear with + gag reflex noted.EOMI. PERRL.

Lungs: Regular resp, CTAB, no stridor/wheeze

Chest: Non-TTP

CVS. Equal and symm pulses, RRR, -murmurs/rubs/gallops

Abd: wnl

Neuro: AAOx3, - FND

DIFFERENTIAL DIAGNOSIS: Tracheal Cartilage Fracture, C-spine hyperextension/fracture, SCM strain, SC joint dislocation, Medial Clavicle Fx,Pneumomediastinum, Deep or superficial Hematoma, Jugular Vein lac, Thyroid/Thyroid artery lac

TEST AND RESULTS: Labs: CBC, BMP wnl (H&H=13&40) CTA Neck: Soft tissue density in the R thyroid lobe measuring 1.8 × 2.8cm. + active contrast extravasation into the R thyroid lobe,+ acute injury to an artery supplying the R lobe. + trach deviation to the left indicating mass effect. + Overlying soft tissue inflamm/swelling. No fractures. No cervical LAD. Lung apices clear. SC joint intact.

FINAL WORKING DIAGNOSIS:Acute thyroid artery injury/ thyroid hematoma

TREATMENT AND OUTCOMES: Pt transferred to tertiary care center for specialized pediatric care. Eval by trauma team: Pt stable, no signs of resp distress. + Discomfort. VSS.Examination is unchanged.CXR wnl -> no sign of trach deviation. Admitted to PICU for Obs. Pt spent one night in the PICU. Swelling and pain decreased. He was released to home under the care of his parents. His swelling was gone ∼ 1 week after the incident and he was essentially pain free 4 days after injury.

RETURN TO PLAY: Pt had a f/u appointment in the trauma clinic 3 weeks after injury. His physical examination was entirely normal and he was cleared to play full contact sports.

752 MAY 30 1:20 PM - 1:40 PM

Chest Pain In A 33-year-old Elite Soldier-Athlete - Combat

James H. Lynch, Shawn F. Kane, FACSM. Womack Army Medical Center, Fort Bragg, NC.

(No relationships reported)

HISTORY: A 33-year-old male U.S. Army Special Operations Soldier was conducting combat operations while deployed to Afghanistan when he was injured by a grenade blast. He sustained multiple fragmentation wounds to his bilateral upper and lower extremities, abdomen and pelvis. The patient was treated at a surgical hospital where he underwent an exploratory laparotomy, which was negative for intra-abdominal injury, a pericardial window which was also negative, and debridement of extremity wounds. He was stabilized and evacuated for definitive care, where he arrived in stable condition but complaining of chest pain. There was no obvious fragmentation wound or evidence of blunt trauma to his chest wall as the patient was wearing body armor at the time of his injury.

PHYSICAL EXAMINATION: On initial presentation, the patient appeared healthy and muscular. Heart was regular rate and rhythm without murmurs, rubs, or gallops. Chest wall was not tender to palpation. Lung sounds were clear. Abdomen was diffusely tender; midline incision was bandaged. Extremities were bandaged but with symmetric movement and no gross neurologic deficits. Lower extremities were of symmetric girth; Homan’s sign was negative.

DIFFERENTIAL DIAGNOSIS:

1. Pulmonary embolism

2. Pericarditis

3. Acute coronary syndrome

4. Pulmonary contusion

5. Chest wall contusion

6. Arrhythmia

TESTS AND RESULTS: Initial EKG: Normal sinus rhythm. ST-T elevation in all leads. Chest X-ray: no fractures. Metallic density overlying the heart at left medial hemidiaphragm Chest CT Scan: metal fragment with streak artifact at anterior inferior right ventricular wall Transthoracic echocardiogram: normal ventricles and valve morphology. <1cm-size object abutting distal RV wall, not in the chamber. EBCT: No pericardial effusion. 8x5mm metal fragment at margin of RV free wall myocardium, deep to pericardium.

FINAL WORKING DIAGNOSIS: 8mm metal fragment in the heart anterior/inferior right ventricular wall

TREATMENT AND OUTCOMES:

1. Telemetry, daily EKGs, and Holter monitor during inpatient stay and rehabilitation

2. Serial transthoracic echocardiograms

3. Restricted activity for six weeks while laparotomy healed

4. Gradual return to exercise following negative exercise stress testing

5. Nonoperative management of heart fragment

6. Return to full activity

753 MAY 30 1:40 PM - 2:00 PM

Abdominal Injury - Football

Emily Wozobski, Gretchen D. Oliver, Jeff Bonacci, Matt Summers. University of Arkansas, Fayetteville, AR. (Sponsor: Heidi Kluess, FACSM)

(No relationships reported)

HISTORY: A 20-year-old NCAA Division I football running back sustained blunt trauma to the abdomen during competition. The athlete was returning a kick when an opposing team member tackled him. After the hit the athlete was able to ambulate to the sideline with assistance and complained of minimal right upper quadrant abdominal discomfort. After approximately 20 minutes the athlete’s condition worsened as he began to vomit, his stomach became rigid and tender, and bowel sounds diminished.

PHYSICAL EXAMINATION: Sideline evaluation revealed minimal abdominal pain, which escalated over time; vital signs were within normal limits. Eventually the abdomen became rigid and tender with diminished bowel sounds.

DIFFERENTIAL DIAGNOSIS:

1. Bruised ribs

2. Perforated viscus

TEST AND RESULTS:

CT scan of the abdomen:

- Free air surrounding the liver

- Free fluid surrounding the liver

- No solid organ injury

Exploratory laparotomy

FINAL WORKING DIAGNOSIS: 1.5 centimeter perforation of the ileum, 30 centimeters from the proximal end of the ileocecal valve

TREATMENT AND OUTCOMES:

1. Surgical repair of perforated bowel, including saline wash of entire abdominal cavity.

2. Insertion of nasogastric tube to allow for drainage of bilious material.

3. Nasogastric tube was removed after 5 days. At this time a diet of clear liquids was resumed.

4. Athlete returned to unrestricted diet as tolerated.

5. Athlete resumed cardiovascular exercise five weeks postoperatively.

6. Sport specific drills were implemented eight weeks post operatively.

7. Beginning week 11, a lumbar stabilization program, as well as weight-lifting program focusing on endurance were implemented.

8. After sixteen weeks, athlete returned to full participation.

754 MAY 30 2:00 PM - 2:20 PM

Elbow Injury in a Hypnotized Cymbals Player

Jennifer Malcolm1, Kevin McAward2. 1Saint Joseph Regional Medical Center - Sports Medicine Institute, Mishawaka, IN. 2Notre Dame University, Notre Dame, IN. (Sponsor: Mark Lavallee, FACSM)

(No relationships reported)

HISTORY: An 18 year old male college freshman bravely decided to allow a new hall mate to hypnotize him. As he went deeper and deeper into his trance, he went through many transformations. During his hypnosis, he became a Super Mario Brother and decided to body slam a turtle landing on his left elbow, hip and lumbar region. The crowd roared and the hypnotist told him he would awake at the count of three without any pain. Five days later, he presented to the health center in a homemade sling complaining of elbow pain. Ice and Ibuprofen did not alleviate his symptoms. His pain and decreased ROM was limiting his cymbals playing. (Hypnotism video available)

PHYSICAL EXAMINATION: Vital signs within normal limits. Tenderness to palpation over the olecranon without tenderness over the radial head, distal humerus, or proximal ulna. Moderate swelling throughout the elbow joint. Flexion and extension limited due to pain and swelling. Supination and pronation nonpainful and without restricted ROM. Distal pulses intact. Sensory examination within normal limits.

DIFFERENTIAL DIAGNOSIS:

Olecranon Contusion/Fracture, Humerus Contusion/Fracture, Hematoma, OCD, Muscular Strain

TEST AND RESULTS:

Left Elbow Xrays: Non-displaced intra-articular oblique fracture of the proximal ulna at the base of the olecranon process

FINAL WORKING DIAGNOSIS: Non-displaced intra-articular olecranon fracture

TREATMENT AND OUTCOMES: The patient was placed in a long arm splint at initial presentation. A custom posterior brace with 45 degrees of flexion at the elbow was later made so he could perform PROM exercises from 0-110 degrees twice daily avoiding deep flexion and AROM to prevent elbow stiffening. The patient returned to clinic every two weeks for repeat X-rays and evaluation of pain and ROM. Follow up X-rays showed evidence of a healing non-displaced olecranon fracture at 2 and 4 weeks. At approximately 4 weeks, this cymbals player decided to come out of his splint and started AROM exercises on his own. He presented at 5 weeks and 5 days with full active and passive ROM without pain. At 6 weeks X-rays showed complete callous formation without evidence of a fracture line and was able to return to his cymbals. He played at a Division 1 Football Game at 6 weeks post elbow trauma and has continued to play without pain. He has not been hypnotized since.

755 MAY 30 2:20 PM - 2:40 PM

Knee Injury In A Football Player

Dug Su Yun1, Steven Collina1, David Webner1, Andrew Reisman2, Daniel Miles, FACSM1. 1Crozer-Keystone, Springfield, PA. 2University of Delaware, Newark, DE.

(No relationships reported)

HISTORY: A 20 year -old division I college football linebacker was participating in a team scrimmage. While pursuing a play, a defensive back, who was blocking a wide receiver, was pushed onto lateral aspect of the player’s left knee, causing his knee to go into a valgus stress. The sideline physicians and ATCs immediately attended to the player.

PHYSICAL EXAMINATION: Initial exam revealed medial knee deformity with the patella palpably dislocated laterally. The team physician reduced the patellar dislocation, returning to its normal anatomical position. Once the player was moved to the sidelines, additional exams were performed showing significant medial swelling and tenderness. Valgus stress test revealed 3+ laxity with no end point with knee in full extension. Lachman test was not performed secondary to patient’s positive valgus stress test with its knee in full extension. The player’s pulses and sensation were intact. The player’s left knee was placed in a vacuum splint immediately. Emergency services were activated and the patient was transferred to a local hospital.

DIFFERENTIAL DIAGNOSIS: Patellar Dislocation, ACL tear, MCL tear, PCL tear, PCL injury, popliteal artery rupture, peroneal nerve injury, tibial nerve injury, fracture

TEST AND RESULTS: X-Rays- No evidence of osseous injury

Arteriogram - Intact lower extremity vasculature

MRI - Extensive full thickness tearing of the medial and anteromedial knee joint capsule and medial collateral ligament. Complete tear of the ACL. Partial tear of the PCL. Impaction fracture in the inferolateral aspect of the lateral femoral condyle. Extensive complete tear of the lateral meniscus posterior horn and body. Partial tear of the medial meniscus posterior horn at the root.

FINAL WORKING DIAGNOSIS: Knee Dislocation with complete ACL tear, complete MCL tear, partial PCL tear, complete LM tear and partial MM tear.

TREATMENT AND OUTCOMES: The player had a successful L knee arthroscopic evaluation and partial lateral menisectomy, left knee ACL reconstruction with allograft, L knee medial meniscus and open capsular and MCL repair. Patient was placed in a hinged locking knee immobilizer, with the instruction of non weight bearing. On follow up in the office 1 week later, the patient was doing well, and the plan was to continue his rehab protocol with gradual ROM and strengthening.

756 MAY 30 2:40 PM - 3:00 PM

Shoulder Injury - Football

Meggan J. Grant-Nierman, Richard Leu, FACSM, Mark Stovak, FACSM. Via Christi Sports Medicine, Wichita, KS.

(No relationships reported)

HISTORY: A 17 year old high school football wide receiver sustained an injury on the field when jumping to catch a football and landing on his left, non-dominant shoulder. He had immediate pain and limited range of motion of his left shoulder. He had no history of injury to this shoulder and he denied neck or back pain. No paresthesias.

PHYSICAL EXAMINATION: On the field - while he was still in shoulder pads, his shoulder was in10-15 degrees of flexion with an inability to externally rotate the shoulder. Normal range of motion at the elbow. Head of the humerus was palpated in an inferior and anterior position. Radial pulses were evaluated frequently and remained strong. Upper extremity sensation was intact, grip strength was normal, and humerus was non-tender.

DIFFERENTIAL DIAGNOSIS: 1. Anterior Shoulder Dislocation 2. Scapular Fracture 3. Rotator Cuff Contusion

INITIAL WORKING DIAGNOSIS: Anterior Shoulder Dislocation

TREATMENT: After several unsuccessful attempts to reduce the shoulder on the field using traction/counter-traction method and Hennipen technique, the athlete was transported by EMS to the local ER. Pre-reduction x-rays were taken of the shoulder but the radiologist saw no shoulder dislocation. The ER provider gave IV sedation and attempted reduction. The post-reduction x-ray was also read as having no dislocation. Patient was put in a shoulder immobilizer and dismissed.

INTERIM HISTORY: Athlete was seen in follow up four days later in our clinic.

FOLLOW UP PHYSICAL EXAM: Shoulder diffusely swollen with limited mobility in all ranges of motion. The humeral head was still in an anterior and inferior position and patient was still in pain. We reviewed the ER films from the outside hospital which failed to reveal dislocation but showed a small lucency suspicious for a fracture. We repeated shoulder x-rays in our clinic.

TEST AND RESULTS: Follow up imaging: scapular neck fracture with anterior angulation of the glenoid

FINAL WORKING DIAGNOSIS: Scapular fracture without dislocation of the glenohumeral joint

TREATMENT AND OUTCOMES: Orthopedist consulted for surgical repair with plating of the scapula using a 2-screw technique followed by a small fragment T-plate applied to the posterior border of the glenoid neck. The patient is recovering well from surgery and has gradually advanced range of motion of the shoulder.

B-69 Clinical Case Slide - Football Issues

MAY 30, 2012 3:15 PM - 5:15 PM

ROOM: 2016

757 Chair: Christian M. Schupp. Kaiser – Fontana, Rancho Cucamonga, CA.

(No relationships reported)

758 Discussant: David Olson. University of Minnesota, St. Paul, MN.

(No relationships reported)

759 Discussant: Christopher C. Kaeding. The Ohio State University Medical Center, Columbus, OH.

(No relationships reported)

760 MAY 30 3:15 PM - 3:35 PM

Knee injury- Football

Kristina F. DeMatas1, David M. Mandel2. 1Mayo Clinic, Jacksonville, FL. 2Nemours Children’s Clinic, Jacksonville, FL. (Sponsor: Robert J. Johnson, FACSM)

(No relationships reported)

HISTORY: 16 year old sophomore high school football player sustained a knee injury during a game. While trying to make a catch, he was hit with a varus load on the medial aspect of his right knee which twisted under him. Due to immediate lateral knee pain and swelling, he was unable to continue playing. He presented to the ER for evaluation where XRAYs were performed, he was placed in a knee immobilizer, crutches and instructed to follow up with Orthopedic surgery. In the office four days after the injury he complained of swelling, decreased range of motion and mild pain.

PHYSICAL EXAMINATION: Inspection: right knee with moderate joint effusion, moderate soft tissue swelling, no rotational or angular deformities. Palpation: tenderness to palpation over the LCL at the proximal fibula, no MCL, medial or lateral joint line tenderness, no tenderness to palpation over patellar ligament or patellar retinaculum. ROM: extension to 0 degrees with mild pain, flexion to 90 degrees with mild pain. Special tests: Lachman equivocal, posterior sag absent, patellar apprehension negative, valgus stress stable with no pain, varus stress unstable with pain, dial negative. No focal neurologic deficits, no peripheral edema

DIFFERENTIAL DIAGNOSIS:

1. LCL strain/tear

2. ACL tear

3. Fibular fracture

4. Patellar subluxation

5. Posterolateral corner injury

6. OCD defect

7. Lateral meniscus tear

TESTS AND RESULTS: XRAY AP/Lat: avulsion fracture of the proximal fibula, no dislocation, patella alta or baha, patellar subluxation, osteochondral defects or loose fragments

MRI: ACL, PCL, MCL intact. Avulsion fracture from fibular head with LCL and popliteal ligament attached. Medial and lateral meniscus WNL. Bone bruising absent, OCD lesion absent

FINAL WORKING DIAGNOSIS: 1. Isolated Posterolateral corner injury with LCL tear and avulsion fracture of the proximal fibula

TREATMENT AND OUTCOMES: Given the extent of the patient’s posterolateral corner injury, open surgical intervention was recommended

1. Reattachment of proximal fibula fragment with biceps femoris and popliteal-fibular ligament

2. Primary repair LCL right knee with suture anchors

Postop rehab

1. Gentle range of motion exercises were started immediately after surgery

2. Formal physical therapy 6 weeks post op

3. Patient’s recovery still ongoing. Update to follow

761 MAY 30 3:35 PM - 3:55 PM

Arm Injury-football

Andrew S. T. Porter. Via Christi Sports Medicine & Family Medicine - KU School of Medicine, Wichita, KS.

(No relationships reported)

HISTORY: A right handed High School Senior Football Quarterback presents with 1 day history of intermittent right arm swelling. The swelling initially presented after upper body weightlifting and resolved after resting. Swelling then represented the next morning after playing basketball and remained after rest. Athlete grew concerned with the persistent swelling and was worked into my schedule that same morning. He also complained of heaviness and associated aching in the right arm. He had no associated chest pain, shortness of air, cough, headache, neck pain, or fever.

PHYSICAL EXAMINATION: Gen: Vital signs stable. Afebrile. CV: Regular Rate and Rhythm without murmurs, clicks or rubs. Resp: Clear to auscultation bilaterally without wheezes, crackles, or rhonchi. Breath sounds were symmetric with no decreased breath sounds. HEENT: No JVD bilaterally. No carotid bruits bilaterally. Midline trachea. Abdomen: Soft, non tender, non distended, positive bowel sounds. Extremities: Right arm edema throughout the entire arm. No edema noted in the left arm or bilateral legs. Negative homan’s sign bilaterally. Musculoskeletal: Full AROM in the bilateral shoulders and cervical spine.

DIFFERENTIAL DIAGNOSIS:

Paget-Schroetter Syndrome (Effort Thrombosis)

Thoracic Outlet Syndrome

Local compression of venous system by neoplasm or mass

TEST AND RESULTS: Right arm ultrasound revealed large thrombus in the right subclavian vein.

FINAL WORKING DIAGNOSIS: Paget-Schroetter Syndrome (Effort Thrombosis)

TREATMENT AND OUTCOMES: I was practicing in a critical access hospital and I discussed the case with a vascular surgeon and the athlete was subsequently transferred to the surgeons tertiary care center. He was admitted to the ICU and catheter-directed thrombolysis was performed. Balloon angioplasty and first rib resection were then performed. Athlete was bridged over to a therapeutic INR on Lovenox and concomitant Coumadin was started. He remained on Coumadin for 3 months. He had a gradual return to progression and had no complications. He currently is a College Football Quarterback with no limitations.

762 MAY 30 3:55 PM - 4:15 PM

Lower Back Pain-Football

Cindy Y. Lin1, Monica Rho1, Sherrie Ballantine-Talmadge2, Carrie Jaworski, FACSM2. 1Rehabilitation Institute of Chicago, Chicago, IL. 2Northwestern University Athletic Department, Evanston, IL. (Sponsor: Joel Press, FACSM)

(No relationships reported)

HISTORY: 22 year old Division I football defensive tackle with 4 weeks of lower back pain without inciting event. He has 4/10 pain at rest and 10/10 pain at worst. No prior history of back pain or injury. No leg pain, numbness, or weakness. Symptoms provoked by sitting, running, or lifting. Coughing and sneezing aggravate his pain. Symptoms improved by lying down. No loss of bladder or bowel control. Patient tried naproxen and celecoxib with no pain relief.

PHYSICAL EXAMINATION: No lumbar shift. Lumbar forward flexion and leftward side bending caused low back pain. No pain with lumbar extension or rotation. Tenderness to palpation of the L5 and S1 spinous processes and the left lower lumbar paraspinal muscles. Negative seated slump, straight leg raise, and femoral stretch test bilaterally. Negative hip exam. Bilateral lower extremity strength, muscle stretch reflexes, and light touch sensation were intact.

DIFFERENTIAL DIAGNOSIS:

Lumbar Discogenic Pain

Lumbar Degenerative Disc Disease

Lumbar Spondylolysis

Lumbar Facet Mediated Pain

Sacroiliac Joint Mediated Pain

TEST AND RESULTS: MRI Lumbar Spine: L3-L4 central disc bulge abutting bilateral L4 nerve roots without central canal or neuroforaminal stenosis. Right paracentral L4-5 disc protrusion.

FINAL WORKING DIAGNOSIS: Axial discogenic low back pain due to L3-L4 and L4-L5 central disc bulges.

TREATMENT AND OUTCOMES:

1. Patient received bilateral L4-L5 transforaminal epidural steroid injections (TFESI).

2. Discussed with athletic trainer graded progression of football practice.

3. Patient started Mckenzie based spine rehabilitation program.

4. Meloxicam PRN for pain.

5. Patient had immediate relief after the injection. He resumed practice and progressively increased his weight training. Four weeks post injection, he woke up with 7/10 lower back pain radiating to his right leg. He denied leg weakness, numbness, tingling, or bowel or bladder changes.

6. Repeat MRI showed large new disc herniation at L3-4 posteriorly to the right with superior sequestration which was not present on MRI four weeks ago.

7. Patient received a right L3-4 TFESI. One week post injection, patient continued to have right leg pain. He was started on neurontin and physical therapy for lumbar radiculitis. Two weeks post injection, he had full pain relief and resumed his practice and game schedule.

763 MAY 30 4:15 PM - 4:35 PM

Acute Renal Insufficiency Secondary to Excessive Sweating - Football

Jessie R. Fudge, Kim Harmon, FACSM, Connie Davis, John O’Kane, Jonathan Drezner. University of Washington, Seattle, WA.

(No relationships reported)

HISTORY: A 21 year old Division I football player with a history of cramping developed fatigue at the end of fall camp. Given a normal exam, he was told to aggressively rehydrate. Three days later, he presented post game with profuse sweating and severe total body cramping despite oral rehydration. He was given 2L of IV fluids with resolution of cramping. He later reported cola colored urine post-game and denied myalgias. His fatigue worsened over the next several days leading to further work up. The athlete admitted to taking “Jacked”, a caffeine supplement prior to games, and Aleve because of pain.

PHYSICAL EXAMINATION: H: 6’6” W: 272 lbs

Post-game exam was remarkable for full body cramping and sweating. The sweating from his feet was so profuse that it was initially thought that he was urinating. The remainder of his exam was normal. Orthostatic vitals could not be obtained due to cramping. Follow-up exam three days later was unremarkable.

DIFFERENTIAL DIAGNOSIS:

1. Dehydration

2. Rhabdomyolysis

3. Renal Failure/Insufficiency

4. Malignancy, Lymphoma

5. Pheochromocytoma

6. Cystic Fibrosis Carrier

TEST AND RESULTS:

9/6/11: Cr 1.76, BUN 19, AST 73, ALT, 71, Ferritin 219, TSH 2.49

9/8/11: Cr 1.02, BUN 18, AST 44, ALT, 66; Mono (-); CK 588; UA nl

INTERIM DIAGNOSIS: Acute Renal Insufficiency presumed to be secondary to hypovolemia

CLINICAL COURSE: He started an aggressive oral hydration regimen, increased dietary sodium and discontinued aleve and caffeine supplements. He did well the following game with 2L of pre-game IV fluids. The following week he did not require pre-game or post-game IV fluids. During a difficult practice two weeks after initial presentation he developed a “shaky” feeling, with “fuzzy vision” and fatigue. He was sent for labs, developed full body cramps, and was given 1 L IVF. Labs pre IV showed a creatinine of 2.09 with hyaline and granular casts on UA. He was referred to nephrology. A 24 hour urine and abdominal CT were negative.

FINAL WORKING DIAGNOSIS: Acute Renal Insufficiency secondary to hypovolemia

TREATMENT AND OUTCOMES: Increased oral fluids and electrolytes at timed intervals during practice and games and 2 liters of pre-game IV fluids have prevented recurrent episodes of ARI. The athlete was advised to avoid supplements and NSAIDs. He was counseled on the danger of repetitive insults to his kidneys.

764 MAY 30 4:35 PM - 4:55 PM

Head Injury in High School Football Player

Jeff Stephenson, Richard A. Okragly. TriHealth/Bethesda Sports Medicine Fellowship, Cincinnati, OH. (Sponsor: Henry Stiene, FACSM)

(No relationships reported)

HISTORY: 17-year-old junior football running back presents to training room with complaints of left retro-orbital pressure without vision changes. During a game, 3 days prior, he took several helmet to helmet hits, but had no complaints suggestive of concussion during the game or immediately after. Later that night, he did report onset of frontal headache with nausea and emesis. By the next morning the nausea and emesis had resolved. His headache persisted until 1 day prior to examination in training room, but still complained of left retro-orbital pressure. Initial training room exam revealed intact cranial nerves and normal upper and lower extremity motor and sensation. IMPACT testing that day showed an improved score from his baseline and normal balance per ATC. He was cleared to return to light aerobic activity. During supervised light running that day, he had return of left retro-orbital and frontal head pain and pressure, as well as, left jaw pain. He was then removed from activity. He had no complaints of nausea, emesis, loss of consciousness or vision change. Later that night, this left sided pain and pressure worsened, and his mother felt that he was becoming more lethargic prompting an ED visit.

PHYSICAL EXAMINATION: Examination revealed normal vital signs (BP 130/65, pulse 73). Cervical neck exam was normal. He had a GCS of 15, his cranial nerves and cerebellum were intact. His pupils were equal and reactive to light. Sensation and motor exam for bilateral upper and lower extremities were intact.

DIFFERENTIAL DIAGNOSIS:

Concussion

Subdural hematoma

Cluster headache

Migraine headache

Acute sinusitis

TEST AND RESULTS:

Head CT w/o contrast

-findings consistent with an acute subdural hematoma overlying the left frontal lobe with some mass effect and effacement of the underlying sulci. Additional hemorrhage was identified layering along the falx. No midline shift.

FINAL WORKING DIAGNOSIS: Acute subdural hematoma

TREATMENT AND OUTCOMES: Admitted Cincinnati Children’s Hospital for observation

Neurosurgery consultation: no surgical intervention was required

NO contact sports, climbing, or wheeled activities until cleared by Neurosurgery

Cognitive rest with modified school schedule

1 month repeat head CT and subsequent follow up with Neurosurgery

Discussion of return to sports, including contact and non-contact

765 MAY 30 4:55 PM - 5:15 PM

Thoracic Spine Injury - Football

Ricardo O. Hamilton1, Keith Feder2. 1Harbor-UCLA, Harbor City, CA. 2West Coast Medical Foundation, Manhattan Beach, CA. (Sponsor: Aaron Rubin, FACSM)

(No relationships reported)

HISTORY: A 15 yo male sophomore high school running back sustained a back injury while being tackled. Prior to the official season starting, the patient was running the football on an off tackle play when he was met squarely by the outside linebacker. He was then forced from a flexed trunk position into a standing extension position and then was hit from behind by a helmet forcing his thoracic spine into hyperextension. He immediately felt a sharp pain in the thoracic region with associated tingling in the area but no numbness or weakness in the lower extremities. He walked off the field under his own strength, but did not continue participation from this point on. He continued to have pain and mild stiffness in the thoracic spine so was seen 10 days later in the orthopedic clinic.

PHYSICAL EXAM: Office exam revealed moderate tenderness of the T6-T8 spinous processes, mild tenderness of the adjacent paraspinal muscles and normal sensation, reflexes and strength of his upper extremities. Full active range of motion of his trunk but pain on extension. No rib tenderness.

DIFFERENTIAL DIAGNOSIS:

1. Thoracic spinous process fracture

2. Thoracic spine paraspinal muscle strain

3. Thoracic spine sprain

4. Thoracic herniated disc

5. Thoracic spine facet syndrome

6. Thoracic spondylolisthesis or spondylolysis

7. Thoracic spine compression fracture

TEST AND RESULT:

Thoracic and lumbar spine x-ray revealed possible loss of vertebral height at T6/T7 vertebral levels

Thoracic MRI revealed minimal compression deformity involving the T6 and T7 superior endplate with evidence of fracture lines. There was no associated bony retropulsion, significant bone edema, or paravertebral hematoma. Remaining vertebral bodies were normal.

Cord was normal.

FINAL WORKING DIAGNOSIS: T6/T7 Compression fracture

TREATMENT AND OUTCOMES:

1. Activity restriction to only ambulation. No contact.

2. At 4 weeks post injury, no point tenderness in the thoracic spine but mild pain with extension of the t-spine. At 6 weeks post injury, he was asymptomatic and started mild physical therapy. CT Scan at 8 weeks showed mild compression fractures involving the superior end plates of T6 and T7. Less than 10% loss of the vertebral body height is present.

3. Currently continuing thoracic spine isometric exercises with no return to sports planned until 12 weeks post injury.

B-70 Clinical Case Slide - Infectious Disease

MAY 30, 2012 3:15 PM - 5:15 PM

ROOM: 2020

766 Chair: Geoffrey E. Moore, FACSM. Cayuga Center for Healthy Living, Ithaca, NY.

(No relationships reported)

767 Discussant: Carlin Senter. UCLA Dept. of Sports Medicine, Los Angeles, CA.

(No relationships reported)

768 Discussant: Thomas Trojian, FACSM. University of Connecticut, Hartford, CT.

(No relationships reported)

769 MAY 30 3:15 PM - 3:35 PM

Infectious Disease - Swimming

Kari Taggart1, Sherrie Ballantine-Talmadge2. 1AthletiCo/Northwestern University, Evanston, IL. 2Northwestern University, Evanston, IL.

(No relationships reported)

HISTORY: 18-year-old female Division I swimmer presented to athletic training room with sore throat, bilateral tonsillar exudates and painful swallowing. She was referred to team physician for further evaluation and treated with Penicillin. Patient improved symptomatically, but returned 13 days later with sore throat, subjective fever, body aches, headache, and muffled voice. She was treated for mono and placed on Prednisone. In four days her condition drastically changed. She called ATC with fever, difficulty breathing, and sharp, constant back/abdominal pain so was sent to ER

PHYSICAL EXAMINATION:

VS: BP 96/55 HR 102 Temp 97.8 RR24

Gen: uncomfortable w/ breathing

HEENT: wnl

CV: S1S2 w/o murmur; tachy rate; regular rhythm

Chest: decreased and course BS at RLL; breath sounds throughout

Abd: ttp in RUQ with no guarding or rebound; (-) Murphy’s sign; ttp along mid thoracic spine, in mid line, radiating around to LUQ

Ext: no clubbing, cyanosis or edema (-) Homan’s B

DIFFERENTIAL DIAGNOSIS:

1. Mononucleosis

2. Strep throat/pneumonia

3. Community-Acquired Pneumonia

4. Sepsis

5. Pulmonary Embolism

6. Endocarditis/pericarditis

7. Peritonsillar abscess

TESTS/RESULTS:

At Hospital

CXR for B infiltrates (+)

Elevated WBC

Blood cultures: Fusobacterium necrophorum & Streptococcus dysgalactiae

Elevated LFTs

TREATMENT/OUTCOMES:

Began Unasyn at hospital for presumed CAP with sepsis

Continued to spike fevers and had persistent RUQ pain; Ultrasound showed mildly enlarged spleen

Thoracentesis performed and chest tubes placed bilaterally

Patient underwent empyema treatment w/ multiple rounds of tPa

Neck CT reviewed again and R IJ thrombus found

Cardiothoracic surgery consulted and decortication of B lungs performed, revealing significant pus throughout RLL and under diaphragm

Patient improved post-op (week 3), but became anemic;transfused prior to discharge

Began light cardiovascular exercise in spring and had tonsillectomy in summer due to persistent tonsillar pain

Progression back to swimming following tonsillectomy and return to pre-illness levels of training in the fall

FINAL/WORKING DIAGNOSIS: Lemierre Syndrome; Mononucleosis; Anemia

770 MAY 30 3:35 PM - 3:55 PM

An Unusual Cause of Hip Pain in a Recreational Walker

Jason Crookham, David Alvarez, Robert Kiningham, FACSM. University of Michigan, Ann Arbor, MI.

(No relationships reported)

HISTORY: “DD” is a 61 y/o woman. She was referred to sports medicine for osteoarthritis of the right hip diagnosed by X-ray. She has had 10 days of anterior hip pain with no overuse or traumatic history. Pain is worse with extending the hip joint and walking. She feels better sitting and has no pain with weight bearing. No hip popping, low back pain or radiation into the legs. She has used Vicodin with minimal relief.

PHYSICAL EXAMINATION: Well-appearing normal weight female with antalgic gait. Abdomen and back exam is unremarkable. Focused exam of the right hip demonstrates no erythema or swelling. No tenderness except over the anterior joint line. Passive hip ROM is limited by pain in internal rotation to 10 degrees and extension to 0 degrees, full passive hip flexion is non-painful. Strength testing is 5/5 except hip flexion which is 4+/5 and painful. Log roll and FABER test elicit anterior hip pain. Thomas test is positive. Normal knee exam, the distal extremities have normal posterior tibial pulses and sensation to light touch.

DIFFERENTIAL DIAGNOSIS:

Hip osteoarthritis, hip impingement syndrome, femoral neck stress fracture, septic arthritis, iliopsoas bursitis/tendonitis

TEST AND RESULTS:

X-ray: mild degenerative changes in right hip

Labs: CRP 33.4 high, ESR 67 high, WBC 9 normal

MRI hip: complex, multi septated iliopsoas abscess

FINAL WORKING DIAGNOSIS: Iliospsoas Abscess, culture identified Methicillin-sensitive Staphylococcus aureus.

