Final 2016 AMSSM Case Abstracts

CASE PODIUM PRESENTATIONS

Acute Testicular Pain Following Blunt Trauma During a Professional Hockey Game

Victoria Chen, MD, Neilson Mathews IV, MD

Affiliation: Lehigh Valley Health Network Sports Medicine Fellowship, Allentown, Pennsylvania.

Case History: A healthy 20 year-old male professional hockey player with no significant past medical history presented with worsening pain and swelling of his left testicle for 3 days after sustaining a groin injury. He was not wearing protective equipment when he took a puck to the groin while trying to block a shot during an away game. Due to pain and swelling of the left testicle, he presented to the local emergency department. Physical exam at that time revealed a tender left testicle that was approximately twice the size of the contralateral side. To rule out testicular rupture, an ultrasound with Doppler revealed a normal right testis while the left demonstrated a subcapsular hematoma, hemorrhagic hydrocele, and no flow to the lower half of the testicle. The emergency physician consulted urology who recommended no surgical intervention, just conservative management with pain medications, ice, and to follow-up with an outpatient urologist when he returns home. After the team returned home, the athlete underwent a follow-up evaluation by an outpatient urologist 3 days after the initial injury.

Physical Exam: Vital signs were normal. General: Well-developed white male in no acute distress. HEENT, cardiovascular, respiratory, neurologic, abdominal, musculoskeletal and skin exams were normal.

Genitourinary: Penis and groin were normal.

Testes: Descended bilaterally. Left testis is very tender, unable to fully examine due to discomfort. Scrotal skin is normal without erythema. Right testis is normal without palpable mass. No hydroceles.

Differential Diagnosis:

1. Testicular rupture
2. Testicular torsion
3. Torsion of a testicular appendage
4. Epididymitis
5. Inguinal hernia
6. Hydrocele
7. Testicular infarction

Tests and Results: Automated urine dipstick analysis: Normal. Ultrasound of the testicles with Doppler Right testis: Normal. Left testis: Large hematoma surrounding left testis. Diffusely heterogenous echotexture and irregular medial contour, suggestive of parenchymal edema and contusion with likely disruption of the medial testicular capsule. No discernible blood flow, with only a small amount of blood flow at the periphery of the inferior pole of the testis.

Final/Working Diagnosis: Ruptured testicle.

Discussion: Scrotal trauma, although rare, is often associated with severe injuries, with testicular rupture amongst them. A missed testicular rupture has an increased risk of secondary infection and atrophy. It also could contribute to impaired spermatogenesis and a hypogonadal state. A timely diagnosis is important since early surgical intervention maximizes the potential for testicular salvage. Unfortunately, one cannot rely solely on a thorough history and exam as they can be misleading and limited. Ultrasound is the imaging modality of choice used to guide management as it has been found to be highly specific and sensitive for testicular rupture. Those with normal ultrasounds may be managed conservatively. One should have a low threshold for surgical exploration in light of the high rate of salvageability with early intervention. If an athlete presents with a history of blunt testicular trauma along with concerning symptoms and examination, these mandate surgical exploration, regardless of ultrasound findings.

Outcome: Based on the elapsed time and follow-up ultrasound results, the likelihood of salvageable testicular tissue was low and so, the patient was offered conservative treatment or surgical exploration with possible repair or orchiectomy. He opted for surgery, which revealed a hematocele, rupture of the tunica albuginea, and absent arterial flow in the left testicle. Due to absence of blood flow, the urologist decided to perform an orchiectomy rather than debride and attempt closure. Surgical pathology demonstrated a left fractured testicle, infarction of the seminiferous tubules, interlobular hemorrhage, and defects in the tunica vaginalis and albuginea.

Return to Activity and Follow-Up: The athlete remained out of activities until his evaluation 8 days post-operatively, at which he was cleared to return to full contact. He was counseled on the importance of wearing genital protection now that he has a solitary testis.

Hand Pain in a 12 Year Old Female Softball Player

Chris Clemow, MD, Scott Counts, MD

Affiliation: AnMed Health Primary Care Sports Medicine Fellowship.

Case History: A 12 year old female softball player presented to our SM clinic 2 weeks after being hit in the left hand by a softball pitch. Initially evaluated in an urgent care for pain around her second MCP where x-rays were negative. Repeat x-rays in our office w/comparison to original and opposite side were negative. She was allowed to do relative rest and improved to near pain free status and function playing softball in a few more weeks. At 1 month she started having pain and swelling again around the second MCP. Repeat x-rays were negative again. MRI at 1 month showed mild bone marrow edema at the second metacarpal physis and epiphysis of uncertain significance.

She was placed in an orthoplast splint to protect her second MCP, given relative rest and allowed to return to play once pain free. She improved but at 4 months pain returned and swelling worsened. Repeat x-rays clearly abnormal at that time.

Physical Exam: Left Hand: TTP surrounding second MCP with mild erythema and swelling. All tendons intact. Full ROM and stability of all joints. No apparent subluxation of the extensor tendons. Neurologically intact.

Differential Diagnosis:

1. Salter Harris 1 fracture of the second metacarpal
2. Soft tissue contusion
3. Persistent synovitis of the second MCP
4. Juvenile Idiopathic Arthritis
5. Stress fracture of the second metacarpal
6. Extensor hood injury
7. Avascular necrosis of the second metacarpal head

Tests and Results:

1. Initial x-rays, 2 weeks x-rays, and 1 month x-rays negative
2. MRI Left Hand (1 month out)—Mild bone marrow edema of the second metacarpal physis and epiphysis “possible stress injury, consider avascular necrosis but felt much less likely”
3. X-rays (4 months out)—Apparent avascular necrosis of the second metacarpal epiphysis without articular collapse
4. MRI (4 months out)—Avascular necrosis of the second metacarpal head without collapse
5. CT (4 months out)—AVN second metacarpal with overall preservation of second metacarpal head architecture

Final/Working Diagnosis: Dietrich's disease (Avascular necrosis of the second metacarpal head)

Discussion: Dietrich's disease is an extremely rare form of avascular necrosis described less than 10 times in the literature. It is even more rare in an immature skeleton. In this case we believe that an undiagnosed Salter-Harris 1 fracture of the second metacarpal was the original injury. This was likely not allowed to completely heal before exposing this girl to the trauma of catching a softball. We believe that this compromised the circulation to her metacarpal had causing the necrosis long term. Treatment of this condition is not well understood or described. There are operative and non-operative treatments described. We opted for nonoperative treatment and added ultrasound based bone stimulation, which has never been used for this indication.

Outcome: She was removed from all sports participation once the diagnosis was made. As a softball and volleyball player, we considered her risk for continued trauma high. She has been in a orthoplast splint at 20° of flexion of the MCP that is being adjusted to different positions to unload the joint and improve motion. She is working primarily on passive ROM due to significant stiffness around the joint. Occupational therapy and hand surgery involved. To this point, 8 months out she has not reconsituted her metacarpal head significantly by x-ray but no collapse.

Return to Activity and Follow-Up: We hope she will reconstitute all of her metacarpal head long term as with other forms of AVN in children. This may take as long as a year. She is being allowed to do as much activity as possible but avoiding all impact force to her left hand. She will be returned to all activity as tolerated once the care team believes she has healed as much as possible.

Incidental Cardiac Findings on PPE: Cause of Sudden Cardiac Death or Physiologic Response to Training?

Justin Conway, MD, Margot Putukian, MD, and Jason Womack, MD

Affiliation: Princeton University, Princeton, NJ and Rutgers—RWJMS, New Brunswick, New Jersey.

Case History: A 17 year old Male African American Division 1 soccer player presented for his PPE. He denied any significant cardiac or past medical history. Specifically, no dyspnea on exertion, palpitations, chest pain or pressure, history of syncope or pre-syncope.

Medications: none; Past Surgical History: none; Family History: Mother and father are of Nigerian descent. Both living, healthy. 7 year old brother, healthy. No known family history of cardiac disease or genetic abnormalities. One paternal uncle with sudden death of unknown cause in his 40's; Social History: Denied use of tobacco, alcohol, illicit drugs or performance enhancers; Full ROS negative.

Physical Exam: Vitals: 5 ft 10.5 in, 183.8 lbs, BMI 26, BP 133/73, HR 72 Gen: Well appearing African-American male, muscular build, NAD. No evidence for Marfan's syndrome. Neck: Supple, No JVD. No thyromegaly, no adenopathy. CV: RRR, normal S1/S2, 2/6 systolic SEM loudest as LUSB in supine position, disappears with Valsalva and when standing. Lungs: Clear to auscultation bilaterally. Extremities: No cyanosis or edema. Normal femoral and radial pulses. EKG: Sinus rhythm, normal axis, LVH by voltage criteria, ST morphology in V1-V3 consistent with early repolarization. Normal by Seattle criteria.

Differential Diagnosis:

1. Benign flow murmur
2. ASD
3. VSD
4. Hypertrophic cardiomyopathy
5. Mitral/tricuspid regurgitation
6. Aortic/pulmonary stenosis

Tests and Results: Due to the new murmur on exam, patient referred to Cardiologist #1 for TTE which showed:

1. Normal chamber size and ventricular function (LVEF 51%). No significant valvular abnormalities.
2. Marked trabeculation of the LV endocardial surface with deep intertrabecular recesses consistent with LV non-compaction versus hypertrabeculation of an athlete's heart. Thick to thin compacted layer ratio meets Zurich and Milwaukee criteria of LV non-compaction (ratio of non-compacted/compacted myocardium >2:1). New differential diagnosis:
• LV non-compaction cardiomyopathy
• Hypertrabeculation as physiologic response to training Patient was referred to 2 specialists in LV non-compaction for further testing and evaluation. He was restricted from athletic participation pending specialist evaluations.

Further Testing:

1. 24-Hour Holter Monitor: Normal
2. Rare PVC's and PAC's
3. Exercise Stress Test—Normal, no arrhythmia, no ST-T changes, exercised to full exertion
4. Cardiac MRI—Increased trabeculations of mid to apical region of LV with ratio of non-compacted to compacted mypcardium of 2.4:1 suggesting component of mild underlying LV non-compaction cardiomyopathy. LVEF 56%

Final/Working Diagnosis: Non-compaction cardiomyopathy with low-normal LV systolic function.

