Lateral Ankle Pain in a Female Runner—An Under Diagnosed Etiology
Primary Author/Presenter: Colleen Maher, DO
Austin Klomp, DO, and Kathryn Vidlock, MD
Affiliation: HCA HealthONE Family Medicine Residency, Aurora, Colorado.
History: A 48 year-old female presented to the clinic with a chief complaint of right ankle pain for several months. The pain was localized to the lateral aspect of the ankle, was described as aching, and was rated moderate in severity. Pain was worse with exercise, particularly running. There was no associated numbness, tingling, swelling, redness, ecchymosis, popping, clicking, buckling, grinding, or instability. Patient had not tried physical therapy (PT) or injections. Her only past medical history was hypothyroidism. Patient had a ganglion removed from her lateral right talus approximately 3 years prior with residual catching over the lateral aspect of her ankle. Prior MRI imaging demonstrated scarring over the peroneal tendons. She had seen several orthopedic surgeons who suggested surgery to debride the scar tissue, but she declined as she was worried about recurrence.
Physical Exam: General: Healthy-appearing, no acute distress, normal body habitus, normal gait, no limp, ambulating without assistance devices, single limb heel rise. Cardiovascular: Posterior tibial and dorsalis pedis pulses normal bilaterally. No edema or varicosities bilaterally. Normal capillary refill bilaterally. Ankles and feet: No erythema, induration, swelling, warmth or deformity bilaterally. No tenderness of the bony, soft tissue, or ligamentous structures bilaterally. Active range of motion limited to 20 degrees of plantar flexion on the right. Negative anterior drawer and talar tilt bilaterally. 4/5 strength of the peroneus longus, peroneus brevis, and posterior tibialis on the right.
Differential Diagnosis:
1. Chronic exertional compartment syndrome
2. Fibular stress fracture
3. Cuboid stress fracture
4. Sural nerve entrapment
5. Achilles tendinitis
Test Results: Ultrasound: intact peroneus longus and brevis tendons without tearing or subluxation. Scar tissue throughout, specifically surrounding the sural nerve. MRI: posterolateral subcutaneous, fascial, and Kager's fat pad scarring with slight subcutaneous tissue and surrounding nerve retraction with concern for nerve entrapment. Mild peroneus longus tendinosis without tear and flattening of the peroneus brevis without tear. No peroneal tenosynovitis. Mild distal achilles tendinosis without tear.
Final Diagnosis: Sural nerve entrapment.
Discussion: Given its superficial location, the sural nerve is a common site for peripheral nerve biopsy, grafting and as a block for general anesthesia. However, the superficial location also predisposes to injury and entrapment. Entrapment is most commonly due to fascial thickening at the superficial sural aponeurosis where the nerve runs superficially to the gastrocnemius. In the literature, sural nerve entrapment is described as rare, however this is thought to be due to underdiagnosis. While surgical intervention for decompression via fascial release is an option, a less invasive option of ultrasound guided hydrodissection can provide significant symptom relief and allow for return to activity.
Outcome: The patient did PT for Graston and dry needling therapy. After 4 weeks, she returned with improved flexibility and balance, but no change to her pain when exercising. She underwent successful ultrasound-guided hydrodissection of the sural nerve with 3 mL of 1% Lidocaine and 1 mg of Dexamethasone. She used crutches as needed for 2 weeks. On re-evaluation, her symptoms had significantly improved.
Follow-Up: The patient was able to return to all of her normal activities including her prior vigorous running routine. She has been able to run several local races and has remained pain-free at all subsequent follow ups.
A Case of Severe, Intermittent Left Gluteal Pain
Primary Author/Presenter: Michelle Gorbonosov, MD
Jill Kropa, MD, and Jason Womack, MD
Affiliation: Rutgers Robert Wood Johnson University Hospital, Family Medicine Residency, New Brunswick, New Jersey.
History: A 46-year-old male was referred to the sports medicine clinic for 7 years of left gluteal pain. The pain was intermittent, radiated down the left leg, and woke him up at night. The pain was triggered when pressure was applied to his left gluteal muscle. He denied weakness, numbness, saddle anesthesia, and bowel or bladder incontinence. He took naproxen and acetaminophen with some relief. Previous imaging of his lumbar spine showed a degenerative disk at L4-L5. He completed over 12 weeks of physical therapy and had multiple lumbar epidural injections with minimal improvement. An EMG showed slowing of the left peroneal nerve. He was referred to the office to evaluate for an ultrasound guided piriformis injection.
Physical Exam: General: No acute distress, sitting comfortably. Back: Tenderness to palpation of the posterior left hip in the area of the piriformis. No tenderness to palpation along the lumbar spine. Strength 5/5 of bilateral iliopsoas, quadriceps, hamstrings, and gastrocnemius. Full range of motion of the back and bilateral hips without pain. 2+ DTRs of the bilateral knees and ankles. Sensation to light touch intact. Normal gait.
Differential Diagnosis:
6. Piriformis syndrome
7. Femoral Acetabular Impingement
8. L4-L5 Disc Herniation
9. Schwannoma
10. Sarcoma
Test Results: POC US: A 2 × 3 cm hypoechoic, non-calcified, well circumscribed mass in the area of the left piriformis and greater sciatic foramen. The sciatic nerve was not well visualized at the level of the piriformis. MRI Left Hip w/contrast: Along the left sciatic nerve is a mildly lobulated, sharply marginated, fusiform 4.4 × 3.5 × 3.2 cm lesion with intermediate T1 and heterogeneous T2 signal. There is intense enhancement post gadolinium and peripheral fat signal intensity with mild central enhancement.
Final Diagnosis: Schwannoma.
Discussion: Point of care ultrasound showed a hypoechoic round mass noted in the left piriformis without good delineation of the sciatic nerve. An MRI of the left hip was ordered to further evaluate the mass before considering further intervention. The MRI showed a probable schwannoma of the sciatic nerve. The patient was informed of this result and was referred to a surgeon for evaluation and removal of the mass.
Outcome: The patient underwent excision and biopsy of the sciatic nerve tumor with decompression of the sciatic nerve. The pathology was consistent with a schwannoma.
Follow-Up: After successful removal of the schwannoma, the patient's symptoms resolved. He was able to return to daily activity without any residual pain.
Groin Pain in a Dancer After Landing a Jump Split
Primary Author/Presenter: Darcy Lei, DO
Victoria Heasley, MD, Stephen Dailey, MD, and Timothy Foster, MD
Affiliation: University of Cincinnati Medical Center, Cincinnati, Ohio.
History: A 13 year old female competitive jazz and pom dancer presented for evaluation of acute right groin pain. During a dance performance, she did a jump and landed in a right leg forward split with immediate sharp, right-sided groin pain radiating to her gluteal region and medial thigh. She reported pain walking off the stage and could not perform the rest of the day. She localized the worst of her pain along the right ischial tuberosity and into the groin. The pain was diffuse even at rest and provoked with walking, standing on the right leg, or trying to turn in bed. She described the pain as sharp with movement, but sore at rest and at the end of the day. She had rested from dance practice and tried ibuprofen without pain relief at the time of presentation.
Physical Exam: She had antalgic gait with moderate limping on the right leg while walking into the exam room. She was tender to palpation along the ischial tuberosity, directly over the pubic symphysis and just lateral to it. Active range of motion was painful with decreased adduction and extension. Her strength was 3/5 with hip extension and adduction, but 5/5 with hip flexion and abduction. Pain worsened with standing on the right leg and log roll maneuver. Sensation to light touch was intact throughout lower extremity dermatomes, and there was no bruising or swelling noted.
Differential Diagnosis:
11. Ischial tuberosity apophyseal avulsion
12. Ischial tuberosity apophysitis
13. Pubic symphysis apophyseal avulsion
14. Adductor strain
15. Quadratus femoris strain
Test Results: Initial x-ray of the pelvis showed open growth plates without avulsion fracture or physeal widening. An MRI was ordered which showed Grade 2 muscle injury with partial thickness tearing of the right obturator internus, obturator externus, and quadratus femoris muscles. There was no evidence of ischial tuberosity avulsion fracture or pubic symphysis abnormality.
Final Diagnosis: Right grade 2 muscle strain with partial tearing of the obturator internus, obturator externus, and quadratus femoris muscles.
Discussion: Obturator externus, obturator internus, and quadratus femoris are external rotators of the hip and help with joint stability. Tears in these muscles are uncommon in adults and adolescents. To our knowledge, there are no current reports of acute injury to all 3 simultaneously. These injuries typically result from strong eccentric contraction or extreme end range of motion. Clinical diagnosis is challenging since tears of these muscles can present as nonspecific groin, hip, or gluteal pain and require MRI for definitive diagnosis. It is important to keep acute injury to the hip external rotators in mind for athletes working at end range of motion, such as in our case.
Outcome: At follow-up after her MRI, she still had pain with range of motion and weakness with hip extension and adduction. Due to her continued pain with weight bearing and limited motion, she was placed on rest from dance practice and competition for 4 weeks. She started with physical therapy to work on hip strengthening and range of motion and used non-steroidal anti-inflammatory drugs as needed.
Follow-Up: After 1 month of physical therapy, she slowly started returning to dance specific activities but continued to have some pain with range of motion. At 2 months post-injury, she started to move through functional progression pain free. By 3 months, she had returned to full dance practice without pain or functional limitations.
Groin Pain in a Lacrosse Player: It Is Not That Hip
Primary Author/Presenter: Caitlyn Haines, MD
Jayson Loeffert, DO
Affiliation: Penn State Hershey, Hershey, Pennsylvania.
History: An 18-year-old male college lacrosse player presented to training room complaining of severe left groin pain and inability to bear weight. He was seen in the Emergency Department a few days prior, was diagnosed with a muscular strain and discharged home with crutches. No imaging was performed at time of initial evaluation. He noted that he had since developed subjective chills and worsening of his pain to the point that he was unable to put weight onto his left leg. Pelvic radiograph was obtained and he was then directed back to the ED for further evaluation. On admission, his vital signs were meeting sepsis criteria.
Physical Exam: General: well-appearing in no acute distress. MSK: unable to weight bear. Tender to palpation over anterior/lateral hip. Full passive range of motion but no active range of motion secondary to pain. Motor strength 2/5 hip flexion and extension. Neurovascularly intact. FADIR positive, FABER negative, 90/90 test negative.
Differential Diagnosis:
16. Septic arthritis of pubic symphysis
17. Osteitis pubis
18. Adductor muscle strain
19. Femoral neck fracture
20. Pelvic stress fracture
Test Results: (1) Bloodwork - leukocytosis 12.25 K/µL, ESR 31 mm/hour, CRP 27.83 mg/dL. Positive blood culture for MSSA. (2) x-ray pelvis—Osteitis pubis and irregularity at the pubic symphysis. (3) MRI pelvis—Numerous subchondral sclerosis about the pubic symphysis and cortical irregularity with some edema. Evidence of symphyseal joint effusion, left adductor/rectus aponeurosis. (4) Ultrasound-guided aspiration—small pubic symphysis joint effusion. Aspiration with return of grossly purulent fluid.
Final Diagnosis: Our patient was diagnosed with septic arthritis of the pubic symphysis.
Discussion: Case reports of spontaneous septic arthritis of the pubic symphysis in athletes have been described but are rare. Other risk factors include female incontinence surgery, pelvic malignancy, and intravenous drug use. The predominant pathogen found in athletes is Staph aureus. It is critical to differentiate this diagnosis from osteitis pubis, which is a sterile inflammation of the pubic bone that results from muscular stress. Septic arthritis usually differs from cases of osteitis pubis due to acute onset and concomitant fever in the majority of cases. Management usually includes antibiotic treatment over 6 weeks due to high prevalence of osteomyelitis.
Outcome: Orthopedic surgery recommended an MRI as well as an ultrasound-guided aspiration of the pubic symphysis, which yielded grossly purulent fluid. He was discharged home on a course of IV cefazolin for 6 weeks. He worked with physical therapy for introduction of gentle exercise. His labs were followed outpatient with improvement in inflammatory markers and resolution of leukocytosis.
Follow-Up: Following completion of his antibiotic course, he began gradual activity progression. At this time, he has resumed all activity without restriction or pain. He recently played in a lacrosse tournament without difficulty and is starting practices in anticipation of the spring season.
Abnormal Involuntary Foot Positioning With Prolonged Biking
Primary Author/Presenter: Crystal Graff, MD
Lindsay Burke, MD, and Adele Meron, MD
Affiliation: Physical Medicine and Rehabilitation Department, University of Colorado, Aurora, Colorado.
History: A 60-year-old male with history of right ankle fracture status post fixation in 2008 and essential tremor presented with right foot pain and muscle spasms while biking. He reports a 2 year history of spontaneous involuntary ankle supination occurring about 5 miles into his typical twenty mile per day bike ride. He notes associated discomfort due to malpositioning of the foot inside his biking shoes, as well as cramping pain which radiates proximally into his calf and posterior knee. Toe curling of the affected foot typically precedes these events. He made mechanical alterations to his bike and used an ankle brace without relief of symptoms. He denies weakness, paresthesias, or history of low back pain.
Physical Exam: Physical exam was significant for tenderness to palpation over the right anterolateral tibiotalar joint near previous hardware placement, full strength throughout bilateral lower extremities, and intact sensation. He had notable large amplitude right upper extremity resting tremor, mild right lower extremity resting tremor, asymmetric bradykinesia and rigidity. Achilles' and patellar reflexes were 2+ bilaterally; he had no clonus and downgoing Babinksi. His posture was stooped and gait was non-antalgic.
Differential Diagnosis:
21. Focal task-specific dystonia
22. Chronic ligamentous ankle instability
23. Ankle fusion hardware failure
24. Peroneal neuropathy
25. Lumbar plexopathy
Test Results: Right ankle x-ray 6/2022: Status post ORIF of a bimalleolar fracture right ankle which appears well-healed without hardware complication. Mild early degenerative changes of the tibiotalar joint. MRI brain w/wo contrast 9/2022: Unremarkable brain MRI. Specifically, no structural abnormalities to account for history of parkinsonism. Dynamic biking video 7/2022: Evidence of involuntary plantarflexion of the foot and inversion of the ankle with prolonged stationary biking.
Final Diagnosis: Focal task-specific dystonia/paroxysmal kinesiogenic dystonia associated with Parkinsonism.
Discussion: Focal task-specific dystonias most often affect the upper limb and are characterized by involuntary sustained muscle contraction. They are often associated with activities such as writing, playing an instrument, or playing sports. In this case, the patient experienced a dystonic posturing of his right foot with prolonged biking, which has not been reported in the literature to date. Symptoms were elicited and captured on video with prolonged stationary biking. Dystonias are often associated with a central movement disorder, such as Parkinson's disease, therefore an extensive work-up is warranted in this case, especially given history of essential tremor.
Outcome: The patient underwent a medical bike fit with physical therapy without relief of his symptoms. Referral was placed to a neurological movement disorder specialist for further work-up for Parkinsonism. He was started on paroxetine for tremor suppression. Future treatment options may include oral anti-spasticity agent or botulinum toxin injections for optimal management of focal dystonia.
Follow-Up: Discussed with patient that he may continue to bike as tolerated; however, pain level and perceived ankle instability may necessitate reduction in bike riding distance at least temporarily. Return to biking at the intensity prior to injury will be determined by his response to oral tremor/tone suppressing medications.
Running Up That Hill: A Case of Nighttime Arm Pain in a High School Cross-Country Runner
Primary Author/Presenter: Dylan Rogers, DO
Laura Owczarek, MD
Affiliation: Henry Ford Health, Detroit, Michigan.
History: A 16 year-old male cross-country runner presents to the sports medicine clinic with right upper arm pain that began 10 months prior. No history of injury or traumatic event. Describes the pain as achy, present throughout the day, but it is much more significant at night and has been interfering with sleep. The pain has been stable since it's onset and is neither improving nor worsening. Lifting weights will mildly aggravate the pain. He has not tried any medications for treatment. He was evaluated at an urgent care shortly after the pain began. X-rays were performed that showed a periosteal reaction, and he was referred to our department. He denied any fever, chills, malaise, fatigue, weight loss.
Physical Exam: Inspection: No erythema or lesion noted bilaterally. Palpation: Tenderness to palpation in the right mid-humerus. ROM: Full active ROM bilaterally. Muscle strength: 5/5 in biceps, triceps, and rotator cuff bilaterally. Pain reproduced with manual muscle testing of biceps, triceps, and rotator cuff on right side. Neurovascular: Intact, no deficits.
Differential Diagnosis:
26. Ewing Sarcoma
27. Chronic Recurrent Multifocal Osteomyelitis
28. Osteoid Osteoma
29. Osteomyelitis
30. Stress Fracture
Test Results: XR: Periosteal reaction of the mid shaft of the R humerus. MRI: Marked periosteal thickening and edema of the posteromedial aspect of the R humeral diaphysis. CT: Long segment of periosteal reaction surrounding the diaphysis of the humerus with thickening of the bone cortex. Bone Scan: Area of increased radiotracer uptake at the site of the periosteal reaction. No other lesions are noted. Path: Fragments of reactive woven bone with associated fibrosis and inflammation. Negative for malignancy.
Final Diagnosis: Chronic Recurrent Multifocal Osteomyelitis (CRMO).
Discussion: CRMO, also described in the literature as Chronic Non-bacterial Osteomyelitis (CNO), is a rare condition with reported prevalence of 0.4/100 000 worldwide. Typical presentation includes insidious onset nighttime bone pain with or without fevers, and 1 to 20 active bone lesions- most commonly affecting the metaphysis of long bones. Histologic hallmarks of this disease process are bone inflammation in the absence of infection or malignancy. NSAIDs are first line treatment, however some patients require methotrexate, TNF inhibitor and/or bisphosphonate therapy. The IL-1 inhibitor, anakinra, has also been reported as a successful treatment option.
Outcome: Our patient underwent a bone biopsy to rule out malignancy/infection and confirm the diagnosis of CRMO. Due to the rarity of this disease, a second opinion was obtained from an outside pathologist, who confirmed the diagnosis of CRMO. NSAID therapy was initiated with resolution of his pain.
Follow-Up: Four weeks after bone biopsy he was cleared to return to running. He will be evaluated by rheumatology as approximately 25% of patients diagnosed with CRMO have an associated autoimmune disorder, including skin disorders and chronic inflammatory bowel disease. Due to an average reported remission rate of 40% (with common recurrence) he will be followed closely by orthopedic oncology.
Friday Night Palsy Saturday Morning Mystery
Primary Author/Presenter: Jorge Sucar-Marquez, MD
Peter Rippey, MD
Affiliation: University of South Alabama, Alabama.
History: Sixteen-year-old male football player with no significant medical history was found face-down on the sideline after unwitnessed injury on the field. Patient was involved in a punt-return play and walked off the field apparently unscathed. A few minutes after, the sports medicine staff was alerted that a player was collapsed on the sideline. He was found face-down, confused, and indicating significant pain in his head and neck; with no recollection of the mechanism of his injury. Spinal stabilization protocol was performed by the Sports Medicine staff. Patient was noted to have altered-mental status and hemiplegia of his right arm and leg. Patient was transferred to the nearest trauma center where seizure activity was noted.
Physical Exam: General: In moderate distress due to pain. Head: Normocephalic and atraumatic. Cardiovascular: Radial and DP pulses 2+ bilaterally and equal Eyes: Pupils equal, round, and reactive to light. Extra-ocular movements intact. Neck: Midline tenderness along C3-C5. Neurologic: AO x2, following commands. Cranial nerves II-XII grossly intact. Hemiplegia of the right upper and lower extremities. Sensation intact bilaterally Musculo-Skeletal No visible deformities. LUE and LLE strength 5/5 grossly. RUE: 1/5 elbow flexion, and shoulder abduction. Unable to grip. RLE: 1/5 plantar/dorsiflexion, 1/5 hip flexion and abduction.
Differential Diagnosis:
31. Spinal cord injury
32. Concussion with abnormal findings
33. Todd's paralysis
34. Intracranial hemorrhage
35. Transient ischemic attack
Test Results: Chest x-ray: Normal. CT head without contrast: Normal. CT cervical spine without contrast: Normal. CT thorax with contrast: Normal. CT abdomen and pelvis with contrast: Normal. MRI head and neck: Normal. Comprehensive metabolic panel: ALT 65, AST 73, otherwise normal electrolytes and renal function. CBC: WBC 5.83, hemoglobin 12.3, hematocrit 36.6, platelets 181 9. Coagulation studies: PT 14.4, PTT 27, INR 1.09 10. Urine drug screen: negative.
Final Diagnosis: Spinal cord injury without radiologic abnormality (SCIWORA).
Discussion: SCIWORA is defined as traumatic myelopathy without radiologic evidence of fracture or instability. It is mostly seen in children often occurring in the cervical spine due to its increased mobility, ligament laxity, and large head-to-body ratio. Incidence reports from different authors vary from 6% to 19% and 9% to 14% of spinal injuries in children and adults respectively. The mechanism of injury is often from hyperextension from direct frontal trauma. The onset of symptoms may be immediate or delayed for up to 48 hours after trauma. Absence of pathology in MRI is predictive of good outcomes. External immobilization and avoiding increased-risk activities are the most common treatments.
Outcome: The day after the incident the patient had significant improvement. However, incomplete resolution of the hemiplegia prior to discharge was noted. The right upper extremity strength was 3/5 and right lower extremity strength was 4/5. Symptoms were completely resolved 2 months after the incident.
Follow-Up: Our patient continued to wear an Aspen collar for 2 weeks post-injury. He followed up with neurosurgery and by 2 months had full return of motion and strength and was cleared to begin a gradual return to sports activities.
Just Keep Swimming … Just Keep Swimming
Primary Author/Presenter: Jack Italiano, DO, RT(R)
Jason Zaremski, MD
Affiliation: Department of Family Medicine and Community Health, University of Florida Health.
History: We present a 15-year-old right hand dominant high school swimmer with no significant past medical history, who complains of right elbow pain along the distal biceps' tendon for a 2 months. Pain was insidious in onset, sharp, intermittent, and described as a 0 to 6 out of 10. The patient has been swimming more frequently over the last few months to prepare for competition and noticed progressive pain with swimming. He went on vacation and then was diagnosed with a COVID-19 infection and took an additional 2 weeks off due to fatigue. He returned to sport without re-integration and increased his swimming intensity to 1 to 2 hours daily, which worsened his pain. Performing the butterfly and breaststroke provoke symptoms and cessation of activity reduces the pain. Denies pain at rest. He took Advil which did not reduce his pain. Denies acute trauma, prior injuries, or paresthesias.
Physical Exam: Inspection of right elbow: no swelling or signs of discoloration. Palpation: Tenderness at the distal biceps tendon but can hook the tendon without pain. No shoulder or wrist tenderness. Active Range of Motion: Elbow extension 0 degrees, elbow flexion 130 degrees, supination and pronation normal. Normal shoulder and wrist ROM. Muscle strength: 5/5 grip, wrist extension, and wrist flexion. Pain elicited with resisted elbow flexion at the distal humerus. Maneuvers: pain with distal humerus squeeze. Negative Maudsley and negative Cozen test.