TREATMENT AND OUTCOMES: Initial antibiotic was vancomycin. Percutaneous abscess drain for 72 hours.Discharged home with PICC line and cefazolin 2gms q 8hours for four weeks. Resolution of abscess on CT at 4-week follow-up. Returned to daily walking.

771 MAY 30 3:55 PM - 4:15 PM

Lower Leg Pain - Sedentary

Rishi K. Bala1, Steve G. Reece2. 1Patterson Avenue family practice - Bon Secours, richmond, VA. 2Advanced Orthopaedic Centers, richmond, VA. (Sponsor: Thomas Howard, FACSM)

(No relationships reported)

HISTORY: A 16-y/o male originally seen by his PCP for right lower leg pain and swelling that had been going on for 1 week. The pain was described as sharp, aching, and intermittent, which he stated he had just awakened with one morning. He had decreased range of motion and warmth at the site of the swelling. He had tried rest and acetaminophen for pain, obtaining mild relief. He denied fever, chills, a recent history of illness, or systemic signs of infection, and there was no previous history of trauma to the site or similar previous episodes. There were no changes in his activity levels and walking was his main mode of transportation between point A and B (i.e. school and home, home to friends, etc.). He denied any animal exposure or recent travel. His initial review of systems was noncontributory. He denied tob/EtOH/drugs, and his family history was unremarkable.

PHYSICAL EXAMINATION: He exhibited tenderness with mild erythema and swelling but no laceration or deformity on the anteromedial distal third of the right tibia. There was no ankle, knee, or hip involvement noted, and no neurovascular deficit was found distally.

Differential:

1. Stress Fx

2. Osteomyelitis

3. Bone cyst

4. Bony tumors (Ewing’s sarcoma and giant cell tumors)

5. Juvenile rheumatoid arthritis

6. Brown tumors of hyperparathyroidism, fibrocortical defects, fibrous dysplasia, and eosinophilic granuloma.

TESTS AND RESULTS: R Tib/Fib and Ankle Radiograph:

- patent lucency distally, probable fibrous cortical defect

MRI Tib/Fib with and w/out contrast:

- Subacute osteomyelitis of the distal tibia, surrounding periositis and possible early abscess formation in the medial soft tissues.

- Fibrous cortical defect within the proximal tibia.

- Cortical avulsive irregularity within the distal femur.

Initial Labs:

- Elevated: CRP (11.0), WBC (13.2), ESR (91), and glucose (154)

FINAL WORKING DIAGNOSIS: Brodie’s Abscess

TREATMENT AND OUTCOMES:

1. Surgical debridement and drainage of abscess.

2. Six weeks of IV antibiotics for MSSA culture, plus 2 weeks of Cephalexin po

3. ESR, CRP, and WBC (<1mm, <0.3, and 5.7) had normalized by week eight post-surgery with good wound healing.

4.Patient d/c’d from further f/u

772 MAY 30 4:15 PM - 4:35 PM

Female Runner With Back Pain

Robert J. Baker, FACSM, Shannon Kusiak, Donald Batts. MSU-KCMS, Kalamazoo, MI.

(No relationships reported)

HISTORY: A 19-year-old white female runner developed worsening sciatica over a 4 month time period. She had trouble sitting, pain with weakness of the right leg, and low back pain symptoms. The pain progressed over the next 3 months. She underwent physical therapy and OMM. She took muscle relaxers and NSAIDs for pain relief. X-ray of her sacral area showed some degenerative changes at the right sacral iliac joint and spinal bifida occulta. Patient denies any constitutional symptoms. She denies ever having STIs. No trauma to her low back. No back or spine operations. She had a fasciotomy of the mid right lower leg for compartment syndrome 1 year prior and labioplasty 6 months prior.

PHYSICAL EXAMINATION: BACK: Sacral area is not inflamed. No induration, no discharge, no tuft of hair or dimple at the end of her spine. She gets a pinching- type sensation with lateral bending. No pain with forward flexion. Back extension is painful and reproduces her symptoms. There is tenderness to palpation of lumbar and sacral regions.Deep tendon reflexes are 1+ and equal throughout. Strength is equal bilaterally with single leg standing. No splinter hemorrhages. No tenosynovitis. Skin is fair, no petechiae, purpura or rashes. NEUROLOGIC: normal.

DIFFERENTIAL DIAGNOSIS:

low back pain - mechanical

Spondylolysis

Disc herniation sacroiliitis

CNS tumor

Tethered spinal cord meningeal cyst

TEST AND RESULTS:

MRI of LS spine and MRI with/without contrast of the sacrum showed discitis, vertebral osteomyelitis at S1-S2, and bicornuate uterus.

ASO titer elevated. WBC 6300, hemoglobin 12.8, platelets 347,000 with a normal differential. BUN 15, Creatinine 1, glucose 92, cultures normal, calcium 9.3. Sedimentation rate 53.

FINAL WORKING DIAGNOSIS: Discitis, vertebral osteomyelitis of S1-S2 from Citrobacter koseri.

TREATMENT AND OUTCOMES:

Ertapenem 1 gm daily via PICC line for 42 days.

No complaints at follow up.

Cleared to return to full activity.

773 MAY 30 4:35 PM - 4:55 PM

Medial Tibial Pain in a Male Rugby Player

David B. Stone, Jaspal Singh, Rachel Brakke. University of Colorado Denver, Aurora, CO.

(No relationships reported)

HISTORY: A 21 year-old male college rugby player presented to the emergency department two days after a game with right-sided medial leg pain, erythema and mild induration. He denies any trauma or direct hits to the leg during the game. His workup in the ED included an x-ray of the right leg, which showed no evidence of fracture, and a Doppler ultrasound, which showed no evidence of DVT. His WBC was 14. He was given two doses of IV Vancomycin for a presumed cellulitis and discharged home with a course of PO antibiotics. He presented to the sports medicine clinic two days after his ED visit, four days after the initial onset of pain with only mild improvement of his symptoms.

PHYSICAL EXAMINATION: Patient was afebrile; other vital signs were normal. Inspection and palpation of the right leg showed marked erythema and induration measuring 10cm longitudinally and 5cm transversely. He was very tender to palpation over the area of induration, but had no bony tenderness. Pain to the leg only occurred with palpation; he was able to bear full weight on the leg without significant discomfort. He had full range of motion of the knee and ankle. There were no neurological or vascular deficits noted in the right leg.

DIFFERENTIAL DIAGNOSIS:

1. Osteomyelitis

2. Cellulitis

3. Tibial periostitis/periostalgia

4. Tibial stress fracture or microfracture

5. Osteosarcoma

6. DVT - Less likely with previous normal ultrasound

TEST AND RESULTS:

1. Repeat Labs: WBC 7.0. ESR and CRP Normal.

2. MRI of the RLE: Deep cellulitis affecting the periosteum consistent with periostitis. There was no evidence of osteomyelitis.

FINAL WORKING DIAGNOSIS:

1. Periostitis of the right lower extremity secondary to an infectious cause

TREATMENT AND OUTCOMES:

1. Discussion with an Infectious Disease consult agreed with diagnosis of periostitis.

2. Patient finished his PO course of Ancef and Levofloxacin with complete resolution of symptoms after 10 days of treatment.

3. Usually periostitis is caused by an inflammation of the periosteum, not infection. There are case reports of periostitis caused by secondary syphilis. This patient, however, denies any risky sexual behavior and there were no other signs of syphilis infection.

4. Source of the infection in this player is unclear.

5. He was able to return to play without further issues of pain or signs of infection.

774 MAY 30 4:55 PM - 5:15 PM

Foot, Knee And Elbow Pain - Spinning

George Guntur A. Pujalte. Penn State - Hershey Medical Center, Hershey, PA.

(No relationships reported)

HISTORY: Thirty-four-year-old female with bilateral foot, knee, and elbow pain, started 5 days prior to consult. Was in spin class 6 days ago, doubling intensity. Day after, could not walk because of pain in ankles and knees. Ankles became swollen and inflamed. Pain was “a lot worse” on left than on her right ankle, worse on right knee than left knee. Pain 6-9/10 in intensity, “achy” with sharp episodes, associated with occasional numbness/tingling, constant, aggravated by “any activity.” Also started having diarrhea. No history of recent travel. Walked dog regularly.

PHYSICAL EXAMINATION: Normal range of motion of both elbows, no pain on active, passive or resisted range of motion testing. Point tender all around elbows. Normal flexion and extension of right knee. Point tender over joint lines of right knee. Negative varus or valgus laxity. No patellar grind or apprehension. Negative anterior, posterior drawer tests. Negative Lachman’s. Negative McMurray’s. Pain on maximal inversion, active or passive, of left ankle. Pain on resisted eversion of left ankle. Point tender over calcaneofibular ligaments and over peroneal tendons of left ankle.

DIFFERENTIAL DIAGNOSIS:

Musculoskeletal bilateral ankle, knee, and elbow pain, related to increased intensity of spinning

Symmetric polyarthralgia, diarrhea, considerations being Lyme disease, reactive arthritis with irritable bowel syndrome, sarcoidosis

TEST AND RESULTS:

X-rays WNL. CBC and CMP WNL. ANA negative, CPK 42, C3 157, C4 elevated at 55, C-reactive protein elevated at 3.80, and ESR elevated at 46. Urinalysis revealed trace hemoglobin and few bacteria.

Lyme and Babesia serologic testing positive.

FINAL/WORKING DIAGNOSIS: Polyarthralgia, probably secondary to Lyme disease and Babesiosis

TREATMENT AND OUTCOMES: Initially, Motrin 600 mg as needed, but did not help. Later, Medrol Dosepak to use as directed, which did help, but pain came back. Referred to Rheumatology for further evaluation, who ordered Lyme tests, which were positive. Doxycycline started at 100 mg PO BID × 3 weeks, with minimal response at 2 weeks. Referred to Infectious Diseases, who ordered Babesiosis tests, which were positive. Started on Mepron 750 mg twice daily for 5 months, together with doxycycline. Joint pains markedly decreased. Returned to spinning with no problems.

C-21 Clinical Case Slide - General Medicine II

MAY 31, 2012 8:00 AM - 10:00 AM

ROOM: 2001

775 Chair: Sandra J. Hoffmann, FACSM. Idaho State University, Pocatello, ID.

(No relationships reported)

776 Discussant: Evan S. Bass. Kaiser Permanente, South Bay, Redondo Beach, CA.

(No relationships reported)

777 Discussant: Brian Krabak. University of Washington, Seattle, WA.

(No relationships reported)

778 MAY 31 8:00 AM - 8:20 AM

Exercise Intolerance In A Division I Female Soccer Player

Benjamin Newton, Richard A. Okragly. TriHealth/Bethesda Sports Medicine Fellowship, Cincinnati, OH. (Sponsor: Henry Stiene, FACSM)

(No relationships reported)

HISTORY: An 18 y/o Division I female soccer player presents to the training room with several weeks of decreased exercise tolerance. She claims she was benched for “poor preformance”. She states she is working as hard as she can, but has significant fatigue and diaphoresis with exertion. She has also noted heat intolerance, tremulousness and palpitations as well. She denies CP, dyspnea, or lightheadedness with exercise. On PPE several weeks earlier it was noted that she had 4 months of amenorrhea since stopping OCP. Blood work at that time suggested hyperthyroidism.

PHYSICAL EXAMINATION: VSS: 112/68, 70, BMI 23

GENERAL: No acute distress

HEENT: extraocular movements normal, eyelids normal, no proptosis, exophthalmos, lid lag, or diplopia

NECK: full appearance, no palpable masses, nontender, moves easily with swallowing, no bruit

CVS: normal S1 and S2. RRR, no murmurs, rubs or gallops. No carotid bruits

LUNGS: CTA bilaterally, no wheezes, rales, rhonchi

NEUROLOGIC: CN II-XII grossly intact. DTRs were brisk, symmetric with normal relaxation phase, moderate intention tremor

EXT: normal skin, no edema, no muscle tenderness

DIFFERENTIAL DIAGNOSIS:

1. Thyroid disorder (thyroiditis vs hyperthyroidism vs pituitary abnormality)

2. Postviral syndrome

3. Iron deficiency

4. Cardiopulmonary

TEST AND RESULTS: July 2010: TSH <0.005, free T4 1.83, nl FSH, LH, prolactin, progesterone, TPO Ab, thyroglobulin, negative hCG; radionuclide thyroid uptake: normal, mild bilateral thyroid enlargement, no focal hot or cold nodules

Nov 2010: TSH 0.04, T4 18.1, free T4 4.1, ferritin 41.4

Dec 2010: radionuclide thyroid uptake: upper limits of normal at 24 hours, uptake by the isthmus, no hot or cold lesions, mildly diffusely enlarged thyroid

FINAL WORKING DIAGNOSIS: Hyperthyroidism - Graves’ disease

TREATMENT AND OUTCOMES: Started on methimazole. Stopped after 3 months due to elevated LFTs, thrombocytopenia and bleeding gums. Thyroid US and repeat radionuclide uptake scan were abnormal. Patient agreed to radioiodide (I131) ablation. One month s/p ablation continued fatigue with less tremulousness, heat intolerance, and palpitations. Was started on synthroid. Three months later, she felt well overall with excellent exercise tolerance. She had resumed monthly menstrual periods. She returned to starting line up with no current symptoms.

779 MAY 31 8:20 AM - 8:40 AM

Anabolic Rehabilitation to Treat Chronic Anterior Knee Pain Associated with Running

Edward Garay, Gary P. Chimes, FACSM. University of Pittsburgh Medical Center, Piitsburgh, PA.

(No relationships reported)

HISTORY: 31 year old man, past medical history of Osgood Schlatter disease, chronic patellar tendonitis, and a lumbar disc bulge, presented with recalcitrant aching anterior knee pain, present for over one year. He noted progressive limitation with running and squatting activities. Failed prior conservative and surgical management. On initial interview, the patient noted functional goals of increasing his ability to squat, bend his knee and run. He expanded on the history of his low back pain, consistent with L5 and S1 radiculopathy and not symptomatic on evaluation. Clinical screening tool for low testosterone noted a high suspicion.

PHYSICAL EXAMINATION: Large, mesomorphic frame, pleasant demeanor and appropriate affect. No anatomical abnormalities, reciprocal gait with normal base of support and cadence. Full range of the left knee. Tenderness to palpation primarily noted over the patellar tendon. No effusion or erythema. A single left leg stance noted a contralateral trendelenburg sign. Provocative belted squats yielded some improvement in his left knee pain. Negative dural tension tests.

DIFFERENTIAL DIAGNOSIS:

Delayed Healer secondary to low testosterone

Patellar tendinopathy

Chronic subpatellar or pes anserine bursopathy

Lumbar radiculopathy

TEST AND RESULTS:

Vitamin 25-OHD3: 22 ng/ml

Total Testosterone: 95 ng/dl

Free Testosterone: 20 pg/ml

Diagnostic infrapatellar nerve block: No significant pain relief

FINAL WORKING DIAGNOSIS: Delayed healer secondary to low testosterone

Chronic patellar tendinopathy

TREATMENT AND OUTCOMES: - Testosterone Cypionate replacement therapy, 200 mg IM every 2 weeks, remained compliant for full course.

- Cotreatment for Vitamin D insufficiency and home hip extensor and abductor strengthening.

- Progressive improvement in pain, with almost near resolution after fifth treatment.

- Progressive improvement in quality of life, energy level, overall strength, muscle mass, and recovery from exertional activity.

- Increased running distance.

- Adverse reactions included a borderline high hematocrit level, managed with periodic blood donations, no changes in mood or emotional instability.

780 MAY 31 8:40 AM - 9:00 AM

Abdominal Injury - Volleyball: Rectus Abdominis Muscle Tear from Spiking a Volleyball

Amy Yin, Nicholas Muraoka, Joanne Borg-Stein. Harvard Medical School/Spaulding Rehabilitation Hospital, Boston, MA.

(No relationships reported)

HISTORY: A 20-year-old right-handed female college volleyball player noted sharp onset of abdominal pain while spiking the ball during a game. She jumped off the ground and extended her back and had a twinge of left lower quadrant abdomen pain. She was able to finish playing the game and participate in subsequent practice. Two weeks after injury, she asked to be removed from a game because the pain was unbearable. She presented to the sports medicine clinic to be evaluated. She described the pain as sharp and burning, and occurring with lumbar extension and rotation to the right. She denied fevers, chills, nausea, vomiting, bowel or bladder changes, menstrual complaints, numbness, weakness, or radiation of pain.

PHYSICAL EXAMINATION: Exam in the clinic was notable for pain with a sit-up or a double straight-leg raise. She also had tenderness to palpation at the left lower abdomen over Hesselbach’s triangle with an otherwise benign abdominal exam with no palpable mass, guarding, or rebound tenderness. She was in no acute distress and afebrile with stable vitals. She had normal strength, sensation, and reflexes, and had full range of motion of her spine and hips. She was able to toe and heel walk without difficulty, and she could do single leg stance and single leg hops bilaterally.

DIFFERENTIAL DIAGNOSIS:

1. Abdominal muscle strain or tear

2. Herniated disc with referred pain

3. Spontaneous rectus sheath hematoma

4. Intestinal pathologies including hernias or volvulus

5. Kidney pathologies including stones or infection

6. Gynecological pathologies including ovarian torsion or ruptured cysts, endometriosis, ectopic pregnancy

TEST AND RESULTS: Bedside musculoskeletal ultrasound showed a left rectus abdominis muscle tear

FINAL WORKING DIAGNOSIS: Left rectus abdominis muscle tear

TREATMENT AND OUTCOMES: 1. Rest from pain provoking activities including spiking volleyballs but otherwise continue non-aggravating exercises such as passing & setting drills.

2. Followed-up in the student center daily with gradually resolution of symptoms and advance in activity level.

3. Cleared to attempt spiking at 6 weeks post injury with minor initial muscle soreness that resolved.

4. Advanced to full performance in her sport by 7 weeks when she had full painless ROM and baseline strength.

781 MAY 31 9:00 AM - 9:20 AM

Exercise Metabolic Dysfunction and Recovery in a Severe Burn Patient

Inigo San Millan, Matthew Godleski, Gordon Lindberg. University of Colorado School of Medicine, Denver, CO.

(No relationships reported)

HISTORY: A previously healthy 53 year-old recreational cyclist was hospitalized after sustaining a 37% total body surface area burn injury involving the face, back, and all four extremities secondary to a house fire. The burns to the posterior legs and the dorsal hands were full-thickness (damage through the entirety of the epidermis and dermis) and required skin grafting through a twenty four day hospitalization. At two months post-injury he began resuming pre-injury activities such as cycling, running stairs, and weight training and noted issues of early fatigue.

PHYSICAL EXAMINATION: Examination when resuming prior cycling activities demonstrated no focal motor weakness and well-appearing skin grafts to the dorsal hands and posterior legs from ankle to thigh bilaterally with moderate hypertrophic skin healing that improved over time.

Comprehensive physiological testing at 6 and 8 months post-injury showed excessive lactate accumulation, no fat oxidation (FATox), and high carbohydrate oxidation (CHOox) at low exercise intensities. This suggested an exercise metabolic dysfunction and a probable skeletal muscle mitochondrial dysfunction the latter in accordance with a previous report by Padfield et al in rats with burn injuries. An individualized exercise training program was prescribed to elicit a metabolic improvement in substrate utilization and lactate clearance capacity.

DIFFERENTIAL DIAGNOSIS: Exercise metabolic dysfunction

TESTS AND RESULTS: After 6 months of the exercise program significant increases in metabolic capacity at different exercise intensities were observed:

-Significant increase in FATox: 2w/kg (0.0g·min-1 vs 0.37g·min-1) and 2.5w/kg (0.0g·min-1 vs. 0.22g·min-1)

- Significant decreases in CHOox: 2w/kg (3.5g·min-1 vs 2.12 g·min-1) and 2.5w/kg (4.55g·min-1 vs. 3.10g·min-1)

- Significant decreases in Blood Lactate: 2w/kg ( 2.5 mmol·L-1 vs 1.7 mmol·L-1 ) and 2.5w/kg ( 6.9 mmol·L-1 vs. 2.87 mmol·L-1 )

FINAL WORKING DIAGNOSIS: Severe exercise metabolic dysfunction secondary to extensive burn injury that improved after the initiation of a specific exercise program.

TREATMENT AND OUTCOMES: The patient has noticed remarkable progress and improvement in his cycling and continues with the prescribed exercise training program.

782 MAY 31 9:20 AM - 9:40 AM

Chest Pain - Cheerleader

David T. Toturgul1, Jennifer King2. 1Atlantic Sports Health & Morristown Medical Center, Morristown, NJ. 2Kapi’olani Medical Center for Women & Children, Honolulu, HI.

(No relationships reported)

HISTORY: A 17 year old female cheerleader sustained an injury to her chest during a cheer maneuver. While she was spotting a basket toss with her arms outstretched, the flier came down after an airborne twist directly hitting the patient’s sternoclavicular area. She felt a sharp chest pain at the time of injury which subsided as well as deep chest pain made worse with deep inspiration and with moving her arm overhead. There was no numbness, tingling or loss of sensation.

PHYSICAL EXAMINATION: Examination reveals a well-appearing female not in distress. There is no deformity, ecchymosis, erythema or warmth. Palpable tenderness is localized near the sternoclavicular joint without tenderness over the clavicle or manubrium sterni. She has mild swelling over the SC joint area. She has a normal neurovascular exam including strength. Her cervical exam is normal. She is able to forward flex her arm to 160 degrees with pain beyond this range radiating deep into the apical chest area deep to the clavicular region. Remainder of shoulder exam is normal. Special tests including O’Brien’s, Apley’s Scratch Test, and tests for apprehension were unremarkable.

DIFFERENTIAL DIAGNOSIS:

1. SC Joint Sprain or Dislocation

2. Cervical Strain

3. Rib Fracture

4. Costochondritis

5. Labral Injury

TEST AND RESULTS:

Shoulder and clavicle radiographs:

-Normal shoulder.

-Reveals a non-displaced left first rib fracture.

CT Upper Extremity with reconstruction:

-Reveals a non-displaced fracture at midportion of first rib shaft.

FINAL WORKING DIAGNOSIS: Isolated non-displaced first rib fracture

Mild SC joint sprain

TREATMENT AND OUTCOMES:

-Immobilization with figure 8 brace for 4 weeks.

-1 week follow up with improvement of symptoms, no pain or swelling in SC joint. Continued deep apical chest pain with forward flexion of arm beyond 170 degrees. Improvement in deep inspiratory pain.

-5 week follow up radiograph demonstrated callus formation, clinically asymptomatic with painless FROM, gradual progression back to cheer started.

-8 week follow up radiographs demonstrated increased callus formation and she was returned to full Cheer.

783 MAY 31 9:40 AM - 10:00 AM

Immune Thrombocytopenia Purpura (ITP) in a Recreational Runner

Leamor Kahanov, Lindsey E. Eberman, Shaun Grammer. Indiana State University, Terre Haute, IN.

(No relationships reported)

HISTORY: A 23-year-old recreational runner presented to urgent care with complaints of excessive bruising with no related trauma. The patient noticed bruising and red marks on her body increasing over a period of 2-days. Bleeding of the lips and gums also began 2 days prior to the urgent care visit. Patient history indicated no recent illness or stress other than graduate class load.

PHYSICAL EXAMINATION: Skin and mucous membranes demonstrated diffuse petechiae on the calf and hand bilaterally, purpura on the back and shoulders, epistaxis in the nostrils bilaterally, and three bleeding ulcerations on the tongue. The remaining HEENT was unremarkable. Cardiopulmonary, musculoskeletal, neurological, gastrointestinal, and lymphatic systems evaluations were all unremarkable. A complete blood count (CBC) indicated a platelet count of 1 K/mL (normal limits 150 - 450 K/mL). The remaining CBC was within normal limits. PT/PTT were within normal limits.

DIFFERENTIAL DIAGNOSIS:

1. Post-transfusion purpura

2. Inherited non-immune thrombocytopenia

3. Aplastic anemia

4. Type IIB von Willebrand’s disease

5. Malignant lymphoproliferative and myeloproliferative disease

6. Leukemia

7. Human immunodeficiency virus (HIV) infection

8. H. pylori infection

9. Cytomegalovirus (CMV) infection

10. Hepatitis C infection

11. lupus erythematosus (SLE)

12. Drug-induced thrombocytopenia

TEST AND RESULTS: • A complete blood count (CBC) indicated a platelet count well below normal (1 K/mL).

• The remainder of the CBC was within normal limits.

• PT/PTT were within normal limits.

FINAL WORKING DIAGNOSIS:

Immune Thrombocytopenia Purpura (ITP).

TREATMENT AND OUTCOMES:

1. Intravenous immunoglobulin G (IVIG) was initiated.

2. Oral prednisone 80mg daily was also initiated with Protonix 40mg daily to reduce GI irritation.

3. Platelet count responded well initially to the IVIG but did not respond to the prednisone.

4. A splenectomy was scheduled after the patient did not respond to two month of prednisone.

5. The platelet count increased 2 days prior to the scheduled splenectomy and was notably higher 1 prior to the splenectomy (75 K/mL).

6. The splenectomy was canceled, and the patient reached and maintained 150 K/mL. Prednisone was slowly tapered over three months.

7. The patient has experienced no relapse.

C-22 Clinical Case Slide - Neurological Issues

MAY 31, 2012 8:00 AM - 9:40 AM

ROOM: 2005

784 Chair: L. Tyler Wadsworth. St. Louis University, St. Louis, MO.

(No relationships reported)

785 Discussant: Pierre Rouzier, FACSM. University of Massachusetts, Amherst, MA.

(No relationships reported)

786 Discussant: Mark Snowise. Suburban Medical, Lee, MA.

(No relationships reported)

787 MAY 31 8:00 AM - 8:20 AM

Neurologic Disorder - Women’s Soccer

Megan Miller, Robet Monaco, Jason Womack. UMDNJ-Robert Wood Johnson, New Brunswick, NJ. (Sponsor: Margot Putukian, FACSM)

(No relationships reported)

HISTORY: 18 yo soccer player presents complaining of a five year history of dizziness, for which she was previously diagnosed with vestibular dysfunction. She has occasional dizziness throughout the day, but it worsens when she plays soccer. At points, the sensation is described as lightheadedness, and other times as vertigo. She notes “black-out” episodes, where she feels like she loses awareness of a few seconds of play on the field. These “black-out” episodes do not happen outside of soccer play and seem to occur during her menstrual cycle. The frequency of these episodes had been 3-4 times a year, but she recently had 3 episodes in a 1 week time period, prompting her visit. She denies chest pain, palpitations, shortness of breath, syncope, headache, weakness, nausea, tongue biting, or urinary incontinence. PMH: 4 concussions - last 4 months ago for which she had a week and a half of symptoms including headache and dizziness. Meds: Minocycline for acne. No alcohol or drug use. No family history of cardiac or neurologic disease. Previous outpatient records demonstrate an electronystagmography showing possible left vestibular dysfunction and a normal head CT.

PHYSICAL EXAMINATION: BP: 113/67, P: 52

Neuro: PERRL; CN II-XII intact; strength, sensation and reflexes symmetric throughout; negative Dix-Hallpikeg normal cerebellar testing

Cardiac: RRR, no murmurs

Pulm: WNL

DIFFERENTIAL DIAGNOSIS: Vestibular Dysfunction, vertebrobasilar insufficiency, Seizure, Post-Concussive Syndrome

Arrhythmia

Electrolyte Dysfunction

TEST AND RESULTS:

EKG: NSR, rate 67

Brain MRI: Normal

Labs: normal Chem, LFTs, CBC, B12, folate

EEG: Rare suspicious left parietal spikes

3-day video EEG: Epileptic spikes

FINAL DIAGNOSIS:

Catamenial seizures, exercise-exacerbated

TREATMENT AND OUTCOMES: Athlete was held out of activity during work-up. Neurology consult was obtained. After the 3-day video EEG, the patient was placed on oxcarbazepine. She was cleared and allowed to gradually return to full contact over 2 weeks with close monitoring for recurrent symptoms. She continues to follow-up with neurology and the team physicians. A discussion was had with the athlete and her parents regarding her history of multiple concussions and the potential impact of continued participation in soccer and its inherent risk for recurrent head trauma.

788 MAY 31 8:20 AM - 8:40 AM

Pelvic Pain - Non-competitive Female Athlete

Heather L. Grothe, Rob Johnson, FACSM. University of Minnesota, Minneapolis, MN.

(No relationships reported)

HISTORY: A 30 year old female presents to the orthopedic clinic with pelvic pain that had an abrupt onset 1 year ago. Upon returning home from a workout, that included squats, she had pelvic pain and urinary urgency and frequency. Pain and urinary symptoms progressively worsened in frequency and intensity over the course of the year. Pain is described as sharp, stabbing, and shooting. Site of maximum pain is in the pelvis and radiates to the abdomen, low back and groin. Pain is worse with sitting, physical activity, sexual activity and having a full bladder and is relieved with standing or lying down. She came to the clinic with imaging and a working diagnosis of pudendal neuropathy.

PHYSICAL EXAMINATION: Hip Exam: No atrophy, ecchymosis or edema. Full AROM without increased pain. Strength is 5/5 with flexion, extension, abduction, and adduction. Palpation over ischial tuberosity bilaterally produces significant pain. No tenderness over the greater trochanter, anterior superior iliac spine, anterior inferior iliac spine, or pubic symphysis. No tenderness over lumber spine, SI joints, or paraspinal muscles. No pain with FABER or FADIR test. No pain with hip abduction/adduction against resistance. Movements do not produce any radicular symptoms. Sitting produces significant pelvic pain.

DIFFERNTIAL DIAGNOSIS:

1. Strain of hip adductors or hamstring musculature

2. Osteitis pubis

3. Athletic pubalgia

4. Nerve entrapment

TESTS AND RESULTS:

1. MRI of lumbar spine

-Disc dehydration and posterior annular tear at L5-S1. No central canal or neural foraminal stenosis. S1 segment has transitional appearance. Normal alignment

2. MRI of SI joints

- No abnormality of SI joints identified

FINAL WORKING DIAGNOSIS:

Pudendal neuralgia

TREATMENT AND OUTCOMES:

1. 3 bilateral pudendal nerve perineural injections at 4 week intervals.

-Pain down to 0/10 after first injection. Urinary urgency and frequency worsened.

-Less pain relief with subsequent injections. Persistent urinary symptoms.

2. Physical therapy focusing on neuromuscular re-education, manual therapy, and therapeutic exercises

3. Medication: 50 mg amitriptyline daily

4. Modification of daily activities to avoid sitting

5. Patient is having no resolution of symptoms with current treatment and is exploring options for decompression surgery of the pudendal nerve

789 MAY 31 8:40 AM - 9:00 AM

An Unusual Occurrence After a Lateral Ankle Injury

Austen S. Musick, Joel Shaw. Grant Hospital - Ohio Health, Columbus, OH. (Sponsor: Kenneth Cayce, IV, FACSM)

(No relationships reported)

HISTORY: A 34 year-old female sustained a right lateral ankle inversion injury while walking. This injury happened approximately 4 weeks prior to presenting in the office. She continued to have pain in her right lateral ankle with walking, but pain at rest subsided. The patient stated that 3 weeks ago, she had begun to develop numbness over her anterior shin into the dorsum of the foot. She had also experienced weakness in dorsiflexion of her right ankle for the last 3 weeks.

PHYSICAL EXAMINATION: Strength was 5/5 in R ankle except in dorsiflexion. She was unable to dorsiflex actively against gravity, although she was able to hold in dorsiflexion after passive dorsiflexion of the ankle. Small muscle fasciculations were noted with attempted dorsiflexion. There was tenderness to palpation inferior to the medial and lateral maleoli. There was no tenderness to palpation along the proximal fibula and there was a negative proximal squeeze test. Sensation was diminished along anterior shin into the dorsum of the right foot. There was no swelling or bruising noted on exam.

DIFFERENTIAL DIAGNOSIS:

1. Right common peroneal nerve injury

2. Right lateral ankle sprain

3. Right proximal fibula fracture / dislocation

4. Lumbar radiculopathy

TEST AND RESULTS:

1. Xray of Right Tibia/Fibula

-No evidence of fracture or dislocation. Normal Xray.

2. EMG / Nerve conduction study

- Profoundly severe (but still present) right peroneal nerve loss of function

- The superficial branch has a greater degree of loss than the deep branch

3. MRI Right knee

- mild abnormal thickening and edemalike signal involving the common peroneal nerve from the level of the posterior aspect of the fibular head to the fibular neck near the entry of the nerve into the peroneal tunnel. There is moderate abnormal edemalike signal involving the visualized proximal tibialis anterior, extensor digitorum longus and peroneus longus muscles.