Discussion:

1. Non-compaction cardiomyopathy (NCCM) is a rare form of cardiomyopathy characterized by increased trabeculations in the LV wall due to abnormal myocardial development in utero
2. Complications of NCCM include the potential for thrombosis and subsequent emboli, arrhythmia, heart failure and sudden cardiac death
3. Hypertrabeculation may also be a physiologic response to training, particularly in males of African ancestry.
4. The 36th Bethesda Guidelines excludes patients with NCCM from most competitive sport, however there is relatively little data about the disease, and the safety of athletic participation in asymptomatic individuals is unclear

Outcome:

Recommendations:

1. Cardiologist #2: No restriction from physical activity. Yearly echocardiogram during college then every 2 to 4 years going forward
2. Cardiologist #3: No restriction from physical activity. Yearly echocardiogram and holter monitor. Aspirin 81 mg daily for intracardiac thrombus prophylaxis. Brother should undergo cardiac screening given possible genetic component.

Return to Activity and Follow-Up: Patient returned to full participation in soccer as soon as specialist recommendations were discussed with team physician, athlete and family. He missed approximately 1 month of his freshman season.

He was started on aspirin 81 mg daily for intracardiac thrombus prophylaxis.

Plan is to repeat echo and holter monitor in 1 year and monitor closely for development of cardiac symptoms.

Should Elite Athletes Abide by a Different Set of “Rules?”

Sourav Das, MD, Valerie E. Cothran, MD, and Andrew M. Tucker, MD

Affiliation: University of Maryland, Baltimore, MD Union Memorial Hospital, Baltimore, Maryland.

Case History: A 21 year old male collegiate pitcher presents to the ER w/bleeding from his gums and bruising. He was in his usual state of health until 3 days prior to admission when he developed epistaxis, which took more than 1 hour to cease bleeding with chemical cautery. He then noticed bruising on his right ankle 2 days prior to ER arrival and further developed petechia along his bilateral lower extremities and arms. His labs revealed a platelet count of 3000. Upon further questioning, he described a mild sore throat 1 week ago. He attributed this to a difference in air quality, as he traveled from Maryland to Idaho. He has no other symptoms and no risk factors for HIV nor Hepatitis C. He has not taken any new medications, specifically no quinine drugs.

Past Medical, Surgical History, Social History, Family History: Non-contributory. No significant bleeding disorders.

Physical Exam: General: pleasant, athletic, healthy appearing male.

HEENT, Cardiovascular, Pulmonary: unremarkable.

1. Abdomen: no organomegaly
2. Extremities: no cyanosis, clubbing, nor edema Lymphatic: no adenopathy
3. Integument: diffuse petechia and purpura
4. Neurological: no focal deficits

Differential Diagnosis:

1. Acute Immune Thrombocytopenic Purpura (ITP)
2. Chronic ITP
3. Infectious Thrombocytopenia
4. Inherited Thrombocytopenia
5. Myelodysplastic Syndrome
6. Vasculitic Purpura

Tests and Results: WBC: 7700, Hemoglobin: 17.2, Normal red blood indices, RDW: 11.2, Platelet count: 3000, 60% neutrophils, 31% Lymphocytes, 6% monocytes, 2% eosinophils. Complete metabolic profile and TSH: normal. HIV, Hep C, Helicobacter pylori Ag/Ab: negative.

Final/Working Diagnosis: Acute ITP.

Treatment Course: Given Dexamethasone 40 mg PO for 4 days, then prescribed similar weekly cycles for 3 weeks. Intravenous immunoglobulin given at 1 g/kg for 2 days.

After the first course of dexamethasone and IVIG, patient's platelets increased to 293 000. However he did not want to take the subsequent steroid pulses in 2 and 4 weeks because of muscle weakness and weight gain. He did comply with the scheduled doses finally, but platelet counts continued to decrease between the steroid pulses (nadir of 34 000) and counts peaked with pulses as high as 310 000. At this point, the patient did not tolerate high dose dexamethasone well, and his condition was refractory to oral prednisone. The patient consulted a second hematologist who started Rituximab. The chemotherapy had limited increase in platelet counts (from 17 000 to 19 000). After 2 rounds of Rituximab, the patient's platelets dropped back to 18 000 and he was having increased frequency of myalgias and arthralgias secondary to the medication. The patient is now seeking consultation for laparoscopic versus surgical splenectomy after 5 months of failed alternate therapies (which is sooner than protocols described in scientific literature).

Discussion: Splenectomy is an invasive, irreversible procedure with potential for post-operative complications. The outcomes are also unpredictable, leading some physicians, patients, and literature to recommend surgery 1 to 2 years after initial diagnosis of ITP because some adults spontaneously improve during that time period. The risk of intracranial, soft tissue and mucosal bleeding secondary to trauma in patients with ITP has the potential to be life-threatening. The lack of evidence-based management protocols is a potential for poor management of ITP, because no evidence clearly demonstrates that treatment alters final outcomes. We discuss our case of a collegiate pitcher with ITP to raise discussion about the following questions: what is a safe platelet count for ITP athletes to resume contact activity? Are there any activities athletes should avoid if platelet counts are below this threshold? And finally, should we be more aggressive in treating elite athletes with ITP in order to expedite their return to play?

Outcome: Final outcome Laparoscopic splenectomy increased platelet count to 193 000—to be determined.

Return to Activity and Follow-Up: Weekly, then biweekly platelet counts as patient is currently in acute phase of recovery.

Diplopia in a 6 Year Old Female After Head Injury

Sean C. Engel, MD, Carrie Jaworski, MD

Affiliation: University of Chicago, NorthShore, Chicago, Illinois.

Case History: During a motor vehicle accident nine days prior to our initial evaluation, a 6 year old female was the restrained passenger traveling in a van at camp that was T-boned by another car. She did not lose consciousness, but had a headache and vomited after the accident. Because of injuries sustained to her head and pelvis she was taken to the hospital for observation. She was discharged with a suspected pelvic fracture the following day. Her nausea and headache had resolved. During her orthopedic surgery follow up appointment, her mother mentioned that she complained of intermittent double vision and she was referred to the sports medicine clinic for an evaluation for concussion.

Her mother noted for the past 2 days her daughter had complained of double vision and was tilting her head awkwardly and closing one eye occasionally. This seemed to be worse at night. The patient states that she only sees double sometimes and not usually when reading. She has had no headaches, dizziness, fatigue, or nausea.

Physical Exam: Post Concussion Symptom Score: symptom score 4, severity score 8.

General: Alert, pleasant, interacts appropriately for age. No distress.

Eyes: OS: 20/25, OD: 20/25, OU: 20/25.

PERRLA and EOMI bilaterally. Double vision with right lateral gaze. Normal convergence.

Neuro: CNII-XII intact, gait and stance normal, balance normal, strength 5/5 and symmetric in UE and LE, sensation intact to light touch on face and extremities.

Differential Diagnosis:

1. Concussion
2. Sixth Cranial Nerve Palsy
3. Convergence Insufficiency
4. Orbital Floor Fracture

Tests and Results: Noncontrast CT scan of the head demonstrated no intracranial lesion.

Follow up evaluation and testing by pediatric and neuro-ophthalmology confirmed presence of right sixth cranial nerve palsy.

Final/Working Diagnosis: Concussion; Post traumatic Sixth Cranial Nerve Palsy.

Discussion: Visual complaints after concussion are a relatively common occurrence. However, the complaint of diplopia is usually related to difficulties with convergence or accommodation. The finding of a cranial nerve palsy in the absence of any finding on CT scan is relatively rare. Additionally, this focal finding complicates the diagnosis of concussion, which is generally thought to be a diffuse process. Along these lines, it is unclear how and when the return to activity progression should be followed when the only remaining symptom is a focal cranial nerve palsy.

Outcome: Diplopia had resolved spontaneously by 6 weeks follow up with neuro-ophthalmology.

Return to Activity and Follow-Up: Since the injury was felt to be related to her head injury, it was recommended she not participate in contact sports until resolution of the nerve palsy. This recommendation was made both out of concern for reinjury as well as with concern for the patient's safety in participating in sports with visual disturbances.

Paget Schroeter in Female Volleyball Player

Timothy J. Gill, MD, Thomas Trojian, MD

Affiliation: Drexel University College of Medcine, Family Medicine/Sports Medicine.

Case History: A 19 year old female college volleyball player presents with 2 days of left upper extremity swelling and decreased sensation. She first noticed swelling the day after a long practice, also noted some discoloration in upper arm. She went to the ER due to pain and swelling. She denies any fevers, weakness of the arm, but notes a numbness sensation throughout the arm. Swelling has progressed since onset while discoloration has resolved. She noted this occurred frequently in high school but resolved next day.

Physical Exam: Examination in the clinic revealed patient to be vascular intact but with uniform edema extending distally from proximal humerus. She had decreased sensation throughout the arm relative to her right. She had full AROM of neck, shoulder, arm and maintained 5/5 strength through her shoulder, elbow, wrist, fingers. There was no focal areas of tenderness or pain elicited with activity, arm was soft. She described an achy sensation through her upper lateral arm. She had erythema throughout the lateral upper arm, but no warmth was appreciated.

Differential Diagnosis:

1. Deep Vein Thrombus
2. Thoracic Outlet Syndrome
3. Upper-Arm Lymphedema
4. Cellulitis
5. Bicep Compartment Syndrome

Tests and Results: Initial Ultrasound performed in ER one day prior to office visit revealed no signs of DVT. Due to the history and continued symptoms a repeat US was ordered and revealed a subclavian vein thrombus. She was then admitted to the hospital for thrombolysis. Imaging revealed a first rib pushing on the vessel and fibrosis of the subclavian vein.

Final/Working Diagnosis: Paget Schroeter Syndrome.