Differential Diagnosis:
36. Distal Biceps Tendonitis/Tear
37. Stress Reaction of the Distal Humerus
38. Medial Epicondyle Apophysitis
39. Capitellar Osteochondritis Dissecans
40. Radiocapitellar Plica Syndrome
Test Results: x-ray right elbow: AP and Lateral views indicate no abnormalities to the bones, alignment, or soft tissue structures. MRI right elbow No IVCON: Biceps tendon intact. There is periosteal edema and endosteal aspect marrow edema along the medial aspect of the distal diaphysis and metaphysis of the humerus. Several small foci of increased cortical signal. No fractures, joint effusion, or chondral defects. Findings comparable to Fredrickson grade 4a distal humerus diametaphysis stress injury.
Final Diagnosis: Right Elbow Supracondylar Grade 4a Stress Reaction.
Discussion: Actives that involve repetitive motion are susceptible to overuse injuries. Cases of upper extremity stress reactions in swimmers have been documented along the inferior angle of the scapula, upper ribs, and olecranon. Stress reactions along the distal humerus in swimmers is not well documented. This pathology has been seen in baseball players, cricket bowlers, and tennis players. In swimming, the butterfly technique requires significant endurance and athletic strength. During a sprint, fast synchronized upper extremity revolutions occurring up to 60 cycles per minute counterforce water surface area friction leading to excessive loading forces even at 50 meter distances.
Outcome: The patient was withheld from upper body work outs and swimming for 6 weeks. Vitamin D and Calcium levels were drawn revealing a normal calcium level (10.2), but a vitamin D level of 28.1. Patient was started on 600 IU of Vitamin D and 1300 mg of Calcium daily. The patient started a return to swim program and returned to full competition at 7 months post presentation.
Follow-Up: At 6 weeks, started an upper extremity low impact non-aquatic physical therapy program. Then a slow progressive return to swimming was initiated at 50% effort for 4 weeks. At 10 weeks, a return to sport plan including 200 m all strokes except butterfly, progressed to 250 m at week 2, 300 m at week 3, and 350 m at week 4. Finally, initiated speed work in 50 to 100 m increments and elbow loading workouts.
Hanging in There: A Unique Case of Shoulder Pain in a Young Female Soccer Player
Primary Author/Presenter: Jeremy Swisher, MD
Zachary Sitton, MD, and Chris Miles, MD
Affiliation: School of Medicine, Wake Forest University, Winston-Salem, North Carolina.
History: This was an 8-year-old female soccer player with a past medical history of Holt-Oram Syndrome who presented with left shoulder pain after a fall the previous day. She reported that she was about to go down a slide when she was pushed off the slide and landed directly on her left shoulder. Since this injury, she had complained of a constant, 7/10, non-radiating, sharp pain in her left shoulder and that she had decreased range of motion. Of note, she had a similar mechanism of injury in which she had a fracture of her left medial epicondyle 3 years ago which has fully healed. She denied hitting her head, having a headache, pain in her elbow, wrist, or hand as well as any changes in sensation.
Physical Exam: Vitals: BP 113/90|Pulse 65|Ht 4'2|Wt 54 lb | SpO2 98% Cardiac: Regular rate and rhythm, III/VI holosystolic murmur heard best at LLSB. Inspection: Left shoulder effusion and deformity present. Absent left thumb and shortened radius/ulna. Palpation: TTP left proximal humerus. No TTP of radius, ulna, SC joint, clavicle, AC joint. ROM: Unable to significantly move left arm with flexion at 10 degrees, abduction to 10 degrees, IR 15 degrees and ER 5 degrees. Strength: exam limited due to pain. Shoulder abduction 1/5, elbow extension 1/5, elbow flexion 1/5, grip strength 5/5. Neurovascular: 2+ radial and ulnar pulses, cap refill < 3s, no deficits in sensation.
Differential Diagnosis:
41. Fracture of the proximal humerus
42. Fracture of the distal clavicle
43. Anterior shoulder dislocation
44. AC Joint Sprain
45. Fracture of the Acromion
Test Results: XR Shoulder Left (7/23/22): Acute displaced fracture along proximal humeral physis with anterior displacement of the humeral shaft (Salter-Harris II). XR Shoulder Left (9/2/22): Healing Salter-Harris II fracture of the proximal left humerus.
Final Diagnosis: Salter-Harris II fracture of the proximal humerus in the setting of Holt-Oram Syndrome.
Discussion: Holt-Oram syndrome is an autosomal dominant condition. It is characterized by upper limb malformation (abnormal carpal bone, radius, or thumb), congenital heart malformation (ASD or VSD), and cardiac conduction disease (sinus bradycardia, AV block, or atrial fibrillation). Patients need to be monitored with serial EKGs/holter monitors to assess their risk for progression of conduction abnormalities as well as receive echocardiograms every 1 to 5 years depending on the significance of septal defects. The upper limb abnormalities are often bilateral and asymmetrical with the left side being more severely affected. The most specific upper limb finding is abnormalities of the carpal bone.
Outcome: She was managed with a hanging arm cast, which uses its weight and length adjustments to correct the angulation and allow for reduction and healing. At 6 weeks, she had significant periosteal reaction as well as clinically no longer having any TTP of the humerus. Her cast was removed, and she was referred to pediatric cardiology for EKG and echocardiogram as well as to PCP follow-up.
Follow-Up: After 6 weeks of immobilization with the hanging arm cast, she was cleared from an orthopedic standpoint to return to soccer. She will continue to have follow-up yearly with her PCP and cardiologist to assess her risk for progression of cardiac conduction disease with EKG and holter monitor as well as to get her echocardiogram to assess the significance of her VSD.
Rib Pain in a Runner
Primary Author/Presenter: Stephanie Clark, DO, MS
Ronan Cahill, MD
Affiliation: Swedish Sports Medicine Fellowship, Rehabilitation and Performance Medicine, Swedish Medical Group.
History: An otherwise healthy 43-year-old male endurance sport athlete presented with 8 months insidious onset left anterior rib pain. Pain was located at approximately ribs 8 to 10 on the left and was initially exacerbated only with running and improved with rest. His pain had progressed to bother him with any up and down movements such as jumping and stairs. He also developed back pain at the same level as the rib pain and it was worse at night. Symptoms were described as achy and stabbing and rated 6 to 7/10 in intensity. An appropriate course of physical therapy and chiropractic manipulation had provided him with minimal relief. He denied associated arm or leg weakness, numbness, tingling, bowel or bladder dysfunction, fevers, chills or recent weight loss.
Physical Exam: GEN: Fit, healthy appearing male in no distress. RESP: non-labored breathing. CV: Pulses are regular rate and rhythm to palpation of radial pulse. Capillary refill is normal. PSYCH: Alert and oriented, mood is stable, and affect is pleasant. Neuro: Sensation intact to light touch. Physiologic and symmetric reflexes in upper and lower extremities. MSK Inspection: No chest wall asymmetry. No exaggerated kyphosis or scoliosis. Palpation: Non-tender anterior rib cage and spinous processes. ROM: full, pain-free spine flexion, extension, rotation and side bending. Strength: Normal muscle bulk, strength and tone in bilateral upper extremities. Provocative maneuvers: Negative Carnett sign.
Differential Diagnosis:
46. Slipping rib
47. Intercostal nerve entrapment
48. Thoracic radiculopathy
49. Spondyloarthritis
50. Malignancy
Test Results: Bedside US: narrowing of the costal space without clear fascia disruption between ribs 8 and 9 which corresponds with his area of pain. x-ray thoracic spine: 14-degree dextroconvex thoracic scoliosis. MRI Thoracic spine w/wo contrast: 2.5 cm enhancing intrathecal extramedullary mass centered dorsal to the spinal cord at T8-T9 with associated cord displacement and compression and relatively high-grade canal stenosis but no cord edema.
Final Diagnosis: Spinal nerve sheath tumor.
Discussion: Back pain has a wide prevalence range among athletes, with thoracic back pain being less common than lumbar. Also uncommon are spinal tumors (ST) which are categorized by their location. Intradural-extramedullary tumors account for less than half of all ST with the most common being schwannomas and meningiomas. The median time to diagnosis is 12 months and pain is the most common initial symptom. MRI is the preferred imaging modality and surgical resection is often required to prevent neurologic compromise. Though ST are rare, they are an important differential to consider in adults complaining of thoracic back pain that does not resolve with conservative management.
Outcome: Patient was referred to neurosurgery who recommend surgical management. He underwent T8-9 laminectomy for gross total resection and final pathology revealed Schwannoma (WHO grade 1). Two weeks post-op, he was only needing over the counter medications for mild incisional pain, and he had a normal neurological physical exam.
Follow-Up: He was started on a gradual return to activity with 10 to 15 pound weight limit and no bending for 6 weeks post-op followed by a 25 pound weight limit and allowance to bend at the waist post-op weeks 6 to 12. At his last follow-up visit, his rib pain had completely resolved, and he was able the sleep, cough and go up and down stairs without any aggravation of symptoms.
Seeing the Bigger Picture: Anterior Shoulder Pain in a Baseball Pitcher
Primary Author/Presenter: Nathaniel Tang, BA Neuroscience
Casey Kohr, DPT, ATC, and Carly Day, MD
Affiliation: Lewis Katz School of Medicine, Philadelphia, Pennsylvania.
History: A 22-year-old right-handed baseball pitcher presented with 3 weeks of right shoulder pain. He first noticed a pulling sensation in his posterior upper arm after throwing a slider. He worked with an athletic trainer/physical therapist on rehabilitation and noted close to 100% improvement over 2 weeks. Unfortunately, shortly after his pain improved, the right shoulder pain returned located primarily in the axilla and posterior upper arm. Pain was up to 9/10 and worse with follow-through during pitching. He did not recall trauma and denied numbness, tingling, and radicular symptoms. He endorsed occasional neck tightness. The athlete tried diclofenac gel 4 times a day and continued rehabilitation with no improvement. Oral anti-inflammatories were not recommended due to congenital solitary kidney.
Physical Exam: Physical examination was notable for full cervical range of motion without pain. There was no tenderness in the shoulder other than at the medial proximal humerus. Bilateral shoulder flexion was 150 degrees, external rotation 70 degrees, internal rotation to T8 and abduction to 160 degrees. There was no pain with active range of motion and there was 5/5 strength without pain during resisted shoulder internal and external rotation, elbow flexion, and empty can. He had mild discomfort with resisted adduction. He had a negative Neer's, Hawkin's, Speed's and Yergason's and a positve O'Brien's. Distal pulses and sensation were normal.
Differential Diagnosis:
51. Glenoid labrum tear
52. Strain of right latissimus dorsi muscle
53. Strain of right teres major muscle
54. Strain of right triceps muscle
55. Tear of latissimus dorsi tendon
Test Results: x-ray of the right shoulder was normal. An MR Arthrogram of the right shoulder showed no rotator cuff tear, labral tear, or cyst. The shoulder MR arthrogram did not give an adequate explanation for this athlete's pain with pitching. Images were inspected again and only a small portion of the proximal humerus was visible. An MRI of the humerus was ordered and a latissimus dorsi tendon avulsion from the humeral attachment with 3 cm retraction into the axillary fold was present.
Final Diagnosis: Avulsion of latissimus dorsi tendon from humeral attachment.
Discussion: With more emphasis on speed in today's pitchers, latissimus injuries are more common. Unfortunately, they remain a challenging diagnosis. One reason is non-specific physical examination findings. Our patient's physical exam and right shoulder MR arthrogram were largely unremarkable. Accurate diagnosis of latissimus tendon avulsion was only found with wide-field MRI of the right humerus because the shoulder MRI did not include the latissimus attachment to the humerus. It is therefore vital to consider imaging that reveals an upper arm injury as opposed to narrow imaging techniques revealing only shoulder pathology when suspicion of latissimus dorsi tendon injury is present.
Outcome: The athlete underwent surgical repair of the latissimus tendon avulsion. Operation was successful and the patient worked with his athletic trainer/physical therapist on post-operative rehabilitation.
Follow-Up: After 4.5 months of rehabilitation, the athlete had full range of motion and strength without pain. However, at 5.5 months follow up, the patient had developed biceps tendonitis in his shoulder and received a biceps tendon sheath injection. After the injection, he was able to progress and return to full activity as a college pitcher 3 months later.
Shot to the Heart, But What's to Blame? A Case of Sudden Cardiac Arrest in a D1 Softball Player
Primary Author/Presenter: Zainab Shirazi, MD
Nicholas Tsitsilianos, MD, and Elan Goldwaser, MD
Affiliation: Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Columbia-Cornell.
History: A 21-year-old female division 1 softball player with no significant history presents to the athletic training room for evaluation 4 days after cardiac event. She was playing in a softball game when she was struck in the chest by an opponent's glove, knocking her down at first base. She began to run back to the dugout but suddenly collapsed followed by whole-body shaking and loss of bladder control. She was not breathing and had no pulse, so CPR was started immediately. One shock was delivered with ROSC achieved after 2 minutes. Initial rhythm on AED is unknown. She was transported to ED for further evaluation. She was ultimately discharged home. On presentation to the athletic training room, she brings all ED paperwork. She reports feeling well and denies cardiac symptoms at this time. Denies previous syncope. She has no family history of sudden cardiac death.
Physical Exam: Physical exam on presentation was unremarkable. Vital signs were normal. She was alert and oriented x3 and well-appearing. Breathing was non-labored, without audible wheeze or cough. Cardiovascular exam revealed regular rate and rhythm with no murmurs, rubs, or clicks. Chest wall movement and rib motion appeared normal. Extremities were well perfused with pulses equal and adequate bilaterally. There was no peripheral edema. She was neurologically intact without focal deficits.
Differential Diagnosis:
56. Commotio Cordis
57. Myocardial Contusion (Contusion Cordis)
58. Hypertrophic Cardiomyopathy (HCM)
59. Congenital Cardiac Anomaly
60. Seizure-induced Cardiac Arrest
Test Results: In ED: Trop normal, CXR without cardiomegaly. EKG with NSR, LVH, and normal QTc. Bedside Echo showed normal EF, no systolic anterior motion of mitral valve. She was referred for additional cardiac workup: TTE without structural abnormalities, cardiac MRI with mildly dilated LV and borderline EF consistent with athletic heart. Loop recorder placed for prolonged monitoring, but no arrhythmia detected. Coronary CTA (CCTA) revealed anomalous left coronary artery from main pulmonary artery (ALCAPA).
Final Diagnosis: Sudden cardiac arrest due to myocardial ischemia in the setting of ALCAPA (anomalous left coronary artery from main pulmonary artery).
Discussion: The leading cause of death in young athletes is sudden cardiac arrest (SCA). Congenital coronary artery anomaly, such as ALCAPA, is the second most common etiology (17%). Initial diagnosis was commotio cordis given the blunt chest trauma and nonspecific cardiac workup. ALCAPA was found on subsequent CCTA, which is not currently required for return to play. Had her condition gone undiagnosed, she would have returned to sport without intervention, increasing the risk of another life-threatening cardiac event. A comprehensive cardiac workup is essential in athletes with SCA. Multidisciplinary collaboration is crucial for prompt diagnosis and management.
Outcome: The definitive treatment for ALCAPA is surgical intervention. After extensive discussion between the patient, her parents, and the medical team, the decision was made to pursue surgery to minimize risk of recurrent cardiac event. She successfully underwent surgical re-implantation of the left main coronary artery. There were no complications and she was discharged home with coordinated follow up.
Follow-Up: Postoperative stress echo showed improved EF and exercise capacity without evidence of ischemia or arrhythmias. Repeat CCTA was normal. She participated in a cardiac rehabilitation program. Three months after surgery, she gradually returned to activity in accordance with the AHA/ACC recommendations. At 6-month follow up, she remained asymptomatic and had resumed strength training and running.
Hut, Hut, High Heart Rate in an Incoming Football Hiker
Primary Author/Presenter: Kathleen Kinderwater, MD
Joseph Armen, DO
Affiliation: East Carolina University, Greenville, North Carolina.
History: Eighteen YO male incoming freshman football long snapper with a history of childhood asthma and one prior uncomplicated concussion presented for his initial, routine, pre-participation exam. He denied any current concerns. He was not taking any medications, had no allergies, endorsed a family history of type 2 diabetes in his father, and denied caffeine, tobacco, drug, or stimulant use. Complete review of symptoms was negative except for an “intentional” weight loss for sport of greater than 20 pounds over the past several months. Standard of care for the university's pre-participation evaluation includes a hemoglobinopathy screen and EKG. His hemoglobinopathy screen was unremarkable and his EKG demonstrated sinus tachycardia without other abnormalities. Clearance was deferred given his sinus tachycardia.
Physical Exam: Vital signs: BP 105/72, HR 104, RR 13, Temp 97.3°F, Weight 195.5 lbs, Height 74 in. Gen: NAD. HEENT: normal appearance, PERRLA, oropharynx without erythema or exudate. Neck: non-tender, no enlarged thyroid, without palpable adenopathy. Cardiac: Tachycardic, regular rhythm. normal S1, S2, no murmurs or rubs. Negative Marfan's screening. Pulm: CTAB. Abdomen: Normoactive bowel sounds, nontender, no rebound or guarding, no palpable mass or hepatosplenomegaly. Derm: no rashes. Neuro: no focal deficits. Lymph: no cervical, supraclavicular, or inguinal adenopathy. MSK: normal tone and strength in the extremities. Mental: oriented to time, place, person, normal affect and mood.
Differential Diagnosis:
61. Anemia
62. Hyperthyroidism
63. Stimulant Use
64. Infection
65. Malignancy
Test Results: His tachycardia persisted. CBC demonstrated a microcytic anemia. Hepatic panel noted low protein and albumin and elevated alkaline phosphate. BMP and TSH were normal. Iron studies had an anemia pattern of inflammation/chronic disease. Ferritin significantly elevated to 1400. He was referred to GI given concern for inflammatory process with additional 7 lbs lost. CT abdomen showed splenomegaly with intra-abdominal and retroperitoneal lymphadenopathy and hepatic lesions concerning for lymphoma.
Final Diagnosis: Hematology/Oncology admitted him to the hospital. Labs remained stable. CT of chest and neck demonstrated bulky thoracic lymphadenopathy. Supraclavicular lymph node biopsy confirmed Hodgkin Lymphoma.
Discussion: The importance of vital signs cannot be underestimated. Resting tachycardia with weight changes are concerning for abnormal pathology. While the most common risk factor for cancer is older age, lymphoma is one of many malignancies that is common in younger patients. Athletes diagnosed with cancer and treated with chemotherapy are unique when considering complications and activity capability post-treatment. Aside from acute complications of anemia, infection, and bleeding, chronic complications can pose lifelong difficulties. Specifically with typical lymphoma treatment, cardiovascular complications, pulmonary fibrosis, and peripheral neuropathy are all common adverse effects.
Outcome: The patient returned home for treatment. A PET scan and bone marrow biopsy done prior to chemotherapy showed extensive hypermetabolic lymphadenopathy above and below the diaphragm with marrow involvement. He was enrolled in a clinical trial that he qualified for based on age and advanced stage 4 disease. He has completed several rounds of chemotherapy and has been referred to radiation oncology.
Follow-Up: Return to play must consider the athlete's physical and emotional status and be a collaborative decision among coaches, care team, and patient. CBC, BMP, heart rate and fatigue level are monitored routinely. His repeat PET scan showed resolution of liver lesions with improvement in both splenomegaly and size of largest paratracheal node. He has not yet resumed activity given ongoing treatment.
Block at the Notch: Shoulder Pain in Volleyball Athlete
Primary Author/Presenter: Bishop Carmichael, DO
Kimberly Kaiser, MD
Affiliation: University of Kentucky, Lexington, Kentucky.
History: Twenty-one-year-old female right hand dominant division 1 volleyball player who presented to training room for right shoulder pain. She stated her right shoulder had started to ache over the past few days with weightlifting. She subsequently woke up with severe right shoulder pain and weakness and presented to training room for evaluation. She described the pain as deep and aching, localized posteriorly and laterally. She denied any specific trauma, fall, or injury. No previous injury or surgery to the right shoulder. No recent illness. No other joint or muscle pains.
Physical Exam: Right Shoulder: No erythema or ecchymosis. Obvious asymmetry of posterior aspect of right shoulder compared to left with decreased scapular muscle volume. ROM Flexion 160, Abduction 160, External rotation 60. Strength is 5/5 with flexion, abduction, 4/5 with external rotation. Pain with empty can and O'Brien's testing. Negative Spurling's.
Differential Diagnosis:
66. Rotator Cuff Tendinitis
67. Labral Tear
68. Shoulder Impingement
69. Rotator Cuff Tear
70. Cervical Disc Disease
Test Results: MRI Right shoulder w/o contrast demonstrated severe chronic atrophy and fatty infiltration of infraspinatus.
Final Diagnosis: Infraspinatus Atrophy due to suprascapular nerve impingement at spinoglenoid notch.
Discussion: Atrophy of the infraspinatus muscle is not uncommonly seen in overhead athletes. Infraspinatus is innervated by the suprascapular nerve which exits the spinoglenoid notch to innervate the muscle. It is at this level entrapment or irritation can be seen. Many mechanisms can cause this such a paralabral cysts, bony compression, or repeated eccentric loading of the area. Specifically in volleyball athletes, rapid deceleration of the overhead movement significantly loads the posterior rotator cuff musculature, which can lead to suprascapular nerve palsy at the level of the spinoglenoid notch, resulting in isolated infraspinatus atrophy.
Outcome: Athlete was mid-season at the time of diagnosis. Given that she had no structural compression on MRI, she was started on methylprednisolone dose pack and began an aggressive physical therapy and rehab program to allow her to continue participating.
Follow-Up: Her rehab focused on strengthening of the periscapular musculature and rotator cuff with several modalities aimed directly at infraspinatus recovery with Russian stim and blood flow restriction being the most effective. After identifying the problem and beginning rehab, the athlete was able to continue in season with minimal time lost due to shoulder pain.
Acute Weakness at the Beach
Primary Author/Presenter: Alex Bonilla, MD
Brendan Bechard, MD, Mirhojjat Khorasanizadeh, MD, Philip Maynard, MD, Masrai, Williams, MD, Gilbert Dagher, and Benedikt Ilyaguyev, MD
Affiliation: Icahn School of Medicine at Mount Sinai Hospital, New York, New York.
History: A 26-year-old female with no past medical history presented to the ED, transferred from another hospital in the system for urgent imaging and neurosurgical evaluation. Earlier that day, she had been surfing when she began to experience fatigue in her lower extremities and a band-like sensation of pain around her pelvis. She returned to shore where, after resting, the pain became numbness and tingling and she was unable to stand, about 1 hour after surfing. At the initial ED presentation, she reported inability to move her lower extremities or urinate and a foley catheter was placed with 1.5 L urine output. She denied headaches, vision changes, trauma, tick bites, abdominal pain, lower back pain, fevers, IV drug use, and recent infections.