FINAL WORKING DIAGNOSIS:

Right peroneal nerve injury

TREATMENT AND OUTCOMES:

1. 9-day prednisone taper without improvement

2. A home program of range of motion exercises progressing to strengthening and proprioceptive exercises without improvement

3. Formal physical therapy program for electrical stimulation and muscle retraining.

4. Currently enrolled in physical therapy and awaiting further follow-up to gauge progress.

790 MAY 31 9:00 AM - 9:20 AM

Charcot Spine in an Elite Paralympic Athlete

Dana H. Kotler, Ellen Casey. Rehabilitation Institute of Chicago, Chicago, IL. (Sponsor: Joel Press, FACSM)

(No relationships reported)

HISTORY: A 27 year-old female with paraplegia due to transverse myelitis, neurodegenerative scoliosis with T12-L4 fusion, competing as an elite wheelchair racer, presented with dull, constant, right-sided lumbar pain for 4 months. Forward flexion, particularly when using her racing wheelchair, exacerbated the pain. She noted grinding sensations, audible cracking with transitional movements, and a loss of power in wheelchair propulsion. Daily meloxicam and a partially rigid lumbosacral orthosis (LSO), worn after training, provided some relief.

PHYSICAL EXAMINATION: Well-nourished female with a well-developed upper body and atrophic lower extremities. L4-S1 spinous processes, zygapophysial (Z-) joints, and paraspinal musculature were tender to palpation, right greater than left. Lumbosacral flexion range was excessive and provoked pain. Extension was moderately restricted, but reduced her pain. Hip range of motion was excessive but non-painful in all planes. Sacroiliac joint provocative maneuvers were non-painful. Sensation was decreased below T10. Lower extremities were hypotonic and areflexic.

DIFFERENTIAL DIAGNOSIS:

Z-joint arthropathy

Lumbosacral Degenerative Disc Disease

Lumbosacral disc herniation

Vertebral fracture

Charcot spine

Spinal infection

Tumor/Metastatic disease

TEST AND RESULTS:

Lumbosacral Xray and CT Lumbar Spine:

Levoconvex scoliosis at L4-5, T12-L4 lateral fusion and vertebral body cages without sclerosis.

Spondylosis and Z-joint arthropathy at L4-5, L5-S1 with R>L sclerosis and hypertrophy.

No evidence of infection, cyst or fistula.

FINAL/WORKING DIAGNOSIS:

Charcot spine

TREATMENT AND OUTCOMES: A treatment plan was designed to decrease pain, facilitate training and competition, with plans for eventual extension of her fusion. Physical therapy focused on extension-biased exercises and core stabilization. Topical agents and right L4-5 and L5-S1 Z-joint steroid injections led to pain reduction for upwards of 9 weeks. Medial branch blocks and radiofrequency ablation were considered for longer-term relief. She was referred to a seating and positioning clinic for wheelchair modifications, and her LSO was modified for use in training and competition. She follows with her team physician and an orthopaedic surgeon, with plans for surgery after the 2012 Paralympics.

791 MAY 31 9:20 AM - 9:40 AM

Head Injury and Anosmia - Swimming

Bradley C. Weinberger, FACSM. Rainbow Babies & Children’s Hospital. University Hospitals Case Medical Center, Cleveland, OH.

(No relationships reported)

HISTORY: 14 year old high school swimmer was evaluated for evaluation of a head injury. Two weeks ago, she slipped and fell on the pool deck, striking the back of her head on the tile surface. She reported 1-2 minutes of post-traumatic amnesia, 5 minutes of retrograde amnesia and no LOC. Immediately following the injury, she experienced multiple symptoms consistent with a concussion, including headache, sensitivity to light and noise, dizziness, nausea, vomiting, trouble falling asleep, feeling in a fog and difficulty concentrating. Following the injury she was transported to the ED where an initial CT was read as normal. She was reevaluated 2 days later after developing multiple bouts of emesis and a repeat CT scan demonstrated a 4 mm punctate focus of hyperdensity in the medial L frontal lobe that was attributed to an intraparenchymal hemorrhage. She was transported to the local children’s hospital and discharged following an uneventful 2-day observation period.

On the day of evaluation, she reported a score of 28 on a standard postconcussion symptom scale. She endorsed 11 symptoms including headache, dizziness, balance problems, sensitivity to light and noise, and difficulty concentrating. She also reported a total absence of smell.

PHYSICAL EXAMINATION: Non-tender cervical spine and surrounding musculature with full, painfree ROM. A&O × 3 with euthymic mood/affect. CN II-XII symmetric and intact, 2 beats of horizontal nystagmus bilaterally. Full strength with normal sensation and reflexes in upper and lower extremities.

SCAT2 Testing: SAC 28. BESS on flat surface - 1 error tandem stance.

DIFFERENTIAL DIAGNOSIS:

Concussion

Cerebral Contusion

Cerebral Hemmorhage

Traumatic Anosmia

Skull Fracture

TEST AND RESULTS: MRI Brain: Hemorrhagic contusions in the medial L frontal lobe, lateral R frontal lobe and inferior frontal lobes.

FINAL WORKING DIAGNOSIS: Cerebral contusion with concussion and secondary anosmia.

TREATMENT AND OUTCOMES:

1. Strict avoidance of physical and cognitive activity..

2. Neuropsychological testing obtained 1 month after injury (while symptomatic) - abnormal.

3. Symptoms abated at rest 7 weeks after injury.

4. Tolerated a graded return to exercise protocol, now swimming competitively.

5. Anosmia has persisted. Guidance to follow weight.

6. Follow up neuropsych testing recommended.

C-23 Clinical Case Slide - Upper Extremity I

MAY 31, 2012 8:00 AM - 10:00 AM

ROOM: 2006

792 Chair: Brent Rich. Utah Valley Sports Med, Provo, UT.

(No relationships reported)

793 Discussant: Jerry W. Hizon. OUCH Sports Medicine Center, Temecula, CA.

(No relationships reported)

794 Discussant: Anastasia Noel Fischer. Nationwide Children’s Hospital, Columbus, OH.

(No relationships reported)

795 MAY 31 8:00 AM - 8:20 AM

A Year Long Case Of Shoulder Weakness And Pain

Ryan Tomlins. Greenville Hospital System, Greenville, SC. (Sponsor: Kyle Cassas, FACSM)

(No relationships reported)

HISTORY: 20 year old right hand dominant student presented to primary care sports medicine for evaluation of right shoulder pain. Patient injured his right shoulder roughly one year ago after he tripped while walking, landing awkwardly on his arm/shoulder. He does remember feeling a pop. It sounds like he may have had a dislocation with spontaneous reduction. Since his initial injury he has experienced continued and progressive shoulder pain, weakness, and numbness of the ipsilateral upper extremity. Symptoms are present both throughout the day and at night. Initial treatment has consisted of chiropractic and NSAID therapy.

PHYSICAL EXAMINATION: Significant atrophy of both supraspinatus and infraspinatus fossa on the right. Scapular winging is noted on the right. There is no limitation of ROM at the shoulder joint on either side. Subjective numbness involving the axillary, median and radial nerve distributions in RUE. Weakness is demonstrated with resisted external rotation and abduction, Strength 4/5 with lift-off test on thr right. Pain is noted with Hawkins and Neer, as well as moving valgus stress of the right shoulder. Negative apprehension. Deltoid strength and function is intact. Normal biceps and triceps strength. Reflexes and pulses normal.

DDX:

1. Suprascapular nerve impingement

2. Rotator Cuff Tear

3. Brachial plexus pathology

4. Thoracic outlet syndrome/Parsonage Turner

TESTS AND RESULTS: Right Shoulder XR

- type II acromion

- normal bony anatomy

MRI

- Moderate atrophy of supraspinatus and infraspinatus

- No evidence of solid or cystic lesion

- Anterior inferior labral tear with associated paralabral cyst formation

- No hill-sachs lesion noted

EMG

-Complete denervation of infraspinatus, decreased amplitude of supraspinatus past suprascapular notch

FINAL WORKING DIAGNOSIS: Right suprascapular nerve entrapment

Treatment and Outcome: Patient was scheduled for arthroscopic suprascapular nerve decompression. He is currently doing well post operatively, engaging in physical therapy to increase muscle strength.

796 MAY 31 8:20 AM - 8:40 AM

Bilateral Wrist And Hand Pain- Hunting, Downhill Skiing

Melissa Knutson. LECOM, Erie, PA. (Sponsor: Patrick Leary, FACSM)

(No relationships reported)

HISTORY: A 36-year-old male downhill skier and bow hunter presented with a history of bilateral hand numbness and tingling for multiple years. His symptoms were more severe in the left hand and involve the middle three digits with a dull ache sensation in his left forearm. These symptoms have been progressing in the past few years and now he has near daily symptoms with occasional weakness. He has tried conventional therapy, including splinting, rest, ice, steroid treatment, and nerve gliding exercises, without relief.

PHYSICAL EXAM: Examination revealed mild weakness with left thumb abduction and decreased sensation over the left median nerve distribution sparing the thenar eminence with no atrophy. Both Phalen and Tinel tests are positive bilaterally. All other muscle testing was normal at 5/5 as well as range of motion and sensation.

DIFFERENTIAL DIAGNOSIS:

1. Neuropathy (median, ulnar, radial)

2. Ganglion cyst

3. Flexor Tendonopathy

TESTS AND RESULTS: Hand x-ray including wrist was negative.

Nerve conduction test- positive median nerve sensory bilateral with left greater than right and positive median motor on left.

FINAL WORKING DIAGNOSIS: Bilateral Carpal Tunnel Syndrome

Treatment and Outcome:The patient was consented for an ultrasound guided hydrodissection of bilateral flexor retinaculums. He tolerated the procedure well with minimal discomfort and stated subjective relief within one hour post procedure. A post procedure nerve conduction test was performed 2 and 6 weeks later with improvements. Patient is currently experiencing no symptoms and has returned to full activity.

797 MAY 31 8:40 AM - 9:00 AM

Shoulder Pain- Football

Katherine Rutherford. Maine Medical Center, Portland, ME. (Sponsor: William Dexter, FACSM)

(No relationships reported)

HISTORY: A 14 year old football player reported a painful bump on his left shoulder. The pain had begun one day prior, immediately after a friend jumped onto this football player’s backpack, carried over his left shoulder. The bump was tender to touch. He had several brief intermittent episodes of tingling down the posterior and ulnar aspect of his arm, with associated numbness of his 4th and 5th digits since the day prior. He denies fevers, night sweats and weight loss. One year prior, he had sustained a Salter-Harris I fracture of his humeral head, and seven months prior, a superiorly angulated, non-displaced mid-shaft clavicle fracture, both of which were reported to have healed normally.

PHYSICAL EXAMINATION: Posture was notable for slight rounding of shoulders. Subtle soft tissue prominence was visible just posterior to medial third of the clavicle, without ecchymosis or erythema. A tender, firm, immobile prominence was palpable in same location, with pressure eliciting localized tenderness as well as tingling in 5th digit. Full range of motion was demonstrated in neck and bilateral shoulders. Strength in left upper extremity was normal. Adson test was positive for diminished radial pulse and tingling in 5th digit. Spurling test elicited no symptoms.

DIFFERENTIAL DIAGNOSIS: 1. Clavicle fracture malunion or refracture2. Bone tumor3. Cervical rib4. Traumatic brachial plexopathy

TEST AND RESULTS: Clavicular anterior-posterior radiographs: Bilateral cervical ribs

FINAL WORKING DIAGNOSIS: Bilateral cervical ribs

TREATMENT AND OUTCOMES: The football player was referred to physical therapy for postural and shoulder girdle strengthening exercises. In retrospect, his mother recalls that he has complained of numbness and tingling in his left arm intermittently for several years, and is therefore seeking surgical consult for his condition. Consult is currently pending.

798 MAY 31 9:00 AM - 9:20 AM

Clavicle Fracture- Longboarding

Christine C. Johnson, Sonal Sodha, Juan Garzon-Muvdi, M.D., Edward G. McFarland, M.D.. Johns Hopkins Medical Institution, Baltimore, MD. (Sponsor: Joe Martire, FACSM)

(No relationships reported)

HISTORY: A 14-year-old male injured his right dominant shoulder after doing a “diving roll off of a longboard at a high rate of speed.” The patient was seen at a local emergency room immediately following the accident and was found to have a displaced right clavicle fracture. Within a week, he was seen by a local orthopedist, who recommended surgical treatment (open reduction and internal fixation), and he presented to our clinic six days later for a second opinion. In the twelve days since the accident, the patient had been wearing a sling to immobilize his shoulder, and his pain had subsided significantly.

PHYSICAL EXAMINATION: The patient was in no acute distress. He had minimal swelling over his distal clavicle, and there was a slight deformity in his acromioclavicular joint area and distal clavicle. He was tender to palpation over his distal clavicle but not elsewhere in his clavicle or shoulder. His shoulder joint motion was congruent, and he had full range of motion of his elbow, wrist, and hand. His neurological and vascular examinations were normal in his upper extremity.

DIFFERENTIAL DIAGNOSIS:

1. Distal clavicle physeal separation

2. Acromioclavicular dislocation

3. Distal clavicle fracture

4. Osteolysis of the distal clavicle

5. Instability of the acromioclavicular joint

TEST AND RESULTS:

Plain radiographs of the clavicle and shoulder showed a right distal clavicle fracture, with superior displacement of the proximal clavicle and an inferiorly displaced distal clavicle fragment approximating the AC joint.

FINAL WORKING DIAGNOSIS: Distal clavicle physeal separation with periosteal sleeve avulsion.

TREATMENT AND OUTCOMES:

1. Informed patient that while fixation of this fracture in adults is controversial, surgical intervention in an adolescent was contraindicated and unnecessary.

2. Recommend use of a sling for comfort only.

3. Range of motion but no strengthening for 6 weeks. Repeat radiographs at 6 weeks showed healing. Limited athletics (running, cycling) allowed until 3 months.

4. Radiographs at 3 months show complete healing with remodeling, and patient returned to competitive athletics with no limitations.

799 MAY 31 9:20 AM - 9:40 AM

Shoulder Pain-weightlifting

Kimberlee Leishear, Gary Chimes. UPMC, Pittsburgh, PA.

(No relationships reported)

HISTORY: 31 year old male amateur bodybuilder presented with a 1 year history of right anterior shoulder pain located 4 cm distal to the bicipital groove that was aggravated by weightlifting. The pain worsened with shoulder internal rotation, adduction, and forward flexion past 90 degrees with elbow flexed and wrist supinated. He had stopped weightlifting for the past 5 months due to the pain. The pain was also limiting him functionally at work as a hairdresser due to using arm positions, particularly sustained forward shoulder flexion, that aggravated his pain, and he had to subsequently decrease his hours at work.

PHYSICAL EXAMINATION: Muscular endomorphic body type with greater development of anterior chain compared to posterior chain. Slightly decreased right pectoralis muscle bulk. Right scapula infero-medial angle prominence. Tenderness at the myotendinous junction of the long head of the biceps, and palpation of the lesser tuberosity mildly reproduced his symptoms. Otherwise normal exam.

DIFFERENTIAL DIAGNOSIS:

1. Long head of the biceps tendinopathy

2. Biomechanics asymmetry with an overdevelopment of his anterior chain and deficiency of his posterior chain

3. Pectoralis major tear, sternal head

4. Labral tear

TEST AND RESULTS:

Shoulder XR: normal

Shoulder MRI arthrogram: anteroinferior labral tear from 3 o’clock to 5 o’clock; mild superior labrum undersurface fraying.

FINAL WORKING DIAGNOSIS:

Long head of the biceps tendinopathy

TREATMENT AND OUTCOMES:

1. Ultrasound guided steroid injection at the myotendinous junction of the long head of the biceps. Other anterior shoulder scanned and nonpainful per sono-palpation. Provided 50% immediate pain relief and 90% pain relief at 1 month post-injection.

2. Physical therapy focusing on scapular rehab.

3. At 1 month follow up, pain was slowly returning to pre-injection level. Recommended a home exercise program focusing on modifications of work environment and posterior chain strengthening, including Good Mornings, Saturday Night Special, Chest Stretch, Low Rows, Supermans, McKenzie Neck Retractions, and Thread-the-Needle. Patient returned 5 months later with significant pain relief and postural improvement. Returned to usual weightlifting routine and resumed a full work schedule.

800 MAY 31 9:40 AM - 10:00 AM

Grip Weakness in a Division I Gymnast

Nahum M. Beard, Jocelyn Gravlee, Michael Seth Smith. UF COM, University Athletic Association, Gainesville, FL.

(No relationships reported)

HISTORY: A 21 year old Division I gymnast presents with left sided grip weakness after beginning an intensive preseason training program with a goal of returning to uneven bars. She spent little time on bars in the past year because of an injury to her right UCL, which required surgery. In addition to increased time on the bars while preparing for the new season, she also focused much of her conditioning on grip strength. Several weeks into her program, as she started to connect moves into a half routine on bars, she began to develop left forearm discomfort, weakness, and fullness. There was no numbness or tingling, but the arm felt weaker the longer her routine became. She also had difficulty catching her release move on bars due to fatigue and weakness in grip strength. Some days she could not hold onto the bar and also had trouble extending her fingers. She has begun to report weakness during daily activities including holding a fork. Training on vault and floor exercises did not exacerbate her symptoms. The athlete reported similar symptoms during her senior year of high school, but her symptoms were mild and improved with massage.

PHYSICAL EXAMINATION: Examination of the left forearm revealed an enlarged tight flexor/pronator mass. Her pulses, sensory and strength testing including an OK sign were normal. There was no medial epicondyle pain or UCL laxity with provocative testing.

DIFFERENTIAL DIAGNOSIS:

1. Strain of Pronator Teres/wrist and hand flexors

2. Mass/neoplasm

3. Compartment syndrome

TESTS AND RESULTS: MRI of the left forearm: Medial epicondylosis and distal stripping of the UCL; no mass or lesion

FINAL WORKING DIAGNOSIS:

Forearm (Flexor/Pronator ) Chronic Compartment Syndrome

TREATMENT AND OUTCOMES:

1. Surgical release was offered but she declined due to the fact that her senior season was to start in 3 months.

2. She has eliminated grip conditioning and simplified her bar regimen by working on individual tricks and forgoing her release move with significant improvement in her symptoms.

3. Acupuncture treatments have improved her swelling for up to 30 minutes after treatment.

4. Final outcome, including her ability to complete a bar routine, is unknown at this point.

D-57 Clinical Case Slide - Cardiovascular Issues

MAY 31, 2012 3:15 PM - 5:15 PM

ROOM: 2005

801 Chair: Warren B. Howe, FACSM. Bellingham, WA.

(No relationships reported)

802 Discussant: Aaron L. Baggish. Massachusetts General Hospital, Boston, MA.

(No relationships reported)

803 Discussant: Steve J. Blivin, FACSM. U.S. Navy, Cedar Point, NC.

(No relationships reported)

804 MAY 31 3:15 PM - 3:35 PM

Recurrent Syncope in an Adolescent Football Player

Mark Riederer, Prince Kannankeril. Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN.

(No relationships reported)

HISTORY: A 17-year-old high school athlete adolescent male is hospitalized overnight after having a syncopal episode. He was “roughhousing” with a few of his friends when he suddenly didn’t feel well and then proceeded to pass out. Two of his friends, trained in cardiopulmonary resuscitation, felt no pulse and performed chest compressions and breaths for about 1 minute until he regained consciousness.

He had two prior episodes of syncope, the first when he was 13-years-old when he collided with another boy while playing lacrosse. He had a very brief loss of consciousness after the hit, and then felt well when he awoke. The second episode occurred one year later while lifting weights he suddenly stood up and lost consciousness. Again after he awoke, he felt relatively well.

He has no other past medical history or surgical history. He plays high school football and club rugby. There is no family history of sudden death or arrhythmia. His mother has had several episodes of syncope with “stress.”

PHYSICAL EXAMINATION: Vital signs: Heart rate 47, blood pressure 122/62. In general, he is awake, alert and well appearing. His breath sounds are symmetric, and clear to auscultation. His heart is regular in rate and rhythm, normal S1 and S2 without murmur or gallop. His abdomen is soft, nontender and nondistended. His strength is normal. There is no clubbing, edema, or cyanosis. He has a nonfocal neurologic examination.

DIFFERENTIAL DIAGNOSIS:

Neurocardiogenic syncope

Long QT Syndrome

Hypertrophic cardiomyopathy

Aortic stenosis

Arrhythmogenic right ventricular cardiomyopathy

Catecholaminergic polymorphic ventricular tachycardia

TEST AND RESULTS:

He had a normal resting electrocardiogram, with a normal QT interval, and normal echocardiogram. An exercise stress test showed bidirectional ventricular tachycardia. An intracardiac electrophysiology study was normal, with no inducible arrhythmias. Resequencing of the cardiac ryanodine receptor (RYR2) gene revealed a nonsynonymous mutation in RYR2 (Arg 15 Pro), a rare variant not previously described in the literature.

FINAL WORKING DIAGNOSIS: Catecholaminergic polymorphic ventricular tachycardia

TREATMENT AND OUTCOMES: He did well on high dose beta-blocker therapy, was restricted from strenuous activity, and is doing well without any further episodes of syncope.

805 MAY 31 3:35 PM - 3:55 PM

Exercise Associated Chest Pain, Dyspnea And Palpitations With Exertion In A Football Player

Colin Conner, Todd Nowlen, Mitchell Cohen, Peter Baron. Arizona Pediatric Cardiology Consultants, Phoeniz, AZ.

(No relationships reported)

HISTORY: A 16 y.o. football player was referred for cardiac evaluation of recurrent episodes of dyspnea, palpitations, lightheadedness and chest pain associated with exertion. The episodes typically occurred following intensive weight training. The symptoms would present as shortness of breath followed by lightheadedness with vision changes followed by crushing left anterior chest pain. The player also related feeling “hot” and occasionally nauseated. The symptoms would resolve with rest. Occasionally, the player would experience rapid palpitations without exertion. No syncope. The symptom would resolve spontaneously within 30 minutes.

PHYSICAL EXAMINATION: Ht. 180.5 cm (82% ile), Wt. 99.9 kg (>95% ile), BMI 31, BP 149/70 mmHg, Pulse 80 BPM; Healthy appearing, lungs clear, CV: quiet precordium, nl S1, S2 no murmur

DIFFERENTIAL DIAGNOSIS:

1. Hypertrophic cardiomyopathy

2. SVT

3. Exercise induced bronchospasm

4. Vasovagal syncope

5. Left anomalous coronary artery

TESTS & RESULTS:

ECG:

1. Normal sinus rhythm

2.No atrial or ventricular enlargement

3.Normal QTc (388 msec)

4.No evidence of WPW pattern

ECHOCARDIOGRAM:

1.Normal cardiac anatomy

2.No evidence of intracardiac shuncting

3.No outflow tract obstruction

4.Normal coronary artery origins

PULMONARY FUNCTION TEST:

1.Post-Exertion:

-FEV1 ↓ 19%

-FEF 25-75% ↓ 39%

STRESS TEST:

1.No tachyarrhythmia or ischemia with exertion

2.Narrow & wide complex tachycardia in recovery without symptoms; spontaneous resolution

FINAL WORKING DIAGNOSIS:

1.Atrial re-entrant tachycardia

2.Exercise induced bronchospasm

3.Hypertension

TREATMENT AND OUTCOME:

1.Verapamil until EP study

2.EP study with 3D mapping & cryoablation

3.Released to resume training

4.Enalapril for HTN

806 MAY 31 3:55 PM - 4:15 PM

Exercise Induced Syncope in a High School Rower

Ryan Foreman1, Mark E. Lavallee, FACSM2. 1Memorial Hospital of South Bend, South Bend, IN. 2Memorial Sports Medicine Institute, South Bend, IN.

(No relationships reported)

Hx: 18 year old female soon to be NCAA Division I rower seen in clinic after three episodes of blacking out and falling off of the ergometer four minutes into timed 2000 meter test. There is a prodrome of tingling in her upper extremities and burning in her lower extremities. The event is followed by 30-60 seconds of tetany and then fatigue as well as being slow to respond verbally though she is awake. She denies shortness of breath, chest pain, tongue biting, tonic-clonic activity, and incontinence. She has a PMH of asthma but has not required albuterol for one year. There is no family history of arrhythmias or sudden cardiac death. She provides a home video of an episode.

PEX: HT 66 in, Wt 152lbs, P 60, BP 117/56 supine, 116/61 sitting, 116/71 standing

G: Alert, NAD

HEENT: normal tonsils/oropharynx, equal pupils

N: no thyromegaly

P: Symmetric chest wall movement, easy effort, clear, normal sounds

CV: RRR with no murmurs

MSK: 5/5 and equal upper and lower strength/tone with R>L hypertrophy of upper trapezius and tight levator scapulae

Neuro: normal DTRs, coordination, sensory, and motor exam

DDx:

1. Seizure/Pseudoseizure

2. Arrhythmia

3. Hypertrophic Cardiomyopathy

4. Performance Anxiety

5. Neurocardiogenic Syncope

6. Vocal Cord Dysfunction

8. Exercise Induced Muscle Injury

9. Lactic acidosis/Rhabdomyolysis

10. Hyperventilation with hypocapnia

11. Cranial Mass

12. Exercise Induced Asthma

Tests:

EKG: Athlete’s heart

Echo, Stress Echo, CT head, MRI head, EEG: Normal

Event monitor, 24 hour video EEG: Normal during recurrence of symptoms

Graded Ergometer stress test with pre and post exercise spirometry: hyperventilation prior to onset of symptoms and paradoxical breathing

Final/Working Dx: Neurocardiogenic syncope secondary to performance anxiety with hyperventilation

TREATMENT AND OUTCOMES:

1. Given Klonopin 0.5mg prn and referral to Sports Psychologist to focus on self-talk, visualization, and breathing control.

2. Referred to Speech Pathologist for teaching of relaxed throat breathing techniques and diaphragmatic breathing and relaxation exercises for head, neck, and torso while rowing.

3. Asymptomatic when distracted by examiner and erg display covered during test. Cleared to play and had no symptoms in the boat (2nd in conference). Symptoms returned only during timed erg test without distraction.

807 MAY 31 4:15 PM - 4:35 PM

Calf Pain - Golf

Aaron E. Bunnell, Mark A. Harrast, Leah G. Concannon. University of Washington, Seattle, WA. (Sponsor: Stanley A. Herring, FACSM)

(No relationships reported)

HISTORY: Previously healthy 49-year-old male presents with right lower extremity pain, cramping and paresthesias. Nine months prior, during a golf outing, he had the onset of right calf cramping. He treated it with 2 months of relative rest, massage, and physical therapy, but symptoms gradually progressed. At presentation he described distal buttock pain radiating into posterior thigh and leg, associated with cramping and non-dermatomal ankle and foot paresthesias. Pain was worst walking up hills. He denied low back pain.

PHYSICAL EXAMINATION: Normal gait. Able to walk on heels and toes. Full strength and normal muscle bulk in bilateral lower extremities. Sensation and deep tendon reflexes normal. Negative Babinski and no clonus bilaterally. Slump and seated and supine straight leg raise negative. Pain not reproduced with palpation, lumbar or hip motion, heel raises or calf stretch. Pedal pulses intact and symmetric.

DIFFERENTIAL DIAGNOSIS:

1. Lumbar Radiculopathy

2. Lumbar stenosis

3. Calf strain/tear

4. Popliteal artery entrapment

5. Peripheral vascular disease

6. Metabolic abnormality

7. Piriformis syndrome

8. Chronic exertional compartment syndrome

TEST AND RESULTS:

1. Right Calf MRI: Normal

2. Lumbar Spine MRI: L5-S1 with circumferential disk bulge and mild right neural foraminal narrowing

3. Post-exercise ankle-brachial indices: Right 0.28, Left 1.26

4. Right Knee MRI/MRA: Multiloculated fluid containing structure encircling the right proximal popliteal artery, causing subtle narrowing

5. Ultrasound: Multilobulated hypoechoic structures without vascular flow causing stenosis of the right popliteal artery

6. Angiography: Narrowing of the proximal popliteal artery

FINAL WORKING DIAGNOSIS: Cystic adventitial disease of the popliteal artery

TREATMENT AND OUTCOMES:

1. Resection of 4 cm of proximal popliteal artery and reconstruction with reversed saphenous vein graft.

2. Formal physical therapy evaluation following surgery.

3. Repeat Ankle brachial indices and doppler ultrasound at 6 weeks and 3 months demonstrated patent popliteal artery bypass graft and normal ankle pressures.

4. Return to full activity by 4 months post-op.

808 MAY 31 4:35 PM - 4:55 PM

Recurrent Post Traumatic Dvt In A Professional Hockey Player

David N. Westerdahl. Cleveland Clinic Florida, Weston, FL.

( D.N. Westerdahl: Honoraria; Ferring Pharmaceuticals.)

HISTORY: 25 y/o Pro hockey player was struck by a puck in the LLE during a playoff game in 5/2009. He noted LLE swelling and localized pain. His LLE pain and swelling resolved with ibuprofen. One month later, he flew home to the Czech Republic and noted worsening LLE edema and pain after his flight. An US was performed by a physician revealing a proximal LLE DVT. He was started on anticoagulation.

He recalled another similar, incident 6 months earlier on his RLE when struck in the right leg by a puck. One week after that injury, he developed RLE ecchymoses, calf swelling, and severe pain. He used ice packs, but didn’t seek medical care. He remembered having right sided pleuritic chest pain and being dx’d with pneumonia a couple weeks later.

PHYSICAL EXAMINATION: BMI 26.83, Ht: 1.81m, Wt 87.9kg, P 50/min, resp 16/min

HEENT: normal

Heart: RRR, no murmurs, gallops

Lungs: symmetric, CTAB, no wheezing or crackles

Extremities: no swelling, no cords, no TTP to LLE and no evidence of post thrombotic syndrome

DIFFERENTIAL DIAGNOSIS:

Thrombophilia

Factor V Leiden mutation

Protein C deficiency

Protein S deficiency

Dysfibrogenemia

Antithrombin deficiency

Prothrombin gene mutation

Vascular endothelial injury

Alteration in blood flow i.e. varicose veins

TEST AND RESULTS:

7/24/09

CBC

WBC 8700

H/H 14.5/41.6

Plt 210K

AT III activity 84.7% (80-120)

10/8/09

CMP: normal except ALT 372 (9-60), AST 128 (10-40)

PCR:

Factor V Leiden mutation: negative

Prothrombin G20210A mutation: negative

Antithrombin activity 99%

Protein S antigen 86%

Protein C Ag 51% (70-140)

DOPPLER US 10/09

Near occlusive clot identified in left popliteal vein. clot is at least 3.3cm in length

3/5/2010

D-dimer <111 (0-200)

F VIII activity 159%

Protein S activity 122%

Protein C antigen = 72% (normal)

Protein C activity = 56% (70-130)

FINAL WORKING DIAGNOSIS: Recurrent DVT with PE due to Protein C deficiency

TREATMENT AND OUTCOMES: 3/10- repeat dopplers negative. anticoagulation was stopped.

12/10- new onset cough and wheezing, no improvement with bronchodilators.

1/20/11- CTA = New PE. Restarted LMWH ->coumadin

2/11 TTE ‘negative for pulmonary HTN’

3/11 Doppler new RT sided DVT (femoral, popliteal, peroneal), and new LT sided DVT (popliteal, peroneal).

4/11- dopplers- clear b/l. IVC filter placed (permanent).

Currently Player uses coumadin out of season, in season is on LMWH regimen.

809 MAY 31 4:55 PM - 5:15 PM

Headache - Football

Michael Seth Smith, Kristy B. Smith, Anthony N. Pass, Sr, James R. Clugston. University of Florida, Gainesville, FL.

(No relationships reported)

HISTORY: An 18-year-old male college football player in his normal state of health was participating in off -season, noncontact, conditioning drills when he suddenly developed a throbbing, posterior headache with associated posterior neck pain. He reported these symptoms to the ATC and was removed from the drills. He continued to complain of a posterior headache and was slightly agitated when evaluated by the team physician. He had used a 5-hour energy drink earlier in the day. Otherwise, he denied any other use of medications, changes in his drills, previous history of headaches, strokes, seizures, weakness, fevers, nausea, vomiting, tingling in arms or legs, or changes in speech or hearing. .

PHYSICAL EXAMINATION: Vital signs stable. Afebrile. Eyes closed due to his severe headache but interactive and cooperative throughout the examination. Cardiovascular and respiratory exam were normal. No head or neck tenderness with palpation. Full range of motion of neck; 5/5 strength in upper and lower extremities bilaterally. Pain with resisted neck extension but not resisted neck flexion. A & O to person, place, and time; normal attention span and concentration; CN II-XII grossly intact including visual fields with confrontation; PERRLA; EOM intact; sensation and DTR symmetric and intact in all four extremities bilaterally; Babinski sign not present; negative Brudzinski and Kernig’s sign; coordination intact. Romberg exam showed no drift. Heal to toe walking was normal.