Discussion: Despite initially negative ultrasound imaging, exam and history were highly suspicious for DVT. Repeat imaging and early intervention were critical for avoiding known co-morbidities of subclavian thrombus. Early heparin infusion when indicated has shown benefit to patient outcomes. The decision to proceed with a rib resection in cases of subclavian thrombus is dependent on anatomy, evaluated via MRI. A three month anticoagulation course is recommended followed by progression of activity with return to play over 3 months.

Outcome: After admission and thrombolysis and heparin infusion, she underwent a left first rib resection. Post procedure, she developed a left chest wall hematoma that required drainage.

Return to Activity and Follow-Up: During outpatient follow-up for therapeutic anti-coagulation, she noted fevers and easy fatigability. She was found to have decreased breath sounds through the left lung, CXR showed opacity of the entire left lung and was admitted. She underwent IR guided thoracentesis of sanguineous fluid. Follow up XR revealed improving consolidation. After release from hospital and cessation of warfarin, she progressed back to walking, then running after 8 weeks. She started return to play with progression of overhead activity after 12 weeks.

Back to Basics: An Atypical Diagnosis for Low Back Pain

Richard Lopez, DO

Affiliation: Morristown Medical Center, Morristown, New Jersey.

Case History: Patient is a 26 year old Caucasian wrestler and mixed martial artist with history of Diabetes Mellitus type I and Lumbar Vertebral Compression Fracture which dates back to 2008 after he sustained a back injury during a wrestling match. His pain was initially managed conservatively with nonsteroidal anti-inflammatory drugs and physical therapy. Seven years later, he returned acutely to the hospital with a 6 week history of progressively worsening, intractable back pain associated with urinary frequency, incontinence and radicular pain down his right leg. The mechanism of injury was unclear at that point, but he did admit that he continued to train in mixed martial arts. An initial MRI showed a herniated disk on the right side of L5-S1 with moderate central stenosis. He would be taken to the operating room for elective right sided L5-S1 hemilaminectomy and diskectomy. There were no intraoperative complications, and after convalescing at home for a brief time period, he again returned with intractable back pain despite high doses of opioid medications. After further investigation, he revealed that over the past 3 months, he had been experiencing occasional fever, night sweats and 25 pound weight loss.

Physical Exam:

Vital Signs on presentation: Temperature: 39.5°Celsius, Heart Rate: 82, Blood Pressure: 117/69, Respiratory Rate 16, O2 Saturation: 95% on room air.

General: Appears in Pain. Has multiple old tattoos.

Cardiorespiratory: Normal Heart and Lung Sounds.

Musculoskeletal: Abnormal Gait. Difficult Exam given pain. Muscle Strength 1/5 of Right Lower Extremity. Reproducible pain on passive/active range of motion of lower extremity bilaterally. No significant tenderness to palpation of paraspinal muscles. Neurological: Cranial II-XII grossly intact. Decreased fine sensation of right lower extremity, S1 territory. Deep Tendon Reflexes 2/4 bilaterally.

Differential Diagnosis:

1. Spinal Cord Compression/Cauda Equina Syndrome
2. Spinal Epidural Abscess
3. Vertebral Osteomyelitis
4. Malignancy/Metastasis
5. Lumbar Radiculopathy
6. Spinal Stenosis
7. Osteoarthritis

Tests and Results: White Blood Cell Count: 15.5, Hemoglobin: 10.2, Platelet Count: 456 000, LDH: 944, ESR: 114, CRP: 335, MRI L-spine: Status Post Right Hemilaminectomy at L5-S1. Scattered, diffuse foci of signal abnormality involving the marrow space highly suggestive of metastatic disease or myeloma. CT-guided Bone Biopsy: Ewing Sarcoma Technetium 99m Bone Scan: Increased activity of right posterior sixth rib, right sacral ala, left proximal femur CT Chest: Numerous pulmonary nodules suspicious for metastatic disease.

Final/Working Diagnosis: Metastatic Ewing Sarcoma.

Discussion: Back pain, especially low back pain, is one of the most common presentations in the outpatient setting in the United States, accounting for nearly 1.3 perent of office visits, and is the fifth most common reason for physician visits in the United States. A detailed history and reliable physical examination is essential in the evaluation of low back pain in adults and athletes. Though rare, bone tumors like Ewing Sarcoma can cause low back pain and should be included in the differential diagnosis. Back injuries are an especially common phenomenon in the young athlete, and in some instance, it is prudent to investigate the etiology when constitutional and red flag symptoms are involved.

Outcome: Patient is being actively treated with radiation therapy and chemotherapy (Ifosfamide alternating with Adriamycin, Cytoxan, Vincristine). He is on a pain medication regimen for chronic pain syndrome. He continues to convalesce at home with his wife and 2 children.

Return to Activity and Follow-Up: There is no immediate plan for return to activity. He hopes to return to coaching wrestling.

Bilateral Anterior Knee Pain in a High School Cross Country Runner

James MacDonald, MD, MPH

Affiliation: Nationwide Children's Hospital, Columbus, Ohio.

Case History: The patient is a 17 year old female senior HS cross-country (XC) runner presenting with insidious onset, activity-related, bilateral anterior knee pain, referred by our hospital urgent care center. Her pain has been relapsing and remitting over 2 years. She is currently in the middle of her XC season and the pain has returned. Her knees tend to “loosen up” with running, but afterwards will ache (Pain 6/10). She also reports difficulty with squatting, present since elementary school (10 years), and describes a positive “theatre” sign with prolonged sitting. Her family is from Ethiopia, but she was born in the USA. Denies any developmental delays or prolonged childhood illnesses. Immunizations up to date. Her only PMH is cyclical vomiting, for which she has visited UC/ED at our institution frequently.

Physical Exam: BP: 114/66; Pulse: 74; Temperature: 37.1°C (98.8°F); Respiration: 20; Weight: 54.7 kg; Height: 165 cm; BMI: 20.1 WDWN adolescent female. Non-antalgic gait. Cannot perform duck walking because she cannot rise out of a squatting position. On inspection there is no malalignment nor limb-length discrepancy; there is decreased muscle bulk in her quads. Knee exam: Non-tender to palpation of the joint line, no effusion. Hypermobile patellae bilaterally; patellar apprehension absent. J sign is absent. On manual muscle testing, 5/5 strength throughout her lower extremities, except for knee extension and hip flexion: 4/5 bilaterally. Upper extremity muscle testing is 5/5 throughout, aside from deltoid strength (4+/5). There is normal muscle tone; no fasciculations are noted. Gower's sign positive. DTRs 1/4 ankles/knee jerks bilaterally. Gross sensation is intact throughout the lower extremities.

Differential Diagnosis:

1. Patellofemoral syndrome (PTFS). PTFS would be secondary to an underlying condition whose DDx would be broad:
• Muscle Dystrophy NOS
• Ullrich's myopathy
• Hereditary motor/sensory neuropathy (Charcot-Marie-Tooth variant)
• Juvenile myasthenia gravis

Tests and Results: Plain films bilateral knees (AP, lateral, Merchant, Notch) WNL and non-contributory. Initial labs included CK, ESR, TSH, CMP, CBCD, Mg. All labs were WNL except for, notably, elevated CK (386) and low WBC (2.7). Subsequent studies included EMG, DNA testing and anti-acetylcholine receptor and anti-MuSK antibodies. EMG showed no evidence of peripheral neuropathy or denervation. AB testing was negative. DNA testing (serum) demonstrated a homozygous deletion of “survival motor neuron 1” (SMN1).

Final/Working Diagnosis:

1. Spinal Muscle Atrophy (SMA) type III
2. PTFS secondary to SMA

Discussion: The patient presented to our sports medicine clinic as a runner with fairly typical complaints of anterior knee pain. She indeed had PTFS, but it was secondary to an underlying, much more serious condition that took several months to workup, involving consultation with Physical Medicine & Rehabilitation and Genetics. The long-term prognosis for patients with SMA III is variable. While increasing muscle weakness is inevitable, amazingly the life expectancy for those with SMA III is no different than the general population. That said, some individuals can have progressive weakness even of muscles such as the diaphragm or may become confined to a wheel chair.

Outcome: We instituted Physical Therapy in an attempt to regain/maintain whatever proximal muscle strength we could. Amazingly, the patient did have slight improvement in her presenting complaint and was able to complete her spring, senior track season with much more tolerable anterior knee pain.

Return to Activity and Follow-Up: The patient has discontinued her long-distance running. She currently lives at home with her family and is under the care of an advanced medical team (hospital multi-disciplinary SMA clinic). She continues to be seen most frequently in our hospital system for recurring episodes of cyclical vomiting.

Not Just an Ankle Sprain

Ariel Nassim, Do, Thomas Trojian, MD

Affiliation: Drexel University College of Medicine, Philadelphia, Pennsylvania.

Case History: A 21 year old collegiate female cross country runner presented for evaluation of left ankle pain. She described rolling over her left foot on the stairs outside her house 3 weeks prior to presentation to our clinic. She described a plantar-flexed inverted foot as mechanism of injury. She initially was limping for 1 week, then saw the ATC at her university, and was presumed to have an ankle sprain. She was not improving over the subsequent 3 weeks and obtained x-rays of her left foot and ankle. She was additionally placed in a walking boot at that time. On our initial evaluation, her pain was described over the dorsal aspect of the foot and ankle. She had 7/10 pain out of the boot, and 4/10 pain while in the boot. The walking boot provided some relief, although she continued to have pain at rest.

Physical Exam: Examination of the left foot and ankle: Inspection—Pes cavus, mild swelling over calcaneocuboidal, calcaneonavicular, and talonavicular joints. Swelling over dorsum of foot, without obvious deformity, no erythema, or ecchymosis. No evidence of ankle effusion noted. Palpation—There was reproducible pain over the dorsal midfoot along the bifurcate ligament and talonavicular joint. There was no pain over the ATFL, CFL, PTFL, or Deltoid ligament. There was no other bony tenderness noted. There was no pain over the medial or lateral malleoli. There was no pain with palpation of the fibular head. ROM—There was pain free motion with ankle plantarflexion, eversion, and inversion. There is pain limiting range of motion and strength testing with dorsiflexion. Otherwise strength testing is 5/5 throughout the ankle joint. Special tests—Anterior drawer was positive for ligamentous instability, but a talar tilt test was negative for talar instability. There was a negative squeeze test.