Physical Exam: Vitals: Temp 36.7°C BP 112/61 Pulse 64. MSK: No midline cervical, thoracic, and lumbar spinous process tenderness, deformities or step offs. Neurological: Intact mental status, CN II-XII intact. Motor: UE: strength 5/5 throughout B/L with normal bulk and tone, LE: strength: 0 to 1/5 Hip flexion B/L, otherwise 0/5 throughout B/L with normal bulk and flaccid tone. Sensory: UE: intact and symmetric to all modalities, LE: light touch decreased to 30% of her normal in B/L LE, pinprick decreased B/L to T10/T11 level, temperature decreased in LE B/L, vibration intact B/L, proprioception (joint position sense) intact B/L. Reflexes: 2+ in B/L UE, 0 in B/L LE (Patellar, Achilles).
Differential Diagnosis:
71. Spinal Cord Compression
72. Transverse Myelitis
73. Guillain-Barre Syndrome
74. Spinal Cord Infarct
75. Mass Lesion
Test Results: CTs of the spine were negative for fractures. Spinal MRIs revealed no extrinsic compression, but were notable for intramedullary T2 hyperintensity from T8/9 to conus, central and expansile, with central gray matter involvement and enhancement at T10 and T11. MRI Brain and c-spine were unremarkable. MRA Spine did not show AVMs. CSF studies revealed WBC 46, RBC 10, glucose 65, protein 44.6. Diagnostic Spinal Angiogram was normal with artery of Adamkiewicz visualized.
Final Diagnosis: Anterior Spinal Cord Infarct - Surfer's Myelopathy.
Discussion: Surfer's myelopathy is a rare, nontraumatic spinal cord injury that has been documented primarily in novice surfers. The literature suggests that the mechanism may be from prolonged hyperextension of the back while in a prone position resulting in insufficient arterial supply to the lower spinal cord. Patients may present with back pain, bladder or bowel dysfunction, paraplegia and sensory deficits. Surfers, especially novices, should be counseled on proper technique and adequate hydration as a preventive measure. With early recognition and appropriate treatment, patients may achieve complete or near-complete recovery.
Outcome: The patient was admitted to the Neurology Stroke service, loaded with aspirin and monitored for hypotension, requiring only IV fluids. A lumbar drain was placed briefly to decrease CSF pressure for management of spinal cord infarct. After maximizing medical management of the spinal infarct, the patient was discharged to the acute inpatient rehabilitation for spinal cord rehabilitation.
Follow-Up: The patient regained significant motor function recovery with 5/5 hip flexion, knee extension, ankle dorsiflexion and plantarflexion and 4/5 extensor hallucis longus. She remained with pain, bowel and bladder dysfunction, decreased sensation to light touch and pinprick in the BLE and impaired mobility. She will continue outpatient rehabilitation to maximize recovery.
Compressed for Time
Primary Author/Presenter: Jacob Holtz, DO
Jordan Geroski, DO
Affiliation: South Bend Notre Dame Sports Medicine Fellowship, South Bend, Indiana.
History: Seventeen-year-old female high school soccer player presented acutely to the office for lower leg pain with numbness of the dorsum of the right foot. She played a soccer game the day before and had to come out of the game due to excruciating right lower leg pain after running. She could not recall any injury nor history of an event this painful or lasting this long, she did, however, endorse a several year history of similar, less severe tingling, numbness, and pain in both lower extremities with exertion, right worse than left. Previously, the pain followed a predictable interval, became severe enough to cause her to stop activity, but had always quickly resolved with rest. She never sought evaluation for this problem prior to this acute event.
Physical Exam: Afebrile with normal blood pressure and pulse. Antalgic gait but without assistive devices. Visibly and palpably taut appearing skin overlying the anterior and lateral right lower leg. Tenderness to palpation of the anterior and lateral right lower leg. No tenderness of the posterior leg. Cold right foot compared to left. Altered sensation of the dorsum of the right foot. Diminished dorsalis pedis and posterior tibialis pulses. Full range of motion, but significant pain with active dorsiflexion. No visible color changes.
Differential Diagnosis:
76. Deep venous thombosis
77. Tibia fracture
78. Acute compartment syndrome
79. Cystic adventitial disease
80. Popliteal artery entrapment syndrome
Test Results: Resting compartment pressure testing performed in the office. Anterior compartment measured 85 mm Hg. Lateral compartment measured 68 mm Hg. Deep posterior compartment measured 15 mm Hg.
Final Diagnosis: Acute on chronic atraumatic exertional compartment syndrome.
Discussion: Chronic exertional compartment syndrome is a relatively rare phenomenon with an incidence of 0.5/1000 person years in active populations. The incidence of conversion to acute compartment syndrome without an associated trauma has not been well defined in the literature, if at all. This case represents an exceptionally rare phenomenon of a patient with chronic exertional compartment syndrome converting to acute compartment syndrome requiring emergent surgical correction to protect the limb. Prompt evaluation of acute compartment syndrome remains paramount. This case also serves as a reminder to be observant for symptoms of chronic exertional compartment syndrome.
Outcome: Patient underwent 4 compartment release emergently within a few hours of diagnosis. She has recovered well with no complications and is planning to return to soccer in the spring.
Follow-Up: The patient's wounds healed well after surgery. There were no post-surgical complications. She transitioned back to running at 4 weeks postoperatively. She is back to soccer drills and is cleared to participate fully in soccer. She has maintained close follow-up with the performing surgeon. She has planned follow-up for evaluation of chronic exertional compartment syndrome of the left leg.
When Catching Air Leads to a Major Scare—An Unfortunate Trampoline Injury
Primary Author/Presenter: Pooja Sharma, MD
Logan Pierce, PA-C and Joseph Powers, MD, FAAP, CAQSM
Affiliation: Northside Hospital, Orthopedic Institute, Atlanta, Georgia.
History: Twenty-seven year old Female presents to clinic for evaluation of right knee pain after an injury sustained at a trampoline park. She injured her knee while jumping on a trampoline and landed awkwardly. She reported feeling a pop and numbness. She was initially evaluated at an outside ER shortly after the injury and diagnosed with tibial plateau and fibular styloid fracture and discharged home to follow up with Orthopedics. Patient was noted to be neurovascularly intact in the ER and discharged in a knee immobilizer. She presents to our clinic approximately 24 hours after the injury, and reports excruciating pain diffusely throughout the leg, rated 10/10. She continues to report numbness in the lower leg.
Physical Exam: Gen: Alert, in discomfort. MSK—(R lower extremity): Inspection: Bruising and hemorrhagic fluid filled blisters on postero-lateral knee; significant swelling of R lower extremity. Palpation: Tenderness diffusely throughout R lower leg. No palpable pulse at dorsalis pedis. Weak pulse appreciated at posterior tibialis with Doppler. No doppler signal in the right dorsalis pedis artery. R foot is warm; capillary refill <3 seconds. ROM: Unable to assess due to pain and swelling. Holds at 10 degrees of flexion. Strength: No active plantar or dorsiflexion of R foot; Unable to move toes. Neurovascular: Loss of sensation in the R superficial peroneal nerve distribution. Special: Unable to assess.
Differential Diagnosis:
81. Compartment syndrome
82. Popliteal artery transection
83. Patellar dislocation
84. Multiligamentous knee injury
85. Tibiofemoral fracture
Test Results: R Knee XR: Comminuted fracture of medial tibial plateau. Fibular styloid avulsion fracture. Displaced flabella. R ABI: Unable to calculate ABI. Monophasic waveform in distal posterior tibial artery. Intracompartmental Pressure (mm Hg): Ant: 50; Lat: 66; Diastolic: 71. R Knee MRI: Comminuted fracture of anterior tibial plateau. Fibular head displaced avulsion fracture. ACL partially torn. Complete tear of PCL. Displaced fracture of medial femoral condyle. RLE CT Angio: Popliteal artery occluded.
Final Diagnosis: Right lower extremity compartment syndrome secondary to patellar dislocation, popliteal artery occlusion, tibial plateau knee fracture and severe multiligamentous knee injury.
Discussion: Trampolining has become an exciting hobby and sport for children and adults alike. While it is gaining popularity, it also poses a significant injury risk. Many trampoline injuries occur in the spine, upper and lower extremities. Recognizing vascular injuries quickly is imperative as it can lead to compartment syndrome, ultimately contributing to increased morbidity, including amputation. Awareness about the long-term impact and seriousness of these injuries will help adults make informed decisions about participating in this activity. Further studies are needed to investigate local and national injury burden, injury prevention, and safety of trampoline parks (Arora, 2016).
Outcome: She was not a candidate for revascularization and would be better served with an amputation. She underwent an ORIF of the medial tibial plateau and fibular head with debridement of fasciotomy wounds. ACL and PCL were not reconstructed. Vascular surgery deemed complete loss of sensory and motor function and new areas of necrosis. She underwent a right lower extremity below knee amputation.
Follow-Up: She experienced phantom limb following surgery. Limb protector remained in place for maneuvering, transitioning and working with physical therapy. Ultimately, she was discharged to a subacute rehab facility.
Cough it Out Palpitations in a College Lacrosse Student-Athlete
Primary Author/Presenter: Emma Cronk, MD
Adriana Isacke, DO
Affiliation: Maine Medical Center, Portland, Maine.
History: Twenty-one year old male college lacrosse player with a long history of palpitations that occur with high intensity exercise. Heart rate noted of 180 bpm during most recent college preparticipation physical. Sensation of sudden heart racing with palpitations, 1 to 2 episodes yearly that last for 30 seconds and are always terminated by coughing or bearing down. Syncopal episode at age 6 was thought to be due to orthostatic hypotension. Underwent cardiology evaluation at 14 years old for presyncope followed by tachycardia/palpitations, negative EKG, ECHO, and Holter monitor, thought to be compensatory sinus tachycardia after postural light-headedness. Denies any other syncope event other than at age 6. Family history notable for father with hypertension. No unexplained deaths in the family. Grandfather died of myocardial infarction at age 82. Takes no medications, no known allergies.
Physical Exam: HR: 49 BP: 118/70 HT: 5'8" WT: 173 lbs BMI: 26.3 Constitutional: well appearing male in no apparent distress, alert, attentive, and pleasant. Neck: no JVD, supple, symmetrical Cardiac: regular rate and rhythm, normal S1/S2 noted, no murmurs, rubs, or gallops Pulmonary: clear to auscultation bilaterally with good air movement, no wheezes/rales/rhonchi Extremities: No lower extremity edema.
Differential Diagnosis:
86. Supraventricular Tachycardia (SVT)
87. Sinus Tachycardia
88. Atrial Flutter
89. Atrial fibrillation
90. Atrioventricular Block (AV block)
Test Results: EKG: sinus arrhythmia, ST elevation probable normal early repol pattern, right axis deviation. Holter Monitor: 3 episodes of high degree AV block, longest pause lasting 3.1 seconds during sleep. 1 episode of tachycardia with rate of 203 bpm. Second Degree AV Block-Mobitz I (Wenckebach) was present. Echo: LVEF 56%. No significant valve abnormalities. Normal right and left ventricular cavity size and systolic function. Treadmill Stress Test: negative in capturing an episode of SVT on EKG.
Final Diagnosis: Supraventricular Tachycardia, Second Degree AV Block-Mobitz I (Wenckebach).
Discussion: Associated with physical activity, there is an increase in resting parasympathetic tone (vagotonia) and a withdrawal of sympathetic activation, resulting in alterations of pacemaker function and conduction. First AV block and second AV block (Mobitz I—Wenckebach) occur in up to 33 and 10 percent of athletes, respectively, as opposed to 0.65 and 0.003 percent of non-athletes. Common alterations to an athletic heart that is associated with vagotonia include sinus bradycardia, sinus arrhythmia, junctional escape beats, first degree atrioventricular block and second degree (Mobitz type I) atrioventricular block. Mobitz type 1 is often a benign rhythm and does not require treatment.
Outcome: Cardiology/Electrophysiology referral. Second Degree AV block-Mobitz I (Wenckebach)- Physiologic in athletes. Echo normal. No further workup. Palpitations-Treadmill stress test negative in capturing an episode of SVT on EKG. Counseled if has sustained palpitations >20 to 30 minutes to seek medical attention. Recommend he obtain the Kardia mobile device or apple watch to record palpitations.
Follow-Up: Per cardiology recommendations, no athletic restriction. If palpitations occurring more than 1 to 2 times per year, recommended to follow up with Cardiology. Upon follow up with student-athlete, no recent sustained palpitations or palpitation events.
Hip, Hip, Hooray: A Case of Adolescent Hip Pain
Primary Author/Presenter: Frances Tao, MD, MPH
Emily Miller, MD
Affiliation: UCLA Family Medicine Residency Program, Santa Monica, California.
History: A 13-year-old previously healthy male presented with right hip pain and fever. While sitting in class 6 days prior to presentation, he felt a sudden throbbing ache in his right anterolateral hip, which worsened upon standing and walking. There was no radiation of pain or paresthesia. He denied hip trauma, however recently sustained a superficial abrasion to his right knee while playing basketball. Despite Tylenol and Motrin around the clock for pain and concurrent daily fevers to Tmax 101°F, his symptoms progressively worsened and caused inability to ambulate. He denied URI symptoms, abdominal pain, N/V/D, dysuria, or urethral discharge. He is up-to-date on vaccinations. There is no family history of joint disease, autoimmune arthritis, or malignancy. He has never been sexually active and denies tobacco, alcohol, or drug use.
Physical Exam: VS: T 101°F, HR 84, BP 116/68, RR 22, O2 97% on room air. Exam: Gen: NAD, well-developed well-nourished teenage male. CV: RRR, no murmurs. Resp: CTAB, no wheezes or rales. MSK: Normal muscle bulk and alignment of RLE. No rashes, erythema or swelling over the right hip. Significant pain on passive hip flexion beyond 90 degrees, unable to flex beyond 90 degrees. Significant pain with log roll, internal and external rotation of the hip, and axial loading. Painless full ROM of right knee, ankle and toes. Healing scab noted over right patella, no active bleeding or drainage. 2+ distal pulses. Sensation intact over all dermatomes. Compartments soft and compressible.
Differential Diagnosis:
91. Septic arthritis
92. Transient synovitis
93. Osteomyelitis
94. Pelvic or intramuscular abscess
95. Legg-Calve-Perthes disease
Test Results: WBC 5.85 (neutrophils 70.6%, lymphocytes 13.0%, monocytes 15.0%, eosinophils 0.2%, basophils 0.3%, immature granulocytes 0.9%). ESR > 40, CRP > 10. Blood cultures grew Staphylococcus aureus. x-ray right hip and pelvis: well-preserved hip without acute fracture. Ultrasound: no joint effusion. MRI right hip and pelvis w/o contrast: asymmetric right hip joint fluid. MRI right femur w/ contrast: increased small right hip joint effusion; No evidence of myositis, osteomyelitis, or osseous lesions.
Final Diagnosis: Septic arthritis of the right hip.
Discussion: Pediatric septic hip is an orthopedic emergency. The joint is often infected through a hematogenous route by Staphylococcus aureus. Patients may present with acute onset hip pain, limping or non-weight bearing. Although more commonly in males under 2 years old, septic hip should still be considered in older children especially in the setting of fever and limping. Maintain a high index of suspicion and a low threshold to repeat work up if the clinical picture is not improving. Use the modified Kocher criteria, imaging, and analyses of aspirated fluid to confirm the diagnosis. Treat within 4 days of symptom onset for a good prognosis. If treatment is delayed, grave outcomes can occur.
Outcome: He underwent fluoroscopic right hip arthrocentesis. Fluid analysis showed WBC 58 480, PMN 89%, and Gram-positive cocci. This prompted emergent right hip arthrotomy with irrigation and debridement. Postoperatively, he was weight bearing as tolerated with early mobilization through physical therapy. IV Vancomycin and Cefepime were de-escalated to IV Oxacillin once blood & fluid cultures grew MSSA.
Follow-Up: The patient followed with Pediatric Infectious Disease and Orthopedic Surgery at 2 weeks post discharge. Repeat x-rays were unremarkable. He continued IV antibiotics for 2 weeks, followed by 5 weeks of oral antibiotics. Inflammatory markers down-trended. One year later, the patient is reported to be doing well. He is now a high school freshman playing tackle football without any limitations.
Forearm Pain and Paresthesia in a Collegiate Baseball Pitcher
Primary Author/Presenter: Shane Davis, MD
Justin Gellman, BS
Affiliation: Tufts Medical Center, Boston, Massachusetts.
History: A 22-year-old male collegiate baseball player presented with 1 day of right distal biceps pain which occurred immediately after throwing a pitch. The pain was mild at rest and worsened with activation of his biceps or attempted throwing. He denied swelling, bruising, deformity or weakness; however, he had developed progressive numbness over the lateral aspect of his forearm. He had a history of Tommy John surgery on the same arm and never fully regained full elbow extension. He otherwise had no prior relevant injuries.
Physical Exam: Examination of the right upper extremity was notable for tenderness at the myotendinous junction of the distal lateral biceps and decreased sensation to light touch over the lateral forearm. There was mild pain with resisted elbow flexion with the arm in pronated and supinated positions. Otherwise, there was no pain with resisted pronation or supination at the elbow, wrist flexion or extension, or rotator cuff testing. There was no swelling, ecchymosis or deformity. The distal biceps tendon was intact. He lacked about 5 degrees of right elbow extension which he stated was his baseline. Strength testing was normal. Cervical spine exam did not reproduce symptoms.
Differential Diagnosis:
96. Lateral antebrachial cutaneous nerve (LACN) injury
97. Musculocutaneous nerve injury
98. Brachial plexopathy
99. Distal biceps tendon injury
100. Cervical radiculopathy
Test Results: In-office ultrasound of the anterior elbow was normal. Elbow MRI showed post-surgical ulnar collateral ligament changes and low-grade tearing of the common flexor tendon but was otherwise unremarkable. Electrodiagnostics performed 16 days post injury revealed reduced amplitude and preserved latency of the LACN but was otherwise normal in evaluation of the C5-6 nerve roots, lateral cord of the brachial plexus and musculocutaneous nerve.
Final Diagnosis: LACN injury with axonal features.
Discussion: The LACN is the purely sensory, distal segment of the musculocutaneous nerve. Compression can occur proximally at the coracobrachialis or distally at the bicipital tendon aponeurosis. Pitching has been linked to proximal musculocutaneous nerve injuries due to excessive neural tension in the late cocking phase. These injuries present with anterolateral forearm numbness and biceps weakness, usually sidelining pitches for 6 to 12 months. Acute, throwing-related injury isolated to the LACN has not previously been described. This injury presents with purely sensory deficits and likely carries a better prognosis.
Outcome: The athlete was treated with rest, oral steroids/NSAIDs and gradual return to throwing. Once pain was controlled, he successfully returned to unrestricted activity despite persistence of lateral forearm numbness. Prior reports of musculocutaneous nerve injury with motor involvement had prolonged recoveries; however, this athlete's isolated sensory deficits likely explain his early return to play.
Follow-Up: Three weeks post injury his pain had largely resolved. He made gradual return to throwing 3-to-4 weeks post injury and resumed competitive play 32 days after injury. Repeat electrodiagnostic studies at 3 months post injury showed improved LACN. While his numbness persisted, it was improving. We expect full resolution of his symptoms over time.
An Adolescent Soccer Player With a Limp for One Year
Primary Author/Presenter: Connor Mitrovich, DO
Suzanne Hecht, MD
Affiliation: University of Minnesota, Minneapolis, Minnesota.
History: A 12 yo male, soccer player presented with one year of bilateral thigh pain and limp. It began as non-traumatic, intermittent, cramp-like pain while standing and was unrelated to exertion. Ice and analgesics did not improve the pain. Over the next 2 months the pain worsened in his right thigh, which caused him to limp and miss soccer and physical education. He had no fevers, easy bruising or bleeding, or weight loss. After 3 evaluations by primary care, which included unremarkable femur and pelvic x-rays, CMP, and CBC, he was then referred to orthopedic sports medicine. Additional history revealed recent night sweats and an extensive paternal and maternal family history of cancer. He performed well in sixth grade classes with no reports of being bullied.
Physical Exam: He had an antalgic gait. His bilateral lower extremity exam revealed no joint swelling, erythema, or ecchymosis. He was unable to actively flex or extend at the waist due to pain. He had no tenderness to palpation of the hamstring belly, iliotibial band, or tensor fascia lata. No masses were palpated. Log rolling did not elicit pain. FABER testing and knee extension produced pain at the posterior hamstring, however, full knee extension was also limited due to tightness and pain.
Differential Diagnosis:
101. Neoplasm
102. Chronic recurrent multifocal osteomyelitis
103. Bone stress injury
104. Complex regional pain syndrome
105. Slipped capital femoral epiphysis
Test Results: MRI femur and thigh revealed abnormal T2 signal bilaterally within the femoral heads and necks, ischial tuberosities, and inferior pubic rami. There was no cortical disruption, intramuscular or subcutaneous abnormality, mass, or fluid collection. Labs revealed CRP: 23.7, ESR: 37, Calcium: 10.1, Vitamin D 25-OH: 25, Alkaline Phosphatase: 229. A bone marrow biopsy was performed with no neoplastic or inflammatory cells and negative infectious cultures including AFB, bacteria, and fungus.
Final Diagnosis: Bone marrow edema syndrome.
Discussion: Bone marrow edema syndrome is most often seen in middle-aged men presenting with hip pain. It is rarely seen in children, as only a small case series exists of this syndrome occurring in the feet and ankles of adolescents and has not been described in the pediatric hip. It is always a diagnosis of exclusion and therefore secondary causes such as trauma, infectious, ischemic, neoplastic, and iatrogenic must first be ruled out. This often contributes to a prolonged time to diagnosis, leading to high morbidity, as physical activity is significantly limited due to pain. Management is further complicated as no guidelines exist for the treatment of children.
Outcome: After an extensive, year-long evaluation that included multiple rounds of laboratory tests, images, and consultations with oncology and an orthopedic bone tumor specialist, 2 months after his MRI, this patient reported less lower extremity pain and improved gait. Expected time to full recovery can take 9 to 24 months.
Follow-Up: A DXA scan revealed normal bone density for age. He began a rehabilitation program to regain his strength and mobility to return to soccer.
Abstract Title: Can’t Stand To Handstand
Primary Author/Presenter: Michael McCoy, MD
Brian Coleman, MD and George Ghata, MD
Affiliation: University of Oklahoma Primary Care Sports Medicine Fellowship.
History: Twenty-year-old LHD F stunt performer presents with approximately 4 year history of intermittent left forearm weakness and change in sensation. She first noticed symptoms during her junior year of high school which were manifested by tingling, forearm pain and weakness in her forearm after exertion during exercises or stunt performance activities. After resting for 5 to 10 minutes symptoms would subside and she would return to being asymptomatic afterwards. No inciting event. Patient experiences symptoms on the ulnar aspect of the left forearm. Patient experiences decreased strength in forearm and grip as well as tingling and pain in forearm.
Physical Exam: No visual abnormalities of elbow and forearm. No erythema, swelling, or calor. Nontender to palpation at olecranon, medial epicondyle, cubital tunnel, and sublime tubercle. No altered sensation to light touch in forearm and hand. Full, symmetric range of motion with flexion-extension of elbow and wrist along with pronation-supination and radial-ulnar deviation. Strength symmetric and full in intrinsic muscles of hand, resisted wrist flexion-extension, resisted pronation-supination. Negative moving valgus stress test or Tinnel sign.