DIFFERENTIAL DIAGNOSIS:

1. Meningitis

2. Migraine Headache

3. Tension Headache

4. Intracerebral hemorrhage

5. Cervical musculature strain

TESTS AND RESULTS:

Noncontrast Head CT in ED

- Acute intraparenchymal hemorrhage of the right thalamus with intraventricular extension

CTA of the Head on Second Day of Hospital Stay

- Acute intraparenchymal hemorrhage with right thalamic arteriovenous malformation measuring 1.8 cm in diameter

MRA of the Head on Day of Discharge

- Interval decrease in the amount of intraventricular blood compared to CTA

FINAL WORKING DIAGNOSIS

Intracranial Arteriovenous Malformation (AVM)

TREATMENT AND OUTCOMES

1. Stereotactic radiosurgery for treatment of AVM

2. Medical exemption from football this year

3. Currently cleared for weightlifting

4. Discussion with neurosurgery within the next year on return to play options

D-58 Clinical Case Slide - General Medicine III

MAY 31, 2012 3:15 PM - 4:55 PM

ROOM: 2007

810 Chair: Mark Bouchard, FACSM. Maine Medical Center, Portland, ME.

(No relationships reported)

811 Discussant: Morteza Khodaee. University of Colorado Denver, Denver, CO.

(No relationships reported)

812 Discussant: Jon Divine, FACSM. Cincinnati Children’s Hospital, Cincinnati, OH.

(No relationships reported)

813 MAY 31 3:15 PM - 3:35 PM

Exercise Tolerance In Post-Bariatric Lapband Patient

Patti L. Symonette. Health Promotion Institute, Nassau, Bahamas.

(No relationships reported)

HISTORY: A 62 year old female referred for a 12-week nutrition and exercise program pre-bariatric surgery in September 2010. Prior to surgery, patient indicated that she participated in aerobic exercise (elliptical trainer) 7-days/week for 45 minutes. Surgery completed November, 2010. Pre-surgery fitness evaluation was conducted to determine base-line values. Patient was unable to participate in supine floor exercises due to chronic back pain. Patient was on medication for hypertension.

PHYSICAL EXAMINATION: Patient classified as severely obese based on anthropometric measurements as follows: Height: 5ft 3ins. Weight: 241 ½ lbs. BMI: 43.4. %Body Fat: > 58. Total inches (girth measurements): 201.25. BP: 113/74. RHR: 70.

DIFFERENTIAL DIAGNOSIS:

1. Morbid Obesity.

2. Hypertension

TEST AND RESULTS:

Pre-surgery fitness assessment and evaluation based on age and gender as follows:

- A VO2Max score of 30.2 (above average) determined using the Ross Sub-maximal Treadmill Test. The 3-Minute Step Test post-exercise heart rate was 110 bpm (above average).

- Muscular strength and endurance (push-up test): Average - 8 Reps

- Abdominal strength and endurance (curl-up test): Marginal - 12 Reps.

- Flexibility (trunk): Very Poor - 5.5 inches

- Shoulder flexibility: Good - fingers touch.

FINAL WORKING DIAGNOSIS: Morbid obesity with limited range of motion and overall poor muscular strength and endurance.

TREATMENT AND OUTCOMES:

1. Started structured exercise program 4 weeks post-bariatric surgery incorporating cardiovascular and strength training five days a week.

2. Aerobic exercise at 60% - 75% of VO2Max for 45 - 60 minutes using heart rate monitor.

3. One (1) year pos-bariatric surgery patient has significantly improved exercise tolerance and fitness level.

- Jogging one half mile at 5.2mph.

- Muscular strength and endurance (push-ups): Excellent ->20 reps.

- Abdominal strength and endurance (curl-up ): Excellent - >30 reps.

- Flexibility (trunk flexibility - sit and reach): Average - 15 inches.

- Shoulder flexibility: Good - fingers can touch (on both sides).

1. Weight one year post-surgery 156 lbs.

2. Patient discontinued hypertension medications.

3. Significantly improved self-esteem.

4. Patient making healthier dietary choices.

814 MAY 31 3:35 PM - 3:55 PM

Improvement in Exercise Capacity following Coronary Revascularization.

Brad Lee Gliha. William Beaumont Hospital, Royal Oak, MI. (Sponsor: Barry A. Franklin, FACSM)

(No relationships reported)

HISTORY: A 50-year-old male presented with dyspnea and exertional chest pain. He underwent a stress echocardiogram which revealed marked ST-segment depression and anterior wall hypokinesis. The patient was referred for coronary angiography and possible intervention. Cardiac catheterization indicated obstructive coronary artery disease: LAD 70% stenosis, mid-to-distal region, 20% stenosis in the mid-RCA, LCX 20% stenosis in the proximal region. Following percutaneous coronary intervention (PCI) and symptom-limited treadmill testing (GXT) with myocardial perfusion imaging (MPI) the patient entered exercise-based phase II/phase III cardiac rehabilitation (CR).

PHYSICAL EXAMINATION:

Variable/Date (post PCI): 03/09, Body mass index (BMI) = 24.3 (kg/m2); Blood pressure (BP) = 150/80 mmHg; Heart rate (HR) = 64 bpm; 04/10, BMI (NA); BP = 154/88 mmHg; HR = 43 bpm; 04/11, BMI =20.7 kg/m2; BP = 128/80 mmHg; HR = 43 bpm.

DIFFERENTIAL DIAGNOSIS:

1. Myocardial ischemia

2. Unstable angina

TEST AND RESULTS:

MPI (GXT) (post PCI): 03/09, (-) test; Ejection fraction (EF) = 71%; Peak BP = 178/82 mmHg; Peak HR =168 bpm; ECG - Unremarkable; Estimated peak metabolic equivalents (METs) = 9.3; 04/10, (-) test; EF = 67%; Peak BP = 218/106 mmHg; Peak HR = 170 bpm; ECG - Unremarkable; Estimated peak METs = 18.4; 04/11, (-) test; EF = 71%; Peak BP = 206/100 mmHg; Peak HR = 171 bpm; ECG - Unremarkable; Estimated peak METs = 20.1.

FINAL WORKING DIAGNOSIS: Coronary artery disease

TREATMENT AND OUTCOMES: Over a 2-year period, the patient made significant lifestyle changes including: adoption of a primarily plant-based diet; regular exercise-based CR and physical conditioning at home. His exercise program included: 45-60 min of aerobic exercise 3 to 5 days a week and resistance training twice a week for 45 min. He was able to discontinue his cholesterol medication after 2 months, reduce BP medications after 12 months, and decrease his BMI to 20.7 kg/m2. Moreover, he doubled his exercise capacity from 9.3 to 20.1 METs! The most recent lipid profile (with the patient no longer taking a statin) revealed: total cholesterol (146 mg/dL); triglycerides (140 mg/dL); HDL-cholesterol (45 mg/dL); and, LDL-cholesterol (73 mg/dL). The patient’s risk factor profile and cardiorespiratory fitness are highly compatible with a reduced risk of future coronary events.

815 MAY 31 3:55 PM - 4:15 PM

Is it Wolf Parkinson White or Not - FBS College Football Player

Steven E. Martin, John S. Green, FACSM, Kory Gill, Brad Lambert, Jon Oliver, Katie McCammon, Justin Dobson, Stephen F. Crouse, FACSM. Texas A&M University, College Station, TX. (Sponsor: Stephen F. Crouse, FACSM)

(No relationships reported)

HISTORY: A 19 year old African American male underwent a physical examination for football participation at a FBS school. He is 189.2 cm tall, weighs 117.2 kilograms. He has a history of exercise induced asthma and his medications include ProAir, an albuterol sulfate based beta-2 agonist and Delsum, a cough suppressant containing dextromethorphan . No observable symptomology was noted.

PHYSICAL EXAM: Physical examination revealed a resting blood pressure of 128/88 and a standing pre-exercise pressure of 130/90. A 12-lead ECG was obtained from the subject. Examination of the ECG yielded a heart rate of 75, no discernable rhythm disturbances, an axis of approximately 70 degrees, a PR-interval of exactly .12 seconds, A QRS interval of .11 seconds, a QT interval of .40 seconds, no signs of left or right atrial enlargement, voltage criteria for left ventricular hypertrophy (Sv3 +Rv5=53mv), and no signs of ischemia or infarction. However, a small delta wave was present . This, in conjunction with a PRI of .12 seconds, cast suspicion on the presence of Wolf Parkinson White syndrome.

DIFFERENTIAL DIAGNOSIS: 1. Normal ECG variant 2. Unconventional pre-excitation syndrome

TESTS AND RESULTS: The patient was referred to an electrophysiologist who subjected the patient to an adenosine challenge test. No antegrade accessory pathways were discovered and it was concluded that no pre-excitation was present. The patient subsequently underwent symptom limited maximal graded exercise testing; achieving a peak heart rate of 204, a peak blood pressure of 206/86 and a maximum oxygen consumption of 30 ml/kg body weight/minute. No ECG abnormalities were noted during testing.

FINAL WORKING DIAGNOSIS: Normal ECG variant

TREATMENT AND OUTCOMES: The patient was ordered to continue on his usual medications and no additional treatments were ordered.

816 MAY 31 4:15 PM - 4:35 PM

Non-Obstructive Coronary Artery Disease with Ischemic Dilated Cardiomyopathy

Aashish S. Contractor, Shraddha M. Khialani, Hetal D. Poptani, Anjali S. Zende, Priyanka M. Mehta. Asian Heart Institute, Mumbai, India.

(No relationships reported)

HISTORY: A 35- year- old male, had sudden onset of chest discomfort associated with perspiration and dyspnea at rest. On being taken to the hospital he was diagnosed with Anterior Wall Myocardial Infarction (AWMI) [ECG- ‘qS’ and ST elevation V1- V5, Left Anterior Fascicular Block, raised cardiac markers] and was thrombolysed with streptokinase. His angiography suggested Non-Obstructive Coronary Artery Disease and 2 D Echo showed reduced EF (30-35%). He had a strong family history, a smoker then, dyslipidemic, non-diabetic, non-hypertensive. He was advised medical management and lifestyle modification. After about a year the patient complained of decreased activity levels, dyspnea- NYHA Class II-III, and sudden increase in weight. He complained of bloated sensation around the abdominal region and bilateral ankle swelling.

TEST AND RESULTS:

2 D Echo- Hypokinetic LV apex, distal antero-lateral and inferior wall, dilated left ventricle and left atrium, reduced LVEF- 15%. Moderate Pulmonary Hypertension- 50 mmHg. Moderate mitral regurgitation.

Coronary Angiography- LMCA: 20% plaque, LAD: Type III artery, 40% plaque in mid segment, Lcx: 40% plaque in mid segment. RCA: normal

USG Abdomen showed massive free fluid in abdominal and pelvic regions and minimal gall bladder thickening.

FINAL WORKING DIAGNOSIS: Non-Obstructive Coronary Artery Disease with Ischemic Dilated Cardiomyopathy.

TREATMENT AND OUTCOMES: Medicines: Frusemide, Spironolactone, Aspirin, Clopidogrel, Carvedilol, Ramipril, Atorvastatin, Multivitatims.

External Counter Pulsation (ECP) and Cardiac Rehabilitation (CR): Patient underwent 35 sessions of ECP treatment, over a period of six weeks. The patient simultaneously also participated in 4 weeks- 13 sessions of cardiac rehabilitation wherein he performed low to moderate intensity aerobic and resistance exercises under ECG telemetry monitoring.

Advised to consider heart transplantation in the future.

OUTCOMES:

6 Minute Walk Distance- Pre- 260 meters, Post- 340 meters.

Ejection Fraction- Pre- 15%, Post- 25%

NYHA Scale- Pre- II-III, Post- I

Currently the patient is continuing with cardiac rehabilitation sessions, has resumed his work and reports improved quality of life.

817 MAY 31 4:35 PM - 4:55 PM

Acute Corticosteroid-Induced Rhabdomyolysis - Golf Player

Christa Janse van Rensburg1, Willem Theron2. 1University of Pretoria, Pretoria, South Africa. 2Private Practice, Pretoria, South Africa.

(No relationships reported)

HISTORY: A 27-year old professional golf player complained of neck- and back pain suggestive of an inflammatory arthropathy. Symptoms included morning stiffness and polyarthritis which responded to anti-inflammatory drugs. He also had a family history of rheumatoid arthritis.

PHYSICAL EXAMINATION:On examination his Schober test and chest expansion was more than 5cm, but he had a positive FABER test and was tender on his sacro-iliac joints and thoracic spinous processes. He had no synovitis of peripheral joints. His systemic examination was normal.

DIFFERENTIAL DIAGNOSIS:

1. Spondylarthropathy

2. Mechanical neck and back pain

3. Overuse injury

TESTS AND RESULTS:

Full blood count: Normal

Erythrocyte Sedimentation Rate: 2mm/hr

C-Reactive Protein: 2mg/l

HLA B27: Negative

Rheumatoid Factor: Negative

Anticitrillunated peptide antibodies: Negative

Bone Scan: low grade inflammatory changes in the superior part of the SI-joints; no increased uptake in spine or peripheral joints.

Neck radiograph: Torticollis

Thoracic Spine radiograph: Kyphosis

Lumbar Spine radiograph: Slight degeneration of the L5/S1 facet joints

WORKING DIAGNOSIS: Because these tests were inconclusive the patient was admitted and treated with high dose cortisone in order to evaluate the effect - inflammatory back pain usually clears up with cortisone treatment; albeit temporarily. The next day the patient complained of generalized myalgia and stiffness. A CK level was elevated to 1568 IU/liter and the myoglobin 448 mg/ml. All other possible causes were excluded:

1. The patient denied:

- Changes in exercise program

- Use of drugs e.g. statins / colchisine

- Use of nutritional supplements

- Exposure to toxins e.g. snake venom

- Phosphate: normal

2. Magnesium: normal

3. Thyroid: normal

4. Electrolytes: normal

5. Metabolic myopathy: history and clinical course not supportive

The following day the CK was 4609 IU/liter and the myoglobin 1566 mg/ml. The patient was treated with intravenous fluid, Sodium Bicarbonate and Mannitol to prevent renal failure. In the meantime the cortisone treatment was stopped.

After two days the CK level dropped to 3301 IU/liter and the myoglobin to 129 mg/ml.

FINAL DIAGNOSIS: Acute steroid-induced rhabdomyolysis.

D-59 Clinical Case Slide - Lower Extremity III

MAY 31, 2012 3:15 PM - 5:15 PM

ROOM: 2016

818 Chair: Stephen M. Simons, FACSM. Saint Joseph Regional Medical Center, South Bend, IN.

(No relationships reported)

819 Discussant: Jeffrey M. Anderson, FACSM. University of Connecticut, Storrs, CT.

(No relationships reported)

820 Discussant: Scott A. Paluska, FACSM. OAK Orthopedics, Urbana, IL.

(No relationships reported)

821 MAY 31 3:15 PM - 3:35 PM

Are Fundamental Movement Patterns Meaningful In Identifying Patients At Risk For Sustaining A Second ACL Tear?

Robert J. Butler, Boyi Dai, Michael P. Reiman, William E. Garrett, FACSM, Robin M. Queen. Duke University, Durham, NC.

(No relationships reported)

HISTORY:A 17-year-old elite female gymnast who sustained an anterior cruciate ligament (ACL) tear of her right knee during competition. The patient landed awkwardly during a tumbling routine, twisting her knee. A pop was felt, followed immediately by swelling in the knee. The patient was 17 months removed from a prior ACL reconstruction on the contralateral limb. For her prior surgery, she was discharged from rehabilitation 6 months post reconstruction with documented symmetrical single hop distance.

PHYSICAL EXAMINATION: Clinical examination revealed minimal effusion in her involved right knee. Range of motion on the involved side was 0 to 120 degrees. Pain was produced with end-range flexion and extension. No instability was detected with varus and valgus stresses. Anterior drawer and Lachman’s tests were positive.

DIFFERENTIAL DIAGNOSIS: No fracture or dislocation was evident. Magnetic resonance imaging confirmed ACL tear without meniscal damage. Bone bruising on the tibia and femur was also evident.

TEST AND RESULTS: (5 months prior to second tear, 12 months following first ACL reconstruction):

Functional Movement Screen

- Total Score = 15

- Number of Asymmetries = 1 (Shoulder Mobility)

Lower Quarter Y-Balance Test (YBT-LQ)

- Composite Score = Left : 98.83 % leg length (LL), Right: 101.7 %LL

- Reach Asymmetries = Anterior : 0.5 cm, Posteromedial: 0.5 cm, Posterolateral : 7.5 cm

Move2Perform Summary (Injury Risk Algorithm software)

- Moderately Increased Injury Risk

Motion Analysis

- 13.0 degree increase in Hip Internal Rotation on the Right Side during Deep Squat

- 3.3 degree increase in Knee Flexion on the Right Side Deep Squat

- 33% increase in Vertical Impulse on the Right Side during Stop Jump Landing

FINAL WORKING DIAGNOSIS: ACL tear indicating appropriateness of surgical reconstruction.

Patient exhibited fundamental movement limitations prior to injury that may have increased the risk for a second ACL tear.

TREATMENT AND OUTCOMES:

1. Surgical reconstruction of ACL

2. Revised return to competition criteria

- Composite FMS score of 17 with a 3 on the Deep Squat and In-line Lunge

- Normalize Asymmetry on YBT-LQ posterolateral reach

- Perform single leg hop, triple hop and triple cross-over hop to examine symmetry (values need to be within 5% with side-to-side comparison)

822 MAY 31 3:35 PM - 3:55 PM

Foot Pain - Cross Country Runner

Nicole K. Huntress, Kyle J. Cassas, FACSM. Steadman Hawkins Clinic of the Carolinas, Greenville, SC. (Sponsor: Del Bolin, FACSM)

(No relationships reported)

HISTORY: A 13-year-old female cross-country runner presented to clinic with bilateral foot pain for one year. Pain had an insidious onset and is localized primarily to the medial aspect of the left foot. She feels this pain almost exclusively while active and is relatively pain-free at rest. It is not associated with swelling, bruising, radiation, or sensory changes. She wears supportive running shoes and has been gradually progressing in her training. Possible associated prior injuries include jumping into a shallow pool causing brief pain in both ankles. No night pain, fever, or systemic complaints.

PHYSICAL EXAMINATION: Inspection revealed normal arches, mild pronation of left greater than right, and a prominent left navicular. FROM with good strength. Resisted inversion is painful on the left. Tenderness was elicited with palpation of the left posterior tibialis tendon and navicular. Bilateral heel cords and hamstrings were tight as well as right hip flexors and quadriceps. Core strength appeared weak with single leg stance, squatting, and side-lying hip abduction. Right foot non-tender. No swelling, ecchymosis, or erythema. Neurovascularly intact.

DIFFERENTIAL DIAGNOSIS:

1. Symptomatic accessory navicular

2. Stress fracture/reaction

3. Posterior tibialis tendonitis

4. Reflex sympathetic dystrophy

TEST AND RESULTS:

Anterior-posterior, lateral, and oblique bilateral foot radiographs

- accessory navicular on left, open physes, no fracture or other abnormality

MRI left foot

- extensive patchy marrow edema of tarsal bones, accessory navicular

MRI right foot

- extensive patchy increased marrow signal of hindfoot and midfoot

Labs:

- Normal: CBC, CMP, Magnesium, Phosphorus, ESR, CRP, Ferritin, Iron, Total Iron Binding Capacity, Reticulocyte, TSH

- Vitamin D low at 29.8

Bone density scan

- lower limits of normal, 0.841 to 0.957gm/cm3, z-score -0.6 to -0.9

FINAL WORKING DIAGNOSIS: Painful Bone Marrow Edema Syndrome

TREATMENT AND OUTCOMES:

1. Activity as tolerated, ice afterward

2. Orthotic shoe insert

3. Physical therapy for flexibility, core and ankle strength

4. Short cam walking boot on left, 1 week

5. Nutrition evaluation

6. Short leg cast on left, short cam walking boot on right, crutches, 6-8 weeks

823 MAY 31 3:55 PM - 4:15 PM

Knee Pain- Resolved by Barefoot Running Pattern

Kristen Schuerle, Gary Chimes. UPMC, Pittsburgh, PA.

(No relationships reported)

HISTORY: A 25 yo police officer presented with left medial knee pain more bothersome with running that started after training for the police academy. He was evaluated by orthopedic surgery and treated for patellofemoral chondrosis with corticosteroid and Euflexxa injections. These helped with pain initially, but he presented to Sports Clinic with continued pain and difficulties with performing work duties.

PHYSICAL EXAMINATION: No significant tenderness to palpation over the inferior pole of the knee, the patellar ligament, the anterior aspect of the medial joint line, or the pes anserine. Tenderness over the middle portion of the medial joint line. Single leg balance is decreased bilaterally. Single leg squats show no fatiguing of the quadriceps, but decrease in balance. No ligamentous laxity of the MCL or LCL. Negative Lachman. Evaluated running barefoot in the hallway and he had a prominent heel strike with increased stride length. He modified his running posture by shortening his stride length and using a midfoot strike rather than a heel strike. He reported significant improvement, although it was fatiguing muscles he was not used to using.

DIFFERENTIAL DIAGNOSIS:1.Patellofemoral Syndrome

2. Abnormal Running Mechanics

3. Medial Meniscus Tear

TEST AND RESULTS:

MRI Knee: Tear in the posterior horn of the medial meniscus, subchondral defect. ACL reconstruction unremarkable. PCL intact.

Diagnostic Ultrasound: Patellar ligament is normal without any evidence of heterogenous signal. No osteophytes noted or enthesopathy noted at the insertion at the patellar ligament onto the tibial tuberosity. Medial collateral ligament appears normal. There is some mild tenderness elicited along the femoral aspect of the patellar ligament, but no abnormality in tissue quality noted. The medial meniscus did have some degeneration of signal, but did not have pain through sonopalpation.

FINAL WORKING DIAGNOSIS: Abnormal Running mechanics in setting of medial meniscal injury

TREATMENT AND OUTCOMES:

1.Running modifications. Softening stride, shortening the stride length and having a more midfoot strike. (A barefoot running pattern)

2.Infrapatellar nerve block at initial visit provided 100% relief.

3.At 6 week follow-up the patient was back to his regular exercise routine and returned to the demands of work with 100% pain relief

824 MAY 31 4:15 PM - 4:35 PM

One-Year Strength Recovery of the Triceps Surae in a Female Runner After Tendon Injury

Brenda Benson, Aaron W. Johnson. Brigham Young University, Provo, UT. (Sponsor: Allen Parcell, FACSM)

(No relationships reported)

HISTORY: A 25 year old female runner suffered a partial Achilles’ tendon laceration

PHYSICAL EXAMINATION: To track rehabilitation of strength and endurance for 1 year, baseline evaluations (4 weeks post-surgery) included Ultrasound imaging (USI) of the tendon at the calcaneal insertion and injury area to measure scar tissue and edema, visual analog scale (VAS), lower extremity functional index (LEFI), and isokinetic measures of plantar and dorsiflexion force (ISOK).

DIFFERENTIAL DIAGNOSIS: A partial Achilles’ tendon laceration with triceps surae strength loss.

TEST AND RESULTS: After initial data collection, therapeutic ultrasound (TU) at 3MHz 1.0W/cm2 for 3.5 min was administered 5 days/week for 2 weeks, along with theraband exercises. Then the tests were administered again, the subject increased rehabilitation to strengthening the injured leg and resumed running. A third measurement was taken 4 weeks later, along with the first ISOK measurement. The runner continued building mileage in a modified marathon training schedule, and doing calf raises 2×/week in the weight room. After the marathon, the runner maintained training by preparing for a half marathon and an olympic triathlon. Pre and post marathon measurements were taken, as well as final measurements 1 year after injury. Results show that pain completely disappeared before the marathon, but post marathon VAS measured pain of 15mm on a 100mm scale. Pre marathon LEFI score was 77/80, with a 15% decrease after the marathon. Pre marathon ISOK tests showed a right leg deficit of 25% and 9% for plantar and dorsiflexion, respectively. Final ISOK results report a deficit of 16% and 6% respectively, compared to the left side. USI show a 42% decrease in tendon thickness from initial to final measurement with a final thickness of .49cm compared to .44cm for the left tendon. An increase in tendon thickness was observed in pre and post marathon measurements, likely due to volume of running.

FINAL WORKING DIAGNOSIS: Final measurements 1 year to date of injury and 8 months after the marathon show complete disappearance of pain, full recovery of LEFI, but not a full recovery of strength.

TREATMENT AND OUTCOMES: It appears that a vigorous training schedule with supplemental resistance training for 1 year restores all functional movement but may not completely restore strength loss.

825 MAY 31 4:35 PM - 4:55 PM

Painless Ankle Swelling - Running

Melody R. Hrubes1, Terry L. Nicola, FACSM2. 1Schwab Rehabilitation Hospital, Chicago, IL. 2University of Illinois at Chicago, Chicago, IL.

(No relationships reported)

HISTORY: A 44 year old previously obese male runner, diagnosed with right calcaneal body stress fracture three weeks prior, returned to clinic complaining of painless right ankle swelling. When diagnosed with stress fracture, he had been given a prescription for a walking boot and compression stockings, but did not obtain the compression stockings. He was also placed on toe touch weight bearing status with the aid of crutches. He stated that swelling was worse at the end of the day but would improve with right lower extremity elevation. Past exercise history includes running for two years. He worked up to two half marathons in the past year and prior to his stress fracture he was participating in a marathon training program and had reached the 20 mile run (during mile 19 his stress fracture symptoms appeared and he had not run since).

PHYSICAL EXAMINATION: Moderate swelling of the right foot and ankle compared with the left. No swelling above the ankle. Negative Homan’s sign, no cords palpated in the right calf. No erythema or pitting edema. No pain with range of motion of the ankle. Dorsalis Pedis and Posterior Tibialis pulses palpable (2+).

DIFFERENTIAL DIAGNOSIS:

1. Dependent edema

2. Deep vein thrombosis

3. Swelling secondary to immobilization

TEST AND RESULTS:

Right Lower Extremity Venous Duplex Scan: Total occlusion of both gastrocnemius veins, soleal vein and one posterior tibial vein in the right calf. The remaining vessels imaged appear patent.

FINAL WORKING DIAGNOSIS: Painless, non-tender right lower extremity deep vein thrombosis

TREATMENT AND OUTCOMES:

1. Sent directly to Emergency Room and educated self-administration of Fragmin, also started on Coumadin.

2. Referral and appointment scheduled with Coumadin Clinic

3. Prescription for compression stockings

826 MAY 31 4:55 PM - 5:15 PM

Foot Pain - Basketball

Aaron Yang, Joseph Ihm. Rehabilitation Institute of Chicago, Chicago, IL.

(No relationships reported)

HISTORY: A 37 year old male developed right medial foot pain after playing basketball. He was moving laterally to his right when he tried to cut back to his left and experienced sharp pain along the medial part of his proximal right foot under his medial malleolus. Pain was rated 2/10 in intensity. He noticed that his pain was exacerbated with running and reported that his foot would feel tired and sore after walking. He did note on occasion that he did have tingling along the medial aspect of his foot whenever he would bend over and tie his shoe. Of note, he stated that he wears custom orthotics for flat arches of both his feet since the 8th grade.

PHYSICAL EXAMINATION: Examination revealed normal gait but he reports reproduction of his pain with heel off during his gait cycle. Standing exam showed pes planus bilaterally. Strength in bilateral lower extremities was normal with no pain elicited with resistance to posterior tibialis, flexor digitorum longus, and flexor pollicis longus. Sensation and reflexes were symmetric and intact. There was focal tenderness along his right medial foot around the area of the sustentaculum tali and just superiorly to this area. There was minimal swelling in the area of pain with no erythema or warmth. He denied any tenderness to palpation along posterior tibialis. Bilateral subtalar joint motion was decreased. He did have reproduction of his pain with passive subtalar inversion on the right.

DIFFERENTIAL DIAGNOSIS:

1. Subtalar (talocalcaneal) joint osteoarthritis

2. Tarsal coalition

3. Sustentaculum tali fracture

4. Posterior Tibialis tendonopathy

5. Ligament sprain (Tibiocalcaneal, Plantar calcaneo-navicular, Medial talocalcaneal)

6. Tarsal tunnel syndrome

TEST AND RESULTS:

X-ray of the Right Foot (AP/Oblique/Lateral):

- Prominent spur along dorsal aspect of the talar dome/neck junction

- Subtalar joint spaces are indistinct, cannot rule out coalition

- No acute fracture or dislocation

FINAL WORKING DIAGNOSIS: Right subtalar joint osteoarthritis

TREATMENT AND OUTCOMES:

1. Trial 1 week of anti-inflammatory medication - i.e. Naproxen twice a day

2. Ice could be applied to the affected area 15 minutes at a time

3. Call 1-2 weeks later regarding progress; if no improvement then physical therapy vs. further imaging would be pursued

4. Stated he had appointment for new orthotic fitting within 1 week

E-17 Clinical Case Slide - Foot and Ankle

JUNE 1, 2012 9:30 AM - 11:30 AM

ROOM: 2014

827 Chair: John Hatzenbuehler. Maine Medical Center Sports Medicine Program, Portland, ME.

(No relationships reported)

828 Discussant: Patrick Leary, FACSM. LECOM, Erie, PA.

(No relationships reported)

829 Discussant: Nailah Coleman. Children’s National Medical Center, Alexandria, VA.

(No relationships reported)

830 June 1 9:30 AM - 9:50 AM

Heel Pain in a Novice Marathon Runner

Douglas A. Pepple. University of Illinois at Chicago, Chicago, IL. (Sponsor: Terry L. Nicola, FACSM)

(No relationships reported)

HISTORY: A 44 year old male novice runner presented with acute right heel pain for 5 days. He was training 30 miles per week for his first marathon, was on his first 20 mile run, and at 19 miles felt sharp 8/10 pain at the right lateral heel and had to stop. No swelling or ecchymosis was noted. He hobbled for a day. Two days later he tried to run but stopped after 100 meters. He went to a PT center, who advised that he seek MD care. At our clinic, he reported his pain had gradually improved to a mild ache, but with toe-off phase of walking his pain was 7/10. His past history was notable for obesity and inactivity, but he lost weight and exercised with personal trainers for the past 2 years, working up to 2 half marathons in the past year. He denied any prior history of foot, ankle, knee, hip or back problems.

PHYSICAL EXAMINATION: No swelling, bruising, or erythema. No pain with walking or heel walking. Pain with toe walking. Severe pain four steps into a running gait. No hallux valgus or varus, no genu valgum or varum. Tenderness at the lateral aspect of the right calcaneus. Talar tilt and anterior drawer negative. Normal dorsalis pedis and posterior tibial pulses. Lower extremity strength 5/5 bilaterally. Pain with resisted ankle plantarflexion.

DIFFERENTIAL DIAGNOSIS:

1. Calcaneal stress fracture

2. Plantar fasciitis

3. Peroneus tendinosis

4. Talar osteochondral lesion

5. Unicameral bone cyst

6. Improper shoe fitting

7. Talon noir

TEST AND RESULTS: Right foot X-rays were unremarkable. Right foot MRI was notable for a grade 3 calcaneal neck-body stress fracture, perpendicular to the cortex and posterior to the superior facet.

FINAL WORKING DIAGNOSIS: Calcaneal neck-body stress fracture, grade 3 by MRI.

TREATMENT AND OUTCOMES:

1. The patient was immobilized in a walking boot with compression stockings, with toe touch weight bearing status and follow up in 6 weeks.

2. After 2 weeks, the patient reported painless calf swelling, which was diagnosed via Doppler the same day as DVT. He was started promptly on anticoagulation for at least 6 months.

3. At 6 weeks follow-up, the patient felt much better, but CT showed persistent stress fracture. Immobilization was continued, bone stimulator was started, and partial weightbearing was allowed to be continued.

4. At most recent visit, DEXA scan showed osteopenia. The patient was sent to endocrinology through his PCP.

831 June 1 9:50 AM - 10:10 AM

Medial Foot Pain- Runner

Levi Miller, Daniel Colonno, Mark A. Harrast. University of Washington, Seattle, WA.

(No relationships reported)

HISTORY: A 27 year-old recreational runner presented to our sports medicine clinic with four months of medial foot and ankle pain following eversion ankle sprain. Initial injury was accompanied by swelling and impaired weight-bearing tolerance. Initial x-rays were negative for fracture. She continued to have medial foot and ankle pain and swelling which improved over the first month, but then plateaued. The swelling resolved with time, but she noticed a significant prominence at her right medial foot. She also continued to have medial foot and ankle pain, particularly when standing for prolonged periods of time. She is a runner and previously ran 10Ks three to five times a week. At the time of presentation, she found that any significant running caused her pain, and she was unable to continue.

PHYSICAL EXAM: Strength and sensation intact except for very mild weakness of inversion at the right ankle. Significant pes planus bilaterally, accentuated on the right. Prominent navicular in her right medial arch that was slightly mobile, but not significantly tender to palpation. Remainder of foot and ankle examination was normal.

DIFFERENTIAL DIAGNOSIS:

-Posterior tibialis tendinopathy

-navicular stress fracture

-accessory navicular

-deltoid ligament injury

-osteochondral lesion

-spring ligament injury

TESTS AND RESULTS: -3 view XR bilateral foot: planovalgus alignment right greater than left. Accessory navicular vs. avulsion fracture vs. effect of posterior tibialis tendon injury.

-MRI right foot and ankle: Pseudoarthrosis at accessory navicular with bone marrow edema.

FINAL WORKING DIAGNOSIS: Type 2 accessory navicular with fracture injury through cartilaginous synchondrosis

TREATMENTS AND OUTCOMES:

-Six weeks in walking boot

-Physical Therapy once out of walking boot and pain free

-In-shoe orthotics

-Patient able to gradually return to running following these interventions

832 June 1 10:10 AM - 10:30 AM

Foot And Ankle Pain-Dancing

Thurman V. Alvey, III. LECOM, Erie, PA. (Sponsor: Patrick F. Leary, FACSM)

(No relationships reported)

HISTORY: A 27-year-old female dancer presented with a 3 year history of chronic intermittent right foot and ankle pain. She is unsure of any event or accident leading to her symptoms. She has no history of fractures and no other medical problems. She has previously undergone x-ray evaluation of her ankle that was normal. Pain is increased with any type of weight bearing activity.