Differential Diagnosis:

1. Anterior talofibular ligament sprain
2. Bifurcate ligament sprain
3. Talonavicular ligament sprain
4. Avulsion fracture of the talus
5. Avulsion fracture of the navicular
6. Anterior tibialis avulsion injury

Tests and Results: x-ray left foot/ankle at 1 week post injury—Apparent avulsion fracture from the superior aspect of the distal portion of the talus MSK Ultrasound of left ankle at 12 weeks revealed a small avulsion fragment at the distal talus at the attachment of the talonavicular ligament. There was no pain with sonopalpation at the distal talus or over the talonavicular ligament. MSK Ultrasound of the left ankle at 16 weeks revealed a normal appearance of the distal talus and talonavicular ligament.

Final/Working Diagnosis: Talonavicular avulsion fracture at the talus.

Discussion: This is a case of a talonavicular avulsion fracture. Our search of the literature reveals there are only a few such cases described in the literature. Additionally, we describe the ultrasound use in the evaluation of the avulsion fracture both at 12 weeks, and at 16 weeks.

Outcome: We recommended well molded short leg cast for treatment at initial diagnosis, however she insisted on a walking boot instead. We added arch support to the walking boot to limit stress over the mid-foot in boot. This produced reduction in pain in boot to 0/10. She remained in a walking boot for 8 weeks, at which point her symptoms improved, and she was instructed to begin short walking exercise and foot and ankle strengthening. We continued to recommend boot for longer walks.

Return to Activity and Follow-Up: At 12 weeks, she began a return to running protocol. At 16 weeks she was progressing in her return to running protocol. At 20 weeks, she was cleared to participate fully in running activities with her team.

When Concussion is Not Really a Concussion

Celestine Nnaeto, MD, Maheep Vikram, MD, Nicholas Crognale, DO, William McCafferty, MD, Gobindveer Sahi, MD, and Michael Jusinski, MD

Affiliation: St Luke's University Health Network Primary Care Sports Fellowship, Bethlehem, Pennsylvania.

Case History: A 17 year old high school student basketball player with history of anxiety disorder and occasional headache who presents for evaluation of concussion which he sustained after he was elbowed on the forehead during a basketball game. He did not fall to the ground. He felt dazed, mildly disoriented and developed instant headache, dizziness, nausea and 2 emetic episodes. No loss of consciousness. He initially went to the urgent care immediately after his injury where he was recommended to go to the ED. Upon arrival to the ED he reports that his symptoms have subsided. He was started on NSAIDs PRN for breakthrough headache and then referred to our service. Upon arrival to our service 3 days later, he reports intermittent headache, nausea, dizziness, photophobia, irritability, difficulty with concentration, drowsiness and sleeping more but denies any amnesia.

Physical Exam: BP: 129/81; P = 81; weight: 179 lb; Abnormal single leg stance bilaterally, abnormal backwards tandem gait with eyes open and eyes closed, positive gaze stability for dizziness after horizontal head motion. Accomdation and convergence were 10 and 8 cm. Negative Romberg's sign, normal forward tandem gait with eyes open; no past pointing, dysdiadokinesia, heel to shin impairment, or finger to nose impairment. He was AAO x3 and in normal mood.

Differential Diagnosis:

1. Concussion
2. Brain contusion
3. Epidural hematoma
4. Subdural hematoma
5. Worsened baseline headache
6. Brain tumor

Tests and Results: Brain MRI with and without contrast obtained 3 weeks after initial visit due to recurrent nausea and vomiting shows a large heterogeneously enhancing 3 × 2 × 2.5 cm mass obstructing the fourth ventricle. Severely obstructive hydrocephalus resulting in severe lateral and third ventricle dilatation, massively distended suprasellar cistern, flattening of the pituitary gland and fossa, prominent dilation of the optic sheath with CSF fluid along the optic nerves, 2.3 cm downward herniation of the cerebellum resulting in Cerebellar tonsillar ectopia/Chiari malformation. Cervical spine MRI was negative except for partially visualized cerebellar tonsillar herniation through the foramen magnum. Pathology report: Pilocytic astrocytoma. CSF cytology confirmed ventricular glioma.

Final/Working Diagnosis: Pilocytic astrocytoma.

Discussion: Over the past decade concussion injury has increased among high school athletes. Some studies has estimated concussion incidence to about 11.2/10 000 athletes exposures. Pathophysiology of concussions does not include gross intracranial pathology. Therefore brain imaging is not usually done to diagnose concussion. However, neuroimaging is an important diagnostic tool used in selected concussion cases to rule out other intracranial pathologies. There has been few case reports of incidental isolated Chiari malformations noted after someone sustained concussion but there's no reported causal effect between the two. Our patient's mechanism of injury, symptoms and physical findings during his initial presentation to the office were consistent with concussion. Therefore, no labs or neuroimaging were initially obtained. He was placed on sports/gym restriction and cognitive rest. However, during his subsequent visit(s), his physical examination improved but his nausea and vomiting slightly increased. His mother states “he is fine, has always had nausea and vomiting before so I don't know why you are making a big deal about him having concussion.” However, our clinical impression was that patient's increasing nausea and vomiting, despite improvement of his other symptoms and physical examination findings is not consistent with concussion so brain MRI was requested which confirmed brain tumor as described above. Patient underwent tumor resection and VP shunt placement. He underwent PT/OT/SLP rehabilitation.

Outcome: His overall recovery was slow with some post op VP shunt pressure complications. However, he has made a remarkable recovery.

Return to Activity and Follow-Up: He has returned to school and work part time, driving without any difficulties but not cleared for sports yet.

It's Not Always in the Knee: A Common Presentation with an Emerging Diagnosis

Steven K. Poon, MD, Henry F. Pelto, MD

Affiliation: University of Washington Sports Medicine at Husky Stadium, Department of Family Medicine, Section of Sports Medicine, Seattle, Washington.

Case History: A 46 year old otherwise healthy female was referred to sports medicine specialty clinic for evaluation of posterior right knee pain. Patient regularly participates in kickboxing and distance running. For the last year, she has not been able to pursue these activities without posterior knee ache that started insidiously. Her PCP had concern for a Baker's Cyst and ordered a MRI which did not show any meniscal damage or a popliteal cyst. She was referred for further evaluation of her unexplained knee pain. At time of presentation, the patient noted that she also developed pain in her bilateral buttocks. The pain in her buttocks and knee worsen with activity, especially running, twisting activities and kicking motions. She tried doing stretches, massage and occasional eccentric exercises at home but without formal physical therapy. The pain has progressed over the course of 1 year and she has not been able to resume her regular exercise.

Physical Exam: General: Well appearing female with pleasant affect Right knee exam: No effusion, no posterior knee swelling, joint line non-tender, normal knee ROM, Strength 5/5 with flexion and extension, negative special tests including negative McMurray's and negative Thessaly's test. Right hip: Inspection of hip with symmetric, palpable tenderness at the ischial tuberosity, negative FABER's test, negative FADIR testing, pain reproduced while patient prone with resisted hamstring contraction at 0°, 45° and 90° of flexion bilaterally. Pain with internal rotation of right leg while in prone and knee-flexed position.

Differential Diagnosis:

1. Hamstring tendinopathy
2. Piriformis syndrome
3. Ischial bursitis
4. Lumbar-sacral disc herniation
5. Referred pain from SI joint
6. Sciatic Nerve entrapment
7. Quadratus Femoris injury
8. Adductor Magnus strain
9. Malignancy

Tests and Results: Office ultrasound of right knee: No Baker's Cyst noted in posterior knee compartment. Distal hamstring muscles/tendons were intact without any abnormality. MRI Pelvis ordered to evaluate for suspected hamstring tendinopathy. Imaging showed bilateral tendinosis of the hamstring origins at the ischial tuberosity. MRI also showed significant edema of the right quadratus femoris muscle.

Final/Working Diagnosis:

1. Bilateral hamstring tendinopathy
2. Ischiofemoral impingement syndrome

Discussion: This case presented as posterior knee pain, which serves as a reminder that examination of joints surrounding the affected presenting joint should be standard in any MSK exam. Presentation of posterior knee pain with radiation invites a broad differential, as above. MRI ultimately confirmed a suspected hamstring tendinopathy, but it also revealed edema of the quadratus femoris muscle (QFM), a finding diagnostic for ischiofemoral impingement syndrome. IFI is an emerging diagnosis most often described in radiology literature and rarely in clinical sports medicine journals. It was initially reported in patients who had undergone total hip arthroplasty, but recent studies have found IFI in patients with no trauma. There is an association between hamstring tendinitis and IFI, with the sciatic nerve often compressed due to close proximity with the QFM. Early studies proposed surgical management while recent reports have shown promising results with physical therapy and anti-inflammatories or corticosteroid injections into the QFM belly for pain relief. IFI diagnosis is still not well understood with very little available guidance for treatment. Further investigations will be needed to understand the efficacy of steroid injections in larger populations, any role for PRP and comparisons between interventional and non-interventional treatment. Studies are needed to distinguish MRI findings in isolation from clinically relevant pain and identify patients prone to this injury [references available].

Outcome: Patient was referred to formal physical therapy to work on eccentric stretching and strengthening exercises, but also with focus on hip adduction.

Return to Activity and Follow-Up: Pain resolved and activity level improved significantly with physical therapy.

Eye Pain and Swelling After Basketball Injury

Eva Seligman, MD, Stephen Hoff, MD, and Brian T. Hang, MD

Affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.

Case History: A 14 year-old male presents with facial swelling and proptosis. He was struck in the face by a basketball 5 days prior to presentation. At the time of the injury, he was evaluated at a local emergency department for facial pain and swelling. He underwent imaging of the face that did not demonstrate evidence of orbital wall fracture and was discharged home with supportive care. Over the following week, he developed progressive right eye swelling, tenderness, blurry vision, and purulent nasal drainage. He denied fever or symptoms of an upper respiratory tract infection. As a result, he presented to our institution for further evaluation.