Differential Diagnosis:
106. Chronic Exertional Compartment Syndrome
107. Pronator Teres Syndrome
108. Cubital Tunnel Syndrome
109. Stress Fracture
110. Posterior Interosseous Nerve Compression Syndrome
Test Results: x-ray- Negative. MRI- Negative. Compartment Testing: Volar Compartment: 1 minute- 15 mm Hg, 5 minute- 15 mm Hg. Mobile Wad Component: 1 minute- 18 mm Hg, 5 minute- 16 mm Hg. Dorsal Compartment: 1 minute- 30 mm Hg, 5 minute- 22 mm Hg.
Final Diagnosis: Chronic Exertional Compartment Syndrome.
Discussion: Chronic exertional compartment syndrome is a common cause of lower extremity pain but is a much more rare diagnosis in the upper extremities. It is most often seen in athletic populations including climbers, rowers, and motorcyclists. Typically bilateral in presentation 70% to 100% of the time. Some research indicates that compartments are interconnected based on surgical evidence. Diagnosis can be made clinically but manometry also used with general consensus of any pressure ≥30 mm Hg supporting the diagnosis. Conservative treatment includes activity modification or cessation. Definitive treatment includes fasciotomy that can be open, mini-open, or endoscopic. Revision is sometimes required.
Outcome: After results of compartment testing obtained, then patient was referred to orthopedic surgeon for consultation on fasciotomy. R/B/A of fasciotomy discussed with patient. Patient and family decided to proceed with fasciotomy.
Follow-Up: Patient continued to participate in stunt activities without further worsening of symptoms and was allowed to stop activity when symptoms became too bothersome. She was shutdown for several weeks after her procedure and then returned to activity under the guidance of her athletic trainers and surgeon.
An Unusual Case of Shoulder Pain in an Adolescent Athlete
Primary Author/Presenter: Meghan Caballero, MD
Kimberly Hornbeck, MD
Affiliation: Medical College of Wisconsin Affiliated Hospitals, Milwaukee, Wisconsin.
History: E.P. is a 15-year-old male baseball pitcher and football quarterback with 1 year history of bilateral scapular winging who presented to the sports medicine clinic for consultation of a 6-week history of right shoulder pain. Pain was located over the periscapular region and described as a “pulled muscle.” Pain was worse with throwing and improved with relative rest. He noted a decreased range of motion (ROM) associated with his scapular winging which had caused him to change his throwing mechanics. He denied neurological symptoms in his upper extremities. He had been actively participating in physical therapy (PT) for his scapular winging for 6 to 7 months which improved his winging slightly, per dad, but provided no relief of his shoulder pain over the weeks during which they were working on it. E.P. had been very compliant with his home exercise program.
Physical Exam: Inspection revealed bilateral scapular winging, loss of cervical lordosis, underdeveloped trunk muscles, and overdeveloped trapezius muscles. Palpation was nontender over the clavicle, acromioclavicular joint, deltoid, upper trapezius, supraspinatus, periscapular region, cervical or thoracic paraspinal musculature or midline. He had no sensory deficit. He had limited ROM with thoracic flexion and shoulder abduction and required arm swinging to get momentum for shoulder flexion greater than 90 degrees. Shoulder internal and external rotator strength was 5/5 but that of periscapular muscles was 2−/5. Special tests for rotator cuff injury and intra-articular shoulder pathology were negative.
Differential Diagnosis:
111. Facioscapulohumeral Muscular Dystrophy (FSHD)
112. Other neuromuscular etiology/muscular dystrophy
113. Peripheral nerve injury/compression/neuritis
114. Radiculopathy
115. Spinal cord injury
Test Results: In-clinic cervical and thoracic spine x-rays were unremarkable. An MRI of the chest was ordered and was also normal. E.P. was then referred to a neuromuscular specialist. Labs were ordered and notable for elevated creatine kinase, protein, bilirubin, alkaline phosphatase, aspartate transferase, and alanine aminotransferase. Based on these results, clinical presentation, and E.P.'s physical features, genetic testing was pursued and positive for a 4q35 deletion, consistent with FSHD type 1.
Final Diagnosis: Facioscapulohumeral muscular dystrophy (FSHD) type 1.
Discussion: FSHD results from a pathogenic contraction of the D4Z4 gene, leading to expression of the toxic DUX4 gene. It has an autosomal dominant inheritance pattern, although approximately half of cases occur in individuals without family history of neuromuscular disease. FSHD is characterized by slowly progressive weakness in the facial, scapular, upper arm, and lower leg muscles. Life expectancy is normal, although other organ systems can be affected. Therefore, annual ophthalmologic exam and baseline cardiac, pulmonary, and audiologic exams are recommended. Patients can benefit from consistent follow up with a multidisciplinary care team for coordination of both medical and functional needs.
Outcome: E.P. had baseline electrocardiogram, pulmonary function tests (PFTs), and audiology and vision screens. PFTs showed a mild restrictive lung pattern, but other tests were normal. He was referred to the multidisciplinary muscular dystrophy clinic, which involves neurology, physiatry and pulmonology. He was advised to continue PT and was prescribed lidocaine ointment for his periscapular pain.
Follow-Up: E.P. was encouraged to participate in sports as tolerated but was advised to avoid strenuous muscle loading. He has continued to play both football and golf without significant difficulty and is set up for annual follow up in the multidisciplinary clinic.
Endurance Runner With Peri-Abdominal Pain Particularly When Running
Primary Author/Presenter: Theodora Swenson, MD
Lauren Porras, MD
Affiliation: Vanderbilt University Medical Center.
History: An 18 year old female long-distance runner with a history of low BMI, growth hormone deficiency, pelvic and renal cysts presented with achy, cramping pain in her lower abdomen and pelvic region that occurs only when running. The pain radiates from her pelvic region up to her stomach and began suddenly during a run. Symptoms recur only when she runs and resolve 1 hour after she stops running. No back pain or radiation down her legs, and she is able to cross train without issue. She took 6 months off of running and completed a course of physical therapy with no improvement in symptoms. Menstrual periods have been regular. Review of systems is significant only for a history of diarrhea and fatigue.
Physical Exam: She was well-developed, well-nourished and in no apparent distress. Lungs were clear to auscultation and heart was regular rate and normal rhythm. Abdomen was soft, non-tender, without hepatosplenomegaly. Musculoskeletal exam demonstrated diffuse, non-focal tenderness to palpation over the lower abdomen, pubic symphysis, and hip flexor area. Hip and back range of motion were without pain or limitation. Strength was 5 out of 5 and sensation was grossly intact along L2-S2. She had a positive left greater than right Trendelenburg with positive bilateral hamstring tightness. Negative log roll, FADIR, FABER, straight leg, and Carnett's sign.
Differential Diagnosis:
116. Primary gastrointestinal pathology
117. Referred genitourinary pathology
118. Intra-articular hip pathology
119. Referred lumbar spine pain
120. Musculoskeletal pathology
Test Results: GI performed lower and upper endoscopies which were negative. Celiac testing was negative. She was trialed on antacids without relief. External ultrasound with OB/GYN was negative for mass. Orthopedics ordered XR and MRI of the pelvis which showed an incidental small cyst in the right pubic root. She was subsequently referred to sports medicine. Due to concerns for hypermobility of the pubic symphysis, she underwent diagnostic corticosteroid injection with 50% to 60% improvement in her pain.
Final Diagnosis: Hypermobility of the pubic symphysis, or pubic symphysis dysfunction.
Discussion: Hypermobility of the pubic symphysis leads to instability in the pelvic girdle. The most frequent causes are sports-related continuous overload and pregnancy-related traumatic injuries. In runners, pelvic instability can mimic abdominal pain. Initial treatment includes physical therapy. Prolotherapy involves injecting a phenol or glucose-based solution to create an inflammatory response that leads to scarring of the ligamentous complex. Prolotherapy has been used to successfully treat sacroiliac hypermobility, and case studies suggest applications for treatment of chronic groin pain in kicking-sports. There may be additional benefits in high-impact sports such as running.
Outcome: Following diagnostic corticosteroid injection to the pubic symphysis, she was able to run for the first time in a year without pain. She was recommended for bracing, pelvic floor PT, and activity modification. Prolotherapy was also discussed as a longer-term treatment option. She elected to undergo prolotherapy of her pubic symphysis with 85% improvement of pain.
Follow-Up: After treatment with prolotherapy, she was able to progress back to running starting with walking without pain. She was very pleased with her progress and at clinic follow-up, she was back to running 35 miles per week. She will return every 1 to 2 years for a booster injection, when treatment efficacy is expected to wear off.
Chest Pain and Dyspnea: An Unexpected Flip Turn
Primary Author/Presenter: Joseph Blessman, MD
Kimberly Kaiser, MD
Affiliation: University of Kentucky, Lexington, Kentucky.
History: Seventeen-year-old male freshman division 1 swimmer with a past medical history of iron deficiency anemia presented to the training room with chest pressure and dyspnea while swimming, especially during breath holding sets. This has been a chronic issue that he first noticed during club swimming and has occurred more frequently since starting collegiate swimming practices. He was previously assessed by a sports medicine physician in his home town with a normal ECG and was released to swim without restrictions. Symptoms resolve within an hour after exertion. He does not have any chest pain or dyspnea at rest. Denies palpitations, wheezing, presyncope, syncope, vision changes, back pain, abdominal pain, gastrointestinal or genitourinary symptoms. Positive FMH of HTN in dad but negative FMH of SCD, CV disease, or Marfan disease.
Physical Exam: Vitals: BP 139/86, Pulse 55, Temp 36.8°C, RR 16, SpO2 98% General: Well developed, no acute distress Heart: RRR. Midsystolic click. Normal S1 and S2. No S3, S4. No murmurs. Lungs: CTAB in anterior/posterior lung fields, no wheezes/rales/stridor Musculoskeletal: No abnormalities. 5/5 strength in bilateral upper and lower extremities Chest Wall: No TTP over anterior chest wall, ribs, intercostal spaces. Neurology: CN 2-12 intact. SILT in bilateral upper and lower extremities. 2+ pulses bilaterally in radial, femoral, posterior tibialis, dorsalis pedis.
Differential Diagnosis:
121. Exercise induced asthma
122. Costochondritis
123. Arrhythmia
124. Hypertrophic Cardiomyopathy
125. Aortic Root Enlargement
Test Results: Twelve lead ECG: Sinus bradycardia at 47 bpm. TTE: Left ventricle mildly dilated with normal myocardial thickness and mass with normal systolic function. LVEF of 59%. Right ventricle normal size and systolic function. Aortic valve is trileaflet with mild regurgitation.
Final Diagnosis: Aortic root enlargement, mild aortic regurgitation, primary essential hypertension.
Discussion: Aortic and valvular disease should always be suspected in athletes with chest pain. Swimming poses an increased risk and has a larger impact on aortic root dimensions. Patients should be referred to a cardiologist for evaluation. Workup includes laboratory evaluation, genetic testing to assess for Marfan's and other hereditary thoracic aortic diseases, ECG, TTE, and CTA/MRA as indicated. Participation in sport is difficult to stratify and determined by type of sport and aortic root and valve findings.
Outcome: Referred to Cardiology. Obtained genetic testing, secondary hypertension labs, renal artery duplex, and MRA. MRA demonstrated morphology of the aorta consistent with Marfan's or familial aortic aneurysm and dissection with tri-leaflet aortic valve, aortic root enlargement with mild aortic regurgitation. Losartan initiated and uptitrated to 50mg with goal blood pressure reached thereafter.
Follow-Up: Disqualified from competitive swimming. Discouraged high intensity exercise and weight lifting over 30 to 50 lb. In regards to swimming, sprint swimming is the highest physical activity and should not be longer than 50 meters. Follow-up appointment with cardiology with repeat transthoracic echocardiogram in January 2023.
When it's Not Just a Concussion
Primary Author/Presenter: John Baker, DO
Eric Friedman, MD and Kevin Shindelus, MD
Affiliation: Trident Medical Center Emergency Medicine Residency, North Charleston, South Carolina.
History: A 9-year-old male who had recently just played in a little league football game presented to the ED for an evaluation of altered mental status. According to the patient's parents there were no specific plays or incidents where the patient may have experienced significant trauma. The patient was in normal health after the game until during the ride home when he became somnolent and confused. The patient was unable to open his front door when he arrived home. He walked into walls, was falling to the right, and was saying things that didn't make sense such as, “I am ready to eat my breakfast” and “I need to get in there.” He began complaining of a severe frontal headache and was unable to sleep so he was brought to the ED by his parents for evaluation.
Physical Exam: GENERAL: Well appearing, well nourished. No acute distress. NEUROLOGICAL: Alert and oriented × 3. CN intact 2-12 intact, 4/5 muscle strength RUE/RLE, 5/5 muscle strength LUE/LLE, mild hemiplegic gait, 5/5 sensory in all 4 extremities. EYES: EOMI. Anicteric. Pupils equal and reactive. HENT: Moist mucous membranes. No scleral icterus. No cervical lymphadenopathy. Nontender to cervical palpation. LUNGS: Clear to auscultation bilaterally. No accessory muscle use. CARDIOVASCULAR: Regular rate and rhythm. No murmur. No JVD. ABDOMEN: Soft, non-tender and non-distended. No palpable masses. EXTREMITIES: No edema. Non-tender. SKIN: No rashes or lesions. Warm.
Differential Diagnosis:
126. Cervical/vertebral artery injury
127. Spinal cord injury
128. Intracranial hemorrhage
129. Diffuse Axonal Injury
130. Mild traumatic bran injury
Test Results: MRI, MRA head/ neck—Concerning for left sided ICA dissection. CTA of the neck confirmed left sided ICA dissection.
Final Diagnosis: Carotid artery dissection.
Discussion: Carotid artery dissection can be difficult to diagnose given its often delayed presentation, vast array of symptoms, and sometimes asymptomatic presentation. Clinicians should keep a high index of suspicion in patients presenting with history of recent blunt trauma associated with any significant neurological symptoms or complaints. In the setting of blunt injury there are screening tools available to help ED physicians and trauma surgeons determine the need for further specialized imaging to assess for vascular injury. Other patients, such as in this case report, may present delayed, have a low mechanism of injury or have an array of neurological symptoms.
Outcome: After approximately 10 hours from his football game, the patient returned to his normal neurological baseline. Upon further examination, his weakness and gait instability had resolved. At that time, the patient denied any symptoms including vision changes, weakness, neck pain, difficulty walking or headache.
Follow-Up: The patient was begun on 81 mg of daily ASA and follow up with neurosurgery regarding length of treatment and return to activity.
Chronic Left Ankle Pain With an Unsuspected Cause
Primary Author/Presenter: Sydney Karnovsky, MD
Nathan Cardoos, MD
Affiliation: Boston Medical Center, Boston, Massachusetts.
History: A 23-year-old recreational runner with 6 years of persistent left ankle pain presented to our clinic. The pain started insidiously. She noted landing awkwardly several times in high school gymnastics but had never sprained her ankle. Fifteen months prior to presentation, the pain in her ankle worsened while training for a half marathon, limiting her with walking. She was treated with antibiotics for an infected bug bite at student health. She ran the half 2 days later, in exquisite pain. She went to urgent care and again was given antibiotics for “an infection.” Three days later, in more pain, she presented to an ED. She was told she had a “tendon issue” and saw orthopedics. Per her report, she had an XR and MRI that were normal. She started PT. She then moved cities and presented to us after waking up with severe swelling and shooting pain from her left arch to medial malleolus.
Physical Exam: General: Well-appearing. Skin: Left ankle without rashes or signs of infection. Left Ankle Exam: Mildly antalgic gait, favoring walking on the lateral portion of the foot. Pain with toe walking and hopping. Can heel walk without pain. Obvious edema over the medial malleolus. There is tenderness along the area of swelling which follows the course of the posterior tibial tendon (PTT). No bony tenderness directly over the medial malleolus or lateral aspect of the ankle. Full range of motion in the ankle but mild discomfort with active dorsiflexion. Strength is 5/5 for eversion and plantarflexion and 4+/5 for inversion and dorsiflexion, limited by pain.
Differential Diagnosis:
131. Posterior tibial tendinopathy
132. Posterior tibial tendon synovitis
133. Tarsal tunnel syndrome
134. Osteochondral defect of the medial ankle
135. Spring ligament sprain
Test Results: US: PTT and FDL sheaths with anechoic fluid and echogeneic material. Possible tenosynovitis. MRI WO Contrast: Mass-like fatty infiltration of PTT with extension to FDL to the navicular insertion of the PTT. Possible intramuscular lipoma versus low grade liposarcoma or lipoma arboescens of the tenson sheath. MRI w contrast recommended. MRI W Contrast: Synovial tendon lipomatosis (lipoma arborescens) of the PTT and FDL. XR Ankle: No osseous lesions. Biopsy: Tenosynovial giant cell tumor.
Final Diagnosis: Giant Cell Tumor, Diffuse Type.
Discussion: This case highlights the importance of using different diagnostic modalities in sports medicine. On initial work up, our patient's tumor was missed. Her in-office US was clearly abnormal, consistent with possible tenosynovitis, prompting the decision to pursue additional imaging. This led to the series of MRIs that identified a mass, described as a synovial tendon lipomatosis, which was not the biopsy proven diagnosis. Giant cell tumors are rarely seen in the ankle, and without the MRI with contrast and eventual biopsy, this would have been misdiagnosed. Given the rarity and high recurrence (up to 45%) of diffuse type giant cell tumors in the ankle, having the correct diagnosis was critical.
Outcome: Our patient had an excisional biopsy of the presumed fatty mass, and the pathology revealed a giant cell tumor, diffuse type. Ninety-nine percent of it was successfully removed during surgery. She was able to return to full activity post-operatively. To our knowledge, the tumor has not recurred, and she is doing well with no more left sided ankle pain.
Follow-Up: She was placed in a boot post-operatively, weight bearing as tolerated and then advanced to a sports brace at one month. She started PT and progressed activity as tolerated. She returned to running by 3 months and jumping by 6 months post operatively.
Atypical Adductor Pain in a Track Athlete
Primary Author/Presenter: Haley Oosterhouse, MD
Haley Oosterhouse, MD
Affiliation: Long Beach Memorial Family Medicine Residency, Long Beach, California.
History: Twenty-one year-old male track and field sprinter presents to the training room with groin/adductor pain occurring on and off for the past 2 to 3 years. The pain is 0/10 at baseline however gets to 10/10 intensity with intense physical activity, such as sprinting in competition, and squatting. The pain is relieved with NSAIDs and foam rolling. Pain has a “sharp” and “tight” sensation. Patient has also noticed a small bump/mass with flexion of the hamstring muscles. Denies knee pain. Patient denies weakness, sensory changes, fevers, night sweats.
Physical Exam: MSK: Tenderness to palpation present over the right hamstring muscles. No tenderness to palpation at greater trochanter or adductors. 5/5 strength in hip and knee flexion and extension, however reports pain with resisted right knee flexion. No pain with resisted hip adduction. With right hamstring flexion, there is a small visible and palpable prominence in the posterior thigh when compared to the left, which is non-tender to palpation and not pulsatile. No overlying skin discoloration. Sensation of the bilateral lower extremities is equal and intact.
Differential Diagnosis:
136. Hamstring tendinopathy
137. Femoral stress fracture
138. Exertional compartment syndrome
139. Soft tissue sarcoma
140. Venous malformation
Test Results: Bedside ultrasound at the time of initial evaluation shows possible soft tissue mass over the right hamstring near the site of pain. Normal XR femur. MRI shows a mass lesion characterized by what appears to be tortuous tubular structures measuring 4.9 × 5.2 cm, with edema in the adjacent muscle belly. Structures abut a portion of the neurovascular bundle but do not encase it.
Final Diagnosis: Right thigh venous malformation.
Discussion: The incidence of VMs is ∼1%, however no clear data exists on prevalence of intramuscular VMs. VMs typically present as a soft, compressible mass with skin discoloration. If the VM is in a joint, tendon, or muscle, pain with intense exertion is a common presenting symptom. Lesions often expand during puberty due to hormonal changes. Doppler ultrasound and MRI with contrast are preferred imaging studies. Complications of intramuscular VMs include deformities, limb length discrepancy, nerve compression, and weakness. Management options include sclerotherapy, which is first-line, and surgical resection for well-demarcated VMs. Recurrence is common and curative treatment is rarely possible.
Outcome: Patient was referred to a vascular surgeon. Due to patient's pain and functional impairment from VM, patient underwent sclerotherapy under ultrasound guidance with 3% sotadecol. Patient was discharged with steroid taper and motrin. Patient followed up with surgeon 6 weeks after procedure, and at that time was recovering as expected with no complications.
Follow-Up: Patient was cleared for full physical activity 2 months post-sclerotherapy and was able to complete his track and field season without pain or impairment from venous malformation. After 10 months, patient continued to have full relief of pain, but did note persistent painless prominence of the right hamstring muscles upon knee flexion.
A Thorn in his Side
Primary Author/Presenter: Joshua Go, DO
Margaret Gibson, MD, FAMSSM
Affiliation: University of Missouri—Kansas City, Kansas City, Missouri.
History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI.
Physical Exam: BMI 26.9 Temp 97.9° Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity.
Differential Diagnosis:
141. Sciatica
142. Lumbar Muscle Strain
143. Disk Herniation
144. Spondylolisthesis
145. Vertebral Osteomyelitis
Test Results: CBC: WBC 10, HGB 13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP 57.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess.
Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess.
Discussion: Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negative HIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10% of patients experience recurrence of back pain or osteomyelitis later on in life.
Outcome: Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID.
Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.
Riding to Stability
Primary Author/Presenter: Mehwish Moinuddin, DO, MA
Affiliation: Department of Orthopedics and Rehabilitation, Penn State Health, State College, Pennsylvania.
History: A healthy, 18 year old female equestrian rider presents to clinic for a second opinion regarding left hip pain. Symptoms began about 1 year ago, with no acute event or injury related to its onset. Pain is localized to left groin and sometimes posteriorly to her buttock. Pain is worse with prolonged walking, but not affected by riding horses. Does endorse a snapping/popping sensation, which is only painful when recurrent, but not when happens just a few times. Denies lower extremity weakness, numbness or tingling. Has tried about 3 weeks of PT, with worsening pain immediately following PT session, but otherwise no change in symptoms. Prior to onset of pain 1 year ago, no previous hip pain.
Physical Exam: BMI 19.42 kg/m2 Focused Left Hip Exam: Inspection: No deformities or skin changes over anterior groin. Palpation: No TTP over anterior groin or greater trochanter. No palpable snapping anteriorly. With active flexion and external rotation, there is snapping palpated posteriorly. ROM: Flexion >130 degrees; IR 45 degrees; ER 65 degrees Strength: 5/5 with hip flexion, hip extension, hip extension, hip abduction and hip adduction. NVI. Special Tests: Positive FADIR and scour; negative FABER, Stinchfield and logroll. Beighton score 4/9.