PHYSICAL EXAMINATION: Examination of the right foot and ankle revealed significant tenderness without deformity to the navicular bone with radiations through the midfoot and talus. There was moderate tenderness to talonavicular and tibionavicular ligaments with associated soft tissue swelling, but without appreciable laxity. Active dorsiflexion of the ankle was guarded, but passive dorsiflexion was normal. Active range of motion to ankle was 20° to dorsiflextion, 40° to plantar flexion, 40° to inversion, 20° to eversion. Gait was antalgic. Neurological exam was normal.

DIFFERENTIAL DIAGNOSIS:

1. Stress fracture of navicular bone.

2. Acute on chronic sprain of navicular ligaments.

3. Navicular cyst or tumor.

4. Osteochondral defect to talus.

5. Tibials posterior enthesopathy

TEST AND RESULTS: Foot and ankle weight-bearing anterior-posterior and lateral radiographs:

-large cystic structure encompassing majority of navicular bone without fracture; no other similar findings to the other bones of foot or ankle

CT scan with 3D reconstruction of foot: cyst in the lateral aspect of the navicular bone

WORKING DIAGNOSIS: Navicular cyst

TREATMENT AND OUTCOMES:

1) Immobilization with boot.

2) Non-weight bearing.

3) Referral for surgical evaluation by orthopedic foot and ankle

833 June 1 10:30 AM - 10:50 AM

Foot Injury Football

Ji Sun Lee. St. Vincent Health Center, Erie, PA.

(No relationships reported)

HISTORY: A 17 y/o high school football player sustained left foot injury while trying to strip a ball from an opponent player 3 days prior to the office visit. He loaded his weight on his foot with his foot dorsiflexed and hyperextending his toes. He felt a “pop” on dorsal aspect of his foot. He has swelling and bruising but no numbness or tingling sensation. The pain is worse with weight bearing and is ambulating with crutches. X-ray done 2 days prior was negative for any fracture or joint space widening.

PHYSICAL EXAMINATION: Foot exam revealed moderate amount of redness and swelling on dorsum of forefoot area. Tenderness on proximal aspect of first and second metatarsals. Ankle ROM limited on dorsiflexion and plantarflexion. Pain on midfoot area on weight bearing.

DIFFERENTIAL DIAGNOSIS:

1. Lisfranc injury

2. Foot sprain

3. Metatarsal fracture.

TESTS AND RESULTS: Foot 3 view: Negative for fracture or joint space widening.

MRI: Severe bone contusion, likely fracture impaction, along the proximal lateral cortical margin of the 1st cuneiform, marrow edema and possible micro-impaction at the distal articular surface of the navicular. Abnormal signal at the level of the Lisfranc joint.

CT: Lisfranc joint injury with diastasis. Comminuted fracture through the base of the 1st cuneiform, small avulsion fracture of the 2nd metarsal base.

FINAL /WORKING DIAGNOSIS:

Lisfranc fracture dislocation

TREATMENT AND OUTCOMES:

1. Long posterior foot splint and no weight bearing until seen by orthopedic surgeon.

2. ORIF by orthopedic surgeon.

3. Non weight bearing short leg cast for 4 weeks

4. Long weight bearing cast for 6 weeks.

5. Out of football for the rest of the season.

834 June 1 10:50 AM - 11:10 AM

Ankle Injury-running

Elizabeth Nguyen, David Lin. New York Presbyterian Hospital/Columbia-Cornell, New York, NY.

(No relationships reported)

HISTORY: An 82-year-old active male presented to rehabilitation clinic with worsening right heel pain for 6 months. He exercises and runs on a regular basis. The pain was localized to his right heel and described as an intermittently throbbing and sometimes sharp sensation. Pain is exacerbated with weight-bearing and improved with rest. Ibuprofen and ice therapy provide moderate pain relief. He denied accompanying numbness, tingling or weakness. On initial exam, the right heel appeared swollen, strength was intact throughout and the patient was able to heel and toe walk. He was diagnosed with Achilles tendonitis and prescribed an anti-inflammatory medication and physical therapy, as well as advised to modify his activities. He returned three months later with worsening pain in the same region. He had continued to jog during this interval time period.

PHYSICAL EXAMINATION: Examination revealed swelling and tenderness in the region of the right Achilles tendon without ecchymosis. Active right ankle range of motion was decreased with regard to plantarflexion. Thompson’s test was positive. The patient was unable to toe or heel walk on the right side. Right plantarflexion strength was decreased. Sensation was normal throughout. Reflexes were normal and symmetric.

DIFFERENTIAL DIAGNOSIS:

1. Haglund’s deformity

2. Achilles tendon rupture

3. Calcaneal fracture

TEST AND RESULTS:

MRI of the right ankle without contrast:

-Diffuse Achilles tendon thickening and edema

-Complete tear at the musculotendinous junction approximately 7.2cm from the superior aspect of the calcaneus with a gap distance of 4.5cm

FINAL WORKING DIAGNOSIS: Complete Achilles tendon rupture

TREATMENT AND OUTCOMES:

1. Orthopedic surgery recommended non-surgical management

2. Advised to immobilize right ankle with controlled ankle motion (CAM) walker for a short duration of time

3. Initiated physical therapy early and as tolerated within limits of pain, with focus on progressive range of motion, stretching and strengthening exercises

4. Gently eased back into light exercise and daily activities

5. Recovered right plantarflexion strength, achieved painless weight-bearing and resumed jogging at 1-year follow-up

6. MRI re-imaging at 1-year post-injury demonstrated complete interval healing of the previously seen complete tear of the Achilles tendon

835 June 1 11:10 AM - 11:30 AM

Novel and Successful Approach to Chronic Heel Pain in a Runner

Eugene Hong, Jocelyn Ricasa. Drexel University, Philadelphia, PA.

(No relationships reported)

HISTORY: A 50-year-old competitive runner with right Achilles tendon pain for 5 years, with increasing severity over the last 2 years. Previously his training included running 30 miles per week and competing in several marathons each year. Presently, the pain has limited weekly mileage to 4 miles, and his pace is severely limited by his symptoms. He only competes in 5km distance races at a very slow pace and with pain. His pain is dull and achy, worse with walking and running. He has daily stiffness and pain with activities of daily living. He has tried rest, oral anti-inflammatory medications, and physical therapy including eccentric strengthening with no improvement in his pain or dysfunction. His goal is to return to running without pain and at a reasonable pace.

PHYSICAL EXAMINATION:

• Palpable focal thickening and tenderness of the right Achilles tendon 2 cm proximal to calcaneal insertion

• Full active range of motion painless of right ankle

• Non-tender calf muscles, retrocalcaneal space, medial & lateral malleoli, midfoot and forefoot

• Thompsons, calcaneal squeeze, syndesmosis stress, anterior drawer and talar tilt tests negative

DIFFERENTIAL DIAGNOSIS:

1. Achilles tendinosis

2. Partial rupture of Achilles tendon

3. Achilles peritendinitis

TEST AND RESULTS:

Musculoskeletal ultrasound of the right Achilles tendon demonstrated changes within the anterior tendon consistent with tendinosis: neovascularization, tendon thickening, disorganization of fibers, and hypoechoic areas. There were no calcifications, full thickness or partial tears, or masses.

FINAL WORKING DIAGNOSIS: Chronic Achilles tendinosis

TREATMENT AND OUTCOMES: • Ultrasound-guided percutaneous needle tenotomy with 3 cc of platelet-rich plasma injection followed by immobilization in a fracture boot for 2 weeks

• 2 weeks post procedure: repeat ultrasound demonstrates improved collagen organization

• 6 weeks post procedure: athlete reports ability to walk without pain, and ultrasound demonstrates decrease in neovascularization and hypoechoic areas within the tendon

• 10 weeks post procedure: athlete is running 5km distances with hills, with no pain and at an improved speed; physical exam notable for visible decreased thickening of tendon with corresponding decrease in measurement on ultrasound

E-18 Clinical Case Slide - Muscle Issues

JUNE 1, 2012 9:30 AM - 11:30 AM

ROOM: 2016

836 Chair: Pierre d’Hemecourt, FACSM. Children’s Hospital of Boston, Harvard University, Boston, MA.

(No relationships reported)

837 Discussant: Joseph Ihm. Rehabilitation Institute of Chicago, Chicago, IL.

(No relationships reported)

838 Discussant: Monica Rho. Rehabilitation Institute of Chicago, Chicago, IL.

(No relationships reported)

839 June 1 9:30 AM - 9:50 AM

Acute Corticosteroid-Induced Rhabdomyolysis - Golf Player

Christa Janse van Rensburg1, Willem Theron2. 1University of Pretoria, Pretoria, South Africa. 2Private Practice, Pretoria, South Africa.

(No relationships reported)

HISTORY: A 27-year old professional golf player complained of neck- and back pain suggestive of an inflammatory arthropathy. Symptoms included morning stiffness and polyarthritis which responded to anti-inflammatory drugs. He also had a family history of rheumatoid arthritis.

PHYSICAL EXAMINATION: On examination his Schober test and chest expansion was more than 5cm, but he had a positive FABER test and was tender on his sacro-iliac joints and thoracic spinous processes. He had no synovitis of peripheral joints. His systemic examination was normal.

DIFFERENTIAL DIAGNOSIS

1. Spondylarthropathy

2. Mechanical neck and back pain

3. Overuse injury

TESTS AND RESULTS

Full blood count: Normal

Erythrocyte Sedimentation Rate: 2mm/hr

C-Reactive Protein: 2mg/l

HLA B27: Negative

Rheumatoid Factor: Negative

Anticitrillunated peptide antibodies: Negative

Bone Scan: low grade inflammatory changes in the superior part of the SI-joints; no increased uptake in spine or peripheral joints.

Neck radiograph: Torticollis

Thoracic Spine radiograph: Kyphosis

Lumbar Spine radiograph: Slight degeneration of the L5/S1 facet joints

WORKING DIAGNOSIS: Because these tests were inconclusive the patient was admitted and treated with high dose cortisone in order to evaluate the effect - inflammatory back pain usually clears up with cortisone treatment; albeit temporarily. The next day the patient complained of generalized myalgia and stiffness. A CK level was elevated to 1568 IU/liter and the myoglobin 448 mg/ml. All other possible causes were excluded:

1. The patient denied:

- Changes in exercise program

- Use of drugs e.g. statins / colchisine

- Use of nutritional supplements

- Exposure to toxins e.g. snake venom

1. Phosphate: normal

2. Magnesium: normal

3. Thyroid: normal

4. Electrolytes: normal

5. Metabolic myopathy: history and clinical course not supportive

The following day the CK was 4609 IU/liter and the myoglobin 1566 mg/ml. The patient was treated with intravenous fluid, Sodium Bicarbonate and Mannitol to prevent renal failure. In the meantime the cortisone treatment was stopped.

After two days the CK level dropped to 3301 IU/liter and the myoglobin to 129 mg/ml.

FINAL DIAGNOSIS: Acute steroid-induced rhabdomyolysis.

840 June 1 9:50 AM - 10:10 AM

Bilateral Upper Extremity Swelling Following Upper Body Workout

Cory Bergman, Morteza Khodaee, John C. Hill, FACSM. University of Colorado Denver, Denver, CO.

(No relationships reported)

HISTORY: A 32 year old Caucasian female presents with bilateral arm swelling 4 days following an intense upper body workout. The workout was supervised by a personal trainer and consisted of several dynamic upper body exercises, including pull ups. The patient was “out of shape” at the time of the workout. Her arm swelling began two hours post workout and progressed over the following three days. She noted limited elbow range of motion and stiffness due to swelling, dull achy pain and slight tingling in her hands. Her history reveals a few episodes of mild swelling, localized to her shoulders, following previous workouts.

PHYSICAL EXAM: BP126/75, HR 67, T 36.9°C, RR 16, Ht 163cm, Wt 58kg, BMI 21.9kg/m2. Bilateral diffuse non-pitting edema extending from midupper arm to midforearm which was more pronounced in the right side. No elbow joint effusion. Bilateral elbow range of motion was normal with the exception of a mild decrease in flexion in the right side. Upper extremity deep tendon reflexes 2+. Elbow flexion and extension strength 5/5. No skin discoloration or skin warmth noted.

DIFFERENTIAL DIAGNOSIS

• Cellulitis

• Exertional rhabdomyolysis

• Necrotizing fasciitis

• McArdle disease

• Hypothyroidism

• DVT

• Dermatomyositis

• Thoracic Outlet Syndrome

TESTS AND RESULTS: Office-based ultrasound revealed no elbow joint effusion, however interstitial edema and thickening above the musculature was noted. Muscle fibers appeared unremarkable.

Chest X-rays, CBC, ESR, CRP, ANA, and TSH were unremarkable. Comprehensive metabolic panel (including renal function) was unremarkable except elevated AST and ALT (360U/L and 103U/L respectively). Office urine dipstick was unremarkable. Microscopic urinalysis was unremarkable except for the presence of trace blood. Creatine kinase was 21,300 U/L.

FINAL WORKING DIAGNOSIS: Exertional rhabdomyolysis without kidney injury.

TREATMENT AND OUTCOME: The patient was followed over the course of three weeks, with special attention paid to kidney function. Her condition was self-limiting with CK levels falling to 3,997U/L within four days and returning to normal ranges within 10 days of presenting to the clinic. Her symptoms also improved and all lab values normalized over the course of 10 days. She gradually eased back into normal daily function and exercise and has not had an exacerbation since.

841 June 1 10:10 AM - 10:30 AM

Seizure and Leg Injury: Hiker

Jennifer Schwartz, FACSM1, Pierre Rouzier2, John Herbert Stevenson1. 1University of Massachusetts Primary Care Sports Medicine, Fitchburg, MA. 2University of Massachusetts Amherst, Amherst, MA.

(No relationships reported)

HISTORY: 20 year-old marching band member hiked 12 miles in 100-degree weather through Grand Canyon, drinking 6 liters of water. At mid-point, feels tired and dizzy. Nausea, vomiting developed. Friends noticed him staggering, acting odd. Finished hiking, suffered a tonic-clonic seizure.

Med-flighted to hospital. Found to be severely hyponatremic and with mild rhabdomyolysis. In ICU and intubated for 3 days. Clinical picture and labs improved.

Suddenly, on day 3, creatine kinase rose dramatically without explanation. Extremity exam initially normal. Over 6 hours, left lower extremity edema developed. Within 12 hours, tenderness and tautness noted over anterior and lateral leg. Taken to the operating room.

PHYSICAL EXAMINATION:Examination of left lower leg on day 3 revealed 2+ soft tissue edema and erythema. Tense, painful to palpation anteriorly and laterally. Full passive range of motion of ankle and toes. Could not actively dorsiflex ankle, extend great toe. 0/5 strength with these. Sensation intact. Trace dorsalis pedis pulse

DIFFERENTIAL DIAGNOSIS:

1. Acute Compartment syndrome

2. Rhabdomyolysis due to hyponatremia, seizure or muscle overuse

3. Deep vein thrombosis

4. Arterial thrombosis

5. Infection with abscess

TEST AND RESULTS: LABS:

Initial Na: 121

Initial CK: 3130

Peak CK: 81642

COMPARTMENT TESTING (mmHg):

Anterior: 95

Lateral: 42

Deep/superficial posterior: 35/22

LOWER EXTREMITY DOPPLER ULTRASOUND: no DVT

HEAD CT: no acute abnormality

INTRAOPERATIVE EXPLORATION:

-Anterior compartment with areas of grey, necrotic muscle tissue >90% anterior tibialis, 100% extensor hallicus longus

-Lateral compartment muscules healthy

FINAL WORKING DIAGNOSIS:

1. Acute anterior and lateral compartment syndrome of left lower extremity with necrotic anterior compartment musculature

2. Secondary to rhabdomyolysis due to hyponatremia vs seizure vs muscle overuse

3. Hyponatremic seizure

TREATMENT AND OUTCOMES:

1. Left lower leg anterior and lateral compartment fasciotomies with debridement of necrotic anterior tibialis and extensor hallicus longus.

2. Began physical therapy at 3 weeks.

3. Cannot actively dorsiflex ankle, extend great toe. Wears a spring loaded brace to assist with this.

4. After 3 months, progressed back to full activities including hiking, marching band, running (with brace).

842 June 1 10:30 AM - 10:50 AM

Calf Pain - Womens Soccer

Matthew D. Sedgley. University of Maryland, Baltimore, MD.

(No relationships reported)

HISTORY: A 21-year-old senior collegiate woems’s soccer player performed calf raises of 85 pounds for 10 repitions and for 3 sets. She experienced cramping pain in her legs that were severe enough to require admission to the ER. Dehydration was diagnosed. She was discharged after IV hydration resolved problems. Ten months later the same symptoms returned after only performing 10 calf raises of 75 pounds.

PHYSICAL EXAMINATION: Examination showed tender calf muscles bilaterally, reflexes and strengthen were normal. Skin and mucous membranes were dry.

DIFFERENTIAL DIAGNOSIS:

1.Strain of calf muscles

2. Vascular claudication.

3. Neuropathic disease of spine.

TEST AND RESULTS: Creatinine 2.6

Urinalysis showed myogobinuria.

LFT elevated.

Nerve conduction studies: normal

Muscle biopsy abnormal.

FINAL WORKING DIAGNOSIS: McCardle’s Disease

TREATMENT AND OUTCOMES: Initial treatment was to treat rhabdomyalysis with IV hydration. After acute renal impairment was resolved, patient clear to exercise supervised. Diet was modified with B6 supplementation and nutritional supplements with sucrose prior to exercise.

843 June 1 10:50 AM - 11:10 AM

Bilateral Arm Pain After Workout

Andrew Sturm. North Shore University Hospital, Manhasset, NY.

(No relationships reported)

HISTORY: A healthy 26 year old male was evaluated in the emergency department because of pain and swelling of the upper extremities. The pain, currently 8/10, started after a 2 hour bicep and triceps exercises two days earlier. The pain is described as tightness, and is associated with diffuse upper extremity swelling. There is no relief with NSAIDs or acetaminophen. He denies any numbness, tingling or temperature complaints to the limbs. He has no past medical or surgical history, takes no medications and has no allergies to medications. In addition he denies use of alcohol, tobacco, or drug use.

PHYSICAL EXAMINATION: Patient is alert and oriented in no acute distress. Triage vital signs noted blood pressure, heart rate, respiratory rate and temperature to be 142/93, 74, 16, 98.30F, respectively. The heart has normal rate and rhythm and examination of the lungs and abdomen is unremarkable. On neurologic examination, cranial nerves are intact and there is 5/5 bilateral upper and lower motor with intact sensation and coordination. Musculoskeletal exam is remarkable for bilateral swelling from the deltoid region to the elbow. There is tenderness on palpation of the biceps and triceps bilaterally. Although, there is worsening pain with flexion, extension and supination at the elbow the patient is able to fully range both upper extremities. Pulses and capillary refill are normal.

DIFFERENTIAL DIAGNOSIS:

1. DVT

2. Muscle Strain

3. Muscle tear

4. Compartment syndrome

5. Exertional Rhabdomyolysis

TEST AND RESULTS:

1. Laboratory Tests: CBC, SMA-20, creatinine phosphokinase, magnesium, phosphorus, and urinalysis: CK was 280,720 U/L and aspartate aminotransferase (AST) were alanine transaminase (ALT) were 2796 U/L and 755 U/L, respectively. Urinalysis was remarkable for large blood.

2. Bilateral Upper Extremity Duplex: Negative for vein thrombosis

FINAL WORKING DIAGNOSIS: Exertional Rhabdomyolysis

TREATMENT AND OUTCOMES:

1. Vigorous IV hydration started in the Emergency Department

2. Admission to the medical ICU for continued hydration with alkaline dieresis

3. Serial monitoring of CK, AST,ALT, and urine output

4. Patient gradually improved over while inpatient with reductions in the CPK, AST and ALT.

5. He was discharged from hospital after 2 weeks, and is followed by medicine and nephrology physicians.

844 June 1 11:10 AM - 11:30 AM

Whole-Body Muscle Cramps in a Young Tennis Player

Roxanna M. Amill-Cintrón, Anita M. Rivera-Brown, FACSM, José R. Rodríguez-Santana, William F. Micheo, FACSM. Center for Sports Health and Exercise Sciences, University of Puerto Rico School of Medicine, San Juan, Puerto Rico.

(No relationships reported)

HISTORY: A 17 year-old tennis player, with unremarkable medical history, presented to our sports medicine clinics 2 weeks after suffering whole body muscle cramps during a 2-day tournament in a hot and humid climate. The first day he played a 3-set singles match at 10 am. That night he felt cramps in his right anterior thigh after receiving a therapeutic massage. The next day he played another 3-set singles match from 9 am to 12 pm, without any symptoms. From 1-2:30 pm he played another 2-set, singles match. He drank a few bottles of water. At 3 pm, he began warming up for the third match of the day and felt muscle cramping on his left thigh after a serve. A massage was given but symptoms progressed to whole-body muscle cramps. He collapsed and after a few seconds was fully alert. He was taken to ER, where IV hydration was given. Vital signs, including oral temperature and CBC were normal, and he was discharged.

PHYSICAL EXAMINATION:A complete physical examination at our sports medicine clinic was normal.

DIFFERENTIAL DIAGNOSIS:

1. Dehydration associated muscle cramps

2. Hypoglycemia

3. Heat illness

TEST AND RESULTS:

In ER: CBC, BMP and ECG were normal. Blood glucose=75 mg/dL; blood Na+= 139 mmol/L.

Two days after discharge from ER: Urinalysis negative. Slightly increased CPK 461.5 U/L. CBC normal. One week later CPK was normal (255 U/L).

Two weeks after discharge from ER: Heat Tolerance Test (1 hr running in 29°C, 59% RH): Sweat rate=1.7 L/h; Sweat [Na+] = 2,093 mg/L (91 mmol/L); % dehydration= 1.1%; Highest Tc= 38.9 °C, Cystic Fibrosis genetic screening for ΔF508 mutation confirmed heterozygous presence of the ΔF508 mutation in exon 10 of the CFTR gene.

FINAL WORKING DIAGNOSIS: Generalized skeletal muscle cramping associated to hyponatremic dehydration that could be related to CFTR gene mutation. Further workup recommended included standardized sweat test with pilocarpine iontophoresis and full gene analysis for cystic fibrosis.

TREATMENT AND OUTCOMES:

1. IV hydration at ER and discharge the same day.

2. Recommendations about proper hydration, electrolyte supplementation, and heat acclimatization were given according to sweat test results.

3. Referred to counseling by a pediatric pulmonologist expert in CF.

4. Patient has continued playing at the national level, consuming sports drinks + sodium, without any other incidents reported.

E-19 Clinical Case Slide - Pediatric Issues

JUNE 1, 2012 9:30 AM - 11:30 AM

ROOM: 2020

845 Chair: Holly J. Benjamin, FACSM. University of Chicago, Chicago, IL.

(No relationships reported)

846 Discussant: Angela D. Smith, FACSM. Children’s Hospital of Philadelphia, Bryn Mawr, PA.

(No relationships reported)

847 Discussant: Brooke Pengel. Rocky Mountain Hospital for Children, Aurora, CO.

(No relationships reported)

848 June 1 9:30 AM - 9:50 AM

Pediatric Knee Injury - Soccer

Mohammed Mortazavi, Rachel A. Coel. University of Colorado at Denver and Health Sciences Center, Aurora, CO. (Sponsor: John Hill, FACSM)

(No relationships reported)

HISTORY: A 10 year old female was playing soccer on a wet grass field when she slipped while running, falling onto her right hip with her right knee hyperflexed beneath her. She felt a pop and developed immediate pain, swelling, and bruising over the right knee. She was unable to return to standing or bear weight on her right leg. She was taken to a local emergency department, where she continued to have right knee pain, inability to extend at the knee or flex the right hip. X-rays and an MRI were obtained and she was subsequently referred to a large regional children’s hospital for definitive diagnosis and treatment.

PHYSICAL EXAMINATION: The patient was unable to bear weight on the right leg. On inspection, she had large swelling with hematoma over the right anterior knee. The patella appeared proximally displaced. Palpation revealed a large knee joint effusion with tenderness over the inferior pole of the patella. The collateral ligaments and joint line were nontender. She had full range of motion of the right ankle but inability to extend at the knee from a seated position and inability to straight leg raise in supine with hip flexion against gravity. Her neurovascular exam was unremarkable. No special maneuvers were performed due to pain and signs of significant knee injury.

DIFFERENTIAL DIAGNOSIS:

Sindig-Larsen-Johanssen disease

Bipartite patella

Quadriceps tendon rupture

Patellar fracture

TEST AND RESULTS: X-ray Right Knee 4 Views: Significantly displaced inferior pole of the patella avulsion fracture and notable patella alta. Bony fragments present anterior to the femoral condyles. Large joint effusion.

MRI Right Knee Without Contrast: Avulsion fracture of inferior patellar pole involving the origin of the patellar tendon with associated patella alta. Large joint effusion. Small anterior medial femoral condyle bone contusion. Intact cruciate and collateral ligaments and menisci.

FINAL WORKING DIAGNOSIS: Patellar sleeve avulsion fracture

TREATMENT AND OUTCOMES: Knee immobilizer brace, nonweightbearing, orthopedic surgery referral

Next day: Open reduction internal fixation of right patella with patellar advancement and patellar tendon and retinacular repair. No complications.

Post-operative: Knee braced in extension at all times with weightbearing as tolerated.

Follow-up pending at 4 weeks post-operative.

849 June 1 9:50 AM - 10:10 AM

Not a Simple Nursemaid’s Elbow

Matthew Leiszler1, Aaron Provance2. 1University of Colorado, Denver, CO. 2Children’s Hospital Colorado, Denver, CO. (Sponsor: John Hill, FACSM)

(No relationships reported)

HISTORY: A two year old male presented to the emergency department four hours after a fall onto an outstretched left arm. He complained of pain in the wrist and elbow and decreased range of motion. Per ED notes, he was tender to palpation over the left forearm, with mid-forearm swelling but no elbow swelling. X-rays were read as distal radius buckle fracture with nursemaid’s elbow. Attempt was made to reduce the presumed subluxation of the radial head. He was placed in a posterior long-arm splint for follow up. He was seen in our pediatric sports medicine clinic 4 days later. History revealed that he had fallen from a bunk bed at 5-6 feet. He continued to have decreased use of the arm due to pain.

PHYSICAL EXAMINATION: Examination of the left upper extremity reveals soft tissue swelling over the wrist and elbow. The distal radial metaphysis and radial head are both tender to palpation. Range of motion of elbow is limited to 100 degrees flexion and 10 degrees extension. Supination and pronation causes pain over the radial head region.

DIFFERENTIAL DIAGNOSIS: Distal radius buckle fracture with Nursemaid’s elbow (radial head subluxation)

Distal radius buckle fracture with Monteggia fracture (dislocation of the radial head with ulnar fracture)

Distal radius buckle fracture with history of congenital dislocation of radial head

TESTS AND RESULTS: X-rays of the wrist and elbow reveal a distal radial buckle fracture, non-displaced, non-angulated, and plastic deformity fracture of the midshaft of the ulna with radial head dislocation.

FINAL/WORKING DIAGNOSIS:

Monteggia fracture involving plastic bowing deformity/fracture of the mid shaft ulna with radial head dislocation and buckle fracture of the distal radius, initially thought to be a nursemaid’s elbow.

Treatment: Upon recognition of the radial head dislocation-Monteggia fracture, the patient was referred to the ED for reduction of the radial head with conscious sedation. He was then placed in a long-arm cast in full supination for 4 weeks, and then posterior splint with activity for an additional 2 weeks.

Outcome: At the time of cast discontinuation, the patient continued to have stable ulnar fracture with normal alignment of radial head confirmed on radiographs. Patient has had a full recovery at this time.

850 June 1 10:10 AM - 10:30 AM

Exercise Fatigue- Physical Education Class

Lauren M. Simon, FACSM. Loma Linda University Medical Center, Loma Linda, CA.

(No relationships reported)

HISTORY: 12 year old female middle school student noticed she was having trouble keeping up with the other students when running in physical education class .She felt tired, a little breathless and thought her hands were a bit shaky. Additional symptoms were 5 pound weight loss in past 3 months ,emotional lability and trouble sleeping. She had recent headache with 1 episode of vomiting after PE class but no visual change. Although she denied fever she described feeling hot at night and having occasional feeling of fast heart rate worse with running but no chest pain.No diarrhea or abdominal pain; no sore throat or cough;no muscle or joint aching . PMH :Kawasaki’s disease age 5.

PHYSICAL EXAMINATION: Ht:147.8cm( 16.7%tile), Wt 39.6kg (29%tile) BMI=18kg/m2. T 97.9F; P 124; RR 22, BP130/74, Pulse oximetry 98%. HEENT: revealed no exopthalmos or lid lag, PERRLA; TMs clear;nose no discharge or erythema;throat no erythema,eyes and mouth were moist; neck: no thyroid masses,no palpable goiter , nontender to palpation, no LAN. CVS: tachycardic, hyperdynamic ,no murmurs or gallops .Lungs: CTA. Abdomen: Soft NT,NABS,no HSM. Skin no rash .Neurologic:Alert and oriented, fine hand tremors present,speech and gait normal

DIFFERENTIAL DIAGNOSIS:

1.Hyperthyroidism

2.Cardiac arrhythmia

3.Anemia

4.malignancy

5.Illicit drug use

TEST AND RESULTS:

TSH: 0.006(nl 0.7-3.8) ,FT4:>7.77(nl <1.70), FT3: >32.5 (nl <5),Thyroperoxidase Ab 460(nl <9), anti-thyroglobulin Ab 1752( nl <116).

CBC, WSR ,CMP: WNL

Echocardiogram normal

Thyroid ultrasound:diffuse enlargement of thyroid gland with markedly increased blood flow suggestive of Hashimotos thyroiditis

FINAL WORKING DIAGNOSIS.:

1.Hyperthyroidism

2. Hashimoto’s thyroiditis

TREATMENT AND OUTCOMES: Patient was admitted for thyrotoxicosis;followed by continuous cardiorespiratory monitoring; started on propranolol 10mg PO TID and methimazole 10mg PO TID ( 0.76 mg/kg/day) .She felt markedly better after treatment started. Her BP and heart rate decreased but she remained tachycardic at discharge. She resumed running in physical education class when her BP and pulse normalized.

851 June 1 10:30 AM - 10:50 AM

Hip Pain - Soccer

Gregory Murphy, Darius Greenbacher. Baystate Franklin Medical Center, Greenfield, MA. (Sponsor: Pierre Rouzier, FACSM)

(No relationships reported)

HISTORY: A 13 year old male soccer player reported intermittent left hip/inguinal crease pain radiating to his knee over the last year. The pain was worse when playing soccer and would last into the night following a soccer game or practice. He also had aching in his hip at the end of the school day. He had occasional sharp stabbing pains that lasted for only seconds. He denied any trauma, popping, clicking or catching. His hip had been feeling less painful since the soccer season ended.

PHYSICAL EXAMINATION: Inspection: non-antalgic gait. normal stance.

Palpation: tenderness to palpation over the left inguinal crease without masses noted.

Range of motion: full-passive and active

Strength: 5/5 flexion, extension, adduction, abduction

Special tests: FABER (Flexion, Abduction, External Rotation): positive for pain in the inguinal crease, FADIR (Flexion, Adduction, Internal Rotation): positive for pain in the inguinal crease, Axial load with grind: positive for pain, Ober’s test: negative, Squatting: positive for pain. No weakness.

Knee, back, and abdominal exams were unremarkable

DIFFERENTIAL DIAGNOSIS:

1. Femoral neck stress fracture

2. Superior ramus stress fracture

3. Hip flexor chronic strain

4. Osteochondral injury - acetabulum or femoral head

5. Iliopsoas tendonitis/bursitis

6. Acetabular labral tear

7. Femoroacetabular synovitis

8. Slipped capital femoral epiphysis

9. Developmental dysplasia of the hip

10. Osseous tumor

11. Legg-Calve-Perthes disease

12. Inguinal hernia

TEST AND RESULTS:

Radiographs of hips: negative

MRI: Increased T2 signal in the posterior acetabulum consistent with stress reaction versus an osseous contusion. Otherwise normal.

CT: Lesion with lucent area with a central sclerotic focus consistent with osteoid osteoma.

Bone Scan: Small focal radiotracer uptake in the left acetabulum that corresponds to focal osseous lesion on CT scan.

FINAL/WORKING DIAGNOSIS: Acetabular osteoid osteoma

TREATMENT AND OUTCOMES:

1. Patient was started on enteric coated aspirin without pain relief.

2. Pediatric orthopedic referral - He was referred to the pediatric orthopedic surgeon at the local children’s medical center. Radiofrequency ablation was performed

3. The patient returned to soccer 4 months after the radiofrequency ablation.

852 June 1 10:50 AM - 11:10 AM

Pediatric Knee Injury in Football

Matthew Taylor, Robert J. Baker, FACSM. MSU-KCMS, Kalamazoo, MI. (Sponsor: Dilip Patel, FACSM)

(No relationships reported)

HISTORY: A 9-year-old athlete in his first season of contact football tackles a larger boy. His left knee is hyperextended while his feet remained planted on the ground. He feels his left knee twist underneath him. He developed swelling and tenderness in the knee, mostly posteriorly. After visiting his primary care physician, having negative x-rays, and 1 month of rest, the patient returns to flag football. While running and cutting he feels a “pop” in the knee and had to stop playing due to recurrence of pain. After evaluation, he is referred to physical therapy for weakness in the left knee. After 3 weeks of PT his strength has returned and he once again goes back to a football clinic. He jumps to catch a ball and twists his knee upon landing, feeling like his knee gives out on him. Parents request referral to sports medicine.