Physical Exam: He was afebrile with unremarkable vital signs. He appeared uncomfortable. The right eye was proptotic, pupil was reactive to light, sclera was injected, and he had blurred vision (at best he identified shapes and 2 fingers at 2 feet). Formal visual exam was notable for complete restriction of extraocular movements and intraocular pressure of 36 mm Hg in the right eye. The left eye was normal in appearance with a visual acuity of 20/30. No other injuries were noted.

Differential Diagnosis:

1. Orbital cellulitis
2. orbital abscess
3. orbital hematoma
4. orbital fracture and entrapment of extraocular muscles

Tests and Results: Serum studies included complete blood count with white blood cell count 10 460 cells/μL (70% neutrophils, 14% lymphocytes, 15% monocytes), hemoglobin 12.8 mg/dL and platelets 311000 cells/μL. CT scan demonstrated retrobulbar fluid and air collection with communication to ethmoid sinuses. Ophthalmology and otolaryngology teams took the patient to the operating room (OR). Culture of right eye abscess and nares grew many Streptococcus anginosus group F and many Fusobacterium species that were beta lactamase negative (pan susceptible). Pathology from OR specimens demonstrated respiratory mucosa with severe mixed inflammation, necrosis, and negative fungus stain.

Final/Working Diagnosis: Right orbital abscess secondary to orbital wall fracture with extrusion of bacteria from severe acute maxillary and ethmoidal sinusitis.

Discussion: Orbital abscess formation is a rare but serious complication of orbital fracture that is often the result of an activity-related injury in teens. If left untreated, orbital abscess can progress to cerebral abscess, cavernous sinus venous thrombosis, and permanent vision loss. Nearly all patients have evidence of pre-existing paranasal sinus infection or develop such an infection within weeks of the injury. The most common cause of abscess formation is pre-existing sinus disease that extrudes to the orbits as a result of fracture. Small or early fracture may not always be visualized on CT scan. These abscesses are typically polymicrobial. Use of prophylactic antibiotics has not been demonstrated to decrease the incidence of posttraumatic infection. At the time of injury, clinicians should take a careful history of sinus disease and allergy symptoms, advise patients to avoid forceful blowing of the nose, and review signs of infection.

Outcome: The patient was treated with 53 days of IV ampicillin-sulbactam. Right orbital proptosis and blurry vision slowly resolved post-operatively, and the patient continued to use nasal fluticasone spray and saline irrigations. He followed up with ENT and ophthalmology until full vision was restored. Repeat CT scan at 61 days after surgical intervention demonstrated resolution of sinus disease.

Return to Activity and Follow-Up: Return to activity is based on the proposed healing timeline for facial fractures (callus formation in the first month, then remodeling of bone structure). Athletes may return to light activity after 21 days, non-contact drills after 31 days, and full play after 41 days. This timeline may be extended for combat sports. Visual acuity must also improve to 20/40 or better. Patients should follow up until swelling and vision changes have resolved and antibiotics are completed.

Chest Pain In a Soccer Player

Benjamin P. Smith, MD, Wade Rankin, DO, Kelly Evans-Rankin, MD, and Sidrah Zaidi, MD

Affiliation: University of Kentucky, Lexington, Kentucky.

Case History: EG is a 32-year-old Hispanic male soccer player with no past medical history who was elbowed in the chest while chasing down a soccer ball in a city league match. Patient removed himself from play due to acute onset of chest pain. EMS was called and transported him to the ED. Nitroglycerine en route to hospital did not relieve his symptoms. Upon arrival to UK ED, patient described pain as severe, persistent and 10/10 stabbing sensation over left midclavicular line between the third and fourth intercostal space with no radiation. He had never had similar pain in the past. Patient denied headache, dizziness, palpitation, shortness of air, nausea, or vomiting.

Physical Exam: Gen: Mild distress, AAOx3 HEENT: NC/AT, PERRL, Extraocular muscles intact Neck: Supple, trachea midline CV: RRR, normal S1&S2, no murmur, tender to palpation over fourth and fifth ribs on left at costochondral junction Pulm: CTA-B, no wheezes or crackles GI: soft, nontender, nondistended Neuro: CN 2 to 12 intact grossly, conversational, sensation intact in all extremities Ext: no cyanosis or edema.

Differential Diagnosis:

1. Rib/sternal fracture
2. Acute coronary syndrome
3. Coronary artery dissection
4. Aortic dissection
5. Pulmonary embolism
6. Tension pneumothorax
7. Cardiac tamponade
8. Panic attack
9. GERD

Tests and Results: EKG: Sinus bradycardia with first degree AV block; ST elevation in leads II, III, aVF and ST depression in leads I and aVL. Troponin: 3.620 ng/mL; CK: 3092 U/L; CBC: WBC 13.6, Hg 13.6, Hct 39.3, PLT, 259; BMP: Glucose 118, K+ 4.3 CTA of thoracic/abdominal aorta: No evidence of aortic dissection; aorta patent Cardiac Catheterization: Thrombotic occlusion found in distal right coronary artery with adjacent focal dissection Troponin 3 hours: 4.570 ng/mL.

Final/Working Diagnosis: Traumatic Right Coronary Artery dissection with occlusive thrombus.

Discussion: Traumatic injury involving the chest during sporting activities should prompt concern for injury beyond the chest wall when appropriate. If suspicion for cardiovascular injury in such patients exists, further work up including electrocardiography, echocardiography, serial cardiac enzymes, and coronary angiography should be obtained. With a rapid response after traumatic chest injury this patient received an appropriate level of care which prevented lasting cardiac defects and possibly death.

Outcome: EG underwent cardiac catheterization after prompt acute coronary syndrome work up. During catheterization right coronary thrombus was found which was aspirated followed by placement of 4.0 × 23 mm drug-eluting stent. ECHO post-procedure showed EF 50% to 55% with inferior wall akinesis. He was discharged from CCU 36 hours after procedure in good condition with prescriptions for dual antiplatelet therapy with Clopidogrel 75 mg and aspirin 81 mg. The patient was advised to take make appropriate lifestyle changes in light of newfound coronary artery disease and initiated on Atorvastatin 80 mg and Lisinopril 5 mg. Beta-blocker was held due to low HR.

Return to Activity and Follow-Up: Patient returned to job in construction 2 weeks after the procedure. He continued to have intermittent chest discomfort associated with activity after the procedure for which he was using nitroglycerine with relief of symptoms. Approximately 2 months post-procedure, he presented to the ED and was admitted for observation for left sided chest pain described as same character and severity of pain endured at time of original event. ECG showed no ST changes and troponins were negative after a 9 hours trend. He was ultimately discharged with no intervention. Three months after the event the patient continues to complain of fatigue after full day of work in construction. He also complains of occasional chest pain. He will undergo stress testing and ECHO on November 9, 2015. He has not returned to soccer.

Twist and Shout: That's No Ankle Sprain!

Elizabeth M. Spero, MD, Khaliliah Q. Clarke, MD

Affiliation: John Peter Smith Hospital, Fort Worth, Texas.

Case History: Patient is a 16 year old AAM high school football player who complained of left medial ankle pain after coming out of the game. He did not report a specific injury at the time and immediately returned to play. After completion of the drive he walked off the field full weight bearing but complained of increasing left ankle pain. On sideline evaluation patient stated he had forced eversion due to another player rolling on him. He reported no prior foot or ankle injuries but did state that he would occasionally have foot pain during the volleyball season 1 year ago. On review of game film it was noted that the athlete attempted a tackle and was forced into eversion and dorsiflexion of his left ankle which was his planting foot during change of direction. No direct contact was seen.

Physical Exam: Left ankle: No erythema, ecchymosis, swelling, effusion. Mild TTP over deltoid ligament, NTTP over medial and lateral malleolus, ATFL, CFL, Achilles tendon, calcaneus, navicular or fifth metatarsal. Anterior drawer test negative. Hoffman's Negative. Pain with resisted inversion. No pain with passive ROM. After exam patient reported unable to bear weight and significant increase in pain to the medial ankle. Patient placed NWB on axillary crutches and next day clinic Follow-up given.

Differential Diagnosis:

1. Deltoid ligament sprain
2. Distal tibia fracture
3. Ligamentous injury
4. Syndesmotic injury
5. Talar fracture
6. Navicular fracture
7. Posterior tibialis strain

Tests and Results: Initial left ankle AP and lateral x-rays were obtained: no acute fractures or dislocation shown. Patient was treated as a medial ankle sprain. He was placed in a boot and ambulated full weight bearing without pain. Started gentle ROM exercises. One week follow-up in the training room patient with significant increase in deep posterior heel pain and was unable to weight bear on his left foot. Due to worsening symptoms and lack of improvement of an ankle sprain the decision was made to obtain a MRI. MRI showed a minimally displaced intraarticular sagittally oriented fracture along the medial aspect of the calcaneus through the base of the sustentaculum tali with articular communication to the subtalar joint and medially aspect of the calcaneocuboid joint.

Final/Working Diagnosis: Calcaneus fracture with minimal displacement of the sustenaculum tali.

Discussion: Approximately 1% to 2% of all fractures are of the calcaneus, 70% to 75% being intraarticular fractures. Majority of calcaneal fractures are due to axial loading of the foot after a fall from height or jump. Due to the severity of the mechanism of injury typically these fractures are associated with other fractures and have evident swelling, tenderness and inability to weight bear. Sustentaculum Tali fractures are very uncommon and most commonly occur due to high energy trauma. This patient has a unique mechanism of injury with a low energy trauma to sustain a fracture of the sustentaculum tali with minimal displacement. At this time, there is no documented report of a sustentaculum tali fracture due to a non-contact eversion injury.

Outcome: Patient is currently in a short-leg cast and non-weight bearing for 2 weeks.

Return to Activity and Follow-Up: Final return to play status undecided at this time.

An Unusual Case of Chronic Foot Pain

Brett Wilhoit, MD, Ricardo Colberg, MD

Affiliation: American Sports Medicine Institute, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama.