Differential Diagnosis:
146. Labral tear
147. Femoroacetabular impingement (FAI)
148. Stress fracture or stress reaction
149. Ligamentum teres femoris tear
150. Coxa saltans
Test Results: XR left hip w/pelvis: No acute abnormalities. No evidence of pincer or CAM lesions. MRI left hip with arthrogram: Subacute appearing high-grade partial with possible full-thickness tear involving a few of the posterior insertional fibers of the ligamentum teres femoris. Normal bone marrow signal. No acute fracture, contusion or stress injury identified.
Final Diagnosis: Ligamentum teres femoris tear with benign joint hypermobility.
Discussion: The ligamentum teres (LT) is an intra-articular ligament within the hip joint. The ligament passes from the transverse ligament and acetabular notch of the acetabulum to the femoral head, where it inserts into the fovea capitis. The LT acts a secondary stabilizer of the hip and prevents subluxation of the femoral head at the extremes of motion. LT pathology, such as tears, are often found while undergoing hip arthroscopy and may not be evident on imaging findings. In this case, the LT tear was seen on imaging in the absence of labral tears and is related to benign joint hypermobility, where there is a high prevalence of LT partial thickness tears.
Outcome: Management options were discussed with the patient and her mother. They have elected to proceed with conservative treatment in the form of physical therapy to work on strengthening to help with management of hip micro instability, and will further consider hip arthroscopy if pain limits her from any activities.
Follow-Up: Athlete was allowed to continue activities as tolerated, but advised to avoid any extremes of motion.
A New Meaning to Tricep Squeeze—An Unusual Case of Posterior Arm Pain in a Weightlifter
Primary Author/Presenter: Michael Lu, MD
Adenike Adewuyi, MD, PhD, Colin Franz, MD, PhD, and Monica Rho, MD
Affiliation: McGaw Medical Center of Northwestern University/Shirley Ryan AbilityLab, Chicago, Illinois.
History: The patient is a healthy 26-year-old male weightlifter who presented for right triceps pain. His symptoms started 6 months ago after quickly pushing himself out of a chair causing a twinge in his right posterior arm. His right arm pain is focal and worsened when performing bench presses or overhead tricep extensions causing him to stop weightlifting in his right arm. He denies any right arm numbness, tingling, or weakness. He denies any neck pain or bowel/bladder incontinence. He reports a history of a left pectoralis strain after lifting weights that took a year to resolve. He underwent 4 weeks of physical therapy focused on triceps strengthening, stretching, and scapular stabilization without improvement. He tried ice and focal massage without improvement. He did not take any medications for his pain.
Physical Exam: NEURO: 4/5 strength with left elbow extension. Otherwise 5/5 throughout upper extremities. Intact to light touch in bilateral upper extremities. 2+ and symmetric upper extremity reflexes bilaterally. CERVICAL SPINE: Full flexion, extension, side bending, and rotation bilaterally. Nontender over the cervical spinous processes or paraspinal muscles. Negative Spurling's maneuver bilaterally. Negative upper extremity tension signs bilaterally. ELBOW: No swelling/erythema bilaterally. Full elbow flexion, extension, supination, pronation bilaterally. Tenderness to palpation over the triceps muscle belly. Pain with resisted left elbow extension.
Differential Diagnosis:
151. Distal triceps tendinopathy
152. Cervical radiculitis
153. Neuralgic amyotrophy
154. Radial nerve mononeuropathy to the elbow extensors
155. Humeral stress fracture
Test Results: MRI Right Humerus: No evidence of abnormal marrow signal, no triceps tear, no muscle edema or fatty atrophy. Neurovascular bundles normal in course, caliber and signal. XR Cervical Spine: No abnormalities. MRI Cervical Spine: Minimal degenerative changes. No disc herniation, spinal canal stenosis, nor neural foraminal narrowing. NCS/EMG: Evidence of mild, chronic motor unit remodeling affecting the branches of the radial nerve to the triceps and anconeus, but spares distal radial nerve targets.
Final Diagnosis: Focal right radial mononeuropathy isolated to the branches of the triceps and anconeus muscle.
Discussion: To our knowledge, this is the first report of a proximal radial neuropathy affecting only the branches to the triceps and anconeus muscle. The patient's symptoms were likely due to sudden muscular exertion with forceful elbow extension while pushing himself out of a chair. The absence of active motor denervation seen on EMG indicates there was no persistent compression of the radial nerve which correlates with the patient's spontaneous improvement with conservative management. Radial neuropathy should be included in the differential diagnosis in the setting of posterior arm pain and elbow extension weakness, despite intact strength of distal muscles innervated by the radial nerve.
Outcome: The patient was offered gabapentin for symptoms but he declined. He underwent radial nerve hydrodissection under ultrasound with a mix of lidocaine and saline of the branches to the right triceps and anconeus muscle with improvement in symptoms for 4 hours without side effects including numbness, tingling, or weakness. He overall felt his symptoms have slowly improved over the last 8 months.
Follow-Up: Given his short-term improvement from the hydrodissection, other options were discussed including repeat hydrodissection with corticosteroid or surgical decompression. The patient's symptoms continued to improve without intervention and he chose to pursue conservative management of his symptoms with gradual progression towards weight lifting.
(Dis)locating the Injury in a Football Player With Chronic Shoulder Instability
Primary Author/Presenter: Sharnee Mead, DO
Kimberly Fazio, MD, Erin Barnes, MD, and Harry Hoyen, MD
Affiliation: Metrohealth Rehabilitation Institute, Cleveland, Ohio.
History: Patient is a 18 years old male football player who initially presented to a pediatric office in 2019 for right shoulder pain after hyperextending his arm while lifting weights in football. Pain was worse with bench pressing. Initial treatment included physical therapy (PT). He did not attend PT but continued to present to 3 additional providers who diagnosed the patient with rotator cuff tendonitis. During workup, a right shoulder x-ray was ordered which was deemed unremarkable. When he presented to the PM&R sports medicine office in 2021, he had 3 years of ongoing right shoulder pain that was worse after playing football. He denied any episode of shoulder dislocation but had multiple repetitive episodes of shoulder instability. His most recent injury and pain was during football this year. Pain was associated with popping, clicking and shifting and he did not have left-sided instability.
Physical Exam: Physical examination of the right shoulder was only notable for a positive apprehension test with a positive relocation test.
Differential Diagnosis:
156. Traumatic shoulder instability
157. Acquired sport specific instability
158. Bankart lesion
159. Bony bankart lesion
160. SLAP lesion
Test Results: Two view x-ray was unremarkable. MR Arthrogram of the shoulder was significant for a non-union glenoid fracture, similar to a bony Bankart lesion but appeared chronic and involved the entire anterior inferior quadrant of the glenoid, with it containing the intact labrum. The fracture measured 2.5 cm in diameter. Associated findings included a Hill-Sachs lesion and complete tear of the inferior glenohumeral ligament (IGHL).
Final Diagnosis: Chronic traumatic shoulder instability due to functional bone loss in the context of a large glenoid fracture with associated Hill-Sachs deformity and IGHL tear.
Discussion: Anterior shoulder dislocations account for a majority of glenoid rim injuries including Bankart and bony Bankart lesions. However, this patient's case is unique in that the labrum was actually intact and attached to a large anterointerior glenoid fracture, which differentiates it from a bony Bankart. Additionally, subluxation/trauma can lead to labral damage and instability, but it is atypical to have a fracture non-union of the glenoid leading to instability. This patient did not present with a history of dislocation which highlights the importance of incorporating instability testing on routine shoulder examination and having a low threshold for advanced imaging when positive.
Outcome: The patient underwent an open reduction and internal fixation using the native glenoid via the deltopectoral approach as well as a capsulorrhapathy to establish stability. Because chronic instability did not lead to bony insufficiency of the glenoid, this allowed for ORIF of the native glenoid instead of requiring bony reconstruction of the glenoid via the Latarjet procedure.
Follow-Up: Patient was discharged in a sling without active range of motion for 6 weeks. At follow up, he progressed to gentle passive and active range of motion and was cleared to return to work as a barber, however was not yet cleared for physical therapy or sporting activity. He has not returned for additional follow up but projected return to sport after fixation is often achieved in 3 to 4 months.
Shoulder Weakness Following Intramuscular COVID-19 Vaccine
Primary Author/Presenter: Abubakar Ahmed, DO
Oliver De Asis, DO and Edward Rosero, DO
Affiliation: Temple University Hospital, Philadelphia, Pennsylvania.
History: Transient and generalized adverse effects are common following COVID-19 vaccination; among other adverse effects, shoulder injuries related to vaccine administration (SIRVA) have been known to occur. In this case, a previously healthy right-hand dominant 62-year-old male presented with left shoulder pain and weakness 3 months after receiving a COVID-19 intramuscular vaccine in the left deltoid. Approximately 2 weeks after the injection, he started experiencing pain and numbness around the injection site along with ipsilateral shoulder weakness. Despite conservative management with Motrin, Medrol Dosepak, gabapentin and physical therapy (PT), the pain and weakness persisted.
Physical Exam: Left Shoulder—No calor or erythema; significant atrophy of the anterior and middle deltoid muscle relative to right side; abduction 4/5; external rotation with shoulder adducted 4/5; range of motion for active forward flexion was 150 degrees and passive was 170 degrees; passive range of motion for external rotation was 70 degrees; internal rotation to the level of L5; sensation to light touch was intact. Right Shoulder—Range of motion, strength, and sensation were intact. Cervical Spine—Full ROM; no cervical paraspinal tenderness noted. Negative Spurling's and Lhermitte's tests.
Differential Diagnosis:
161. Axillary Nerve Palsy 2/2 Chemical Neurotoxicity
162. Brachial Neuritis
163. Mechanical Axillary Nerve Palsy 2/2 Vaccination
164. Partial-Tear of Left Supraspinatus Tendon
165. Acromioclavicular Osteoarthritis
Test Results: Left Shoulder—XR: Mild pseudo-subluxation; MRI w/o contrast: 8 × 9 mm partial-thickness articular surface tear of the distal supraspinatus tendon (<50% fiber thickness). Minimal subacromial bursitis. Mild acromioclavicular joint osteoarthritis. EMG/NCV: Left and Right Axillary Motor Nerves: prolonged distal onset latency; Left Deltoid: increased insertion activity, moderately increased spontaneous activity, reduced recruitment;Remaining LUE muscles without evidence of electrical instability
Final Diagnosis: Axillary Nerve Palsy Secondary To Chemical Neurotoxicity from Intramuscular COVID-19 Vaccine.
Discussion: We postulate that the neurologic deficits presented in our case may be attributed to chemical neurotoxicity to the axillary nerve following vaccination as the delayed onset of pain and weakness are most consistent with this differential. There are several cases of brachial neuritis following vaccination for the prevention of COVID-19, however, EMG/NCV results in our patient were not consistent with brachial plexopathy. Additionally, while there have been a handful of reported cases of bursitis following COVID-19 vaccines falling under the SIRVA classification of injuries, this is the first case of reported axillary nerve neurapraxia.
Outcome: The patient's left shoulder numbness and pain improved with PT and medical management. While mild improvement in strength was noted, weakness and atrophy persisted even on the third follow up visit 6 months after the initial appointment. He was counseled on his injury and was recommended to undergo repeat EMG testing to document recovery after his 6-month follow-up appointment.
Follow-Up: The patient did not follow-up for a repeat EMG after his 6-month follow-up appointment. At that time, the patient was clinically stable, tolerating PT, and expecting recovery of his deltoid function.
Doctor I Dont Feel So Good Episodic Lightheadedness in a Collegiate Basketball Player
Primary Author/Presenter: David Neuberger, MD
Brittney Richardson, MD
Affiliation: University of Louisville Sports Medicine, Louisville, Kentucky.
History: An 18-year-old female collegiate basketball player presents to clinic at request of her athletic trainer for evaluation after syncopal episode during practice. She was participating in conditioning drills when she started to feel lightheaded, had blurry vision, and had palpitations. Moments later she collapsed on the court and regained consciousness approximately 30 seconds later. Afterwards, she was asymptomatic. Further history revealed that it was her sixth syncopal episode, with 5 happening over the course of the last several months. Her first episode was when she was 6 at which time she had a negative cardiac work-up. The other 5 have all happened in relation to exertion in practice or workouts. She had previously been told that she has a murmur. She has no family cardiac history. She was appropriately hydrated, had no dietary changes and had no other pertinent medical history.
Physical Exam: BP 112/76, Pulse 60 bpm, Resp 16, O2 sat 100% General: Awake alert oriented x3. Tall, thin female. HEENT: Mucous membranes moist. No increase in the JVP on visual examination Cardiovascular: Regular rate, rhythm. Normal PMI. No murmurs, rubs, or gallops and none elicited with valsalva. Peripheral pulses 2+ bilaterally. No carotid bruits. Lungs: Clear to auscultation bilaterally. No wheezes, crackles, or rhonchi Abdomen: Soft, nontender, nondistended, no rebound or guarding Extremities: No clubbing, cyanosis, or edema. 2+ pulses Neuro: CN testing all within normal limits. Sensation intact in all extremities. 2+ reflexes in all extremities Musculoskeletal: 5/5 strength in all extremities
Differential Diagnosis:
166. Hypertrophic Obstructive Cardiomyopathy
167. Cardiac Arrhythmia
168. Exercise Induced Vasovagal Syncope
169. Postural Orthostatic Tachycardia Syndrome
170. Orthostatic Hypotension
Test Results: Orthostatic vitals WNL. Bloodwork showed mild iron deficiency anemia. EKG showed NSR with normal intervals. Echocardiogram showed normal EF (63%) and no hypertrophy of cardiac tissue. No valvular abnormalities. Cardiac event monitor showed no arrhythmia. Cardiac MRI normal for age without hypertrophy. Exercise stress test was normal (9 minutes in Bruce protocol.) Positive tilt table test for vasovagal syncope with recreation of presyncopal symptoms and drop in BP and heart rate.
Final Diagnosis: Recurrent exercise induced vasovagal syncope likely caused by inappropriately increased parasympathetic tone in response to increase in rigor of practices and workouts at the collegiate level.
Discussion: Syncope during activity has a broad differential and requires significant cardiac and neurologic workup prior to being cleared for return to play. Structural heart disease or arrhythmia are of concern given potential to lead to sudden cardiac death. Athletes are predisposed to exercise induced vasovagal syncope which is neurocardiogenic in nature. The mechanism is not well understood but it is thought to be secondary to a Bezold-Jarisch reflex, potentially activated by reduced ventricular volume which triggers bradycardia and hypotension via augmentation of vagal tone. This is rarely seen in non athletes as exercise increases sympathetic tone in these patients and prevents fall of HR an.
Outcome: When she was at a lower level of activity when she was in high school, she was able to regulate her exertion and avoid repeated episodes when she felt her symptoms start. Unfortunately at the division 1 level the demand of practices and games is not conducive to her condition. Even though her heart is structurally and functionally normal, the decision was made to medically remove her from pla.
Follow-Up: Since being medically removed from play she has remained with the team and has participated in drills and exercises that are not as high demand from a cardiovascular perspective. She continues to play recreationally and is asymptomatic when doing so. Cardiac follow up has been reassuring and she has not had any recurrent episodes or symptoms recently.
Primary Amenorrhea in a College Cross Country Runner
Primary Author/Presenter: Joe Robinson, MD
Affiliation: Mercer Medicine, Macon, Georgia.
History: Eighteen year old female cross country runner presenting to her preparticipation physical exam with primary amenorrhea. She had developed breasts and pubic hair at age 14. She has never been sexually active. She has maintained stable weight, not on a restrictive diet, denies purging behavior and does not have a history of stress fractures. She had bilateral inguinal hernia repairs as an infant. She is unsure if any tissue was removed.
Physical Exam: T 97.8°, P 60, BP 110/64, BMI 19.08 Gen: NAD Lymph: No lymphadenopathy CV: RRR, no murmur laying/standing, symmetrical radial & femoral pulses Abd: no palpable pregnancy Derm: no rash, no course facial hair MSK: no stigmata of Marfan's syndrome
Differential Diagnosis:
171. Androgen Insensitivity Syndrome
172. Relative Energy Deficiency Syndrome
173. Turner Syndrome
174. Vaginal Agenesis
175. Kallman Syndrome
Test Results: Karotype 46 XY, 17-Oh Progesterone 46, DHEAS 440, Estradiol 37, FSH 4.19, LH 10.93, Prolactin 8.2 TSH 2.23, Total Testosterone 723, Pelvic US with no evidence of uterus.
Final Diagnosis: Androgen Insensitivity Syndrome.
Discussion: This case brings many issues forward. The current NCAA allowable testosterone for a female is <10 nmol/L and thus this athlete was ineligible to compete regardless of if this gave her an advantage. It was also important for her health and ability to exercise regardless within an NCAA framework.
Outcome: She was seen by gynecology for assistance with management who planned to perform a gonadectomy after graduating. She was also seen by psychology for an assessment.
Follow-Up: She was held from activity while an investigation was ongoing to determine the cause of amenorrhea. She unfortunately transferred to a different school and continued her running career. She had planned to have a gonadectomy at the conclusion of her college running career.
A Rare Cause of Right Plantar Foot Pain
Primary Author/Presenter: Robert Pagan Rosado, MD
Affiliation: Mayo Clinic, Rochester, Minnesota.
All Co-Authors: Jeffrey Payne, MD
History: A 53-year-old male presented with a chief complaint of right plantar foot pain. The pain began 3 days prior to his visit, when he awoke from sleep and began walking. He noted a sudden onset, achy pain in the right mid plantar foot. He rated the pain 0/10 at its best, and 5/10 at its worst. Although he had experienced plantar fasciopathy approximately 5 years prior, and he felt that these symptoms were similar, he emphasized that his pain was in a different location this time. He reported that the pain became worse whenever he walked and exerted pressure against the plantar aspect of his midfoot. He reported that rest and walking primarily on the balls of his feet to avoid any compression in the midfoot relieved his pain. He denied any swelling, bruising, paresthesia, or weakness.
Physical Exam: There was no swelling, erythema, or warmth noted in the plantar aspect of the right foot or right calf. He preferred to walk on the ball of his right foot, and he had no pain with walking on his toes or heels. There was no tenderness to palpation of the right calf musculature and no tenderness of the anterior-medial calcaneus. There was mild tenderness to palpation along the central cord of the plantar fascia at the level of the midfoot. There was more marked tenderness lateral to the central cord of the plantar fascia in the region of the quadratus plantae and flexor digitorum brevis. He had no pain with resisted toe flexion or extension. Calcaneal squeeze test was negative.
Differential Diagnosis:
176. Plantar fasciopathy
177. Flexor digitorum brevis strain
178. Quadratus plantae strain
179. Metatarsal stress fracture
180. Plantar vein thrombosis
Test Results: A right foot x-ray did not reveal osseous abnormalities. Following a point-of-care ultrasound (US) examination in the office which showed findings suspicious for a plantar vein thrombosis, the patient was sent for a complete right lower extremity venous duplex US which confirmed a short segment thrombus along the plantar venous arch at the patient's level of pain. The patient was referred to vascular medicine, who recommended surveillance ultrasound scans of his lower extremity every 5 days.
Final Diagnosis: The patient was diagnosed with a plantar vein thrombosis (PVT).
Discussion: PVTs are very rare, and their specific etiology is currently unknown. Studies have shown that PVT formation occurs in 10% of patients compared to 44% who developed a thrombus within calf veins. There is limited data about prognosis and treatment for a PVT. Treatment with NSAIDs has been reported, as well as with LMW. Individuals whose thrombi extended to the calf veins have been treated according to DVT guidelines for 3 months with anti-coagulation. This case shows the importance of including plantar veins as part of a DVT protocol if clinically indicated for active patients with plantar foot pain.
Outcome: The first surveillance US did not show extension or enlargement of the clot. He was counseled to avoid running or jumping and to contact us if his symptoms worsened. A second surveillance scan performed a week later revealed a new occlusive DVT in the mid to distal posterior tibial vein in the right calf. He was started on apixaban 10 mg BID for 7 days and then 5 mg BID thereafter.
Follow-Up: At his 3-month follow-up appointment, a repeat US did not show a clot in his lower extremity, and he was able to discontinue his anticoagulation regimen per the vascular medicine specialist's recommendations. He was instructed to gradually return to his previous level of exercise intensity, including running, and other high impact exercises.
The Kick That Took Down the Elite Soccer Player
Primary Author/Presenter: Chad Norton, DO
Jason Valadao, MD and Laura Kline, MS
Affiliation: Fort Belvoir Community Hosptial, Fort Belvoir, Virgina.
History: Twenty-one-year-old male soccer player who presents to the clinic with worsening left anterior hip pain. He reports a history of mild persistent hip pain for the past 3 weeks since the start of the soccer season, but activity was not limited. However, one day before the presentation, the athlete had acute worsening pain after a forceful kick with an externally rotated femur. He felt immediate severe pain. The pain is now described as sharp, constant, and worse with ambulation. Pain is localized to the deep anterior hip without radiation to the lower extremity or back. He denies popping or clicking of the hip. He can bear full weight but has an antalgic gait. The athlete endorses a history of similar hip pain 6 months ago, treated with NSAIDs and total rest from soccer activities with complete resolution of symptoms at that time.
Physical Exam: Left hip exam: Inspection: Mild swelling of the anterior thigh compared to right. No bruising or erythema. Antalgic gait favoring the left hip Range of motion: Full AROM. Deep anterior hip pain with flexion, extension, and internal rotation Strength: 5/5 in all planes of motion. Pain with resisted hip flexion and external rotation Special tests: FADIR: POSITIVE FABER: POSITIVE Stinchfield test: NEGATIVE Log roll: NEGATIVE Scour test: NEGATIVE.
Differential Diagnosis:
181. Rectus femoris strain
182. Iliopsoas strain
183. Inguinal groin pain
184. Obturator externus strain
185. Labral tear
Test Results: MRI left hip without contrast showed High-grade partial-thickness obturator externus tear with intramuscular hematoma measuring up to 4.9 cm. Mild osteitis pubis without tear about the symphysis. Four weeks later, sport ultrasound demonstrated significant improvement of the hematoma, with no evidence of injury to surrounding structures including adductors, quadriceps, or gluteal muscles.
Final Diagnosis: Grade 2 obturator externus tear.
Discussion: The differential diagnosis for acute hip and groin injuries is broad, and recovery times can range from days to months. After an extensive literature review, there are only 2 small case series describing obturator externus injuries in elite soccer players (N = 15). These case reports describe vague treatment modalities including rest, cryotherapy, electrotherapy, and rehab exercises. Obturator externus injuries are likely an underrecognized and treatable source of hip pain, specifically in soccer players, but there is not a standardized approach to treat this injury. We present the specific rehabilitation protocol that was used to quickly return the athlete to full activity.
Outcome: A team of multidisciplinary team of sports medicine physicians, athletic trainers, and orthopedic surgeons discussed treatment options including surgical vs nonsurgical routes, and ultimately developed a progressive rehabilitation protocol. The protocol included lower extremity stretching, adductor, external rotator, and core strengthening, cardiovascular training, and soccer-specific drills.
Follow-Up: The initial goal at the start of treatment was to return to play in 6 weeks. The athlete progressed well through the rehab protocol and was able to return to game activity within the designated timeline. He gradually increased game time for several matches, followed by a complete return to play. He remained pain-free throughout his return to play and for the remainder of the season.