PHYSICAL EXAMINATION: In consultation 14 weeks after original injury. No left knee effusion. Increased laxity on Lachman’s testing. PCL intact. Positive pivot shift test. No laxity on varus/valgus stress testing. Normal range of motion with good strength. Negative McMurray’s testing. No crepitus. Some tenderness to distal femur at the growth plate. Able to stand and hop on left knee without difficulty. Right knee is stable with normal ROM. Bilateral hips and ankles stable with non-painful ROM.

DIFFERENTIAL DIAGNOSIS:

1. Patellar subluxation

2. Osteochondral defect

3. Referred pain from the hip

4. Anterior cruciate ligament sprain

5. Occult distal femur growth plate fracture

TEST AND RESULTS:

Knee x-rays

• Open growth plates, no fractures

Non-contrast MRI

• Complete ACL tear

• Suspected posterior horn lateral meniscus tear

FINAL WORKING DIAGNOSIS: • ACL tear

TREATMENT AND OUTCOMES:

1. Referred to orthopedic sports medicine, then pediatric orthopedic sports medicine for second opinion

2. Underwent arthroscopic-assisted ACL reconstruction using physeal sparing over-the-top technique with autograft IT band

3. Partial weight bearing with progressive increase over 6 weeks

4. CPM, progressive ROM and strengthening exercises, electrical stimulation, patellar mobilization, followed by proprioception and balance training and increasing strength

5. At 6 weeks post-op, able to flex to 105°, solid end-point on Lachman’s testing, negative pivot-shift

853 June 1 11:10 AM - 11:30 AM

Medial Elbow Pain in a Softball Pitcher

Joel Ramirez, Joseph Luftman, John Su. Kaiser Permanente Los Angeles, Los Angeles, CA.

(No relationships reported)

HISTORY: An 11 year-old right-handed softball pitcher presented to clinic with right elbow pain. She reported that while swinging a bat, she felt a pop and pain in right elbow. The elbow swelled up immediately and movement at the joint was painful. There was no numbness, tingling, weakness or radiation of pain pain into the forearm or hand. Prior to injury, she was pitching 200 pitches daily.

PHYSICAL EXAMINATION: General: in no acute distress, well developed, well nourished.

Right Elbow: mild soft tissue swelling medially; no effusion; neutral alignment; range of motion limited to extension of 160 degrees and flexion to 20 degrees; no tenderness to palpation of the lateral epicondyle, common flexor origin, triceps insertion, biceps tendon, lateral joint line, cubital tunnel, lateral ligament, radial tunnel, or wrist; positive tenderness over the medial ligament; no crepitus; normal motor strength; milking maneuver positive; moving valgus stress test positive for pain and laxity Grade 1; sensation normal.

DIFFERENTIAL DIAGNOSIS:

1. Medial apophyseal avulsion injury

2. Ulnar collateral ligament sprain

3. Ulnar fracture

4. Olecranon impingement

5. Olecranon bursitis

6. Pronator teres syndrome

7. Ulnar nerve entrapment

8. Osteochondritis dessicans

9. Osteomyelitis

10. Malignancy

TEST AND RESULTS: XR Right Elbow: no fracture or dislocation

XR Left Elbow: no fracture or dislocation

US Right Elbow: grade II partial thickness UCL tear

MRI Right Elbow: defect in the trochlea of the humerus extending articular surface, patchy areas of bone marrow edema and peripheral sclerosis suspicious for large erosion or osteochondral defect.

FINAL WORKING DIAGNOSIS: Osteochondral defect of the trochlea (most likely from AVN due to injury/surgery)

TREATMENT AND OUTCOMES:

1. No throwing, pitching and hitting × 9 weeks. Ice and elevation as needed. Gentle ROM exercises started after 2 weeks. No immobilization due to concern for flexion contracture.

2. After 9 weeks, swelling and pain improved so patient advanced to light movements with right arm.

3. Physical therapy started at 10 weeks from injury to work on upper extremity muscle group strengthening

4. Plan is for repeat x-ray at 6 months from injury to monitor the chondral defect. If no clinical improvement, possible osteochondral allograft was discussed.

F-57 Clinical Case Slide - Endurance Medicine

JUNE 1, 2012 3:15 PM - 5:15 PM

ROOM: 2006

854 Chair: John M. Martinez. Coastal Sports and Wellness Medical Center, San Diego, CA.

(No relationships reported)

855 Discussant: Steven D. Stovitz, FACSM. University of Minnesota, Minneapolis, MN.

(No relationships reported)

856 Discussant: John Cianca, FACSM. Houston, TX.

(No relationships reported)

857 June 1 3:15 PM - 3:35 PM

Right Foot Numbness With Calf Claudication - Cross-Country/Long Distance Track

Kathryn M. Godard1, Edwin L. Card1, Michael P. Godard, FACSM2. 1McDonough District Hospital, Macomb, IL. 2Western Illinois University, Macomb, IL.

(No relationships reported)

HISTORY: A 23-year-old male collegiate cross-country and track athlete presented with intermittent numbness in his feet. It was more prominent on the right side but occurred on the left as well. Discomfort would begin after he ran about three miles, along the medial plantar aspect of the foot and would extend up over the anterior tibial compartment. There was also aching noted in the posterior calf. The patient would stop running and the discomfort would resolve in one to two minutes. At rest or not running, he had no symptoms. He denied any history of trauma to his lower extremities.

PHYSICAL EXAM: The patient showed symmetrical lower extremities with no evidence of wasting or atrophy. Distal pulses were somewhat difficult to palpate. They did not increase or decrease with positioning of the leg. Examination of the popliteal space showed no palpable abnormality. Femoral pulses were 3+ bilaterally.

DIFFERENTIAL DIAGNOSIS:

1. Popliteal Artery Entrapment Syndrome

TEST AND RESULTS:

Segmental Pressure and Doppler Study- Ankle/Brachial Index (ABI)

- With knees extended in neutral position, normal resting ABIs and wave forms bilaterally

- Right 1.12

- Left 1.11

Arterial Duplex Imaging and Doppler Exam, diagnostic maneuvers consisted of active plantar flexion, dorsiflexion of foot, knee hyperextension and plantar flexion with resistance

Right Popliteal Artery

- Normal flow velocities at rest, Distal Popliteal Artery Velocity 66 cm/sec

- Abnormal flow velocity with plantar flexion, Distal Popliteal Artery Velocity 297 cm/sec

- Complete occlusion with plantar flexion against resistance

Left Popliteal Artery

- Normal flow velocities at rest, Distal Popliteal Artery velocity 52 cm/sec

- Abnormal flow velocity with plantar flexion, Distal Popliteal Artery Velocity 124 cm/sec

MRA Lower Extremity neutral position and plantar flexion

- Surgeon review of MRA , probable anomalous origin of medial head of gastrocnemius muscle bilaterally

FINAL/WORKING DIAGNOSIS:

Popliteal Artery Entrapment Syndrome, based on history, physical exam and Arterial Doppler

TREATMENT AND OUTCOMES:

1. Surgical division of the anomalous medial head of the gastrocnemius muscle right and left leg

2. 6 weeks rest

3. 1 month follow-up patient was pain free at rest

4. Patient resumed running 10 weeks post-operative with minimal to no discomfort in feet bilaterally.

858 June 1 3:35 PM - 3:55 PM

Bilateral Thigh Pain - Cross Country

Emily Martin1, Aurelia Nattiv2. 1University of California Los Angeles, Santa Monica, CA. 2University of California Los Angeles, Los Angeles, CA.

(No relationships reported)

HISTORY: A 20 year-old healthy collegiate cross-country athlete presents with bilateral thigh pain. The athlete reports the thigh pain started about 6 weeks prior to her presentation. It was gradual in onset and progressively worsened from pain with running to pain with walking. The pain is located in the center of both of her thighs with no radiation to the hip or knee. She reports running up to 70 miles/week when the pain started (training 7 days/week with few rest days), which was increased from about 35 miles/week. Of note, she has a history of oligomenorrhea, but no history of disordered eating or stress fractures.

PHYSICAL EXAMINATION: On exam, she is a well-developed, well-nourished young woman in no acute distress. She had no tenderness to palpation along either of her thighs. No bruising or bony abnormalities noted. Full ROM in her hips and knees. 5/5 strength through BLE, no pain with resistance. She is neurovascularly intact. She has pain when hopping on either foot and has a positive Fulcrom’s test bilaterally.

DIFFERENTIAL DIAGNOSIS:

1. Bilateral Quadriceps Strain

2. Bilateral Stress Fractures

3. Lumbar Radiculopathy

4. Bilateral Bony Neoplasm

TEST AND RESULTS:

XR Femurs: No evidence of fracture or mass

MRI R Femur: Stress reaction within the proximal and middle thirds of the right femoral diaphysis. No fracture.

MRI L Femur: Stress reactions within the proximal left femoral diaphysis and left pubic symphysis. No fracture.

DXA: PA lumbar spine: Z = -1.6 (80% of normal), left total hip: 87% of normal, left femoral neck: 82% of normal

Labs:

Total Prot: 7.3

Alb: 4.8

TSH: 1.6

DHEA: 1290

Estradiol: 66

FSH: 4.1

LH: 6.7

Testosterone Free/Tot: 2.8/29

PRL: 14.4

PTH: 25

Ca: 9.5

Vit D: 44

FINAL/WORKING DIAGNOSIS:

1. Stress Reactions of Bilateral Femoral Shafts and Left Pubic Symphysis

2. Female Athlete Triad

TREATMENT AND OUTCOMES:

1. Restrict to non-weight bearing activities such as swimming and cycling for ∼8 weeks

2. Gradual return to weight bearing exercise as long as athlete remains pain-free

3. Calcium/Vitamin D supplementation

4. Meet with nutritionist to ensure adequate caloric intake that exceeds her exercise energy expenditure

5. Add rest days to exercise regime

859 June 1 3:55 PM - 4:15 PM

Bilateral Foot Pain In Cyclist

Shawn Hsieh, Brandee Waite. UC Davis Sports Medicine, SACRAMENTO, CA. (Sponsor: Brian Davis, FACSM)

(No relationships reported)

HISTORY: This is a 37 year-old male seen for bilateral foot and ankle pain that started about two years ago when he was cycling. It began in the medial aspect of his mid- and hind-foot. Reducing physical activities did not decrease symptoms. The pain progressively worsened and now radiates from the medial mid-foot, behind his medial malleoli and up his legs. In the past few months he has used a wheelchair for long distances and avoids prolonged standing, as pressure on the medial foot exacerbates symptoms. He denies muscle atrophy or weakness, loss of hair, or hot, swollen joints. Ice and rest will decrease his pain, and acupuncture, craniosacral therapy and chiropractics with cold laser helped him minimally. Physical therapy for plantar fasciitis and neuropathic pain medications did not help.

PHYSICAL EXAMINATION: There is no evidence of atrophy in bilateral lower extremity muscles. He is tender to palpation in the medial plantar foot and behind the medial malleoli along the posterior tibialis muscles bilaterally and has a positive Tinel’s at the tarsal tunnel bilaterally, but is otherwise non-tender to palpation. Range of motion and manual muscle testing of the ankles and feet is entirely normal. There is decreased sensation to pinprick in bilateral L3 dermatomes. No pain with plantar fascia stretching, and anterior drawer, talar tilt and straight leg raise test are all negative.

DIFFERENTIAL DIAGNOSIS: Tarsal tunnel syndrome, plantar fasciitis, peripheral neuropathy, complex regional pain syndrome, spinal stenosis

TEST AND RESULTS:

MRI L spine: diffuse facet disease, L4-5 disc bulge, but no significant canal narrowing

L spine films, left and right foot and calcaneus films, MRI left foot, MRI right ankle, arterial/venous ultrasound: all normal

Bilateral lower extremity three phase bone scan: negative for reflex sympathetic dystrophy

EMG study: decreased conduction velocity of the tibial nerves

FINAL WORKING DIAGNOSIS: Tarsal tunnel syndrome

TREATMENT AND OUTCOMES: -received lidocaine+ dexamethasone tibial nerve blocks at bilateral tarsal tunnels with significant relief of pain

-will undergo radiofrequency ablation at these same locations

860 June 1 4:15 PM - 4:35 PM

Buttock Pain in a Female Runner

Farah Hameed1, Ellen Casey1, Sherrie Ballantine-Talmadge2, Carrie Jaworski, FACSM2. 1Rehabilitation Institute of Chicago, Chicago, IL. 2Northwestern University Athletic Department, Evanston, IL. (Sponsor: Joel Press, FACSM)

(No relationships reported)

HISTORY: A 21 yo female cross country athlete presents with persistent left buttock pain. Her pain began during a training session 6 months prior. She started a rehab program consisting of lower extremity strengthening and stretching. She continued to have pain while running and had a steroid injection into her left peri-trochanter region that partially improved her pain for 2 months. As she increased her training, her pain returned. She complains of 3/10 pain in the left buttock without radicular symptoms. Pain is aggravated by sitting, running, and hamstring strengthening. She denies any trauma, pain or dysfunction with bowel/bladder or pain with intercourse.

PHYSICAL EXAMINATION: Alignment is neutral without lumbar shift or scoliosis. She has a right pelvic obliquity with functional leg length discrepancy. She is tender to palpation at the left sacral sulcus, but no peritrochanteric tenderness. Range of motion reveals mildly restricted lumbosacral extension. Strength is full in bilateral lower extremities, sensation is intact without reflex changes or upper motor neuron signs. Seated slump, straight leg raise and femoral stretch are negative. Hip range of motion is symmetric, without pain at end range and negative thigh thrust, FABER or active straight leg raise. Pelvic floor exam reveals tenderness of the left deep levator ani and obturator internus with weak pelvic floor contraction.

DIFFERENTIAL DIAGNOSIS:

1. Pelvic Floor dysfunction/myofascial pain

2. Lumbosacral radiculitis

3. Sacral stress fracture

4. Femoroacetabular impingement

5. Sacroiliac joint dysfunction

6. Gluteus medius tendinosis

TEST AND RESULTS:

1. MRI of lumbar spine showed a small right L5-S1 disc protrusion without narrowing.

2. MRI pelvis showed bilateral T2 signal at the attachment of the gluteus medius to the greater trochanter.

3. Left hip xray was normal.

FINAL WORKING DIAGNOSIS: Pelvic floor dysfunction

TREATMENT AND OUTCOMES:

1. Referral to women’s health PT to work on core and lumbopelvic stability, internal myofascial release and strengthening, endurance and coordination of pelvic floor musculature.

2. Pain control with ice, heat and Acetaminophen prn.

3. Gradual return to running program.

4. By 12 weeks, she was able to return to a full running program after treatment with pelvic floor PT.

861 June 1 4:35 PM - 4:55 PM

A Severe Femoral Neck Stress Fracture in a Triathlon Athlete: A Case Report

Annemarie E. Gallagher1, Jeffrey Radecki2. 1New York Presbyterian Hospital, Columbia & Cornell, New York, NY. 2New York Presbyterian Hospital, Cornell, New York, NY.

(No relationships reported)

HISTORY: A 24 year old triathlon athlete with no significant past medical history presented with 3 weeks of right hip pain. She was training for a triathlon, and 2 days prior to the event, she developed right anterior groin pain after a 4 mile run. She completed the triathlon, but had worsening pain and difficulty ambulating afterwards, particularly when climbing stairs.

PHYSICAL EXAMINATION: The patient presented with a sharp, aching pain in the right anterior groin. On examination, she had pain with right hip flexion, both active and resisted, as well as pain with right hip internal rotation. Gait was asymmetric and antalgic. Neurologic examination was unremarkable with normal strength, reflexes, and sensation in the lower extremities.

DIFFERENTIAL DIAGNOSIS:

1. Labral tear

2. Femoral acetabular impingement

3. Stress fracture

TEST AND RESULTS:

MRI of the right hip:

-A compressive side basi-cervical stress fracture involving greater than 75% of the femoral neck with a marked surrounding bone marrow edema pattern

-A split through the base of the anterior labrum

-Mild acetabular dysplasia

Bone mineral density measurements:

-Measurements were within the expected range.

Laboratory results (including complete metabolic panel, complete blood count, Vitamin D,25-hydroxy level, and corrected calcium level):

-All values were within normal limits

FINAL WORKING DIAGNOSIS: Right compressive-side femoral neck stress fracture

TREATMENT AND OUTCOMES:

1. The patient was made non-weightbearing for 4 weeks and was given forearm crutches to maintain this non-weightbearing status.

2. Repeat right hip x-rays at 4 weeks showed a healing femoral neck stress fracture.

3. She was advanced to partial weight-bearing for a total of 8 weeks and started a physical therapy program.

4. Mobility has significantly improved, enabling her to ambulate around her house and the campus where she is a student currently. Pain is also intermittent and minimal.

862 June 1 4:55 PM - 5:15 PM

Lower Extremity Pain, Paresthesia and Foot Drop - Distance Running

Christian Appel, Shannon McCarthy. Great Northern Physical Therapy, Bozeman, MT.

(No relationships reported)

HISTORY: A 20- year old female presented with a 3-year history of intermittent numbness, tingling, weakness and foot drop in her lower extremity when running on pavement. Her symptoms did not occur when running on trails. The frequency and intensity of her symptoms had been increasing and limiting her ability to run greater than 1.5 miles. She also described the appearance of “bumps” on her calves when the symptoms occurred and had provided pictures. Her symptoms intensified with palpation of these “bumps.” Symptoms would subside within ten minutes of cessation of running.

PHYSICAL EXAMINATION: • Bilateral Strength: Hip flexion: 3+/5, knee extension: 5/5, knee flexion: 3+/5, dorsiflexion: 5/5, great toe extension: 5/5, hip abduction: 3+/5, ankle inversion, eversion, dorsiflexion and plantar flexion: 5/5

• ROM: Within normal limits

• Reflexes: Patellar: 2+, Achillies: 2+

• Palpation: She was not tender to palpation over the patella, tibia or fibula. She did not have any palpable “bumps” in the resting position. We were able to reproduce these “bumps” with repeated calf raises and leg presses. Three were produced (two on the right and one on the left), and palpation intensified her symptoms. They were approximately 5 cm in diameter.

• Gait: The patient has normal gait biomechanics with no deviations noted

• Spine Screen: Negative

DIFFERENTIAL DIAGNOSIS:

• Anterior tibial stress syndrome

• Exertional compartment syndrome

• Fibular nerve entrapment

TEST AND RESULTS: Bilateral tibia/fibula x-rays were normal

FINAL WORKING DIAGNOSIS: Exertional compartment syndrome

TREATMENT AND OUTCOMES: The patient received instrument assisted soft tissue mobilization (IASTM) to her anterior and lateral lower extremity compartments. She received 8 treatments over the course of the first 1.5 months and was able to compete in a ½ marathon on pavement with no numbness, tingling or foot drop. At a three-month follow-up she had been running up to 10 miles at a time on pavement with no symptom reproduction. This case study may provide evidence that IASTM can produce changes in especially think and/or inelastic fascia, which may contribute to exertional compartment syndrome.

F-58 Clinical Case Slide - Hip and Pelvis I

JUNE 1, 2012 3:15 PM - 4:55 PM

ROOM: 2008

863 Chair: Rob Johnson, FACSM. University of Minnesota, Minneapolis, MN.

(No relationships reported)

864 Discussant: Michael D. Pleacher. Intermountain Health Care, Layton, UT.

(No relationships reported)

865 Discussant: Jonathan T. Finnoff. Bend, OR.

(No relationships reported)

866 June 1 3:15 PM - 3:35 PM

Groin Pain - Weight Lifting

B. Joy Codera, Gary P. Chimes. UPMC, Pittsburgh, PA.

(No relationships reported)

HISTORY: A 28 year-old male with low back and bilateral groin and inner thigh pain for four months. During a clean-and-jerk, he heard a pop and immediately experienced low back pain. He continued to lift after the injury for 1 month with periods of improvement followed by exacerbation with activity. He denied any weakness, numbness or tingling. No bowel or bladder changes.

PHYSICAL EXAMINATION: No pain to palpation of the lumbar spine. Normal strength at the lower extremities except 4/5 hip flexors limited by pain and unable to test hip adductor strength due to pain. Normal reflexes. Slump sit and straight leg raise exams were negative. Tenderness along the superior pubic ramus and adductor longus bilaterally. No tenderness along the ASIS, AIIS or inguinal area.

DIFFERENTIAL DIAGNOSIS:

1. Lumbar radiculopathy at the L1-L2 or L2-L3 levels

2. Spondylolisthesis/Spondylolysis

3. Obturator neuropathy

4. AVN of the femoral head

5. Athletic pubalgia (sports hernia)

TEST AND RESULTS:

Lumbar spine MRI: Normal with no foraminal narrowing or high intensity zone

Lumbar spine X-rays with flexion and extension views: Right L5 pars defect with no evidence of instability

Pelvis MRI: Bilateral adductor longus myotendinous strain with edema. No tendon avulsion or injury to the rectus abdominis or rectus aponeurosis.

FINAL WORKING DIAGNOSIS: Low back pain secondary to pars defect

Bilateral groin pain consistent with bilateral adductor strain (athletic pubalgia)

TREATMENT AND OUTCOMES:

1. Physical therapy for lumbar stabilization and adductor strain

2. Referred for platelet rich plasma (PrP) therapy for treatment of sports hernia

3. Repeat MRI: resolution of adductor longus edema with marrow edema in the parasymphyseal pubic bones, rectus abdominis aponeurosis, bilateral strains of the adductor magnus muscle. Still unable to return to weight lifting

4. Testosterone injection therapy to assist with the healing process.

5. With PrP and testosterone injections, he was able to gradually increase activity with no pain and overall 95% improvement in pain.

867 June 1 3:35 PM - 3:55 PM

An Interesting Case of Groin Pain

Sashil Kapur, William Briner, Jr., FACSM. Advocate Lutheran General, Park Ridge, IL.

(No relationships reported)

HISTORY: 59 year old white male presenting with L thigh pain for about 2.5 weeks after cross country skiing without trauma. The day after skiing he developed moderate posterior L thigh discomfort, difficulty with walking and sitting, and swelling. No radiation or ecchymosis. He is on long term warfarin therapy given a history of calf DVT and lupus anticoagulant. Before his skiing trip his INR was 4.7 and a single dose was held. He was initially seen in the acute clinic, repeat INR was 3.2. He was diagnosed with a hamstring hematoma and told to rest and ice with resolution of symptoms. However a week later he noticed swelling and moderate tenderness of his inner thigh. He was diagnosed with an adductor hematoma, once again was prescribed rest. Two days later he was seen by his PCP with complaint of worsening thigh pain. Xrays of the hip and lower back were negative and he was referred to us. He was noted to be an active individual who works out six days a week. He has a desk job as an attorney. He is also noted to have a history of L5-S1 ALIF due to RLE radiculopathy.

PHYSICAL EXAM: Examination of the lower extremities revealed mild swelling of medial aspect of L proximal thigh, mild redness, and no ecchymosis. Large tenderness to palpation at the medial thigh, also similar tenderness at the proximal hip flexor. Not tender at the adductor origin. No pain with resistance to adduction. Straight leg raise was normal bilaterally passively and against resistance, but some discomfort with actively lowering LE after straight leg raise. FROM bilateral hips, no pain with internal or external rotation. Neurovascularly intact BLE.

DIFFERENTIAL DIAGNOSIS:

1. adductor strain

2. hip flexor strain

3. hematoma

4. compartment syndrome

5. DVT

TESTS AND RESULTS: MRI of L hip and thigh w/o contrast- grade one strain of adductor group, large DVT.

Urgent doppler venous ultrasound- acute extensive DVTs of the L common femoral vein, proximal profunda femoris, femoral vein in the thigh, popliteal vein, and gastrocnemius vein.

FINAL WORKING DIAGNOSIS: Acute extensive DVT LLE

TREATMENT AND OUTCOMES: Warfarin was discontinued and enoxaparin was started. The patient was referred to hematology. There, advancement of the clot was found on repeat doppler. At this point his enoxaparin was discontinued and fondaparinux was started. The clot has since stabilized.

868 June 1 3:55 PM - 4:15 PM

Inguinal Pain- Middle-Aged Competitive Tennis Player

Lucas M. McCaffrey, Ralph K. Della Ratta, Kevin J. Curley. Winthrop University Hospital, Mineola, NY. (Sponsor: Robert M. Otto, FACSM)

(No relationships reported)

HISTORY: A 59-year-old competitive tennis player developed insidious right inguinal pain during competition over a two-week period. Pain is non-radiating and poorly localized. Lateral movement and cough worsen the pain. The patient denies dysuria, frequency, and pain with intercourse. He has not noticed a bulge nor swelling in the area of pain. He has a past medical history significant for well-controlled hypertension and hyperlipidemia. His medications include: aspirin 81mg, ramapril 2.5mg, and simvastatin 40mg.

PHYSICAL EXAMINATION: BP 120/80mmHg, Temp of 98.0°

He has a normal lumbar lorditic curve with painless full ROM of the spine. Straight leg raise test is negative. Hips have painless full ROM, except limited right external rotation of hip to 25-30°. The following tests are negative: FABER, Thomas, Ober, piriformis, log roll, and Trendenlenberg. True leg length is equal. Abdominal exam: non-tender no masses. Genito-urinary exam: normal penis, normal scrotum, normal testes, no hernia appreciated. Neurological Exam: Motor 5/5, no atrophy, DTR 2+. Gait is normal.

DIFFERENTIAL DIAGNOSIS:

1. Occult inguinal hernia

2. Athletic pubalgia / sports hernia

3. Adductor muscle injury / strain

4. Iliopsoas bursitis

5. Hip pathology: osteoarthritis, degenerative labral tear

TEST AND RESULTS:

A trial of rest from tennis with heat, stretching, and naproxen sodium did not alter the pain pattern. Therefore, MRI of right hip was obtained.

MRI right hip:

-Increased signal at the myotendinous junction of the right adductor longus muscle

-Edema adjacent to the pubic tubercle

-Hyperintense fluid near the pubic symphysis

-Small femoral head-neck junction osteophytes

-Degeneration of the right hip labrum

FINAL / WORKING DIAGNOSIS:

1. Sports Hernia

2. Early degenerative arthritis of right hip

TREATMENT AND OUTCOMES:

1. Physical therapy and rest from tennis did not alter symptoms.

2. Referred to orthopedic surgeon with expertise in sports hernia repair 2 months after onset of symptoms. Resulting in uncomplicated repair.

3. Returned to full competitive tennis without pain next season

869 June 1 4:15 PM - 4:35 PM

Low Back Pain - Soccer

Brian Michalsen. Resurrection Medical Center, Chicago, IL. (Sponsor: Poonam Thaker, FACSM)

(No relationships reported)

HISTORY: 20-year-old female soccer player sustained a low back injury after she collided with an opposing player in mid-air. She landed on her low back and buttocks while attempting to head the ball in the first half of a mid-season game. At next stoppage of play, she came off the field under her own power and complained of low back and buttock pain. The Athletic Trainers on the sideline noted severe low back tightness. She was unable to walk the next day without the help of crutches because full weight bearing with walking caused low back pain. She was unable to sit in class secondary to pain.

PMH: She had been treated previously by Athletic Trainers for Low Back Pain and SI Joint Dysfunction.

ROS: No distal numbness, weakness, nor tingling. No saddle anesthesia. No bowel nor bladder incontinence.

PHYSICAL EXAMINATION: : Examination in the Training Room 3 days after injury revealed tenderness along L2-L5 spinous processes, lumbar paraspinal muscles bilaterally, right SI joint, and pubic bone. lumbar paraspinal muscles in spasm. Pain with rocking of pelvis. Limited flexion, extension, sidebending and rotation secondary to pain and discomfort. Lower extremity sensation, strength, and reflexes were intact bilaterally.

DIFFERENTIAL DIAGNOSIS:

1. Pelvic fracture

2. SI joint dysfunction

3. Pubic Symphysis diastasis

4. Lumbar paraspinal muscle strain

5. Iliac crest contusion

TEST AND RESULTS:

Anterior-posterior radiograph of the pelvis:

-Pubic Rami diastasis of 0.7 cm and left pubic ramus 0.2 cm elevated above right

-Malalignment of right SI joint

AP, Lateral, and oblique radiograph of lumbar spine:

-No acute bony pathology

FINAL WORKING DIAGNOSIS: Pubic Rami Diastasis with SI Joint Dysfunction secondary to trauma

TREATMENT AND OUTCOMES:

1. Rest, ice, and NSAIDs first 36 hours

2. Flexeril and Norco prescription given

3. Range of motion exercises, core strengthening, heat to affected area started 4 days after injury

4. Check MRI after 1 week to evaluate for ligamentous damage

5. Dynamic warm up, non-contact drills, and ball work 2 weeks after injury

6. Full practice with no pain 3 weeks after injury, followed by a full game the same week

870 June 1 4:35 PM - 4:55 PM

Hip Pain in a Diver

Dena Florczyk, Jeremy Vail, Aurelia Nattiv. University of California, Los Angeles, Los Angeles, CA.

(No relationships reported)

HISTORY: A 20-year old Caucasian female NCAA Division I diver presented for evaluation of three weeks of progressively worsening right anterior hip pain. The pain was described as a deep aching groin pain. Initially, pain was noted with egg-beater kick and progressed to pain with hip flexion, internal rotation, and with impact activity. Pain improves with rest, but returns during and after workouts. No alleviation with NSAIDs. Denies preceding trauma, numbness or tingling. She did have a recent increase in training volume and changed to a hop hurdle approach.

Her past medical history is significant for bilateral MTSS, migraines, and secondary amenorrhea at the age of 17 for which she was started on OCPs. Her current medications include loestrin, calcium, MVI, and relpax as needed. She denies disordered or restrictive eating, binging, purging or use of illicit drugs.

PHYSICAL EXAMINATION: Height 5’4½”, weight 131lbs, BMI 22.1, HR 64, BP 100/70

General: WNWD, without physical stigmata of anorexia or bulimia nervosa.

Right Hip: FROM. Tender to palpation over the proximal rectus femoris and TFL. Pain with FADIR, normal FABER. Normal strength of hip, but pain with resisted flexion. Normal gait with full weight bearing.

Back: FROM and no tenderness to palpation. BLE were neurovascularly intact.

DIFFERENTIAL DIAGNOSIS:

Hip Flexor Tendonitis

Hip Labral Tear

Femoral Neck Stress Reaction or Fracture

Avascular Necrosis

Lumbosacral Disc Disease

TEST AND RESULTS:

XR R hip and AP Pelvis: Normal

MR Arthrogram of Right Hip: Compression sided femoral neck stress fracture

Normal CBC, electrolytes, renal and liver function, TSH, T3, T4, Prolactin, PTH, and 25-OH Vitamin D. Hormonal labs were not assessed due to use of OCPs.

DXA (Z-score): lumbar spine -0.2, left total hip +0.3, left femoral neck -0.3

FINAL WORKING DIAGNOSIS: Right femoral neck compression sided stress (fatigue) fracture

TREATMENT AND OUTCOMES:

-Patient education

-Sports dietitian referral

-Calcium and Vitamin D

-NWB until pain free followed by NWB activities for 8 weeks (swimming, stationary bike and core strengthening). At 8 weeks began gradual re-introduction of WB activity (Alter G, weights, diving specific drills) with dive count limits that are gradually being increased. It is anticipated that she will be able to compete in the latter half of the 2011-2012 season.

F-59 Clinical Case Slide - Spine

JUNE 1, 2012 3:15 PM - 5:15 PM

ROOM: 2005

871 Chair: Pierre d’Hemecourt, FACSM. Children’s Hospital of Boston, Harvard University, Boston, MA.

(No relationships reported)

872 Discussant: Gary P. Chimes. Northwestern University, Chicago, IL.

(No relationships reported)

873 Discussant: Natalie Voskanian. UCLA, Los Angeles, CA.

(No relationships reported)

874 June 1 3:15 PM - 3:35 PM

Neck Injury - Treadmill Walking

Kyle Lennon, Philipp Underwood, John Munyak. North Shore University Hospital, Manhasset, NY.

(No relationships reported)

HISTORY: An 86 year-old male with a history of hypertension and high cholesterol tripped while walking on a treadmill. He fell forward, striking his face on the treadmill. He presented to the emergency department complaining of mild posterior neck pain. There was no associated numbness, tingling, or weakness. The pain did not radiate into his arms. He denied symptoms of near syncope and did not lose consciousness.

PHYSICAL EXAMINATION: The patient had normal vital signs and was alert and oriented. There was no midline cervical spine tenderness. He had full range of motion of his neck, but flexion produced mild left posterolateral neck pain. A cervical collar was placed. His neurologic exam was unremarkable. He had normal strength, sensation, and reflexes in his upper extremities. The patient had mild swelling and multiple abrasions to his forehead and nose.