Case History: A 19-year-old female presents for evaluation of right foot pain that started nearly 2 years ago after she was stepped on by a horse. She had moderate-to-severe sharp aching pain that has progressed and worsened. She notices it now when she is standing for prolonged period of time, but gets better with sitting and resting. She does feel weakness associated with the pain but denies any numbness or tingling. She is a nonsmoker. Symptom has been recalcitrant despite rest and activity modification. Three views of the right foot were obtained that showed periosteal erosion on the lateral side of the second metatarsal head. There was severe periosteal erosion on the medial and lateral sides of the third metatarsophalangeal joint, both on the metatarsal sides and proximal phalanx side. The articular surface was intact. Medications: Medroxyprogesterone IM, Zyrtec and Advil prn Medication allergies: none Past Medical History: Celiac Disease Surgical History: Tympanostomy tubes 1997 Family History: HTN, HLD and Diabetes Social History: High school student that denies any alcohol, tobacco or drugs. Review of Systems: No rash, fevers, edema, vision change, chest pain, dyspnea, weight change or bleeding.

Physical Exam:

1. Constitutional: VSSAF, NAD
2. Skin: No rash or lesions noted on the trunk, upper or lower extremities.
3. Vascular: No swelling, symmetric DP and PT pulses in bilateral lower extremities.
4. Left foot: No atrophy. No discoloration. No deformity. No swelling. Severe tenderness over the second and third metatarsophalangeal joint lines. No crepitation. Range of Motion: 50° plantarflexion. 20° dorsiflexion. 25° eversion. 35° inversion. Negative anterior drawer. Negative Laxity with inversion talar tilt. Negative squeeze. Strength: 5/5 plantarflexion. 5/5 dorsiflexion. 5/5 eversion. 5/5 inversion. No pes planus. No ankle valgus.
5. Right ankle/foot: No atrophy. No discoloration. No deformity. No swelling. No tenderness to palpation. No crepitation. Range of Motion globally symmetric. Negative anterior drawer. Negative Laxity with inversion talar tilt. Negative squeeze. Strength: 5/5 plantarflexion. 5/5 dorsiflexion. 5/5 eversion. 5/5 inversion.

Differential Diagnosis:

1. Stress fracture
2. Osteomyelitis
3. Gout
4. Juvenile rheumatoid arthritis

Tests and Results: CT revealed marginal erosive changes involving the third metatarsal phalangeal joint with associated joint effusion. Tiny foci subcutaneous gas seen along the dorsum of the foot at the level of the third MTP joint without associated subcutaneous stranding. Labs: CRP, <0.29; ESR, 9; CCP, Ab-negative; RA, factor-negative. White blood cell count is 5.5; hemoglobin, 11.2; hematocrit, 36.4; and platelets, 285. HLA-B27 positive.

Final/Working Diagnosis: Psoriatic Arthritis.

Discussion: Psoriatic Arthritis is an HLA-B27 associated inflammatory arthritis that is often precipitated by an acute traumatic event and causes characteristic erosions at the distal interphalangeal joints. Erosive joint disease occurs in 40% to 60% of these patients, and nearly 20% will develop severe destructive arthritis. The patient and family were educated about her diagnosis and initially treated with an ultrasound guided corticosteroid injection of the second MTP joint for acute modulation of her pain and inflammation. In addition, the right foot was stabilized in a CAM walking boot for 4 weeks and referred to physical therapy while she awaited Rheumatology referral. Her symptoms improved but will likely not significantly improve until she is started on a DMARD agent (disease-modifying antirheumatic drug). The patient was also referred to GI for further consideration of her chronic gastrointestinal complaints in light of her new diagnosis and positive HLA-B27 marker.

Outcome: Patient was evaluated by Rheumatology who agreed with her diagnosis of Psoriatic Arthritis. The plan is to start her on Entanercept once insurance approval is obtained.

Return to Activity and Follow-Up: Close observation will be required for monitoring of disease progression as well as medication side effects.

An Unusual Cause for Wrist Pain in a Rower

Reed C Williams, MD, Sean Colio, MD

Affiliation: Swedish Spine, Sports and Musculoskeletal Center, Seattle, Washington.

Case History: A 15-year-old female competitive rower presented with 1 year of persistent and progressive right, volar, wrist pain. It was described as achy and dull, graded a 1 out of 10 at rest, and exacerbated to a 3 out of 10 with activity; specifically rowing. Gripping her pencil in school and other grip-based actions produced these symptoms. She reported feelings of intermittent grip fatigue, cramping and twitching around a lump in the volar wrist. The mass has been enlarging over the past year. There was no prior wrist injury. She modified her rowing technique and grip but was unsuccessful in reducing her symptoms. Refraining from rowing alleviated her symptoms.

Physical Exam: On inspection there was a protruding mass on the volar right wrist about 3 cm proximal to the wrist crease, absent on the left. It measured 2 cm in length and 1 cm in width. It was soft, non-tender, and non-pulsatile. Strength testing was 5/5 in the wrist and fingers. The mass enlarged during opposition of her thumb to fifth digit and simultaneous wrist flexion. Fatigue and pain in the hand were reproduced by this action. Sensation over the median and ulnar nerve distributions was normal and symmetric.

Differential Diagnosis:

1. Focal dystonia
2. Accessory muscle
3. Ganglionic cyst
4. Tendon sheath cyst
5. Neoplastic lesion
6. Soft-tissue pseudo-tumor (Lipoma, Leiomyoma)

Tests and Results: MRI noted mild median nerve irritation within the carpal tunnel and a 6 × 3 × 7 mm volar radiocarpal ganglion cyst, however the mass in question was not identified. Diagnostic MSK ultrasound (US) evaluation revealed the mass to have an echotexture of skeletal muscle. It lay adjacent to the flexor carpi radialis over the median nerve and flexor digitorum superficialis, and inserted into the transverse carpal ligament. Scanning proximally, this muscle was identified as a reversed palmaris longus (RPL) or palmaris inversus. Dynamic US evaluation showed the muscle belly to contract with wrist flexion directly over the median nerve proximal to the carpal tunnel.

Final/Working Diagnosis: Reversed palmaris longus (RPL) with dynamic median nerve compression during muscle contraction.

Discussion: The palmaris longus is a vestigial flexor of the wrist (absent in 11.2% of the population) and is one of the most variable muscles in the forearm, with an overall incidence of anomalies of 9%. Occasionally, the muscle belly lies distally with a long proximal tendon, resembling a reversed palmaris. The distal muscle belly can cause a mass effect on the underlying flexor tendons and median nerve leading to a dynamic effort-related median nerve compression during muscle contraction.

Outcome: At 3 months post-Botox injection she reported decreased pain, fatigue and cramping while rowing along with 70% improvement in her strength and endurance during rowing. Her symptoms at rest resolved. Follow-up musculoskeletal US at 3 months showed muscular echotexture consistent with chemodenervation atrophy and confirmed the RPL had decreased in size, reducing circumferential surface area from 0.44 cm² to 0.3 cm² and length from 1.72 cm to 1.5 cm.

Return to Activity and Follow-Up: She returned to competitive rowing in starboard position 1 week post Botox injection. She plans to continue competitive rowing and repeated the Botox injection 4 months after the first injection. Follow-up will occur 3 months from this second Botox injection to reassess her symptoms and muscle size on US.

Why Am I'm Laughing A Lot Over Nothing

John J. Wilson, MD, Michael Moll, ATC, and Jeremy Johnson, MD

Affiliation: Department of Orthopedics, University of Wisconsin, Madison, Wisconsin.

Case History: A previously healthy 20-year-old white male collegiate football player (offensive line) presented with headache and blurry vision 2 days following a game during which he suspected he sustained a concussion. No prior history of concussions, headaches, or learning disabilities. He reported receiving a blow to the side of his head while blocking for a field goal attempt, and felt “dizzy” for a brief moment after the hit. Headache was relieved with Ibuprofen. Initially treated per institution concussion protocol with cognitive and physical rest. On sixth day post-injury, athlete contacted athletic training staff via text message, “I feel uncoordinated and small motor movements are hard. I can't write or text well. I am having trouble doing stairs. I am laughing a lot over nothing.” Athlete presented to athletic training facility for re-evaluation. Athlete was referred emergently to Emergency Department for Neurology evaluation and imaging following his training room examination.

Physical Exam: Day #2 to Day #4 Post Injury: Glasgow Coma Scale 15 Alert and Oriented. Normal speech and affect. Cranial nerve testing, balance testing, coordination, cognitive testing normal. ImPACT testing normal. Reported a total SCAT3 symptom score of 18 on Day #2, 7 on Day #3 and 16 on Day #4 (athlete reported increased symptoms with walking, return to classes). Day #6 Post Injury: Afebrile, Normal vital signs. Alert and oriented × 3. Speech is slurred. Abnormal affect, laughs inappropriately. Gait and tandem gait are antalgic, ataxic. Difficulty with stair stepping. Normal cranial nerves. Normal strength, muscle tone, and sensation in all extremities. Decreased fine motor coordination, worse on right. Dysdiadochokinesis present. SCAT3 symptom score 14, penmanship notably worse.

Differential Diagnosis:

1. Concussion
2. Intracranial mass
3. Ischemic infarct
4. Intracranial hemorrhage
5. Atypical migraine

Tests and Results: CT Head: recently hemorrhage of mid-pons cavernoma with mild cerebral edema with brainstem compression MRI/MRA Head and Neck: multiple cavernous malformations, large 2.5 cm transverse diameter pontine lesion with surrounding edema.

Final/Working Diagnosis: Hemorrhagic Central Pontine Cavernoma.

Discussion: Cavernomas are abnormal cerebral cavernous malformations found in the brain and brainstem. Cavernomas may bleed spontaneously, or due to head trauma. Risk of re-bleeding varies widely (<1%-23% annually) and is difficult to predict. Brainstem cavernomas may carry higher risk of hemorrhage. There is a paucity of literature to help guide return-to-play decision making in contact-sport athletes.

Outcome: Athlete was admitted to neurology service for close neurologic monitoring and observation. Athlete remained stable, no interventions were recommended. Athlete was discharged with close follow-up in outpatient setting. Referred for intensive outpatient physical therapy, speech therapy, and occupational therapy.