Botox Reverses More Than Wrinkles: A Case of Suspicious Supination
Primary Author/Presenter: Steven Hale, MD
Taylor Christophel, MS4 and Angel Bermudez, MD
Affiliation: Central Michigan University, Saginaw, Michigan.
History: A 12-year-old female presents to Sports Medicine clinic 6 weeks after sustaining a right ankle inversion injury during a soccer game. Injury was complicated by subsequent trauma (being kicked and stepped on) several days later at practice. She developed moderate right ankle pain with an equinovarus contracture and tremors upon attempts to evert. Initial radiographs obtained at local urgent care were negative for fractures. She underwent formal physical therapy per her PCP with no improvement followed by Orthopedic Surgery referral with failed serial casting and CAM boot. Despite these interventions, her pain, contracture, and tremor persisted. PMH: Scoliosis of lumbar region.
Physical Exam: General: Healthy, well-nourished female in no acute distress. Inspection: No swelling or ecchymosis present. Resting inversion station. Palpation: Tender over the distal fibula, lateral malleolus, peroneal muscles, calcaneofibular ligament (CFL), and anterior talofibular ligament (ATFL). Range of motion: Plantar flexion 20/45, dorsiflexion neutral, inversion 25/30, eversion 0/20 with significant tremors on attempt. Strength: Plantarflexion 2/5, dorsiflexion 2/5, inversion 2/5, eversion 2/5 with tremors, extensor hallucis longus (EHL) 5/5. Neurological: Sensation intact to light touch. Special testing: Laxity in anterior drawer. Talar tilt negative.
Differential Diagnosis:
186. Peroneal tendon rupture
187. Distal fibular fracture
188. Focal dystonia
189. Complex regional pain syndrome
190. Functional neurological symptom disorder
Test Results: Three-view radiographs of the right ankle negative for fractures, dislocations, or abnormal muscle calcification. MRI of right lower leg (tib/fib) revealed mild edema in the gastrocnemius/soleus muscle and the tibialis posterior muscle. MRI of right ankle revealed contusion of the calcaneus but otherwise intact bones and ligaments. EMG of right lower extremity revealed spasticity with poor relaxation in the deep compartment muscles especially tibialis posterior consistent with focal dystonia.
Final Diagnosis: Focal dystonia of the right ankle.
Discussion: Although focal dystonia is most often idiopathic, it can be acquired secondary to medications, metabolic disorders, stroke, traumatic brain injury, or less commonly peripheral trauma. MRI and EMG following trauma help rule out structural or neurological abnormalities but are often nonspecific. Therefore, to diagnose clinically the injury must be severe enough to cause local symptoms for at least 2 weeks, and the onset of dystonia anatomically related to the site of injury must occur within days and up to one year after the injury. A multimodal approach to treatment includes physical therapy, psychological therapy, and botulinum toxin injections once other causes have been ruled out.
Outcome: The patient was referred to a PM&R where she underwent botulinum toxin injections to the gastrocnemius and posterior tibial muscles. She had significant improvement in her contracture and symptoms within a week. She continued with physical therapy for an additional 8 weeks and eventually regained full ROM and strength.
Follow-Up: She returned to organized sports 3 months after the injections. She was advised not to play soccer due to the repetitive ankle stress of kicking a ball. Instead, she joined 2 volleyball teams and continues to play competitively. She uses kinesiology tape but does not require any ankle bracing. At one-year follow-up, she continues to have full ROM and strength without any active complaints.
A Baseball Player's Weak Pitch Was a Curve Ball Case
Primary Author/Presenter: Sarah Robinson, DO
Matthew Sedgley, MD and Stephen Petr, MD
Affiliation: MedStar Health, Baltimore, Maryland.
History: This case details a 14-year-old baseball player who presented with left arm weakness after being hit by a baseball over his left humerus. Injury resulted in pain and ecchymosis of the area, but patient continued to play for the following month after the initial injury. The patient experienced no associated symptoms, denied fevers, chills, vomiting, diarrhea, rashes, ulcers, or weight loss. Endorsed transient bruising with ongoing weakness affecting his throwing leading to cessation in play. Past medical history: None; Past surgical history: Two surgical cyst removal on face; Family history: None; Social history: Middle school baseball player, left handed pitcher, denies tobacco or EtOH use; Medication: None.
Physical Exam: General: Tall 14-year-old male well developed, well nourished. Neurologic: Sensation to light touch intact down the bilateral upper extremities. No focal motor deficits. Reflexes are +2 and symmetric at the biceps. Musculoskeletal, Left Upper Extremity: No gross deformity. The humerus mid-shaft and distal shaft without ecchymosis or swelling. Palpation: No tenderness over the olecranon, medial or lateral epicondyle, or humerus. Range of motion of the elbow is full in flexion and extension with no crepitus or locking. Strength: Left upper extremity with 3 out of 5 strength on testing of the biceps, supraspinatus, and infraspinatus. Of note, he throws with his left arm. Skin: no ulcer or rash.
Differential Diagnosis:
191. Subacute Fracture
192. Avascular Necrosis
193. Lymphoma
194. Osteomyelitis
195. Ewing Sarcoma
Test Results: Hematology/Chemistry: unremarkable; Sed Rate:55 CRP:6.35 x-ray: mid-distal humerus lesion with medial cortex onion skinning and moth-eaten changes in the diaphysis. MRI: 15 cm lesion with marrow edema, cortical thickening, abnormal marrow signal in circumferential cortical thickening with periosteal reaction. Bone Scan: uptake of the left humeral diaphysis could represent neoplasm or osteomyelitis. Biopsy: Loosely fibrotic marrow, acute/chronic inflammation. No malignancy, bacteria, fungi, yeast.
Final Diagnosis: Patient underwent an aggressive open biopsy of his left humerus with pathology concerning for chronic recurrent multifocal osteomyelitis.
Discussion: Chronic recurrent multifocal osteomyelitis is a rare not well-defined inflammatory disorder likely mediated by osteoclast disease. It is thought to be an autoimmune disease that primarily affects children and commonly found in long bones with only 500 cases reported worldwide. It has been seen in individuals who also have inflammatory bowel disease and psoriasis. Treatment regimens include NSAID, anti-rheumatic medication like steroids and methotrexate or biologics. This case highlights the importance of an in-depth multi-specialty workup to correctly diagnose and successfully treat chronic recurrent multifocal osteomyelitis.
Outcome: Originally patient was placed in a well-padded posterior arm splint and instructed to use a sling due to concern for subacute fracture. However, after thorough multidisciplinary workup with an orthopedic oncologist and pediatric rheumatologist the imaging and biopsies confirmed chronic recurrent multifocal osteomyelitis. Once diagnosis was confirmed he was prescribed prednisone and methotrexate.
Follow-Up: Patient's weakness improved over the next year with the assistance of physical therapy and medication. He is back to his baseline activities including returning to baseball without symptoms. Patient continued to follow up with rheumatology and orthopedic oncology for medication adjustments and periodic imaging which remains stable.
Is it Time to Get Back in the Saddle? Persistent Knee Pain After OCD Lesion
Primary Author/Presenter: Constance Lents, MD
Ramon Ylanan, MD and Larry Balle, MD
Affiliation: University of Arkansas for Medical Sciences Sports Medicine, Fayetteville, Arkansas.
History: A 13-year-old female track, cross country, and equestrian athlete presented to clinic with right knee pain. She noted 3 years of medial knee pain without mechanical symptoms that had recently worsened despite no acute inciting event. x ray noted a possible osteochondritis dissecans lesion of the distal medial right femoral condyle. MRI showed 9 × 7 mm osteochondritis dissecans of the same location. She was instructed to discontinue impact exercises such as running and equestrian. She was permitted to cross train and was fitted in a hinged knee brace. At 3 month follow up, she was having minimal pain with the permitted activities and OCD lesion was healing well on x ray. She was released to start graded return to activity, including running and equestrian. However, at one month follow up, she was experiencing persistent knee pain without effusion and new mechanical symptoms.
Physical Exam: Patient appeared well and in no acute distress. Inspection of the right knee revealed no ecchymosis, effusion, or erythema. Gait was abnormal with a limp. Mild tenderness to palpation was noted along medial and lateral joint lines, medial and lateral patellar facets. Active range of motion was limited to 5 to 130 degrees. Muscle testing revealed 5/5 strength with knee flexion, knee extension, and hip flexion. J sign and crepitus of patella were present. Negative Lachman, anterior drawer, posterior drawer, medial McMurray's, lateral McMurray's. Negative varus and valgus stress testing at 0 and 30 degrees. Distal pulses were 2+ and symmetric. Distal sensation was intact to pain and light tou.
Differential Diagnosis:
196. Incomplete healing of osteochondritis disseca
197. Medial meniscal tear
198. Patellofemoral pain syndrome
199. Patellar instability
200. Femoral stress reaction
Test Results: MRI of the right knee without contrast revealed redemonstration of stage 2b osteochondritis dissecans along the medial femoral condyle measuring 9 × 7 mm, with suggestion of healing but with persistent subchondral marrow edema in the medial femoral condyle. New focal periosteal and endosteal edema along the posteromedial cortex of distal femur suggestive of a grade 3 stress reaction. Intact menisci, cruciate, and collateral ligaments.
Final Diagnosis: Healing osteochondritis dissecans with new grade 3 distal femoral stress reaction.
Discussion: Femoral stress reactions are not uncommon in athletes, accounting for 0.7% to 20% of sports medicine clinic injuries. It is unusual to have a stress reaction after an acute injury, especially where management required protected weightbearing and activity modification. Very few examples of stress reactions after OCD lesions exist in the literature, so mechanism is not well described. Altered biomechanics after injury could have led to an overload of bony stress. Healing OCD might have created a mismatch between native bone strength and the mechanical load placed on the bone. Additionally, the increased energy demands required for OCD healing might have predisposed the patient to stress react.
Outcome: Mother and patient were informed of the results of the MRI. The patient was held out of running until follow up. She was started in physical therapy for quadriceps, hip, core strengthening, and functional movement to prevent recurrence. She began to train in aqua running during that time and was released to equestrian events.
Follow-Up: The patient was seen for her final follow up 8 weeks after discussing her MRI. She was progressing well through therapy and aqua running. In true runner fashion, she had run a mile each of the prior 2 days without formal release. She denied any pain during therapy, running, or physical examination. She was released to running through a return to run plan developed by her physical therap.
Chest Side Story
Primary Author/Presenter: Aditya Dave, MD
Christian Schupp, MD
Affiliation: Houston Methodist Hospital-Willowbrook, Houston, Texas.
History: A 15-year-old wide receiver presented in our PCSM clinic with right clavicle pain that was going on for 2 days. Patient was injured at a football game 2 days earlier, when he was tackled and fell backwards. Ever since then he had been having pain along the right clavicle from the mid clavicle to Sternoclavicular joint. He initially went to the emergency room the day of the injury where an x-ray was done, which showed mild angulation of the clavicle that could represent a plastic bending/nondisplaced fracture and this was treated as acute clavicle fracture, placed in a sling and told to follow-up with Orthopedics/Sports Medicine. He was seen in our clinic 2 days later. Patient stated that he had been using his sling every day and only removed it when he went to sleep. He had been taking over-the-counter Tylenol for pain but his pain had not improved.
Physical Exam: BP: 121/83, Pulse: 67, Weight: 77.1 kg (170 lbs.), Height: 5'11'' Constitutional: General: He is not in acute distress. He is not ill-appearing, toxic-appearing or diaphoretic. Pulmonary: Pulmonary effort is normal. Normal breath sounds. Chest wall: Deformity, swelling and tenderness along the Right SC joint present. No mass, lacerations, crepitus or edema. Musculoskeletal: General: Tenderness present. R Sternoclavicular joint tenderness and there is depression of the R Sternoclavicular joint. Decreased ROM in the right shoulder. Skin: Skin is warm. Skin is not jaundiced or pale. No bruising, erythema, lesion, or rash.
Differential Diagnosis:
201. Proximal Clavicle fracture
202. Posterior Sternoclavicular joint dislocation
203. Anterior Sternoclavicular joint dislocation
204. Medial clavicle physeal fracture
205. Midshaft clavicle fracture
Test Results: CT: Posterior dislocation of the head of the right clavicle at the level of the SC joint by a full shaft diameter. Mild superior migration of the clavicular head relative to the sternal manubrium, findings consistent with disruption of the SC ligaments and capsule. CTA: No arterial vascular injury. Dislocation of right SC joint with posterior displacement of the right clavicular head by approximately 1 shaft width in close approximation to the brachiocephalic artery but does not contact it.
Final Diagnosis: Posterior Sternoclavicular joint dislocation.
Discussion: Posterior SC joint dislocation is a rare but potentially serious and life-threatening injury that is usually caused by acute trauma. There is an indirect anterolateral or posterolateral force on the shoulder causing damage to the SC and CC ligaments. Anterior dislocation is more common than posterior dislocation, however posterior dislocation is more serious due to the risk of damage to the vital structures behind it. CT is imaging of choice, CTA if vascular injury. Acute posterior dislocation less than 3 weeks old without evidence of vascular damage can be managed with closed reduction under general anesthesia. If vascular injury is suspected, it is a surgical emergency and will need ORIF.
Outcome: Patient was immediately sent to Texas Children's Hospital once CT results were back. The next day he underwent successful open reduction and fixation after the initial closed reduction failed in the OR. Patient then was placed in a sling for the next 6 weeks with non-weight bearing in right upper extremity.
Follow-Up: Patient was seen 1 week after his surgery at his surgeon's clinic. He was doing well after surgery. He was in a sling and non-weight bearing in right upper extremity for the next 6 weeks. He was cleared to start scapular squeeze, curls with arms at side, and lower exercises with body weight. He will follow up again in 4 weeks.
When Pressure Becomes Too Much: Evaluation of a Healthy Young Hockey Player's Hypertension
Primary Author/Presenter: Jana Qiao, MD
Matthew Silvis, MD
Affiliation: Penn State Milton S. Hershey Medical Center.
History: Twenty-three-year-old professional male ice hockey goalie who presented for pre-season medical evaluation and was found with elevated blood pressure. He denied any headaches, dizziness, vision changes, chest pain, heart palpitations, shortness of breath, musculoskeletal weakness, tremors, or paresthesias. He endorses a distant history of being informed that he had elevated blood pressures when he was younger. Denies use of supplements or pre-workout beverages. Reports low caffeine consumption. No history of mental illness, denies significant stressors. States he may have had anxiety surrounding the doctor's office growing up.
Physical Exam: General: Patient was found in no acute distress, well-appearing, well-nourished. Cardiovascular: regular rate and rhythm, no murmurs, rubs, or gallops. Well perfused extremities, non-diaphoretic, distal pulses 2+ bilaterally, no peripheral edema. Respiratory: Clear to auscultation bilaterally, no appreciable rales or rhonchi. Abdominal: no tenderness to palpation, no appreciable hepatomegaly or splenomegaly. MSK: no CVA tenderness, full range of motion. Skin: No rashes or lesions.
Differential Diagnosis:
206. White Coat Syndrome
207. Essential Hypertension
208. Renal Artery Stenosis
209. Polycystic Kidney Disease
210. Primary Aldosteronism
Test Results: BMP showed an elevated creatinine (1.71). Urinalysis showed proteinuria (30), Random urine protein level was also elevated (52). Abdominal Ultrasound: R kidney enlarged, complete replacement of the renal parenchyma with multiple different-sized cysts without hydronephrosis. L kidney enlarged with multiple cysts without hydronephrosis. No perinephric fluid.
Final Diagnosis: Polycystic Kidney Disease, suspected autosomal dominant variant.
Discussion: Hypertension in young patients tends to have innocuous etiologies, and can be overlooked in healthy athletes. Polycystic kidney disease is the most common hereditary renal disease that arises in pediatric and adult patients. Individual and family history are tantamount for new diagnosis. While PCKD management has been well-studied, this disease has unique consequences for athletes in contact sports. In several case reports, athletes have developed hypovolemic shock requiring resuscitation and blood transfusion due to ruptured kidney cysts from collisions and falls. Other complications include liver cysts and berry aneurysms. No guidelines presently exist for surveillance or return to play.
Outcome: Placed on long-term losartan for hypertension with sufficient normalization of blood pressure. Athlete completed pre-season training without complications associated with his medical disease. Patient has had subsequent trending creatinine levels that have demonstrated stability.
Follow-Up: Athlete has remained clinically asymptomatic from pre-season training into the current hockey season. Athlete has been cleared for unrestricted hockey play with no limitations. He plays the goalie position which minimizes kidney risk based on protective equipment. Ongoing surveillance with close coordination between sports medicine, orthopedics, and nephrology is planned.
To Fracture or Not to Fracture
Primary Author/Presenter: Daniel Payne, MD
Oluwarotimi Adesina, MD, Brock Niceler, MD, and Donald Fru, MD
Affiliation: Waco Family Medicine Sports Medicine Fellowship.
History: Patient is a 12-year-old male who presents to the sports medicine clinic with a 3-day history of left ankle pain. He suffered an eversion injury while attempting a triple jump at a track meet. He was evaluated at a local urgent care where there was concern for an ankle fracture. He reports dull, non-radiating pain that is aggravated by weight bearing.
Physical Exam: Well appearing male with no signs of distress. He has a slight antalgic gait. On inspection there is no deformity, swelling, or ecchymosis. He is tender to palpation along the medial malleolus. He has full range of motion at the ankle with some pain with eversion. He has 4+/5 strength at the ankle due to pain. He is neurovascularly intact.
Differential Diagnosis:
211. Salter Harris fracture of the distal tibia
212. Medial malleolus fracture
213. Triplane fracture
214. Deltoid ligament sprain
215. Syndesmotic ankle injury
Test Results: Radiographs of the left ankle showed a skeletally immature patient with a clearly demarcated vertical lucency at the medial malleolus. CT without contrast showed redemonstration of an apparent nondisplaced Salter-Harris type III fracture at the distal tibia. Repeat imaging at 4 weeks and 4 months demonstrated no evidence of bone healing.
Final Diagnosis: Cleft epiphysis of distal tibia.
Discussion: A cleft epiphysis is a normal variant seen in adolescents that persists until fusion of the growth plate. Incidence is highest at the epiphysis of the first proximal phalanx of the foot but is rare at the distal tibia. This case emphasizes the importance of accurate diagnosis because if findings are discovered with post injury imaging, misdiagnosis of a Salter-Harris III or IV fracture may occur. Correlating pain location with radiographic findings is paramount. If diagnosis is unclear, immobilization and repeat imaging at 3 to 6 weeks to evaluate bone healing may aid in diagnosis. Accurate recognition and management of cleft epiphyses can prevent unwarranted surgery or immobilization.
Outcome: He is initially immobilized in a posterior short leg splint until his CT is completed. He transitions to a Cam boot for 3 weeks. At the 4-week follow up he has full range of motion with no pain and normal strength.
Follow-Up: He returns to track 4 weeks after his injury. He reports no limitations to his participation. Follow up imaging at 4 months shows no bone healing consistent with his diagnosis.
Cool Your Jets Bro
Primary Author/Presenter: Preston DeHan, DO
Blair Rhodehouse, DO
Affiliation: Benning Martin Army Community Hospital.
History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be > 107°F. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED; however, his temperatures subsequently spiked >103°F. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required.
Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4°F Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities.
Differential Diagnosis:
216. Septic Shock
217. Hypothalamic Stroke
218. Exertional Heat Stroke (EHS)
219. Neuroleptic Malignant Syndrome
220. Thyroid Storm
Test Results: CBC: 18.2 > 14.5/40.6 < 167 CMP: 128/3.5|88/18|31/2.7 < 104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl.
Final Diagnosis: Exertional Heat Stroke.
Discussion: No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS.
Outcome: Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient’s antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic.
Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.
Hitting a Wall on the Basketball Court
Primary Author/Presenter: Catherine Fairgrieve Appel, DO, MS
Ross Mathiasen, MD
Affiliation: Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
History: A 26 year old man presents to the emergency department the morning after injuring his shoulder during a pickup basketball game. The night before he had been pushed from behind into a padded gym wall, noting a popping sensation followed by pain and difficulty moving the left arm. History is significant for multiple shoulder dislocations in the past, but he reports that this feels different than previous injuries. The only interventions undertaken prior to arrival include ice and ibuprofen. He is otherwise healthy, takes no medications, and denies other injuries.
Physical Exam: Vitals are within normal limits. 6'4" 160 lbs. Patient appears uncomfortable, laying in the gurney holding the left arm close to his body. The left arm is held in an adducted and internally rotated position. He is unable to abduct or externally rotate, but can initiate a small degree of flexion and extension at the shoulder. There is an area of non-tender soft tissue fullness palpable over the anterior shoulder and a subtle palpable deformity at the posterior glenohumeral joint. The distal left extremity is unremarkable though he reports pain radiating down the arm. Neurovascularly intact.
Differential Diagnosis:
221. Biceps tendon rupture
222. Glenohumeral joint dislocation
223. Acromioclavicular sprain
224. Humerus fracture
225. Pectoralis muscle strain
Test Results: Three-view x-ray of the left shoulder demonstrates a posterior dislocation of the glenohumeral joint. Review of images shows classic findings including the “rim sign” and “lightbulb sign.” On initial exam up to 50% of posterior dislocations are missed, in part due to subtle findings on standard AP imaging. This highlights the importance of obtaining multiple x-ray views or more advanced imaging if initial studies are non-diagnostic.
Final Diagnosis: Posterior glenohumeral joint dislocation.
Discussion: Posterior shoulder dislocations are rare, accounting for 2% to 4% of shoulder dislocations. Classically attributed to seizure or electrocution, traumatic sports-related injury is particularly unusual but chronic instability increases risk. To reduce, internally rotate the arm, apply caudle traction, and manipulate the proximal humerus laterally (DePalma method) or anteriorly. Frequently sedation is required due to spasm. CT and MRI can evaluate for associated injuries include rotator cuff, Reverse Hill Sachs or Bankart lesions, humeral neck and glenoid rim fractures. Missed or delayed diagnosis of these injuries can lead to avascular necrosis and chronic pain. Neurovascular injury is rare.
Outcome: For this patient procedural sedation facilitated successful reduction, including a satisfying “clunk” and resolution of the previously noted anterior soft tissue findings. Post reduction films were obtained and the arm was immobilized in external rotation. The patient was seen next day in Ortho clinic where CT showed a small Hill Sachs lesion and findings consistent with chronic instability.
Follow-Up: Operative management was deferred in favor of 4 weeks of immobilization and physical therapy, focusing on rotator cuff strengthening. Though he may require operative stabilization in the future, the patients goal is to return to his usual activities and be ready for the next Rec League basketball season this spring.
Not All Knee Pain, Is Knee Pain
Primary Author/Presenter: Matthew Apicella, DO
Alejandro Sanoja, MD and Michael Rosselli, MD
Affiliation: Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida.
History: A 34-year-old male runner presented to the emergency department with bilateral severe generalized knee pain. This was the patient's third presentation to an emergency department for the same complaint and he noted that he first noticed the pain after waking from sleep one morning and it was worse in his right knee. A review of prior ED visits revealed radiographs showing small effusions without evidence of fractures or arthritis.