DIFFERENTIAL DIAGNOSIS:

1. Cervical spine fracture

2. Cervical sprain

3. Cervical strain

TEST AND RESULTS: Cervical Spine CT without contrast - nondisplaced fracture though the base of the odontoid process consistent with a type II odontoid fracture.

FINAL/WORKING DIAGNOSIS: Type II odontoid fracture

TREATMENT AND OUTCOMES:

1. Admitted to the orthopedic/spine service.

2. Discharged hospital day 2, once pain well controlled.

3. Immobilization in rigid cervical collar for 8 weeks.

4. Repeat CT scan and flexion and extension radiographs revealed successful union of fracture and no instability.

5. Range of motion and neck strengthening exercises started 8 weeks post injury.

6. Patient returned to treadmill walking 3 months post injury.

875 June 1 3:35 PM - 3:55 PM

Neck Injury - Football

Kelley A. Anderson. UPMC St. Margaret, Pittsburgh, PA. (Sponsor: Jeanne Doperak, FACSM)

(No relationships reported)

HISTORY: 22 year old senior Division I football player complains of left anterior neck pain after practice. Athlete does not recall specific trauma, but remembers forced head extension on multiple occasions. His pain became progressively worse and is described as sharp, 8/10 radiating from his clavicle superiorly to the left neck. His initial diagnosis was cervical strain and he began rehabilitation and NSAIDs.

PHYSICAL EXAMINATION: Examination in the training room revealed tenderness of the sternocleidomastoid at the insertion of the clavicular head. Athlete had full range of motion of the neck but pain with rotation and strength testing to the right. There was no pain along the spinous processes of the cervical spine and no radicular symptoms. No mass was palpated and no cervical lymphadenopathy. The following day his neck became stiff and pain with ROM and strength testing worsened.

DIFFERENTIAL DIAGNOSIS: soft tissue injury, SCM strain, muscle spasm, cervical herniated disc, cervical spondylolisthesis.

TESTS AND RESULTS: Xrays of cervical spine (frontal, lateral oblique): one day later

- mild flexion of cervical spine with reversal of usual cervical lordotic curvature (may be due to spasm)

- No cervical fracture or listhesis, normal disc height.

MRI cervical spine:

-Acute grade 2 strain involving the clavicular origin and proximal myoteninous junction of the left sternocleidomastoid with a very small fluid cleft interposed between clavicle and torn origin fibers.

- No significant retraction, normal sterna origin and mastoid insertion.

- No clavicle fracture, normal SC joints.

FINAL WORKING DIAGNOSIS:

Acute Grade 2 strain of the clavicle origin of L SCM

Tratement and Outcomes:

1. Rehabiliation, NSAIDs and topical lidocaine/ketoprofen initially

2. ACP injection #1 on Day 3 and Day 6 at clavicular origin of L SCM in addition to rehab, non-contact during practice except on game days (he played in 3 official games during this injury).

3. Day 13 athlete had 90% overall improvement.

4. Day 17 he played in his third Division I football game post injury without any issues.

876 June 1 3:55 PM - 4:15 PM

Low Back Injury - Football and Lacrosse

Lindsay Maier1, Stacy A. Frye2, Cynthia R. LaBella, FACSM3. 1Loyola University, Chicago, IL. 2Geisinger Medical Center, Danville, PA. 3Children’s Memorial Hospital, Chicago, IL.

(No relationships reported)

HISTORY: A 16-year old football lineman sustained a low back injury while weightlifting. Sharp pain occurred at the right lumbar area while doing squats/cleans. He denied neurologic symptoms or feeling a pop or pull. He reported chronic pain in the area since lacrosse 4 months ago. Spine extension initially caused pain; flexion and bilateral rotation continued to be painful. Non-steroidal anti-inflammatory medication and ice gave temporary relief.

PHYSICAL EXAMINATION: Exam 10 days post injury revealed no swelling, tenderness or spinal asymmetry. Painful motions included flexion and rotation (right > left). Negative straight leg raise test; right SLR triggered low back pain. Positive slump test and stork test bilaterally. Normal strength, sensation to light touch and temperature. Reflexes 2+. Normal gait and posture.

DIFFERENTIAL DIAGNOSIS:

1. Strain of right lumbar paraspinal muscles

2. Herniation of lumbar disc

3. Spondylolysis

TEST AND RESULTS:

Lumbar spine anterior-posterior, lateral and bilateral oblique radiographs:

- Questionable abnormality at left L5 pars interarticularis

Lumbar spine MRI:

- Bilateral L5 pars interarticularis abnormalities: Reactive edema, thinning, sclerosis on right suggesting spondylolysis. Cortical discontinuity and edema on left, consistent with chronic spondylolysis.

- Fatty infiltration of filum terminale

- No disc protrusion, listhesis, stenosis

- Paraspinal soft tissues unremarkable

FINAL DIAGNOSIS:

Acute right L5 spondylolysis, chronic left L5 spondylolysis, fatty filum

TREATMENT AND OUTCOMES:

- Initial: Began non-steroidal anti-inflammatory medication and stretching twice daily.

- 1 month post injury: Diagnosis revealed on MRI. Began immobilization with lumbosacral orthosis (LSO) for 23 hours/day and physical therapy (PT) - level 1 core stabilization exercises with neutral spine.

- 2 months post injury: LSO weaned to daytime use. PT exercises advanced to include lumbar flexion and rotation.

- 3 months post injury: LSO weaned to school-time use. PT guided transition to jogging.

- 4 months post injury: Pain with prolonged sitting/standing - resumed LSO at night as needed. Unable to progress to sports-specific training due to pain with higher level strengthening exercises.

- Neurosurgery consultation: no tethered cord symptoms; fatty filum is normal variant.

877 June 1 4:15 PM - 4:35 PM

Low Back Pain-Runner

Allison C. Bean, Tanya J. Hagen, Gary P. Chimes. University of Pittsburgh Medical Center, Pittsburgh, PA.

(No relationships reported)

HISTORY: A 47-year-old male recreational runner presented to the clinic with one year of worsening, exercise related, right-sided low back pain. Pain initially improved with rest and NSAIDs, but returned with increased activity. Pain was localized to the right SI joint, with radiation into the buttocks. Pain increased with knee flexion and rotation. Patient also reported fatigue, increased time to recover from exercise, and decreased explosive strength.

PHYSICAL EXAMINATION: Examination revealed tenderness over the right SI joint and pain in the same area with hyperextension. Forward flexion reproduced pain into the buttocks, but not into the thigh. No pain with slump maneuver or straight leg raise. No findings of intra-articular hip pathology with provocative maneuvers. Noted hip and core weakness, but symmetric distal strength. Lower deep tendon reflexes were 2+ and equal.

DIFFERENTIAL DIAGNOSIS:

Pain:

1. SI joint

2. Disc disease

3. Facet

Fatigue:

1. Low testosterone

2. Hypothyroidism

3. Low vitamin D

4. wDepression

TESTS AND RESULTS: X-Ray/MRI of lumbar spine:

— Sacralized L5 segment

— Mild degenerative changes

— L4-5 lateral disc protrusion with left neural foraminal narrowing

Labs:

— Serum testosterone: 241 ng/dL (<5th percentile)

— TSH & Vitamin D within normal limits

FINAL/WORKING DIAGNOSES:

Symptomatic lumbar degenerative disc disease; low testosterone

TREATMENT AND OUTCOMES:

1. Physical therapy to increase strength and flexibility in hip, lumbar spine, and abdominal muscles.

2. Right L5 transforaminal epidural steroid injection

3. Testosterone injections q2 wks × 10.

4. Patient reported improved energy, exercise recovery, and possibly increased muscle mass. He noted increased sexual interest and erections. He denied chest pain, shortness of breath, left arm/shoulder/jaw pain, or mood irritability. Patient stated that he is now able to run 5 miles daily without pain.

5. Low testosterone may decrease responsiveness to routine treatment for lumbar pain. Utilized in conjunction with traditional treatments, testosterone administration can theoretically shift non-responders into an anabolic state that improves healing.

878 June 1 4:35 PM - 4:55 PM

A Case Of Persistent Back Pain In A 14 Year Old Male Football Player

James C. Hwang, MD, Joseph Luftman, MD. Kaiser Permanente Los Angeles, Los Angeles, CA.

(No relationships reported)

HISTORY: A 14 year old male running back sustained a lower back injury while playing football. He was pushed down during football practice onto his tailbone. Three days later, he suffered another fall onto his back with another player falling on him. He was seen by a pediatrician due to worsening back pain and sent home with rest, icing and NSAIDs. His exquisite pain persisted for another week with development of a bulge on his low back. He returned to pediatrics for re-evaluation and imaging as well as referral to sports medicine clinic due to persistence of the lesion and amount of pain.

PHYSICAL EXAMINATION: Inspection reveals a superficial 5cm × 6cm sized bulge with no ecchymosis on the right paraspinous region at L4-T1. On palpation there is a superficial soft, tender mass. He had limited range of motion with significant soft tissue pain with flexion, mild pain with extension.

DIFFERENTIAL DIAGNOSIS:

Hematoma of the lower back

Cyst

Fat necrosis

Morel-Lavallee syndrome

Coagulopathy-related hematoma

Soft tissue mass

TEST AND RESULTS:

Xray imaging: No acute fracture or periosteal reaction.

MRI scan: Peripherally rim enhancing fluid collection in the posterior soft tissues of the lower lumbosacral spine. Surrounding soft tissues demonstrate prominent enhancement.

Initial Musculoskeletal Ultrasound: 8 × 3.5 × .75 cm hypoechoic fluid collection seen in lumbar superficial soft tissue area.

Ultrasound guided aspiration: Cell Count and differential

-RBC’S, BODY FLUID : 17600

-WBC’S, BODY FLUID 30

-PMN’S: 2%

-MONONUCLEAR CELLS: 98%

Gram Stain: Moderate WBCs seen, No organisms seen

Wound culture: No growth

Repeat musculoskeletal ultrasound:

Findings: 7 × 0.5 × 4.5 cm hypoechoic fluid collection seen in lumbar superficial soft tissue area.

Impression: Re-accumulation of low lumbar seroma with persistent tenderness and pain to lumbar area.

FINAL WORKING DIAGNOSIS: Morel-Lavellee syndrome

TREATMENT AND OUTCOMES:

1. Rest with use of ice, compression and NSAIDs

2. Lesion and pain persisted despite conservative management and he underwent ultrasound guided aspiration with compression dressing

3. The patient’s seroma re-accumulated despite aspiration.

4. Reevaluated by interventional radiology for sclerotherapy of the persistent lesion, but given resolving mass but controlled pain was recommended to continue observation.

879 June 1 4:55 PM - 5:15 PM

Thoracic Spine Pain In A College Student With Scoliosis

Jonathan P. Bonnet, Jess A. Wertz, Thomas A. Best. The Ohio State University, Columbus, OH.

(No relationships reported)

HISTORY: 19-year-old male college student with progressive atraumatic upper thoracic pain for 3 months, presented with sharp 10/10 interscapular pain for 24 hours. No relief with anti-inflammatories. Denied numbness, tingling, neck/shoulder pain, and night pain. No recent fevers, night sweats, or weight loss. Medical history significant for congenital Pierre-Robin Sequence, and Stickler’s syndrome diagnosed at age 13 with concomitant mild thoracic scoliosis. Has underlying chronic lumbar back pain, but upper thoracic pain was of new onset. Past history of patellar dislocation, multiple stress fractures of the right tibia, tympanoplasty, sensorineural hearing loss, and cleft palate repair. He was unable to play contact sports due to prior bilateral retinal detachment.

PHYSICAL EXAMINATION: Micrognathia, flattened facial features, mild left convex scoliosis of the thoracic spine without obvious masses or bony prominences, and no leg length discrepancy. Diffuse left thoracic paraspinal muscle hypertrophy without scapular dyskinesis. Thin extremities with relative muscle hypoplasia, Marfanoid habitus, but normal height. Back range of motion was within normal limits except active standing flexion elicited mild thoracic pain. Palpation revealed mild paraspinal tenderness bilaterally with increased mobility at intervertebral segments. No chest or costovertebral tenderness. Normal shoulder and hip strength, range of motion, without tenderness bilaterally. Straight leg raises were negative bilaterally. Reflexes were 2+ in upper and lower extremities with no strength deficits.

DIFFERENTIAL DIAGNOSIS:

1. Paraspinal Muscle Strain

2. Muscular Spasm

3. Congenital Spinal Anomaly

4. Scheuermann’s Disease

5. Costovertebral Joint Sprain

6. Connective Tissue Disorder

7. Trigger Point

8. Tumor

TEST AND RESULTS:

Thoracic spine anterior-posterior and lateral radiographs:

- mild left convex thoracic spine scoliosis

- no specific vertebral abnormalities noted

FINAL WORKING DIAGNOSIS: Congenital Thoracic Scoliosis with underlying Stickler’s Syndrome

TREATMENT AND OUTCOMES:

1. PT referral for 6 weeks

- Back and shoulder static stretching and ROM

- Weighted forward and lateral shoulder raises

2. Follow up at 3 weeks revealed decreased thoracic back pain and no further episodes of sharp interscapular pain

F-60 Clinical Case Slide - Tumors and Abnormal Growths

JUNE 1, 2012 3:15 PM - 5:15 PM

ROOM: 2016

880 Chair: Kevin R. Vincent. University of Florida, Gainesville, FL.

(No relationships reported)

881 Discussant: Suzanne S. Hecht. University of Minnesota, Minneapolis, MN.(No relationships reported)

882 Discussant: Craig C. Young, FACSM. Medical College of Wisconsin, Milwaukee, WI.

(No relationships reported)

883 June 1 3:15 PM - 3:35 PM

Head Injury-football

Robert M. Hays, Stephen Simons, FACSM. Saint Joseph Regional Medical Center, Mishawaka, IN.

(No relationships reported)

HISTORY: A 16-year-old sophomore football player presented approx. 1 month following a helmet-to-helmet hit during practice. His immediate symptoms were headache and dizziness. He did not lose consciousness and had no initial memory problems. He initially continued to participate in practice and did not tell anyone about his symptoms. About 1 month later he was still having sharp headaches about 10 times per day that lasted 15-20 seconds and were made worse by standing up. Also continued to have dizziness/lightheadedness exacerbated by physical activity. His headaches did not keep him from sleeping.

PHYSICAL EXAMINATION: Vital signs were within normal limits. SCAT2 score was 28 with scores of ‘6’ for headache and ‘pressure in the head.’ Balance was normal at presentation. He had little difficulty performing cognitive testing.

DIFFERENTIAL DIAGNOSIS:

1. Concussion/Traumatic Brain Injury

2. Post-concussion syndrome

3. Depression

TEST AND RESULTS:

MRI of Brain wo/w: Remarkable for a predominantly cystic lesion in right cerebellar hemisphere, extension across midline into the vermis. The lesion measured 5.3 × 4.1 × 4 cm. Associated with the well-circumscribed cyst was a densely enhancing mural nodule measuring 2.4 × 2.4 × 1.9 cm in diameter. These findings were most consistent with a juvenile pilocystic astrocytoma. The lesion is posterior to the fourth ventricle and has mass effect on the fourth ventricle. It also caused downward herniation of the tonsils by approximately 1 cm, and there was mass effect on the cerebellum and medulla. The ventricles and cortical sulci had a normal appearance. No other abnormalities were present.

FINAL WORKING DIAGNOSIS: Cerebellar Pilocytic Astrocytoma

TREATMENT AND OUTCOMES:

1. Neurosurgical consultation was obtained

2. Suboccipital craniectomy was performed for resection of the tumor, pathology revealed a grade I pilocytic astrocytoma

3. Follow up MRI revealed a small area of encephalomalacia, but the tumor appeared to be entirely removed

4. At neurosurgical followup, the patient was doing quite well. He felt his balance and coordination were normal. He was released to baseball without restrictions and was released to practice for wrestling. Football season had ended, it was expected that he will be able to be released to play this year.

884 June 1 3:35 PM - 3:55 PM

Headache in a Football Player

Kelsey Logan, Mehran Mostafavifar. OSU Sports Medicine, Columbus, OH.

(No relationships reported)

HISTORY: 16 year-old Caucasian male high school football player presented with persistent headaches originating from a concussion sustained after a helmet to helmet hit 2 years ago in football. Headache is a bilateral, diffuse, dull and ache pain that is worse with playing football and better with rest. Associated symptoms include: night pain, confusion, photophobia, and balance problems. He has no history of ADHD or migraines. He denies vision change, weight loss, focal neurologic deficits, fever, or chills. He has always been a B to C student at school and has had no formal testing for learning disabilities.

Physical Exam

Mental Status

Alert and Oriented × 3

Concentration normal

Memory normal

CN II-XII intact

Motor 5/5 in bilateral upper and lower extremities

Sensation intact to light touch in bilateral upper and lower extremities

Cerebellar intact

Reflexes equal and symmetric bilaterally

Babinski downgoing bilaterally

Balance normal

Differential Diagnosis

Concussion with post-concussive symptoms

Primary headache disorder

Learning disability

Attention Deficit Disorder

Chronic subdural hematoma

Brain tumor

Tests/Results

MRI Brain

Right basal ganglia lesion with no associated enhancement or restricted diffusion. This may represent a low-grade neoplasm or may be of infectious or inflammatory etiology.

Neuropsych Testing:

He performed well below average in many areas of higher cognitive function.

Final Diagnosis:

Brain Tumor with no pathology as of yet

Post concussion syndrome

Unclear definite cause of his symptoms (tumor vs brain injury) and educational/neuropsychological performance (underlying cognitive issues vs tumor vs brain injury)

Treatment/Outcome:

1. Patient is followed by neurosurgery for brain tumor management. He will get another MRI Brain in a few weeks to determine if tumor is growing in size. At that time biopsy will be discussed.

2. There still is concern over continued symptoms that are consistent with post concussive symptoms.

3. Thus he was started on amitriptyline with improvement in symptoms.

4. Educational psychologist in school system to test for learning disabilities.

5. He gets special assistance and accommodations at school for his classes.

No grant funding.

885 June 1 3:55 PM - 4:15 PM

Neck Pain - Recreational Athlete

Bernadette Pendergraph, Ingrid Liu. Harbor-UCLA Medical Center, Harbor City, CA.

(No relationships reported)

HISTORY: 50 year old female with hypertension referred for rotator cuff tendinitis presented with one year of worsening neck and right arm pain with 3 months of left arm pain. She complained of chest tightness, clumsiness of her right hand, intermittent coldness of her left arm/leg, and multiple falls but no issues with memory or bladder/bowel incontinence. She tried chiropractic and acupuncture treatments with improvement in pain and range of motion but no change in strength.

PHYSICAL EXAMINATION: Asian female with wide based shuffling gait and difficulty holding her head and truck upright in the seated position. Her cranial nerves were intact. She had mild atrophy of her proximal right upper extremity muscles, decreased sensation in the right upper/lower extremities with preserved strength, and hyperreflexia in bilateral upper extremities. She was unsteady with Romberg testing and had difficulty performing finger to nose, heel to shin, and alternating hand movements. The neck exam was significant for decreased lateral bend/rotation and the shoulder for decreased active and passive range of motion.

DIFFERENTIAL DIAGNOSIS:

Spinal cord: Transverse myelitis, syringomyelia, meningioma, schwannoma, spinal stenosis

Systemic: Multiple sclerosis, Vitamin B12 deficiency

Infection: syphilis, tuberculosis

Brain: tumor, Arnold-Chiari malformation, aneurysm

Adhesive capsulitis

TEST AND RESULTS:

Shoulder ragiographs and brain MRI were normal

Cervical MRI showed a well circumscribed enhancing mass within the spinal canal at C1-C2 level that appeared intradural and extramedullary involving the right exiting nerve root at C1-C2 and severely narrowing the spinal canal at this level.

FINAL WORKING DIAGNOSIS: Intradural extramedullary spinal tumor, resolving adhesive capsulitis

TREATMENT AND OUTCOMES:

1. Neurosurgery performed C1, C2, and partial C3 laminectomies. Frozen section showed schwannoma with nuclear atypia

2. Postoperatively she had weakness of her right upper and lower extremities 4/5 that gradually improved. Repeat MRI showed complete resection of the intradural mass

3. She was transferred to an inpatient rehabilitation facility for persistent gait imbalance and right upper extremity weakness

886 June 1 4:15 PM - 4:35 PM

Back Pain - Volleyball

Rebecca A. Myers, Stephen M. Simons, FACSM. South Bend Notre Dame Sports Medicine, South Bend, IN.

(No relationships reported)

HISTORY: 18 year-old NCAA Division III volleyball player presents with lumbar back pain. Back pain started insidiously six months ago. She denies any preceding trauma or history of back problems. Describes the pain as a constant ache. Pain is located just to the right of her lumbar spine. Occasionally her pain radiates to her right side. She denies any leg weakness or numbness. Pain is exacerbated with playing volleyball and in particular with back extension while hitting and serving. Pain is worse after playing volleyball. Pain is relieved with non-steroidal anti-inflammatory medications and physical therapy. The pain is becoming progressively worse and keeping her from sleeping at night. The pain does not wake her up from sleep. She denies fevers or recent weight changes.

PHYSICAL EXAMINATION: VS: BP 116/70, Ht 66.5 in, Wt 130.0 lbs, BMI 21

General: alert, athletic build

Musculoskeletal:

Normal lumbar lordosis. No scoliosis.

Full lumbar ROM. Pain with flexion, extension, and right lateral flexion.

One-leg standing lumbar extension test positive bilaterally.

Tender over L3, L4 right transverse processes.

Tender over right lumbar paraspinous muscles.

Bilateral lower extremity strength and sensation are intact and symmetric.

Patellar reflexes 2+ bilaterally.

Straight leg raise negative bilaterally.

DIFFERENTIAL DIAGNOSIS:

Lumbar muscle strain

Paraspinous muscle enthesopathy

Spondylosis

Spondylolisthesis

Spinal stenosis

Herniated disc

Osteoid osteoma

TEST AND RESULTS: Lumbar x-ray: Mild facet ligamentous hypertrophy at the L5-S1 level bilaterally. No definite pars defects.

Bone Scan with SPECT CT: Increased activity within right inferior facet of L3. Small lytic lesion at the anterior inferior aspect of the facet.

Fine slice CT L3-L4: 5 × 4 × 3 mm elliptical lucency at the right L3-4 facet with a L3 inferior facet lucency.

FINAL WORKING DIAGNOSIS: Right L3 - 4 facet osteoid osteoma with L3 inferior facet pathologic fracture

TREATMENT AND OUTCOMES: Patient was started on aspirin which did not relieve her pain.

Non-steroidal anti-inflammatory medications taken before games helped her pain while playing.

Patient continued playing volleyball and was able to finish her freshman season.

She is currently undergoing percutaneous radiofrequency ablation.

887 June 1 4:35 PM - 4:55 PM

Unusual Hamstring and Pelvic Pain in an Adolescent Soccer Player

Philip F. Skiba. University of Exeter, Exeter, United Kingdom.

(No relationships reported)

HISTORY: An 11 year-old male without past medical history presented to the office for bilateral hamstring pain, right greater than left. He stated that he developed the pain after falling on his buttocks on the football field, and complained of severe pain when running short distances. This had progressed to pain which was awakening him from sleep. The patient was extremely tearful, which the parents reported as highly unusual.

PHYSICAL EXAMINATION: The patient reported tenderness to palpation of the ischial tuberosities, right greater than left. There was severe pain to palpation of the hamstrings bilaterally, which extended approximately 25% the length of the muscles. ROM testing resulted in pain at 45 degrees of hip flexion on the right and 60 degrees on the left. There was tenderness in the substance of the left piriformis. Strength and sensation were well preserved throughout the lower extremities, and all reflexes tested at 2+. Fabre and Ober tests were negative. Vascular exam was unremarkable. Of note, the patient was found to be unable to rise to a seated position from the supine position. There was no pain evident, but the patient was found to be without a lumbar lordosis. Lumbar ROM had cogwheel character and was limited to less than 20 degrees of lumbar flexion. Provocative testing was otherwise negative.

DIFFERENTIAL DIAGNOSIS:

1. Hamstring tear

2. Enthesiopathy

3. Tendinopathy

4. Avulsion

5. Occult fracture

6. Ankylosing spondylitis

7. Nervous system pathology

TEST AND RESULTS:

1. CBC, RF, ANA: (-)

2. Lyme: (-)

3. Pelvic X-ray: (-)

4. Lumbar X-ray: (-)

5. MRI Lumbar Spine: Heterogenous and intensely enhancing intradural mass extending within the spinal canal from the conus through L2.

6. Histopathology: Uniform spindly cells with nuclei arranged in ill-defined aggregates. Perivascular pseudorosettes were identified. No necrosis. GFAP+, KI67/MIB1 Proliferation Index < 5%.

FINAL WORKING DIAGNOSIS: Cellular ependymoma, WHO Grade II

TREATMENT AND OUTCOMES: Patient was taken to the OR within 24 hours, where a 3.6 × 3.1 × 1 cm tumor was resected. The tumor was adherent to multiple nerve roots and the filum. The patient recovered well and completed postoperative rehabilitiation. He is pain free and remains neurologically intact. He has not returned to competitive sport.

888 June 1 4:55 PM - 5:15 PM

Recurring Knee Pain and Effusions in an Adolescent Ballerina

James Patrick MacDonald. Nationwide Children’s Hospital, Westerville, OH.

(No relationships reported)

HISTORY: A 13 y.o. ballerina presented with six months of atraumatic left knee pain. She would report activity-related popping and swelling of the knee. She was subsequently treated with physical therapy and a patellar stabilizer brace. She continued to dance. Despite full compliance with prescribed treatment she would complain of recurring pain, ‘popping,’ and knee ‘swelling’. Her symptoms responded somewhat to ice and ibuprofen. Past Medical History remarkable for a history of psoriasis and of Severs disease. Family History a maternal aunt with psoriatic arthritis.

PHYSICAL EXAMINATION: WDWN young woman in no distress. Ambulatory with a non-antalgic gait. Mild quad atrophy noted on the left leg. No limb length discrepancy. Examination of the knee showed no effusion, and full, pain-free range of motion. There was a fullness and excess soft tissue appreciated over medial joint line, thought to be a prominent fat pad; this was painful to palpation. A “J” sign was absent. Provocative tests such as Lachman’s, Apley’s and McMurray’s all negative.

Plain films obtained on day of visit, consisting of AP/lateral/notch/Merchant views showed a skeletally mature knee, with an incidental non-ossifying fibroma in the distal femur.

DIFFERENTIAL DIAGNOSIS:

Patellar instability, PTFS, medial plica, Hoffa’s fat pad syndrome, discoid meniscus, meniscal tear or cyst, juvenile rheumatoid arthritis, synovitis NOS.

ADDITIONAL DATA/STUDIES:

Labs were notable for pertinent negatives (ESR, CRP, rheumatoid factor, Lyme profile, CBCD and Complete Metabolic Panel all within normal limits) and a pertinent positive (ANA titer of 1:80). An MRI was ordered. It revealed marked proliferation of the synovium posterior to Hoffa’s fat pad, consistent with focal pigmented villonodular synovitis (PVNS).

The patient was referred to an orthopaedic surgeon, who performed left knee arthroscopy with synovial biopsy and partial synovectomy. Pathological diagnosis made on biopsy specimens was Focal PVNS.

FINAL DIAGNOSIS: Focal pigmented villonodular synovitis (PVNS).

TREATMENT AND OUTCOMES: Rheumatology consult was obtained. She is on celecoxib b.i.d. and continuing a home exercise program. She has had no other significant joint involvement to date. She is in school and has no compromise in ADL’s. She has still been unable to return to dancing.

G-26 Clinical Case Slide - General Medicine IV

JUNE 2, 2012 9:00 AM - 11:00 AM

ROOM: 2006

889 Chair: Peter Sedgwick. Central Maine Sports Medicine, Lewiston, ME.

(No relationships reported)

890 Discussant: Bobby Huggins. Kaiser Permanente, Fontana, Fontana, CA.

(No relationships reported)

891 Discussant: Luis D. Salazar. The Ohio State University, Columbus, OH.

(No relationships reported)

892 June 2 9:00 AM - 9:20 AM

Palpitations And Dyziness Induced By Exercise

Ana Ramoa, Helena Leal, Lucimere Bohn. Ciafel-Reserch Center in Physical Activity, Health and Leisure, Porto, Portugal.

(No relationships reported)

HISTORY: A 33-year-old fitness teacher without known diseases, reported a few weeks ago dyspnea and fatigue during intense activities acompagned with palpitations, dyziness and pre-syncopes after intense exercise. Without alcool consuption, drugs, cafein or smoking. Without weight alterations.

PHYSICAL EXAMINATION: physical examination unchanged

DIFFERENTIAL DIAGNOSIS: Anemia, tireotoxicosis, anxiety disorder, hypoglicemia, cardiac conduction disease

TEST AND RESULTS:Analytical study no significant alterations, with normal thyroid function and thyroid Eco unchanged. The resting electrocardiogram showed sinus rhythm with a frequency of 55 beats per minute. A transthoracic echocardiogram (EcoTT) was also normal. Holter monitoring showed sinus rhythm with heart rates between 43-136 bpm, with periods of tachycardia morning; second degree AV block Mobitz I; Pause 1670 ms; 3 ventricular extrasystoles.

FINAL WORKING DIAGNOSIS: Mobitz I second degree AV block by vagal hypertonia-dependent exercise habits intense and prolonged

TREATMENT AND OUTCOMES: Advised to maintain moderate aerobic exercise. Follow-up: After moderate physical activity, a new Holter and EcoTT mantained unchanged with only one episode of the second degree AVB Mobitz I. Clinic Surveillance.

893 June 2 9:20 AM - 9:40 AM

Pneumomediastinum In A Lacrosse Player

Karl Ziermann. Winthrop University Hospital, Mineola, NY. (Sponsor: Robert Otto, FACSM)

(No relationships reported)

HISTORY: A 20-year-old college male lacrosse player with history of exercise-induced asthma, pyloric stenosis repaired as child, presented with chest pain and dyspnea. This was the first practice of the season and towards the end of practice during a 3-mile run he began to have difficulty breathing and began coughing. He was able to finish the run and symptoms improved temporarily but recurred that evening with increasing coughing and retching that made it difficult to breath. He began having midsternal chest pain and dyspnea “felt like I was breathing through straw”. Patient was referred to the emergency room.

He denied any recent upper respiratory infection, fever or chills.

PHYSICAL EXAMINATION: Pulse 90, BP 132/76, respirations 22 and pulse ox 99% on room air.

Chest exam revealed diffuse subcutaneous crepitus in anterior sternum bilaterally and into the neck bilaterally, the left greater than right. His lung exam revealed bilateral late expiratory wheezes and diminished air movement throughout. Cardiac exam revealed regular rhythm without murmur. The rest of the exam was unremarkable.

DIFFERENTIAL DIAGNOSIS:

1. Spontaneous pneumomediastinum

2. Boerhaaves syndrome

3. Pneumothorax

4. Tracheobronchial tree rupture

5. Exercise induced asthma

TEST AND RESULTS:

Chest radiograph

-Pneumomediastinum with air in subcutaneous soft tissue of neck and thorax

Neck and soft tissue radiograph

-Diffuse subcutaneous emphysema

CT scan of chest and thorax

-Extensive pneumomediastinum and subcutaneous emphysema. No definitive

evidence of pneumothorax. 3.4 cm bleb in medial aspect of left lung base.

FINAL WORKING DIAGNOSIS: Spontaneous Pneumomediastinum

TREATMENT AND OUTCOMES:

1. Observation in hospital for 24 hours

2. Symptoms slowly began to improve; the patient had chest pain with certain movements, including bending forward

3. Video Esophagram ordered due to the patients’ history of pyloric stenosis with repair

4. Patient was lost to follow up. His college uses a different health system for their medical care

894 June 2 9:40 AM - 10:00 AM

Paget-Schroetter Syndrome In A Competitive Swimmer

Andrew C. Hsu, Brian J. Krabak, Stanley A. Herring, FACSM. University of Washington, Seattle, WA.

(No relationships reported)

HISTORY: A 15 year-old right-handed female swimmer with no significant past medical or family history presents with a three week history of an atraumatic onset of intermittent right upper extremity pain, numbness, weakness, and swelling only during swimming. Symptoms would occur over 30-60 minutes, sometimes prompting her to stop swimming. Symptoms would resolve over several minutes with cessation of swimming. She denied any neck pain or symptoms in her other extremities. She was seen in the emergency room two weeks prior to our visit with negative x-rays of the chest and duplex ultrasound of the right upper extremity. Symptoms increased in frequency, prompting a visit to our sports medicine clinic.

PHYSICAL EXAMINATION: She was well developed and in no acute distress. She had a normal respiratory and cardiovascular exam. Inspection revealed no swelling in the right upper extremity or asymmetric arm circumferences. She had normal range of motion, strength and reflexes in the upper extremities. She was hypermobile (Beighton Scale 9). Adson’s test was negative; however Roos test was positive for symptomatic sensation of paresthesias down her right arm and hand. Spurling’s was negative. There was multi-directional laxity, but no instability of the shoulder. Impingement sign was negative.