Return to Activity and Follow-Up: Athlete was disqualified from future participation in football, retired from sport.

An Unusual Case of Exertional Leg Pain in a Cyclist

Carmen Wong, MD, Michelle Pepper, MD

Affiliation: University of Colorado, Aurora, Colorado.

Case History: A 39 year old cyclist presented to a sports medicine clinic with complaints of progressive intermittent right foot pain which progressed proximally to the thigh with mild discomfort with exertion over the prior 6 months. Initially the pain was present only after aggressive mountain biking. Over the course of the preceding week, however, her symptoms had progressed to pain in the thigh after walking up 1 flight of stairs. She described the pain as a sensation that her “thigh was going to explode.” She also stated that her leg felt numb/cold after cycling for a few minutes. Her past medical history was significant for hypothyroidism on levothyroxine. Medications include oral contraceptives. She denied tobacco use, cardiovascular disease, diabetes, and hypertension and worked as a family physician.

Physical Exam: She is 5′3″ and weights 115 lbs. She has full range of motion of bilateral hips without pain and strength and sensory testing. There are diminished femoral, posterior tibial and dorsalis pedis pulses on the right. After less than 5 minutes of cycling, she had reproduction of her symptoms, with her physical exam demonstrating pallor of the right foot with absent dorsalis pedis and posterior tibial pulses. Femoral pulse was present but diminished to palpation on the right.

Differential Diagnosis:

1. Neurogenic claudication
2. Vascular claudication
3. Chronic exertional compartment syndrome
4. Medial tibial stress syndrome
5. Stress fracture
6. Deep vein thrombosis
7. Popliteal artery entrapment

Tests and Results: ABI's were 0.63 (right), indicating moderate arterial insufficiency and 1.32 (left), indicating normal perfusion. The duplex ultrasound evaluation of the right lower extremity demonstrated right external iliac artery occlusion with collateral reconstitution of the femoral and popliteal arteries. There were also findings suggestive of a distal right posterior tibial artery occlusion. She subsequently underwent angiography, revealing an occlusion of the right external iliac artery with reconstitution via internal iliac collaterals. Segmental occlusion of the tibial vessels of the proximal calf were also present, revealing embolization to the tibial arteries from the more proximal external iliac artery lesion.

Final/Working Diagnosis: External iliac endofibrosis with acute superimposed thrombosis.

Discussion: External iliac artery endofibrosis that was first described in competitive cyclists, however this condition has also been described in running, speed skating, triathletes, and soccer with no defined prevalence. It may also be complicated by an overlying thrombus, as in this patient, or with dissection and atherosclerosis as well. This patient underwent bypass of the internal iliac to the external iliac artery. Intra-operatively, she was found to have a large fibrotic occlusion of the external iliac artery with thrombus propagating to the internal and circumflex iliac arteries proximally and distally. Thrombectomy of this region was performed.

Outcome: She had well palpated distal pulses immediately post-intervention. Post-op day 4 ABI revealed 1.26 (left) and 1.12 (right) and post-op ABI 4 months after intervention revealed 1.12 (left) and 1.16 (right). She was able to walk on a treadmill with increasing speed intervals without symptoms of claudication. She discontinued oral contraceptives after diagnosis, but did not receive a hypercoagulable workup. She underwent follow-up duplex ultrasound and ABIs every 2 years between 2011 and 2015, revealing stable and patent graft without narrowing over time, as well as ABI's within normal range.

Return to Activity and Follow-Up: She returned to pre-surgery activity over the course of 6 months. At 2 week follow-up, she was cleared to resume swimming and running, but continued to be restricted in lifting less than 5 lbs for an additional 6 weeks. She returned to cycling gradually, starting with running indoors, indoor elliptical and cross training over the course of 3 to 6 months. After 6 months, she returned to outdoor recreational cycling, cycling 2 to 3 days a week 1 to 2 hours at a time, and not participating in races.

Right Elbow Pain in an Adolescent Teenage Baseball Player

Ryan Woods, MD, Karen Newcomer-Aney, MD

Affiliation: Mayo School of Graduate Medical Education, Rochester, Minnesota.

Case History: A 15-year-old right-hand dominant male baseball player presents with right elbow pain following injury while throwing a dodgeball during gym class. Patient felt a pop in the posterior aspect of his elbow that was associated with pain but no swelling or ecchymosis. He presented to the Emergency room. X-rays were negative and a sports medicine follow up scheduled. At his follow up he endorsed increasing discomfort with any attempts to throw a baseball following his injury. He was pain free at rest, with no paresthesias or associated weakness. His exam was unremarkable. Given his vague presentation conservative management was recommended and his pain improved with activity modification. Patient was doing well but returned to sports clinic two months later after reinjuring his elbow again throwing a dodgeball. He experienced a sharp pain over the right anterior lateral elbow with associated tingling into the fingers. Symptoms resolved but were provoked again and remained persistent during his acceleration phase of throwing a baseball. Rehab was unsuccessful, and he continued to have persistent pain and paresthesias localized over anterior lateral elbow and into the ulnar nerve distribution of the hand respectively. At this point, patient had been seen multiple times in clinic with vague symptoms. On his third follow up appointment to the Sports clinic an MRI was performed for further evaluation.

Physical Exam:

1. General: Well-developed, no acute distress.
2. Musculoskeletal: No swelling. Examination of the elbow demonstrated tenderness over intact distal biceps tendon, radial capitellar joint and discomfort over the insertion of the triceps tendon. He also experienced tenderness of the ulnar nerve with a positive Tinel's sign at the cubital tunnel. Elbow displayed normal range of motion with pain on resisted extension from the fully flexed position. Ulnar nerve did not subluxate. Ulnar nerve examination distally was normal. No paresthesias on exam. Valgus stress was normal. Moving valgus stress was negative. Neurological: Intact strength throughout bilateral upper extremities in proximal and distal groups.

Differential Diagnosis:

1. Ulnar neuritis/neuropathy secondary to compression in the cubital tunnel
2. Biceps tendonitis/tendinopathy
3. Lateral epicondylitis
4. Medial epicondylitis
5. Intraarticular elbow abnormality (ie OCD lesion)
6. Ulnar collateral ligament injury

Tests and Results:

Right Elbow X-ray:

1. No right elbow fracture or dislocation. Normal radiocapitellar and ulnotrochlear articulations. No elbow joint effusion. Right Elbow MRI
2. Small accessory anconeus epitrochlearis muscle causing slight mass effect and associated T2 hyperintensity of the ulnar nerve within the cubital tunnel. Right elbow MRI is otherwise negative.

Left Elbow MRI:

1. Negative for accessory anconeus epitrochlearis muscle. Evidence for T2 hyperintensity of the ulnar nerve within and proximal to the cubital tunnel.

Final/Working Diagnosis: Anconeus epitrochlearis avulsion causing compression of the ulnar nerve in cubital tunnel.

Discussion: Orthopedics was consulted following MRI evidence of anconeus epitrochlearis causing compression of ulnar nerve. Patient underwent right ulnar nerve decompression and transposition with release of anconeus epitrochlearis muscle. Operative reports demonstrated adhesions between undersurface of the epicondylar end of the epitrochlearis muscle and ulnar nerve. The muscle was contiguous with the olecranon but not with the epicondyle. During flexion, the nerve appeared to be tethered by these adhesions. It was determined that the pop the patient heard was likely the avulsion or partial avulsion of the anconeus muscles which resulted in scar tissue formation with subsequent ulnar nerve adherence and compression.

Outcome: Complete pain resolution post operatively.

Return to Activity and Follow-Up: Full strength and pain free range of motion at follow up appointment. He was allowed unrestricted return to play 3 weeks following surgical release of anconeus muscle with associated ulnar nerve decompression and transposition.

Peculiar Hip Pain in a Post-Pubescent Athlete

David Woodson, DO, Lara Quinlan, MD

Affiliation: VCU-Riverside Family Medicine Residency, TPMG Orthopedics, Spine and Sports Medicine, Newport News, Virginia.

Case History: A 18-year-old male presented with progressively worsening, bilateral, non-radiating, aching hip pain for 4 months duration. There was no inciting injury. Symptoms aggravated with weight-bearing activity and hip flexion and alleviated with ibuprofen and hydrocodone. Patient denied fever, warmth, erythema, ecchymosis, clicking, locking, popping, slipping, snapping, crepitus, grating, grinding, numbness, paresthesia, weakness. Patient played high school basketball, however now plays occasional pick-up basketball but follows no regular exercise regimen. Patient admits chronic knee pain and personal history of sickle cell trait. Patient denies tobacco, alcohol, or illicit drug use.

Physical Exam: Visual inspection normal. Gait antalgic requiring crutches for ambulation. Leg lengths grossly equal. Pain-limiting active range of motion; passive range of motion relatively full and symmetrical but painful with internal rotation. Muscle strength full and symmetrical with hip and knee flexion and extension and hip abduction and adduction. No tenderness to palpation at greater trochanter, gluteal or sacroiliac region bilaterally; mild bilateral iliopsoas tenderness. FABER and Ober's test negative bilaterally; FADDIR, log roll, and scour test positive bilaterally. Neurovascular exam intact. BMI 21 to 23.

Differential Diagnosis:

1. Femoroacetabular impingement
2. Synovitis
3. AVN
4. Osteochondritis dessicans
5. Acetabular dysplasia
6. Legg-Calve-Perthes
7. Slipped capital femoral epiphysis

Tests and Results: AP pelvis, frog-leg, and lateral plain films showed symmetrical findings with bilateral tiny broad osseous bump at the superior lateral femoral head-neck junction and small, well-corticated ossific fragments adjacent to the lateral acetabular rim; no fracture, dislocation, suspicious lesion; joint spaces symmetrical and maintained; pelvic ring intact; unremarkable SI joints and soft tissues. Pelvic MRI without contrast (March 30, 2015) showed small foci of alteration in subchondral signal and minimal surrounding marrow edema, right more prominent than left; edematous signal 1.5 to 2.0 cm in diameter; well-rounded femoral heads with preserved joint spaces; no paraosseous abnormalities. Repeat pelvic MRI without contrast (July 14, 2015) showed 1.4 × 0.7 cm area of decreased signal intensity in the right femoral head with increased surrounding edema and slight focal subchondral collapse; 7 × 6 mm area of decreased signal intensity in the left femoral head with surrounding edema and no subchondral collapse; no effusion or significant arthritic changes; otherwise normal osseous and muscular structures.