Physical Exam: The physical exam performed in the emergency department was unremarkable. He did not have any skin changes, swelling, warmth, instability, range of motion or strength deficits.
Differential Diagnosis:
226. Osteoarthritis
227. Patellofemoral pain
228. Iliotibial band pain
229. Meniscus injuries
230. Malignancy
Test Results: Radiographs were found to be negative for any acute findings to suggest an answer for the patient's pain. Blood work revealed a white blood cell count of 395 000 (u/L) with 33% blasts, hemoglobin of 3.9 (g/dL), and platelet count of 38 000 (u/L). He was also noted to have an acute kidney injury with a creatinine of 1.35 (mg/dL), potassium of 8.7 (mmol/L), and uric acid level of 11.7 (mg/dL). Subsequent testing was positive for Philadelphia chromosome.
Final Diagnosis: acute lymphoblastic leukemia.
Discussion: ALL is commonly considered a childhood disease but may present in older patients in rare occurrences. Due to its significant morbidity and mortality, early diagnosis is paramount. The symptoms of ALL can be nonspecific ranging from the more common “B symptoms” to the joint and bone pain seen in our patient. This often makes the diagnosis difficult on initial presentation leading to a delay in diagnosis and treatment. As sports medicine physicians may be the first to evaluate these patients, it is imperative they maintain a high degree of suspicion in patients with joint and bone pain not responding to conservative measures.
Outcome: His hospital stay was further complicated by a cerebral hemorrhage requiring craniotomy and tracheostomy prior to being discharged home on chemotherapy 54 days later.
Follow-Up: He was able to be discharged and is continuing care with outpatient oncology.
The Last Dead-Lift
Primary Author/Presenter: Michelle Wheeler, MD
Daniel Santa Maria, MD and David Schmidt, DO
Affiliation: Texas Institute of Graduate Medical Education, University of Incarnate Word, San Antonio, Texas.
History: A 25 year old healthy female presented to the clinic with left knee pain. She had been having mild anterior knee pain for the past month made worse with squats, lunges, and climbing stairs. She has done split work-outs in the gym 5 to 6 days per week for the past 3 years with no previous history of knee pain. She went to her primary care provider initially and left knee x-ray was ordered with no abnormalities seen on imaging. She was started on Meloxicam and placed on complete rest for 2 to 3 weeks. After the short period of rest, she immediately resumed her normal work-outs in the gym. The first day back while bending down to pick up the bar for a deadlift, she suddenly felt a sharp pop in her knee and fell to the floor.
Physical Exam: MSK Left Knee: Gait: toe walk, crutches. Effusion: mild. Atrophy: quadriceps femoris. Tenderness to palpation of medial patellar facet, diffuse. Range of motion: 10 degree extension to 50 degrees flexion. Strength 4/5 with knee flexion and extension. Positive patellar apprehension test. Lachman's, McMurray lateral, anterior and posterior drawer, varus and valgus tests were all negative. Positive McMurray medial.
Differential Diagnosis:
231. Patella Dislocation
232. Medial Meniscus Tear
233. Patella Chondromalacia
234. Patella fracture
235. Patella Tendon Rupture
Test Results: Left Knee XR: Left transverse patella fracture of the upper 1/3 of the patella displaced by 1.25 mm. Left knee MRI: transverse oblique mildly displaced fracture through the superolateral aspect of the patella. Distraction of patella fracture fragment measures 5 mm.
Final Diagnosis: Left patella stress fracture progressing to complete transverse patella fracture.
Discussion: Patella stress fractures are rare occurrences with less than 25 cases being reported in literature. The patella is the largest sesamoid bone in the body and can withhold a force as much as much as 6 times a person's body weight. Its extensive blood supply consisting of a network of 6 different blood vessels helps to explain the rarity of such diagnosis. The mechanism of her injury was related to repetitive knee flexion during squats, lifting, and bending causing an increase in patella-femoral contact stress. This increase of tensile stress over the knee slowly overtime caused microfractures which led to a complete transverse patella fracture by indirect force of the deadlift.
Outcome: Patient was scheduled for surgery the following day and patella fracture fixation with 2 screw placements was performed.
Follow-Up: Patient is doing well and currently undergoing physical therapy. She now has flexion of the knee to 120 degrees and can perform body weight squats, BOSU ball squats, and lunges.
65-Year-Old Male Golfer With Acute Left Heel Pain: A Case Report
Primary Author/Presenter: Andrew Alexander, MD
Ike Hasley, MD, Justin Schappell, MD, and Shelby Johnson, MD
Affiliation: Mayo Clinic, Rochester, Minnesota.
History: A 65-year-old male golfer presented with acute on chronic left posterior ankle pain. Two days prior to presentation, the patient felt an acute popping sensation and severe pain at the posterior ankle while walking uphill during a round of golf. He was unable to continue golfing due to pain and difficulty ambulating. The pain was a constant ache that became sharp with weight bearing or any plantar flexion movement at the ankle. His pain improved with rest. He was previously diagnosed with mid-substance Achilles tendinosis at an outside facility 18 months ago. At that time, he initiated physical therapy and, over the course of 14 months, received 4 ultrasound-guided left retrocalcaneal bursa corticosteroid injections (CSI). The most recent injection was 6 weeks prior to his current presentation.
Physical Exam: Gait: Unable to bear weight through his left lower limb. Inspection: Mild ecchymosis at the medial ankle. Diffuse edema of the posterior calf, extending from the junction of the gastrocnemius muscle bellies to the ankle. Palpation: Tenderness to palpation at the gastrocnemius muscle bellies extending distally to the midsubstance Achilles tendon where there is a small palpable defect laterally. Range of Motion: Pain reproduced with passive ankle dorsiflexion. Limited active ankle range of motion. Strength: Pain inhibited weakness (2/5) with ankle plantarflexion. Special Tests: Thompson test revealed minimal plantarflexion in comparison to the asymptomatic side.
Differential Diagnosis:
236. Achilles tendon rupture
237. Gastrocsoleus muscle strain
238. Plantaris tendon rupture
239. Midsubstance Achilles tendinosis
240. Deep venous thrombosis
Test Results: x-ray left ankle: Distal Achilles tendon calcifications US left posterior ankle: Severe hypoechogenicity, hyperemia and thickening of the mid-substance Achilles tendon. Loss of normal tendon architecture with less than half of the cross-sectional area (CSA) intact, located 2 cm cranial to the calcaneus. Dyskinetic motion with plantarflexion. MRI left ankle: Severe Achilles tendinopathy. Partial tendon tear 2 cm cranial to the calcaneus, involving 80% of the CSA and 3.5 cm in length.
Final Diagnosis: Left high-grade partial Achilles tendon tear.
Discussion: Partial Achilles tendon tears are infrequent and may be mistaken for a flare of chronic tendinosis. This patient was at risk for rupture after 4 intrabursal CSIs within 14 months. Corticosteroids have well known detrimental effects on human tendon cells. Animal studies have shown adverse effects on biomechanical properties after intrabursal and intratendinous Achilles tendon CSI. CSIs can be helpful in the short term, but there are multiple cases of subsequent rupture. A case series found a 1.8% rupture rate within 60 days after a single image-guided retrocalcaneal bursa CSI. This case highlights the importance of using caution with CSIs in this region, even with image guidance.
Outcome: After discussing the risks and benefits of nonsurgical versus surgical treatment, the patient proceeded with nonsurgical management. He was fit for a tall walking boot with a 15-degree heel wedge and axillary crutches for toe-touch weight bearing. He was advised to initiate physical therapy and follow-up in 2 weeks.
Follow-Up: The patient followed our clinic's protocol for non-operative treatment of Achilles tendon rupture. This includes progressive ankle range of motion after 2 weeks, progressive weight bearing with cessation of crutches after 6 weeks, removal of the wedge after 8 weeks, and wean of the boot after 10 weeks. The patient was doing well with low impact activity at 12 weeks and plans to return to golf.
A Clot to Remember
Primary Author/Presenter: Songita Choudhury, MD, PhD
Joshua Bies, MD and Natalie Ronshaugen, MD
Affiliation: University of Nebraska Medical Center, Omaha, Nebraska.
History: A 16 year-old Caucasian male, who participates in basketball, football, golf, and track, presents to the emergency room with back and pelvic pain. His mid to low back pain began 3 weeks ago, which he associated with a muscle strain. Naproxen provided no alleviation of symptoms, and he refrained from sports for 2 to 3 weeks. He developed calf tightness and leg pain 3 days after the back pain began, which improved after 3 days without intervention. The pelvic pain started 3 days ago and has been worsening. At rest, his pain is a 3/10 and 7 to 8/10 while walking. Naproxen provides no relief. Other symptoms include decreased oral intake and night sweats. No recent trauma or illnesses. No color change, swelling, numbness or tingling to his lower extremities. No loss of bowel or bladder continence. Past medical history of syncope and nocturnal enuresis as a child. No significant family history.
Physical Exam: Patient is a well-developed, athletic male with BMI of 20.6. He is afebrile and hypertensive (130/60) with normal heart rate (70) and respiratory rates (16). He is sitting comfortably in no acute distress. Heart has a regular rate and rhythm, and upper and lower extremity pulses were 2+. Lungs were clear bilaterally with no increased work of breathing. Bilateral lower extremities were normal in color, no swelling or pitting edema, cap refill was delayed at 4 to 5 seconds, popliteal pulses were 2+ bilaterally, pedal pulses were difficult to palpate. Remaining exam was within normal limits.
Differential Diagnosis:
241. Muscle Strain
242. Herniated Disk/Nerve Root Impingement
243. Cancer
244. Deep Vein Thrombosis (DVT)
245. Compartment Syndrome
Test Results: CBC was significant for anemia with hemoglobin of 9.3. Basic metabolic panel and PTT were within normal limits. PT, INR, CRP, ESR, and D-dimer were elevated. MRI of lumbar spine noted to have “vascular congestion.” CT abdomen and pelvis with contrast revealed absence of the inferior vena cava (IVC) between the liver and renal veins, collateral vessels, and extensive thrombus below the level of atresia. Lower extremity ultrasound demonstrated diffuse DVTs.
Final Diagnosis: The patient was diagnosed with IVC atresia with development of paraspinous collateral vessels and extensive, occlusive, acute deep vein thromboses.
Discussion: IVC atresia has a prevalence of 0.3% to 1%. The underlying pathogenesis is unknown. Patients with this condition are often asymptomatic due to development of extensive collaterals. Symptoms such as back pain, musculoskeletal complaints, or LE DVT may develop as the collaterals are unable to cope with the demands of increased blood flow. Diagnosis is confirmed using ultrasound. Treatment includes the use of anticoagulation, catheter directed thrombolysis, and endovascular stenting. The length of anticoagulation is unknown. There have been cases of thrombus recurrence while on anticoagulation. In young patients with extensive DVT, imaging of the IVC is recommended to ensure patency.
Outcome: Patient was started on heparin and transferred to a tertiary care center for thrombolysis and thrombectomy. He underwent mechanical thrombectomy and subsequently, had catheters placed in bilateral popliteal veins for directed thrombolysis therapy using both heparin and TPA. Thrombolysis was discontinued after blood flow returned. He was transitioned to enoxaparin prior to discharge.
Follow-Up: He transitioned to rivaroxaban after he was found to be Factor V Leiden positive. Lifelong anticoagulation was recommended and participation limited to minimal contact sports (i.e., golf, track). Intermittent anticoagulation is an option for some athletes; it is unclear if it is a safe option in this case. He is seeking an opinion from a hematologist who works with athletes on anticoagulation.
Burning Ankle
Primary Author/Presenter: Joseph Marquez, DO
Jeremy Ramsey, MD
Affiliation: Naval Hospital Camp Pendleton, Oceanside, California.
History: Twenty-seven year old F with left medial heel pain for 6 months. No MOI and no prior ankle injuries or surgeries. Pain characterized as burning in nature without radiation, numbness, or associated weakness but the pain does worsen throughout the day with prolonged standing and walking; she is not an avid runner. She denies any similar symptoms on the contralateral side. The patient has attempted conservative therapy to include rest, physical therapy, and orthotics without resolution of her pain. The patient noted that eversion therapy exercises tended to worsen her pain.
Physical Exam: Patient was well nourished and in no acute distress. The patient was noted to have hind foot valgus alignment and collapse of arch with weight bearing. Gait was noted to be well coordinated without antalgia. Left ankle examination revealed full ROM without pain. Patient was tender over the medial portion of the calcaneus. She did not experience discomfort with palpation of the Achille's tendon, medial malleolus. Tinel's was positive over the flexor retinaculum. All tendon and ligamentous structures were intact.
Differential Diagnosis:
246. Baxter Nerve Impingement
247. Tarsal Tunnel Syndrome
248. Degenerative Changes of the Subtalar joint
249. Achilles tendinopathy
250. Posterior Tibial Tendinopathy
Test Results: Plain films of the ankle showed: Pes planus and small posterior calcaneal spur. Diagnostic ultrasound significant for reproduction of pain with sonopalpation of the medial calcaneal nerve just distal to the branch point off the tibial nerve and proximal to the flexor retinaculum. All other structures in the posterior, medial, and plantar ankle were within normal limits.
Final Diagnosis: Medial Calcaneal Nerve Entrapment.
Discussion: Medial calcaneal nerve entrapment tends to be more common among runners with burning pain over the medial calcaneus and radiation to the sole of the foot. There is vast anatomic variation with the medial calcaneal nerve, but most commonly branches off the tibial nerve just proximal to the flexor retinaculum. Over pronation of the ankle and valgus alignment of the hindfoot tend to be risk factors for this issue, particularly if the patient does not wear appropriate shoes. The key in treatment is to relieve the compression of the nerve. This is best achieved by correcting for alignment issues with orthotics, proper shoewear, PT and reducing inflammation with rest and anti-inflammatories.
Outcome: Hydrodissection of the medial calcaneal nerve was performed under USG with 2 mL 1% lidocaine, 1 mg Kenalog, and 13 mL 5% dextrose. A total of 15 mL was dispersed around the nerve. The patient noted 100% improvement after the procedure. She was encouraged to use her orthotics more consistently and continue all therapeutic exercises as well as use of topical NSAIDS.
Follow-Up: The patient was contacted 7 days after the procedure and noted sustained relief of pain. However, when contacted at the 1 month mark she noted that her pain had returned.
Pinned by an Invisible Opponent: Acute Weakness Takes Down Otherwise Healthy Collegiate Wrestler
Primary Author/Presenter: Kaylin Strauser-Curtis, DO
Christopher Varacallo, DO
Affiliation: Penn Highlands Healthcare, Dubois, Pennsylvania.
History: Patient is an otherwise healthy 22-year-old male college wrestler with no significant past medical history who presented to his college training room with complaints of acute onset right sided paresthesia following wrestling practice. The patient began to notice right sided whole body numbness after being on the elliptical for approximately 10 minutes. No reported trauma or mechanism of injury noted. No recent illness noted. Patient denied headache, dizziness, visual or auditory disturbances, or neck/back pain. Patient denied recent use of illicit drugs or alcohol. Further medical evaluation recommended by athletic trainer due to patient's acute ongoing symptoms. Patient proceeded to the nearest emergency department.
Physical Exam: Vitals: Unremarkable. General: Patient alert, oriented, and cooperative. No obvious distress. HEENT: PERRLA, EOMI, gross vision/hearing intact Cardio: RRR, no murmurs, rubs, gallops. Pulses palpable in all extremities. Pulm: Unlabored, CTA bilaterally Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly or masses. NEURO: Motor: 5/5 BUE, 5/5 BLE Sensation: diminished RUE and RLE Reflexes: DTR WNL CN: CN I-XII intact MSK: Moves all extremities without difficulty, gait and balance grossly normal. No tenderness or deformity noted with palpation over cervical spine. Derm: No suspicious lesions on clothed exam. Psych: Affect and mood appropriate, normal interaction, good eye contact.
Differential Diagnosis:
251. Electrolyte Imbalance
252. Space Occupying Lesion
253. Cerebrovascular Accident
254. Atypical Migraine
255. Zoster Infection
Test Results: Patient's lab work was unremarkable and EKG showed normal sinus rhythm. CT head w/o contrast showed no evidence of acute process. CTA head showed possible left P2 thrombus. TTE showed normal left ventricular function with an EF of 60%, normal wall thickness, and early positive agitated bubble study. MRI brain w/o contrast and MRA brain showed complete occlusion left P2 segment posterior cerebral artery with several acute left deep brain infarcts.
Final Diagnosis: Cerebrovascular accident secondary to patent foramen ovale.
Discussion: Most patients with a PFO are asymptomatic. Most notable manifestation is a cryptogenic stroke. Workup for PFO should be considered when a cryptogenic stroke is identified, particularly in patients under 55 years old for whom a PFO is more likely to have a causal relationship. Diagnosis can be accomplished with the use of ultrasound testing in conjunction with agitated saline contrast, also known as a “bubble study.” If the PFO is found incidentally, the patient may not require routine follow up or treatment. If it is suspected to have been related to a stroke, the discussion for treatment will include medical or surgical management.
Outcome: Patient underwent PFO closure 2 months after initial incident. Patient was on dual platelet therapy with aspirin and Plavix for 6 months. He was also under SBE for 6 months due to placement of his graft. When patient was 6 months post-op he underwent repeat ECHO which showed normal LV systolic function, LVEF 60%, and no shunt noted.
Follow-Up: Dual platelet therapy was stopped when patient was 6 months post PFO closure. Patient was released back to full activity 8 months after initial incident with mild residual numbness on the right side of his body. Patient's strength remains intact. He currently is preparing to participate in this season of wrestling with no restrictions.
Left Shoulder Pain in Baseball Player With Previous Humerus Fracture Repair
Primary Author/Presenter: Caleb Holder, DO
Andrew Porter, DO
Affiliation: Ascension Via Christi—Kansas University Sports Medicine, Wichita, Kansas.
History: A 23 y/o baseball player with a hx of humeral head fracture s/p repair as a child, presents with left shoulder pain for the past 2 weeks. He was benching and felt a pop in his left shoulder with immediate pain. He has been unable to play baseball and now has limited ROM of left arm. He was seen in the ED twice in the past 2 weeks with normal vital signs and unremarkable x-rays of the shoulder. He was discharged in a sling with instructions to f/u for concerns with proximal biceps tendon rupture based on exam. He was offered CT, ultrasound, and MRI, but declined due to cost. His pain has been constant and uncontrolled with Lortab q4hrs. He was seen by the athletic trainer yesterday and was noted to have a small rash on his left shoulder. He was started on Bactrim DS. Today, he reports worsened swelling throughout his entire arm with redness and inability to flex his arm.
Physical Exam: Vitals: Temp 36.3, HR 93, BP 146/88, SPO2 97%; General: appears fatigued, mild distress secondary to pain, left arm is held in extension due to weakness and pain. CV: RRR, no murmurs. Resp: no distress, lungs clear. MSK: Loss of biceps contour, strength: elbow flexion 0/5, supination 2/5, deltoid 5/5, supraspinatus 4/5, internal/external rotation 5/5. Very tense 3 cm × 3 cm erythematous superficial abscess near prior surgical incision over lateral deltoid. Significant swelling to the shoulder, down to the distal forearm, and up the left trapezius. Neurovascularly intact through radial/ulnar/median distribution. 2+ distal pulses.
Differential Diagnosis:
256. Septic Joint
257. Abscess
258. Biceps Tendon Tear (Long Head)
259. Rotator Cuff Tear
260. Labral Tear
Test Results: WBC 24.3, Hgb 12.7, Plt 373, Neutrophils 82%, bands 3%. BMP unremarkable. Alk phos 293. ESR 41 mm/hour, CRP > 160 mg/L, Lactate 0.8 mEq/L. XR Shoulder-no acute fracture or dislocation. CT Shoulder w/o contrast-large aggressive-appearing collection centered around the glenohumeral joint extending into the deltoid and biceps. There is a sinus tract extending from the anterior humeral neck to the lateral upper arm. MRI Shoulder-as above with pyogenic arthritis. Abscess drained 1.8L with culture + OSSA.
Final Diagnosis: Proximal humerus osteomyelitis with subdeltoid abscess secondary to chronic osteomyelitis of proximal humerus as a result of pinning from previous humeral neck fracture.
Discussion: The very large subdeltoid abscess was due to chronic osteomyelitis of his proximal humerus from the pinning of his left humeral head and neck as a child. He remained afebrile throughout the entirety of the illness. His main symptomatology after injury presented similar to a biceps tendon injury and/or rotator cuff injury without bruising. He did not show any signs of infection until 2 weeks after the initial injury with a pustule and cellulitis near his previous surgical site. Despite the rarity of septic joint and osteomyelitis, it must remain high on the differential for anyone that has a history of hardware placement. Advanced imaging is crucial.
Outcome: He underwent I&D at bedside and in the OR with 1.8 L pustular drainage removed. Cultures revealed oxacillin-sensitive staphylococcus aureus. Cortical drilling of the humerus revealed significant pus in the bone marrow. He lost 22 pounds in the 5 days of his admission. After discharge, he was treated with IV Ancef for 6 weeks through a PICC Line.
Follow-Up: On follow up, he underwent physical therapy and continued to work with his athletic trainers. He continues to struggle with range of motion and has regained close to 20% of his strength. Follow up has been every 2 weeks to evaluate for surgical complications while PICC line was in place. After PICC Line removal, follow up monthly or sooner as needed.
The Case of the Missing Hit
Primary Author/Presenter: Thomas Ricks, MD
Jay Umarvadia, MD and Daniel Lindsey, ATC
Affiliation: American Sports Medicine Institute at Andrews Sports Medicine and Orthopedic Center, Birmingham, Alabama.
History: A 19-year-old D1 collegiate offensive lineman presents with recurrent syncope and headache during summer camp. He had suffered from several weeks of heat intolerance at a much higher rate than teammates leading up to this incident including daily muscle cramps and easy fatigability. He also had 2 prior syncopal events once undergoing a complete cardiac work-up and the second felt to be vasovagal related to poor hydration status. After progressively worsening symptoms and despite appropriate cooldown measures and rehydration, he was sent to the ER where he arrived with severe retrograde amnesia, lethargy, nausea, photophobia and headache. Notably, during this practice when he presented he had no notable head trauma which was confirmed when ATCs rewatched film. He also had no prior history of concussions.
Physical Exam: HEENT: Head atraumatic, TM intact with no hemotympanum, nose normal, nares patent, dry mucous membranes Eyes: PERRL, EOMI, severe photophobia, no nystagmus on exam Resp: CTAB, no wheezes, rhonci, rhales, normal work of breath on room air Cardio: NR/RR, no murmurs, radial pulses 2+ bilaterally Neuro: AAOx3, normal language, CN II-XII intact, normal tone, no fasciculations, strength 5/5 throughout, no clonus, reflexes 2+ bilaterally with patellar, Achilles, biceps, brachioradialis, and triceps.