DIFFERENTIAL DIAGNOSIS:

1. Thoracic outlet syndrome (vascular vs. neurogenic)

2. Effort-Induced Thrombosis

3. Brachial plexopathy

4. Cervical Radiulopathy

5. Tumor

TEST AND RESULTS:

- Chest X-Ray: Normal

- NCS/EMG: Normal

- Right UE Ultrasound (initial): Normal

- Right UE Ultrasound (week 3): DVT in the medial aspect of the right subclavian vein

- Venography: 4 cm DVT in the right subclavian vein with extension into the brachiocepahlic trunk

FINAL WORKING DIAGNOSIS: Paget-Schroetter Syndrome (Upper Extremity Effort-Induced Thrombosis)

TREATMENT AND OUTCOMES:

1. Admit to ICU; emergent thrombolysis and TPA treatment for 48 hours with resolution of symptoms.

2. Repeat Duplex US and Venography at 48 hours revealed near complete resolution of thrombus.

3. Hypercoabulability work-up revealed that patient was hetetrozygous for Factor V Leiden.

4. Further treated with long term low molecular-weight heparin.

895 June 2 10:00 AM - 10:20 AM

Arm Swelling - Weight Lifting

Vincent J. Stracuzzi, M.D., Natalya Urovish, M.D., John Munyak, M.D., Philipp J. Underwood, M.D.. North Shore University Hospital, Manhasset, NY.

(No relationships reported)

HISTORY: A healthy 23 year-old male notices swelling of his right arm two days after lifting weights and brought himself to the Emergency Department. He works out regularly and completed his regular exercise routine without changing his usual amount of weight, reps or sets. The swelling extends from his shoulder to his wrist. He complains of some decrease in his range of motion at the elbow and minor pain around the biceps. He denies any shortness of breath, chest pain, fever or any family history of blood clots or strokes. The patient is diagnosed with a biceps tear and referred to the Sports Medicine clinic. Patient is seen and examined and sent back to the ED to rule out an upper extremity DVT.

PHYSICAL EXAMINATION: Patient is alert and oriented with all vital signs within normal limits. He grades his pain at 1 of 10. Lungs are clear and equal bilaterally. Heart is regular rate and rhythm with no murmurs, rubs or gallops. Abdomen is soft and non-tender. Right arm is uniformly swollen from shoulder to wrist. Decreased range of motion with flexion of elbow. Pulses are 2+ and sensation is intact. Strength is 4/5 at biceps. Minor venous engorgement of right arm. Skin is non-erythematous. The remainder of exam is unremarkable.

DIFFERENTIAL DIAGNOSIS:

1. Upper extremity DVT

2. Biceps Tear

3. Biceps Strain

TEST AND RESULTS:

- Chest X-Ray: normal

- D-Dimer Assay: 1983

- Duplex Ext Veins Upper RT: Right upper extremity DVT involving the subclavian and axillary veins

- Protein S Free Antigen: 63 [67-141%]

- Right Extremity Venogram and Venacavogram: Thrombus of the right axillary and subclavian veins. Patent superior vena cava. Findings compatible with thoracic outlet compression syndrome.

FINAL WORKING DIAGNOSIS: Right upper extremity subclavian and axillary DVT, Protein S Deficiency, Thoracic Outlet Compression Syndrome

TREATMENT AND OUTCOMES:

1. Patient started on anticoagulation

2. Admitted to vascular surgery service on day 23 for transaxillary exploration and decompression of the thoracic outlet with pectoralis minor myotomy

3. Repeat venogram and superior venacavogram after procedure showed a successful thrombolysis, mechanical thrombectomy and venoplasty of a right thoracic outlet compression syndrome

4. Returned to weight training after 140 days when he had sufficient improvement of his swelling and ROM

896 June 2 10:20 AM - 10:40 AM

“To Ride Or Not To Ride?” That Is The Question

David S. Edwards. Texas Tech University Health Sciences Center, Dep’t of Family Medicine, Lubbock, TX.

(No relationships reported)

HISTORY: An 18 year old male presents for pre-participation physical exam to participate in rodeo competition. Pertinent positive answers on his athletic participation certificate include: presence of chronic illness, hospitalization overnight, surgery, use of vitamins and nutritional supplements, chest pain during or after exercise; cough, wheeze, or trouble breathing during or after activity; asthma, and wanting to weigh more than now.

PHYSICAL EXAMINATION: Vision 20/25 O.U., Ht 5’7”, Wt 115 lbs., BP 120/60, HR 74, RR 12, Oxygen saturation 93%. He has a thin appearance, moist mucus membranes, and no nasal polyps. There is no cervical lymphadenopathy or thyromegaly. He has symmetric femoral and radial pulses without delay. Supine and standing cardiac examination shows regular rate and rhythm with no murmur, rub, or gallop. Lung auscultation is clear with diminished breath sounds throughout. A port-a-cath is present to the left upper chest and without overlying erythema or fluctuance. His abdomen is soft, non-tender, and non-distended with no hepatosplenomegaly. A gastric-button is present. Extremities are warm, well-perfused, and non-edematous. Fingernails are clubbed. Musculoskeletal, genitourinary, and neurologic examinations are unremarkable.

DIFFERENTIAL DIAGNOSIS: 1. Congenital heart disease, 2. Chronic obstructive lung disease, 3. Bronchiectasis, 4. Pulmonary hypertension

TEST AND RESULTS: A sweat chloride test in infancy was elevated. Pulmonary function testing is consistent with previous values indicating severe obstruction. Vital capacity was 56% of predicted, forced expiratory volume (1 second) was 36% of predicted and 45% of predicted after albuterol. Sputum culture grew Staphylococcus aureus (oxacillin sensitive) and Aspergillus fumigatus.

FINAL WORKING DIAGNOSIS: Cystic Fibrosis clinically at baseline

TREATMENT AND OUTCOMES: His medications are salmeterol-fluticasone, albuterol, fexofenadine, cyproheptadine, esomeprazole, mometasone spray, pancreatic enzyme replacement, multivitamin, dornase alfa nebulized, and chest physiotherapy.

He was cleared for participation in team roping, advised to stay well hydrated, and scheduled to establish care with a pulmonologist. He received an influenza vaccination and is no longer requiring supplemental tube feeds.

897 June 2 10:40 AM - 11:00 AM

Case Report Of An Obese Female Following A Combined Exercise Training Program Over 18 Months

Daniel C. van der Westhuizen. Victoria University, Melbourne, Australia.

(No relationships reported)

HISTORY: A 55-years old morbidly obese, hypertensive woman (BMI=62.2 kg.m-2, resting BP= 152/102 mmHg) with knee pain, who fatigues easily, when undertaking physical activities. Drugs were Atacand and Voltaren. She wishes to increase physical activity and reduce body fat mass by exercise only, whilst combining exercise with dietary intervention, 13 - 18 mnths.

PHYSICAL EXAMINATION: Palpation of knees indicated tenderness. Pain during full extension and below 90 deg flexion with resistance loading. VO2peak of 7.3 ml·kg-1·min-1 indicates low level of fitness. Initial body mass (BM) and height was 151.1 kg and 156 cm, respectively.

DIFFERENTIAL DIAGNOSIS:

1. Cardiac problems

2. Post Menopausal Syndrome (PMS)

3. Patellar femoral pain syndrome

4. Knee Osteo-arthritis

TEST AND RESULTS: first 12 months: % change, pre - post training, first 12 wks and post 52 wks, respectively: BMI (-4.9, -4.0), BM (-5.5, -4.0), TC (1.1, -12.5), LDL-C (11.8, -7.1) and HbA1c (0, -0.6). Exercise time (47.3, 71.4), (32.1, 45.1), 1RM leg press (24.9, 37.9), 1RM bench press (48.1, 55.0) and exercise-specific self-efficacy (90.6, 70.7) improved. Changes 13 to 18 mnths (combined exercise and dietary modification): reductions in BM 145.3 kg - 141.8 kg and 137 kg. BMI declined to 56.3 kg.m-2 . Marked bony degenerative changes at femorotibial and patellofemoral articulations.

Final working/Diagnosis:

PMS and Osteo-arthritis

TREATMENT AND OUTCOMES: Before and after 12 and 52 wks combined exercise training, 3 d/wk (aerobic: 45min, RPE=13 - 15, recumbent cycle, aqua jogging, elliptical) and 2 d/wk (resistance: 45min, 8 exercises, 3 sets of 8 - 12 reps, 65-75% of 1RM ). No dietary change over first 12 mnths. 13 - 18 mnths: followed similar exercise program plus dietary modification. Prescribed Hormonal replacement drugs, Sotalol replaced Atacand. Combined exercise training attenuates metabolic risk factors, improves exercise-specific self-efficacy and functional capacity in morbid obese individual with osteo-arthritis and PMS.

G-27 Clinical Case Slide - Hip and Pelvis II

JUNE 2, 2012 9:00 AM - 10:40 AM

ROOM: 2005

898 Chair: Steven D. Stovitz, FACSM. University of Minnesota, Minneapolis, MN.

(No relationships reported)

899 Discussant: Scott Magnes, FACSM. North Chicago, IL.

(No relationships reported)

900 Discussant: Peter Gerbino, FACSM. Monterey Sports Medicine, Monterey, CA.

(No relationships reported)

901 June 2 9:00 AM - 9:20 AM

Pubic Stress Fracture - Lacrosse

Yuri Hosokawa, Gretchen D. Oliver. University of Arkansas, Fayetteville, AR. (Sponsor: Heidi Kluess, FACSM)

(No relationships reported)

HISTORY: A 21-year-old female Division I college lacrosse player presented with occasional right hip discomfort while continuing to participate without limitations. Once the athlete was promoted to the varsity level where her training regimen intensified, she repeatedly complained of intense right hip pain upon activity.

PHYSICAL EXAMINATION: Clinical evaluation revealed moderate hamstring tightness and tenderness near the origin. Pain intensified upon passive hamstring stretching. One week after the initial examination the athlete returned for further evaluation complaining of pain on the ipsilateral pubic bone near adductor muscle group origin. Intense pain and tenderness was revealed about the symphysis pubis and pubic tubercle upon palpation.

DIFFERENTIAL DIAGNOSIS:

1. Adductor strain

2. Sports hernia

TEST AND RESULTS:

Coronal radiographic image of the pelvis:

- increased signal at the superior pubic ramus

Transverse T-2 weighted MRI image of the pelvis:

- increased signal in the right pubis

Coronal T-2 weighted MRI image of the pelvis:

- increased signal at the superior pubic ramus

FINAL WORKING DIAGNOSIS: Pubic stress fracture

TREATMENT AND OUTCOMES:

1. Daily intake of NSAIDs when the pain was present.

2. Application of hot pack to adductor muscles.

3. Application of ultrasound (0.8 Hz, 1.0W/cm2, 50%, 5min.) to adductor tendon origin at pubis.

4. Hip joint mobilizations were applied before exercise.

5. Non-weight bearing strengthening exercise of the hip joint muscles was done throughout the rehabilitation program.

6. Jogging was permitted after two weeks with controlled duration, starting from 10 minutes.

7. The athlete was allowed to return to practice after 5 weeks but was limited to low intensity drills.

8. After 7 weeks the athlete was released for full participation.

902 June 2 9:20 AM - 9:40 AM

Hip Injury - Soccer

Bryan Murtaugh, Monica Rho. Northwestern McGaw Medical Center/Rehabilitation Institute of Chicago, Chicago, IL. (Sponsor: Joel Press, FACSM)

(No relationships reported)

HISTORY: A 16-year-old male high school soccer player presented with 4 weeks of right hip pain that was previously diagnosed by another clinician as hip adductor strain.

He played in a soccer game earlier in the week without any significant pain; however he woke up the next morning with severe right anterior hip pain, especially with weight bearing. He has not been able to go to soccer practice since his pain worsened and presented to our outpatient sports medicine clinic.

PHYSICAL EXAMINATION: Examination revealed pain elicited with right hip internal rotation. Limited right hip flexion and external rotation. Positive Stinchfield test. Positive right hip impingement. Tenderness over the right ASIS. Single leg hop on the right reproduced his typical pain.

Pain with resisted right hip adduction.

Gait was moderately antalgic, difficulty bearing weight thru right lower extremity. Normal neurological exam.

DIFFERENTIAL DIAGNOSIS:

1. Hip adductor strain

2. Apophysitis

3. Hip labral tear

4. Femoroacetabular impingement

TEST AND RESULTS:

Radiographs of bilateral hips:

–significant femoral

head-neck offset consistent with the cam deformity. Retroversion of the bilateral acetabula and pincer deformity. No joint space narrowing.

MRI of pelvis:

– There is a small chondral defect at the superior aspect of the femoral head.

FINAL/WORKING DIAGNOSIS:

1. Bilateral mixed CAM and pincer femoroacetabular impingement

2. Small chondral defect at the superior aspect of femoral head

TREATMENT AND OUTCOMES:

1. Physical therapy for hip strengthening and stabilization.

2. Ibuprofen 600mg PO TID for one week.

3. Intra-articular diagnostic right hip injection with complete relief of pain, and subsequent MRA right hip performed

4. MRA right hip: Focal chondromalacia of posterior acetabular roof including full thickness cleft. Focal capsular very small paralabral ganglion. Negative labral tear.

5. Patient sought surgical consultation and chose to pursue a right hip arthroscopy and osteotomy. The surgeon then recommended a left hip MR arthrogram and subsequent osteotomy on the left despite the fact that the patient was asymptomatic on the left. It has been 6 months since the patient had bilateral hip arthroscopies and osteotomies and the patient is still in PT and unable to jog lightly without pain.

903 June 2 9:40 AM - 10:00 AM

Post-operative Management Of Femoroacetabular Impingement Utilizing The Stalzer Protocol: Hip Injury; Triathlete

Craig Lowery1, Allston J. Stubbs2, Lisa Cooper3. 1North Louisiana Sports Medicine and Orthopedic Clinic, Monroe, LA. 2Wake Forest University Baptist Medical Center, Winston-Salem, NC. 3University of Louisiana at Monroe, Monroe, LA. (Sponsor: Lisa Cooper Colvin, FACSM)

(No relationships reported)

HISTORY: A 43 year female triathlete was swim training when she sustained a right (R) hip injury while kicking with fins. Immediate pain in the R hip flexor and groin was noted. 3 weeks later,she felt a “pop” in the left (L) hip and experienced the same pain as in the R hip. She reported her pain initially to an athletic trainer and later to orthopedic surgeons A & B & a physical therapist.

PHYSICAL EXAMINATION: Examination in the clinic revealed decreased right hip range of motion and a fair (-) dynamic balance single leg. Right hip active range of motion was limited to 35 degrees of external rotation, 5 degrees of extension, 30 degrees of internal rotation, 20 degrees of adduction, and 33 degrees of abduction. Palpable scar tissue at the incision sites and decreased tissue mobility. Pain in posterior hip with FABER test was noted. The patient was neurovascular and neuromuscular intact.

DIFFERENTIAL DIAGNOSIS:

1. Femoralacetabular impingement (FAI)

2. Labral tear

3. Hip flexor strain

4. Piriformis syndrome

TEST AND RESULTS: Exam by Physician A: dx: labral tear right hip and early CAM-type FAI. Arthroscopic debridement of the anterior-superior labrum and osteoplasty of the femoral neckof R hip. Patient continued to experience pain with hip flexion at or above 90 degrees and internally rotation. Patient obtained a second opinion from Physician B. It was the opinion of Physician B that patient needed a revision of the R hip. Follow-up with Physician B revealed that a third procedure on the R hip was needed. R hip revision and partially release of iliopsoas was performed. Physician B later performed a successful FAI procedure on the L hip.

FINAL/WORKING DIAGNOSIS: R hip FAI with labral tear, synovitis, bursitis (right); L hip FAI left with labral tear.

TREATMENT AND OUTCOMES:

1. Arthroscopic R hip revision using FAI procedure to relieve CAM and pincer impingements; labral repair, synovectomy, bursectomy; procedures performed by Physician B bilaterally.

2. Rehab: Use of modified Stalzer Protocol with additional of PNF

3. After procedures 3 and 4, patient was discharged from PT and was able to return to competition.

904 June 2 10:00 AM - 10:20 AM

Groin Pain - Cycling

Matthew Maxwell, Megan Cortazzo. University of Pittsburgh Medical Center, Pittsburgh, PA.

(No relationships reported)

HISTORY: 56 year old competitive cyclist with persistent groin pain and previous diagnosis of sports hernia. Pain began after a cycling accident two years prior, after he was struck by a car falling to the ground in split position. Initial MRI showed injury to the left adductor brevis and edema of the distal left rectus abdominis insertion. He pursued physical therapy to strengthen and stretch the adductors and rectus to no avail. Pain was worse with hip adduction and getting out of bed. He underwent adductor tendon release and rectus repair five months after injury with mild improvement. He had continued pain restricting his activity to 75% of baseline , worst with sprints and hills. He continued to have pain for several days after high intensity workouts and races, limiting daily function.

PHYSICAL EXAMINATION: Pain to palpation of the left adductor tendon and pubic symphysis. Pain reproduced with active adduction and trunk flexion. MMT revealed normal strength except left hip adduction, abduction, and flexion which was 4-/5. Normal painless PROM was noted in the hips and knees bilaterally, less flexible in the left adductors. Hip scour, impingement, and FABER tests did not produce concordant pain. No neurological deficits were noted.

DIFFERENTIAL DIAGNOSIS:

1. Sports Hernia

2. Chronic adductor strain

3. Osteitis pubis

TESTS AND RESULTS: New MRI obtained 18 months post-op showed edema in pubic body with fluid cleft extending into aponeurosis of the adductor longus and rectus abdominis tendons. Moderate adductor longus atrophy, muscle edema , subchoondral cyst of left pubic body, and symphysis pubis edema were also noted.

FINAL DIAGNOSIS:

Sports Hernia

TREATMENT AND OUTCOME:

- Patient initially pursued home exercise program with increasing intensity strength training and stretching to address left adductor weakness and atrophy to no avail.

- Patient then underwent diagnostic ultrasound which revealed marked scarring and calcification of the rectus and adductor longus tendons. Tenotomy with subsequent platelet rich plasma injection was performed in the insertions of both the rectus abdominis and adductor longus onto the pubis. Genitofemoral nerve block was performed for periprocedural analgesia.

- Patient reported continued pain relief on follow up over two months after PRP injection

905 June 2 10:20 AM - 10:40 AM

Gluteal Pain-runner

Angela H. Smith, Tara Jo Manal. University of Delaware, Newark, DE.

(No relationships reported)

HISTORY: A 33 y/o female runner reports to IE with chief c/o R sided gluteal fold and proximal posterior thigh pain. Localized gluteal pain increases with running, particularly up hills; prolonged sitting brings on radiating proximal posterior thigh pain. Pain is sharp with activity, dull ache with sitting. When running, pain increases at heelstrike as well with high tempo runs or speed workouts. Pt. identifies ischial tuberosity as primary pain location. Past medical hx significant for pubic rami stress fracture.

PHYSICAL EXAMINATION: Hip ROM WNL bilaterally. Pain reproduction with: resisted hip adduction and ER, SLR with hip adduction, hamstring (HS) stretch with lumbar flexion. Unable to recreate pt’s pain with palpation. Lumbar screen: Repeated flexion and max open R and L of the lumbar spine recreate pt’s pain. PT treatment initiated, including Hi-Volt neural probe e-stim, eccentric hamstring and hip extension/ER activities, nerve glides, hamstring stretching, and lumbar traction. After 10 visits, pt. did not note improvement. Re-evaluation showed (-) lumbar findings. Gluteal pain recreated with: stretching HS with a bent vs. straight knee and contracting HS at initiation of prone knee flexion and end-range SLR position. Due to non-responsiveness to PT interventions and past hx pt. was referred for imaging.

DIFFERENTIAL DIAGNOSIS: proximal HS tendinopathy, stress fracture, nerve entrapment

TEST AND RESULTS: MRI of the right hip without contrast

1. Moderate increased signal in the ischial tuberosity indicative of a stress reaction. Heterogeneous signal within the hamstring muscle complex at the level of the ischial tuberosity indicating sprain

2. Tendinopathy of the gluteus medius tendon at the level of the insertion

3. No focal labral tear

FINAL WORKING DIAGNOSIS:

1. Insertional hamstring and gluteus medius tendinopathy

2. ischial tuberosity stress reaction

TREATMENT AND OUTCOMES:

1. Pt. underwent a nerve stimulator guided cortisone injection to the soft tissue surrounding the ischial tuberosity

2. Four weeks post-injection pt. was able to run 6 miles and drive >800 miles without pain.

3. Running gait analysis completed and pt. given program of eccentric hamstring strengthening and running retraining to include increased gluteal activation and forward trunk lean to decrease demand on hamstrings.

G-28 Clinical Case Slide - Upper Extremity II

JUNE 2, 2012 9:00 AM - 10:40 AM

ROOM: 2007

906 Chair: Mark R. Hutchinson, FACSM. University of Illinois at Chicago, Chicago, IL.

(No relationships reported)

907 Discussant: Mary Lloyd Ireland, FACSM. Kentucky Sports Medicine Clinic, Lexington, KY.

(No relationships reported)

908 Discussant: Aaron Rubin, FACSM. Kaiser Permanente, Fontana, CA.

(No relationships reported)

909 June 2 9:00 AM - 9:20 AM

Shoulder Injury - Lacrosse

Berdale S. Colorado1, Karie N. Zach2, Anne Z. Hoch, FACSM1. 1Medical College of Wisconsin, Milwaukee, WI. 2Gundersen Lutheran Health System, La Crosse, WI.

(No relationships reported)

HISTORY: A 25-year-old, right-handed, male lacrosse player (recreational) presents with posterior right shoulder pain and weakness that began 5 weeks prior, after playing in a lacrosse game. There was no trauma and no associated neck pain or radicular symptoms.

PHYSICAL EXAMINATION: Inspection of the right shoulder reveals minimal atrophy of the infraspinatus. No tenderness to palpation at the shoulder. There is full active shoulder range of motion. Manual muscle testing reveals 4/5 strength for shoulder external rotators, and 5/5 strength for shoulder internal rotators and abductors. Remainder of the upper extremities have 5/5 strength, intact sensation, and normal reflexes. Hawkin’s and O’Brien’s tests were positive.

DIFFERENTIAL DIAGNOSIS:

1. Rotator Cuff Tendinopathy

2. Glenoid Labrum Tear

3. Suprascapular Neuropathy

4. Cervical Radiculopathy

5. Neuralgic Amyotrophy

TEST AND RESULTS:

Right shoulder MRI:

- Posterior glenoid labrum tear with small paralabral fluid tract and cyst.

Right upper extremity EMG:

- Electrodiagnostic evidence of denervation to the infraspinatus (2+ fibrillations and 3+ positive sharp waves). No evidence of denervation to the supraspinatus or other shoulder muscles. Motor units were normal in morphology and recruitment.

FINAL WORKING DIAGNOSIS: Right suprascapular neuropathy to the infraspinatus (secondary to traction injury or paralabral cyst from posterior glenoid labrum tear or both)

TREATMENT AND OUTCOMES:

1. 2-week course of NSAIDs and rest for the right upper extremity (no lacrosse, weightlifting, or overhead activities) for 1 month. This resulted in decreased pain and mild improvement in weakness.

2. Referral to orthopedic surgery, with subsequent recommendation for right shoulder arthroscopy posterior labrum repair.

3. Post-operative rehabilitation following surgery.

DISCUSSION: Suprascapular neuropathy to the infraspinatus is an uncommon cause of shoulder pain and weakness. It has been associated with volleyball players, baseball pitchers and tennis players. This case suggests lacrosse as a potential risk factor for suprascapular neuropathy due to repetitive overhead motions. These motions may cause traction injury to the nerve or labral tears that can produce a cyst that may entrap the nerve (particularly at the spinoglenoid notch).

910 June 2 9:20 AM - 9:40 AM

Shoulder Pain in a Football Player

Jess Wertz, James R. Borchers, FACSM. The Ohio State University, Columbus, OH.

(No relationships reported)

HISTORY: 15 year old male with progressive, atraumatic left shoulder pain × 5 days. Offensive guard/defensive end for his high school football team, pain with contact. Exacerbated with overhead weight lifting radiating into left scapula. Pain uncontrolled with anti-inflammatories. Denied numbness/tingling/burning at initial visit, but had noted weakness in the arm with pain at night. Denied previous shoulder injury.

Physical Exam: No atrophy or asymmetry noted. Tenderness at AC joint, biceps tendon and left trapezius. No C-spine tenderness, but with some left sided paraspinal tenderness with pain radiating into left scapula with Spurlings. Abnormal active ROM in all directions with global weakness upon resisted upper extremity strength testing. Positive impingement signs. Positive left scapular dyskinesis. +2 upper extremity reflexes with symmetric sensation and +2PP of upper extremities.

DIFFERENTIAL DIAGNOSIS:

1. Cervical disc herniation

2. Cervical Stenosis

3. Unresolved stinger

4. Brachial Plexopathy/Neuritis

5. Brachial Plexus Avulsion

6. Thoracic Outlet Syndrome

TESTS AND RESULTS: MRI Cervical Spine: Degenerative disc disease at C3/4 level with no evidence of disc herniation, central canal stenosis or neuroforaminal narrowing.

MRI Brachial Plexus:

1. Left T1 rib fracture with associated soft tissue edema.

2. Hyperintensity lesion on STIR images noted along left superior and medial aspect of the brachioplexus consistent with brachial plexopathy.

EMG/Nerve Conduction:

1. No electrophysiological evidence for brachial plexopathy or radiculopathy on the left arm. Of note, patient only 9 days into symptoms.

Final/Working Diagnosis:

1. Brachial Plexopathy/Neuritis

2. T1 Rib Fracture

Treatment and Outcome:

1 . Prednisone taper

2. Complete rest from sports

2 weeks - Moderate improvement of pain and function with rest and steroids. Continued to have abnormal ROM and resisted strength testing . Started HEP.

4 weeks -Return of normal ROM of shoulder and resisted muscle strength except for 4/5 internal/external rotation. Started formal Physical therapy.

6 weeks - Completed 6 PT sessions with 85-90% improvement, still with some residual weakness, but denied any pain. Full, painless ROM, normal strength. Cleared for slow progression return to play.

7 weeks - cleared to play contact football.

911 June 2 9:40 AM - 10:00 AM

Acromion Injury- Skiing

Sonal Sodha1, Christine Johnson1, Juan Garzon-Muvdi2, Edward G. McFarland2. 1Johns Hopkins University School of Medicine, Baltimore, MD. 2Johns Hopkins Medical Institution, Baltimore, MD. (Sponsor: Joe Martire, FACSM)

(No relationships reported)

HISTORY: A 52-year-old right-hand dominant male recreational skier sustained a left shoulder injury following a skiing accident. He slipped off the tracks of a ski course and into the woods where he hit a boulder. After he was transported to the base of the mountain, his only complaint was of left shoulder pain. The patient had no prior history of shoulder injury or pain and rated his pain as 3/10. He presented to our clinic two weeks later. He is very active and recreationally runs, skis, golfs, bikes, and weight-lifts.

PHYSICAL EXAMINATION: Examination revealed a significant amount of edema and ecchymosis around the left shoulder, upper chest, upper arm, and back. There was no atrophy or winging bilaterally. He was tender to palpation over the left acromion but not extremely uncomfortable. He had limited range of shoulder motion due to pain but full range in his elbow, wrist, and fingers. His deltoid could contract but produced pain. He was entirely neurologically intact including motor and sensation to his left extremity. Vascular examination was equal in both extremities.

DIFFERENTIAL DIAGNOSIS:

1. Fracture of scapula or proximal humerus

2. Acromioclavicular joint dislocation

3. Glenohumeral instability

TESTS AND RESULTS:

1. Plain anterior-posterior and axillary radiographs of the shoulder: significantly displaced fracture of the acromion with no other bony abnormalities

2. CT of the shoulder: confirmed the findings on the plain radiograph

FINAL WORKING DIAGNOSIS:

Displaced and comminuted fracture of the left acromion

TREATMENT AND OUTCOMES:

1. Left shoulder ORIF of acromion fracture with cannulated screws and one suture anchor.

2. Non-weight bearing with left arm and in an abduction pillow for 6 weeks. Allowed passive and active range of motion of elbow, wrist, hand, and fingers, but not shoulder. NSAIDs as needed for pain.

3. Radiographs at 2 months post-op showed no displacement or fixation failure. Discontinued abduction brace and started gentle passive ROM of shoulder.

4. Started physical therapy at 3 months post-op with range of motion only and no strengthening.

5. Radiographs at 11 months post-op showed complete union of the fracture. Returned to sports with full, painless ROM and normal strength.

912 June 2 10:00 AM - 10:20 AM

Shoulder Injury - Tennis

Giselle Aerni1, Michael E. Joyce2. 1University of Connecticut, Storrs, CT. 2St. Francis Care Hospital, Glastonbury, CT. (Sponsor: Thomas H. Trojian, FACSM)

(No relationships reported)

HISTORY: A 25yo right hand dominant female recreational tennis player in excellent health without prior right upper extremity or shoulder problems developed insidious onset of rapidly progressive right shoulder pain over one month. She also complained of a small indentation at the direct lateral aspect of her shoulder, less than 1cm. The pain localized mostly to the posterior and slightly to the lateral aspect of her shoulder and was constant. She had minimal relief only with complete rest. Unsuccessful treatments at the time of presentation included immobilization, physical therapy, activity modifications and NSAIDs.

PHYSICAL EXAMINATION: Examination showed a subtle deformity at the lateral aspect of the deltoid which appeared to be an area of deltoid atrophy. Pronounced focal tenderness was noted along the posterior shoulder over the quadrilateral space. Patient had full passive range of motion, though pain was noted to be worse with the arm in an abducted and externally rotated position. Strength testing showed 4/5 weakness with middle deltoid testing and external rotation. Additionally the patient was noted to have moderate multidirectional instability bilaterally.

DIFFERENTIAL DIAGNOSIS:

Muscle Atrophy

Muscle Tear

Posterior Labral Injury

Rotator Cuff Tendinopathy or Tear

Suprascapular Nerve Entrapment

Quadrilateral Space Syndrome

TEST AND RESULTS:

XRay - type 2 acromion, no other abnormalities

MR arthrogram - subcutaneous edema at the lateral deltoid, significant vascular congestion at the quadrilateral space that extends distally

Neurology/Nerve Conduction Studies +EMGs - minimal dysfunction of the axillary nerve with decreased sensation, abnormal recruitment pattern which may represent a focal muscle injury

Marcaine block test to quadrilateral space - complete pain relief

FINAL WORKING DIAGNOSIS: Quadrilateral Space Syndrome

TREATMENT AND OUTCOMES: Surgical Decompression of the Quadrilateral Space - large venous plexus was identified and dissected, the pt had substantial pain relief immediately following surgery.

Physical Therapy - to correct deltoid weakness secondary to pain-induced inactivity and improve shoulder posture.

Gradual Return to Play - as she continued to be pain free and recovered her strength.

913 June 2 10:20 AM - 10:40 AM

Shoulder Pain in a Gymnast

Ahmad M. Mostafavifar, James Borchers, FACSM. Ohio State University, Columbus, OH.

(No relationships reported)

HISTORY: 14 year-old Caucasian female gymnast with bilateral shoulder pain left greater than right for two years. Associated symptoms include upper extremity numbing, tingling, weakness, forearm swelling and discoloration, and pain that radiates to her hands. Symptoms are brought on by overhead activities and relieved with rest. She has been followed at an outside hospital for two years now, where she has had shoulder MRI’s, X Rays, EMG/NCS, and Ultrasound without a diagnosis. Treatment has included physical therapy, NSAIDs, and rest without improvement. No previous shoulder injuries. No mechanism of injury.

PHYSICAL EXAMINATION: 14 year-old Caucasian female in no acute distress and stable vital signs. On inspection she has no swelling, discoloration, or muscle atrophy. There is tenderness to palpation of the left supraclavicular fossa. Patient has FROM of neck, shoulder, and elbow. Strength is 5/5 in the neck, shoulder, and upper extremities bilaterally. Sensation is intact to light touch. Reflexes in upper extremities are 2+ bilaterally. Shoulder exam is negative for Speed’s, Neer’s, Hawkin’s, Cross Arm, O’Brien’s, Apprehension, and Inferior Sulcus. Tinel’s sign of brachial plexus is negative. Pulses are palpable and symmetric. Adson’s test is positive.

DIFFERENTIAL DIAGNOSIS:

Thoracic Outlet Syndrome

Axillary Artery Occlusion/Aneurysm

Effort Thombosis

Quadrilateral Space Syndrome

Parsonage Turner Syndrome

Brachial Plexopathy

TESTS AND RESULTS:

Vascular Thoracic Outlet Maneuvers

Right SideAbnormal - Findings are suggestive of arterial thoracic outlet syndromeSignificant decrease in the PPG waveform with the 180 degree maneuver.Left Side

Abnormal - Findings are suggestive of arterial thoracic outlet syndrome.Significant decrease in the PPG waveform with the 180 degree maneuver.

Final Diagnosis

Thoracic Outlet Syndrome

Treatment AND Outcome:

1. Patient was restricted from activities that exacerbated her symptoms.

2. She was referred to Vascular Surgery.

3. Vascular Surgery agreed with diagnosis and recommended a left first rib resection.

4. Patient is considering her options.

No Funding.

©2012The American College of Sports Medicine

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