Final/Working Diagnosis: bilateral AVN of the femoral heads, acetabular dysplasia with underlying CAM type FAI.

Discussion: This patient presents a peculiar case of hip pain. MRI findings indicatate progressive bilateral femoreal head AVN; however, the pateint does not fit the typical presentation with regards to age or risk factors. He is past the expected age range for idiopathic AVN of the femoral heads. He has no known exposure to glucocorticoids, alcohol, or radiation therapy; nor does he have a history of lupus, HIV, thromophilia, Gaucher's disease, or organ transplantation. Although a history of athletic competition hints toward the possibility of injury as an inciting event, there is no history of trauma. Additionally, the patient has sickle cell trait but not disease. Thus, no definitive cause for his AVN has been found.

Outcome: Patient remains moderately compliant with activity restrictions. Follow up pending with orthopedic surgery for possible hip arthroscopy or acetabular retroversion correction/pelvic osteotomy. Pain is improved but still present without NSAIDs.

Return to Activity and Follow-Up: After discovery of bilateral AVN, the patient was referred to orthopedic surgery at a local academic center and minimal weight-bearing with symtomatic treatment was recommended. Initial surgical evaluation agreed with continued minimal weight-bearing for 3 months followed by repeat MRI. Given findings on repeat MRI, patient was referred for a second surgical opinion which believed acetabular dysplasia was the primary underlying cause of patient's findings. A third opinion was sought and concurred that acetabular dysplasia is likely at fault. Six additional weeks of conservative management was recommended. Patient currently attends nursing school. Activity restrictions remain, and he is still using NSAIDs.

Not So Funny Elbow Pain

Derek Worley, MD, Dean Padavan, MD, Damion Martins, MD, Hsiu Su, MD, and Danielle Palestina, ATC

Affiliation: Atlantic Sports Health, Morristown, New Jersy.

Case History: A 16 year old right hand dominant baseball player presents to the clinic with 2 years of left sided elbow pain. He had previously undergone 6 weeks of physical therapy with no improvement of symptoms. Described the pain as 5/10 in intensity, located along the medial, anterior, and posterior aspects of the elbow. The pain is throbbing, wakes him up at night, and worsens with applied pressure. The pain is also worsened by swinging a bat. Pain is relieved by applying ice directly onto elbow. He also notes less pain when actively using the joint. Denies prior injury to the elbow. Denied erythema, swelling, warmth, or burning sensation in the elbow. Noted occasional tingling radiating distally along ulnar aspect of forearm. ROS: Negative unless otherwise noted in HPI. PMH: None. PSH: None. Medications: None.

Physical Exam: BMI: 22.4. General: well-developed, well-nourished. Musculoskeletal: Neck: supple, full range of motion, no cervical tenderness, negative Spurling's test. Left shoulder: Normal ROM, no tenderness, 5/5 strength. Left Elbow: No swelling, erythema, gross deformities, or muscle wasting. Tenderness on medial epicondyle and radiocapitellar joint. Normal sensation in ulnar, median, and radial distributions. Range of Motion: flexion: 140°, extension: 10°, supination: 80°, pronation: 75°. Strength: 5/5 flexion and 5/5 extension. Reflexes: 2/4 biceps, 2/4 triceps, 2/4 brachioradialis. Special Tests: varus: negative, valgus: negative, tinel's sign: positive at medial epicondyle, resisted wrist extension: negative, resisted wrist flexion: negative, no pain with repetitive elbow flexion and extension, noted hypermobility fingers and elbows, and Froment's Sign: negative.

Differential Diagnosis:

1. Cubital tunnel syndrome
2. Ulnar nerve neuropathy
3. Osteochondral defect
4. Valgus extension overload syndrome
5. Triceps tendonitis

Tests and Results: X-Ray Left Elbow: No acute fracture, dislocation, or effusion. MRI Left Elbow without Contrast: Intermediate signal intensity lesion seen along the medial aspect of the olecranon posterior to the humerus which measures 1.2 × 1.4 × 3.2 cm causing mass effect on the ulnar nerve as it passes posterior to the humerus.

MRI Left Elbow With and Without Contrast: Well-circumscribed, soft tissue structure posterior to the medial epicondyle which abuts the ulnar nerve in the cubital tunnel. Signal intensity is identical to muscle on all sequences and demonstrates no enhancement following administration of IV contrast. Findings consistent with an accessory muscle, specifically the anconeus epitrochlearis.

EMG Left Arm: Normal electrophysiological findings. No evidence of focal compression of ulnar nerve at the elbow.

Final/Working Diagnosis: Cubital tunnel syndrome secondary to anconeus epitrochlearis compression of the ulnar nerve versus pain from the anconeus epitrochlearis muscle.

Discussion: Medial elbow pain is reported in 18% to 69% of overhead athletes between the ages of 9 and 19. Likely due to valgus stresses focused on the medial side of the elbow. The anconeus epitrochlearis muscle is superficial to the ulnar nerve and attaches from the inferior surface of the medial epicondyle to the medial cortex of the olecranon. Similar anatomic course as the cubital tunnel retinaculum, therefore it is postulated that the muscle may be a remnant. Reported prevelance ranges from 4% to 34% in cadaver studies. Exists in both elbows in ∼25% of patients with cubital tunnel syndrome.

Outcome: Failed 6 to 8 weeks of conservative management with physical therapy and NSAIDs. Referred for surgical consultation. Underwent anterior transposition with neurolysis of ulnar nerve. Anconeus epitrochlearis muscle left intact. Small layer of subcutaneous fat was used to hold the ulnar nerve in its transposed position. Resolution of symptoms within 1 week of surgery. Given resolution of symptoms with transposition of ulnar nerve and no removal of anconceus epitrochlearis muscle, final diagnosis likely cubital tunnel syndrome secondary to compression of ulnar nerve by anconeus epitrochlearis.

Return to Activity and Follow-Up: Physical therapy post-operative. Cleared to resume overhead activities 6 weeks after procedure with no restrictions.

Baastrup's Disease in an Elite Rhythmic Gymnast

Katherine V. Yao, MD, James F. Wyss, MD, PT

Affiliation: New York Presbyterian Hospital, University Hospital of Columbia & Cornell, New York, New York.

Case History: A 16-year-old elite female competitive rhythmic gymnast presents with acute on chronic low back pain. Her pain began 5 months ago insidiously over her gymnastics practices. She had been treated with physical therapy successfully in the past. She recently experienced a recurrence of severe sharp low back pain with some radiation down the right leg with spine extension during a competition. Her pain is described as located in the mid-lumbar spine and mid-sacral regions with minimal radiation down the legs, exacerbated by gymnastics practice and sitting, and improved with physical therapy. She has no weakness, numbness or tingling of her lower extremities.

Physical Exam: The patient is a healthy-appearing 16 year-old with normal spine alignment and curvature on inspection. Lumbar spine range of motion is full in all planes except limited in extension to 15° due to pain. Left side bending and left oblique extension also reproduce pain at the midline L4-5 and S1 levels. There is interspinous tenderness to palpation at the L4-5 level and superior aspect of the sacrum. Her hip range of motion is full and painless. Neurologic exam reveals a non-antalgic gait. Her strength is 5/5 in all lower extremity myotomes except 4+/5 with right side hip abduction, ankle dorsiflexion and extensor hallucis longus extension. Sensation is intact in all lower extremity dermatomes and reflexes are 2+ in the patella and achilles bilaterally. There are no dural tension signs.

Differential Diagnosis:

1. Herniated lumbar discs
2. Diskitis
3. Facet arthopathy
4. Spondylolysis
5. Spondylolisthesis
6. Pars interarticularis injury/fracture
7. Spinous process fracture
8. Inflammatory arthropathies
9. Muscle Strain
10. Myofascial pain

Tests and Results: XRAY lumbosacral spine: normal soft tissue bony anatomy with minimal dextroscoliosis curvature of the lumbar spine without fractures. MRI of the lumbar spine: L4-5 right central to foraminal protrusion with mild impingement of the right L5 nerve root, L4-5 degenerative disc changes and circumferential disc bulge causing mild central stenosis, minimally degenerated facet joints. EMG of the lower extremities: normal findings including no evidence of lumbar radiculopathy or sciatic neuropathy. Bone Scan: negative for stress reaction/spondylolysis. Epidural Steroid Injection to the Right L5 and S1 levels: no lasting pain relief. Facet joint steroid injections to the bilateral L4-5 levels: no pain relief. Repeat MRI of lumbar spine: Hyperintensity noted at the interspinous ligaments and surrounding spinous processes at L4-5 and L5-S1 levels.

Final/Working Diagnosis: Baastrup's disease at the L4-5 and L5-S1 levels.

Discussion: Baastrup's disease is a condition of pathologic changes in the lumbar spine involving adjacent spinous processes and the soft tissues between them. The disease usually results from a degenerative process related to repetitive straining of the interspinous ligament typically affecting the elderly population. Our case demonstrates an atypical manifestation of the disease, occurring in a young active female with history of excessive strain on posterior elements of her spine through gymnastics training.

Outcome: The patient received a diagnostic fluoroscopy-guided percutaneous interspinous ligament injection with 2% lidocaine at L3-4 and L4-5 levels. The following week she returned for a therapeutic injection with 2% lidocaine + 20 mg triamcinolone at the same levels. She had immediate relief of pain after receiving the diagnostic lidocaine injection to the L3-4 and L4-5 levels with improvement of lumbar extension by 10 to 20° within 30 minutes post-procedure. She had pain relief following the therapeutic injection with lidocaine + triamcinolone for 3 to 4 months.

Return to Activity and Follow-Up: The patient was able to have a gradual return to gymnastics training following her injection treatment with concomitant physical therapy treatment within 2 weeks.