Differential Diagnosis:
261. Concussion
262. Heat Illness
263. Demyelinating Disease (MS, NMO, Etc…)
264. Complex Migraines
265. CVA
Test Results: MRI Brain: No focal mass, hemorrhage, hydrocephalus or ischemia. Nonspecific white matter changes seen in both cerebral hemispheres the majority of which are located in the periphery of the parietal lobes with small amount seen in the periventricular region. Cryptococcal antigen: Negative. Glucose: 63. Protein 33.6. VDRL: Non-reactive. RBC: 4. WBC 0. Bacterial Antigen: Negative. Gram Stain: No cells seen. Culture: No growth. CBC: 10.10 > 13.9/40.6139/4.3|105/25.5|9/1.5.
Final Diagnosis: Migraine Disorder, exacerbated by dehydration, causing chronic white matter changes in the brain.
Discussion: Neurological disorders are often difficult to diagnose in the sports medicine setting. Common conditions in the community can often be mistakenly attributed to concussions due to the nature of contact sports. Migraines are an often-debilitating condition that can mimic many symptoms of concussion. Demyelinating diseases such as MS are rarer neurological disorders that can mimic concussions, and both can cause chronic white matter changes. While there are theories regarding white matter changes seen in CTE there is no evidence of correlation between concussions and these changes. Athletes without clear trauma should be considered for other neurologic diagnoses, especially with abnormal MRIs.
Outcome: He was referred to a neurologist who felt that his symptoms were related to a concussion. He continued to have persistent daily symptoms for 4 more weeks despite rest. Second opinion with MS specialist yielded diagnosis of complex migraines exacerbated by dehydration. Started on Elavil 50 mg daily and imitrix 50 mg PRN with 6-month follow-up for repeat MRI.
Follow-Up: After about 8 weeks of no contact activity, the patient's symptoms were manageable, and he was able to return to light work-out activity. Despite ample rest and appropriate medication, every time he attempted to return to contact sport, he had severe re-exacerbation of symptoms and ultimately requested a medical disqualification from sporting activity which was granted.
A Real Pain in the Neck
Primary Author/Presenter: Mary Grace Castro, DO
Clarence Kong, MD, Victor Huang, MD, and Philipp Underwood, MD
Affiliation: North Shore University Hospital at Northwell Health, Manhasset, New York.
History: A 19-year-old male was elbowed in the neck while playing a pick-up game of tackle football. The players were not wearing helmets or pads. The patient presented to an urgent care center 3 days later with right neck pain and swelling, and was sent to an emergency department. The pain was rated 6 out of 10 in severity and improved to 2 out of 10 in severity with Tylenol. The pain was worse with neck movement. He was able to swallow, but with mild discomfort. He denied fever, chills, difficulty breathing, ear pain, dental pain, headache, dizziness, numbness, tingling, and weakness.
Physical Exam: Vital signs were within normal limits. The patient was well-appearing and in no acute distress. There was right lateral neck swelling and tenderness without fluctuance, erythema, or warmth. The patient had pain with active range of motion of his neck. There was no paracervical muscle or midline cervical spine tenderness. The uvula was midline. The oropharynx had no vesicles, erythema, or exudates. No bruits were auscultated. Breath sounds were clear and equal bilaterally. There was no stridor. The patient had a normal neurological exam. Cranial nerves 2 to 12 were grossly intact. Strength was 5/5 in the bilateral upper and lower extremities. Sensation to light touch was intact.
Differential Diagnosis:
266. Cervical strain or sprain
267. Cervical hematoma
268. Cervical artery dissection
269. Cervical lymphadenopathy
270. Deep neck space infection
Test Results: Initial labs were significant for a white blood cell count of 16.60 (K/uL). CTA of the neck showed an acute dissection of the right internal carotid artery; an intramuscular hematoma in the right sternocleidomastoid muscle (SCM); and enlarged adenoids and tonsils with airway narrowing. MRA and MRI of the brain and neck showed right internal carotid dissection with no acute infarcts or hemorrhage; right neck inflammatory change with a necrotic mass involving the SCM; and cervical lymphadenopathy.
Final Diagnosis: Traumatic internal carotid artery dissection (TICAD) Sternocleidomastoid hematoma infection.
Discussion: Both TICAD and neck abscesses are rare complications of blunt cervical trauma. Initial clinical presentation may be subtle but may progress to major sequelae, including airway obstruction and death. Cervical artery dissection is an important cause of stroke, particularly in young patients. Cervical pyomyositis may lead to internal jugular vein thrombosis and sepsis. This patient presented 3 days after trauma with normal vital signs and a normal neurological exam, which highlights the importance of maintaining a high-index of suspicion for these diagnoses. Early diagnosis with CTA or MRA/MRI and multidisciplinary team involvement are essential to optimal treatment and outcomes.
Outcome: Vascular surgery and neurosurgery started the patient on Aspirin. A bedside incision and drainage of the infected neck hematoma was performed, but ultimately required a washout with wound VAC placement. The wound culture grew Streptococcus pyogenes. The patient received intravenous antibiotics and was transitioned to oral antibiotics. ENT performed a laryngoscopy showing no airway narrowing.
Follow-Up: The patient followed up with vascular surgery and ENT 3 weeks after hospitalization. His right neck incision was completely healed. A duplex examination showed that the internal carotid dissection was healing. He was instructed to continue taking the Aspirin and to discontinue taking the antibiotics.
A Pain in the Neck-Lacrosse Player
Primary Author/Presenter: Jared Astrow, DO
John MacKnight, MD and Siobhan Statuta, MD
Affiliation: University of Virginia, Charlottesville, Virginia.
History: Twenty year old male lacrosse defender was struck in the left side of his neck by a lacrosse ball shot at close range during practice. He noted immediate onset of pain, difficulty breathing, and dysphagia/odynophagia. He spit out a small amount of blood at the time but rapidly regained comfort with his breathing. However, because of a decrease in his vocal quality and difficulty coordinating his swallowing, he was seen urgently in the athletic training room clinic. At that time, he otherwise denied neurologic symptoms and felt well.
Physical Exam: Well male in mild distress Oropharynx clear without lesions or evidence of trauma. No mandibular findings or trismus. Neck reveals mild soft tissue swelling anteriorly. 3 cm area of erythema left anterior neck at site of ball impact. Maximal tenderness is appreciable at the left lateral margin of his trachea and thyroid cartilage. Carotid artery on the left palpates normally with 2+ pulse and no thrill or bruit. Movement of his trachea and thyroid cartilage is normal and mildly painful. Observing his voluntary swallowing shows that he must flex his neck, drop his jaw, and repeatedly try to accomplish the swallowing motion. There is no stridor with normal air movement.
Differential Diagnosis:
271. Carotid Artery Dissection
272. Esophageal perforation
273. Lateral mass fracture of the cervical spine
274. Thyroid cartilage fracture
275. Hyoid bone fracture
Test Results: The patient was transferred to the ED that day and ENT was consulted. CTA of the neck revealed: Acute vertically oriented displaced fracture of the thyroid cartilage to the right of midline with approximately 5 mm of fracture fragment overlap Associated submucosal hemorrhage with no evidence of airway compromise Intact cricoid cartilage and tracheal rings Flexible laryngoscopy was performed and showed a patent airway. He was placed on airway observation and the following morning taken to the OR.
Final Diagnosis: Displaced Thyroid Cartilage Fracture.
Discussion: This case represents a rare injury occurring in a division 1 lacrosse athlete. Laryngeal cartilage doesn't typically ossify before 20 years of age making this injury all the more dangerous in the collegiate population. Fracture of the larynx can lead to swelling and the potential for airway compromise requiring prompt evaluation. Timing of surgery is controversial; however, many propose early reconstruction of the larynx to improve the prognosis for phonation and decannulation. This case highlights the role of the inter-professional team in evaluating and treating patients with this condition and detailed history taking with meticulous examination to minimize missing a laryngeal fracture.
Outcome: ORIF of the larynx with resorbable plating system and pins. Excellent approximation of thyroid cartilage in anatomic position. Normalization of vocal quality. Preserved airway.
Follow-Up: The athlete had no operative or post-operative complications. He was seen in follow-up 5 weeks post-op at which time he was cleared to return to contact sports. He now wears a neck guard to protect from future injury to the larynx with lacrosse.
A Head Turning Cause of Syncope in a Division 1 Collegiate Diver
Primary Author/Presenter: Nicholas Chill, MD
Brenden Balcik, MD, Aaron Monseau, MD, and Scott Meester, MD
Affiliation: West Virginia University, Morgantown, West Virginia.
History: A 19 year old female division one diver presents to the training room with multiple episodes of syncope over a 2 week period. The episodes only happen in her bedroom, usually in the morning when getting out of bed quickly or when stretching her arms above her head. This has been witnessed by her roommate who describes the patient going “completely out,” for a few seconds before returning to her baseline. No witnessed seizure-like activity, no post-ictal state. She has had no issues at practice since the onset of symptoms. She denies any heart palpitations, chest pain, shortness of breath, loss of bowel or bladder. She has a history of depression and anxiety and was recently started on bupropion which she feels has suppressed her appetite. She is otherwise healthy with no significant medical history.
Physical Exam: HR 92, BP 137/81, T 36.7°, O2 100% on RA HR increased to 132 when standing, BP remained stable at 132/77 General: Well-developed, well-appearing female in no acute distress, Heart: Regular rate and rhythm with no murmurs, Lungs: Clear to auscultation bilaterally, no wheezes, Abdomen: soft, nontender, non distended, HEENT: Mucous membranes moist, trachea midline, no masses. Neurologic: Cranial nerves II to XII grossly intact. Normal speech. Moves all extremities with 5/5 and equal strength bilaterally. Normal gait.
Differential Diagnosis:
276. Orthostatic syncope
277. Hypoglycemic episodes
278. Cardiac dysrhythmia
279. Neurovascular syncope
280. Postural orthostatic tachycardia syndrome
Test Results: CBC, BMP, Troponin, TSH, ferritin, vitamin D all within normal limits; EKG—NSR, rate 93, normal intervals; Echocardiogram—Normal study; 30 day event monitor—Normal sinus rhythm throughout; MRI Brain—Possible Chiari 1 malformation; MRI Cervical spine—normal; Carotid Ultrasound—Normal; EEG—normal; CTA Neck—Impingement of bilateral vertebral arteries by C1 lateral mass osteophytes; Dynamic Catheter Angiography-Anomalous L vertebral artery with reduced flow on right head rotation.
Final Diagnosis: Bow Hunter Syndrome resulting from anomalous left vertebral artery with reduced flow on right head rotation with compression by posterior C1 lateral mass osteophytes.
Discussion: Bow Hunter Syndrome is a rare cause of positional vertebrobasilar insufficiency caused by rotational compression of the vertebral artery, often by mass effect from osteophytes, disc herniation, tumors or cervical spondylosis. It was first described in 1978 in a patient who developed a posterior circulation stroke during archery practice. Presenting symptoms can include syncope, vertigo, nystagmus, vision changes or nausea which occur with head rotation and resolving shortly after returning to neutral position. Definitive diagnosis is made with digital subtraction angiography showing patent arteries in a neutral position and stenosis during rotation.
Outcome: Initial cardiology workup was negative. She was sent to neurology and was ultimately referred to neurosurgery for Chiari 1 malformation, which was thought to be incidental. CTA of the neck showed vertebral artery compression from C1. Dynamic catheter angiography confirmed Bow Hunter Syndrome and she underwent posterior C1 laminectomy and decompression/skeletonization of left vertebral artery.
Follow-Up: Post-operative CTA imaging of the neck shows filling defect of the vertebral artery with distal reconstitution. She is symptomatically improved and no longer has syncope. She continues to follow with cardiology for concomitant POTS diagnosis with lightheadedness and has been started on low-dose beta blocker. She has been cleared for full activity but has not yet returned to competitive diving.
An Unusual Case of Chronic Knee Pain and Swelling in a Mountain Biker
Primary Author/Presenter: Christopher Smith, MD
Kenton Fibel, MD
Affiliation: Cedars-Sinai Kerlan Jobe, Los Angeles, California.
History: Thirty-seven-year-old male with no past medical history who presents to sports medicine clinic complaining of left knee pain and swelling that began 1 year ago. The symptoms started after a 14 mile mountain bike ride, and primarily endorses symptoms after biking or running. He has no other joint complaints and denies trauma to the knee. Denies mechanical symptoms or instability. He takes Motrin, and does not utilize a knee brace during activity. He believes that his symptoms are from overuse through years of biking and running. He reports having fluid removed from his knee at an outside sports medicine clinic around 6 months prior to initial presentation.
Physical Exam: His left knee has mild swelling in the medial popliteal space adjacent to the medial gastrocnemius. No palpable deformity, no joint line tenderness, normal strength, normal range of motion, negative McMurray, negative Lachman, negative anterior/posterior drawer. Varus and valgus stress negative.
Differential Diagnosis:
281. Synovial (Baker's) Cyst
282. Pigmented Villonodular Synovitis
283. Synovial Chondromatosis
284. Rheumatoid Arthritis
285. Osteoarthritis
Test Results: Arthrocentesis showed hazy fluid which had 4700 WBC, predominately lymphocytes and monocytes. Fluid culture- no growth. Coccidioides IgG and IgM reactive. Complement fixation titer 1:16. CBC, ESR, CRP, Rheumatoid factor, CCP, and Lyme antibodies were negative. MRI of left knee showed moderate knee effusion, large popliteal cyst with extensive synovitis. Left popliteal mass sent for pathology, which showed necrotizing granulomatous inflammation, GMS stains consistent with coccidioidomycosis.
Final Diagnosis: Coccidioidomycosis of the left knee.
Discussion: Coccidioidomycosis is a systemic fungal infection caused by inhalation of spores from dimorphic fungi that infect around 150 000 Americans each year. These fungi reside in the soil of certain parts of central/southern California, the deserts of Arizona, and other areas of southwestern United States, Mexico, Central, and South America. Obtaining a history of residence or travel to an endemic area is critical to diagnosis. Less than 1% of patients have disseminated coccidioidomycosis, which may include bone/joint involvement. Definitive diagnosis can be established through serologic testing and tissue biopsy. Initial treatment consists of oral antifungals for a minimum of 1 year.
Outcome: Patient underwent radical resection of left popliteal mass by orthopedic oncology. He completed a course of fluconazole 800 mg daily for 1 year by infectious disease specialist, and followed up periodically for complement fixation titers which gradually improved. On follow up with orthopedic oncology he still endorsed mild symptoms, but was advised against additional surgical intervention.
Follow-Up: He will follow up with orthopedics as needed. He may participate in activity as tolerated. He continues to bike, but now utilizes an e-bike. He was encouraged to utilize a knee brace during running, hiking, and biking.
My Legs Are Entrapped
Primary Author/Presenter: Lovepreet Singh, DO
Yao-Wen Eliot Hu, MD
Affiliation: Naval Hospital Camp Pendleton, Oceanside, California.
History: A 22-year-old active duty female presented with a 3-year history of bilateral leg pain along the anterior tibia. She denied history of trauma or injury. The pain begins after several minutes of exercise, especially running, with associated numbness and tingling in the anterior compartment of the legs. She is a heel striker. Patient states there is slight purple discoloration of the legs when the symptoms are severe. She denied swelling or pallor. She has tried and failed physical therapy, ice, NSAIDs, orthotics/arch support and rest. She has seen several providers over the last 2 years with no complete diagnosis, expressing frustration. Plain film imaging was negative for bilateral knee, tibia/fibula, and ankle/foot. Subsequent MRI of tibia/fibula was negative as well. Patient began rehab focusing on gait retraining from heel strike to midfoot strike, soleus stretching and massage.
Physical Exam: Height 160 cm, Weight 67 kg, BMI 26.2 kg/m2. General: Well developed, no acute distress. Inspection: No rashes, bruises, atrophy or bleeding. Palpation: Pain on palpation over bilateral soleus canal and popliteal artery and soleus. Range of motion: Full ROM at ankles and knees. Strength: Full throughout. Neurologic: Intact and equal bilaterally. Special testing: Positive tinels over DPN and SPN, no decrease in pulse with popliteal artery dynamic ankle dorsiflexion with knee extension.
Differential Diagnosis:
286. Popliteal artery entrapment syndrome
287. Tibial stress syndrome
288. Exertional compartment syndrome
289. Lumbar radiculopathy
290. Peripheral vascular disease
Test Results: MSK ultrasonography of the soleus canal demonstrated normal power doppler flow of the anterior tibial artery (ATA) branching off the posterior tibial artery at rest, but with dynamic knee extension and ankle dorsiflexion, there was significant decrease in power doppler flow of the ATA through the soleus canal, simultaneously increasing the patient's symptoms in real time.
Final Diagnosis: Bilateral soleus canal syndrome.
Discussion: Soleus canal syndrome (SCS) occurs when compression of the anterior tibial artery occurs as it passes posterior to anterior through the space just proximal to the interosseous membrane. The entrapment point in SCS is more distal than the typical entrapment point seen in popliteal artery entrapment. Patients often present with claudication-like symptoms. CTA and MRA are the main diagnostic modalities used for evaluation, but dynamic doppler ultrasonography proved valuable in our case as we were able to visualize the decrease in blood flow in the ATA and an increase in patients symptoms in real time. Initial treatment is conservative measures though cases may require hydrodissection or surgery.
Outcome: Reported 20% decrease in symptoms. The patient likely had improvement in symptoms as her biomechanical compensatory mechanisms were corrected from conservative management. The delay in diagnosis and patient's lack of consistency with PT are probable causes of failure of conservative management initially. The patient restarted focused physical rehabilitation with continued improvement of symptoms.
Follow-Up: Patient has returned to full activity. Follow-up plan included consideration of hydrodissection with steroid, and possibility of surgical decompression of anterior tibial artery should symptoms reoccur.
An Apple That Day Kept the Athlete in Play
Primary Author/Presenter: Leanna Brooks, MD, MS
David Price, MD
Affiliation: Atrium Health Carolinas Medical Center - Charlotte, NC
History: A 43 year-old male, otherwise healthy CrossFit athlete, was working at his desk when he noticed his Apple watch reading heart rates in the 210 seconds. He initially ignored the readings as he was asymptomatic, however after an hour he called his sports medicine physician friend. He was advised to first correlate the watch readings with his actual pulse. Once confirmed, his physician friend advised vagal maneuvers—when they were unsuccessful, he presented to the ED (3 hours after initial onset). The patient denied significant symptoms, just felt a little “off.” Patient had no history of hypertension, hyperlipidemia, prior palpitations or cardiac events. He had no family history of sudden cardiac death. He denied illicit drug use, though he does drink 2 cups of coffee daily and drinks alcohol socially.
Physical Exam: Vital signs: Temperature 97.4°, HR 212 to 218, BP 107 to 131/74 to 96, RR 16 to 21. Patient is well appearing, no distress. No JVD. Normal respiratory effort, lungs clear to auscultation. Significant tachycardia. Extremities warm, without edema. Alert and oriented x3. Remainder of exam is normal.
Differential Diagnosis:
291. Supraventricular Tachycardia (SVT)
292. New onset atrial fibrillation with RVR
293. Atrial Flutter
294. Ventricular Tachycardia (VT)
295. Multifocal Atrial Tachycardia
Test Results: In ED: Urine drug screen negative, CBC within normal limits, Potassium and Creatinine within normal limits. Cardiac studies: Troponin 2569. BNP 117. EKG showed wide complex regular tachycardia, HR 216 with no acute ST-T changes. Questionable SVT with aberrant conduction versus VT.
Final Diagnosis: Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)—predominantly left sided.
Discussion: ARVC is characterized by fibrofatty infiltration of the myocardium leading to RV dilation, RV dysfunction, ventricular arrhythmias, and even sudden death. Patients may also have left ventricular involvement. Unfortunately high intensity exercise, even of short duration, may accelerate the condition. Patients may be asymptomatic or present with palpitations, dizziness, syncope and chest pain. The most common presenting arrhythmia is monomorphic VT with LBBB. Detraining can modify ARVC disease progression but cannot halt it. Gene mutations have been found in about 60% of people with ARVC. Most familial cases of the disease have an autosomal dominant pattern of inheritance.
Outcome: Adenosine and Diltiazem initially given for suspected SVT without success. Amiodarone then given with successful conversion to NSR confirming VT. Coronary cath normal. Cardiac MRI showed EF 35%, LV scar burden of 5%, LV wall thinning with fatty infiltration and mild RV dysfunction. Patient diagnosed with LV variant of ARVC. A dual-chamber ICD was placed and he was started on B-blocker and ARB.
Follow-Up: Patient will have genetic testing followed by repeat cardiac MRI within the year. He was restricted to recreational low intensity activities with HR < 131. Incredibly, he remained asymptomatic during years of CrossFit despite high heart rates and probable cardiac deterioration. Fortunately and ironically, his watch worn to track his heart rate during activity probably saved his life during rest.
When Your Spine Keeps You From the Line
Primary Author/Presenter: Nicole Prendergast, MD
Warne Fitch, MD
Affiliation: Division of Sports Medicine, Department of Orthopaedic Surgery, Vanderbilt University Medical Cen
History: A 20-year-old male division I college football lineman presented during practice with neck pain and spasms. The patient sustained a frontal hit while blocking during which his neck was “jammed back.” He initially presented to athletic training staff for neck spasm who were concerned given limited range of motion, bilateral pain with provocative maneuvers and midline tenderness, therefore requested further evaluation. On physician assessment he reported bilateral pain worse on the right. He noted the pain radiated down his right arm and was associated with paresthesias, weakness and numbness. He also noted spasms in his right neck and trapezius. He had experienced stingers in the past but felt this was different given the duration of symptoms. He denied loss of consciousness and headache. No past medical history, surgical history or medications were reported.
Physical Exam: General: Well-appearing, no acute distress HEENT: Normocephalic, atraumatic, pupils equal and reactive bilaterally, extraocular eye movements intact Respiratory: Normal respiratory rate Neuro: CN II-XI grossly intact, strength upper and lower extremity 5/5, steady gait, sensation deficits as noted below otherwise grossly intact Focused: No midline cervical, thoracic, or lumbar spine tenderness, right cervical paraspinal and trapezius tenderness, decreased sensation over deltoid area, limited ROM of cervical spine due to pain and spasm to the right of midline, Spurling test positive bilaterally.
Differential Diagnosis:
296. Transient brachial plexopathy “Stinger”
297. Cervical disc herniation
298. Cervical strain/sprain with spasm
299. Cervical spinous/transverse process fracture
300. Cervical spine ligamentous injury
Test Results: x-ray cervical spine AP, lateral and flexion and extension: congenital absence of portions of the C1 posterior neural arch. Otherwise, bones and joints were unremarkable. Cervical curve reversal was noted to be likely in the setting of pain or muscle tightness. Cervical spine MRI: mild interspinous ligamentous edema at C5-6 without evidence of spinal cord contusion or stenosis. No disc herniations, central or foraminal stenosis were noted. CT cervical spine: congenitally absent C1 ring.
Final Diagnosis: Congenital incomplete C1 ring with a transient brachial plexopathy, “Stinger,” versus spinous ligament strain with persistent neurological deficits due to spinal cord apraxia.
Discussion: An incomplete C1 ring is a rare congenital anomaly with an incidence of 0.7% to 3% with a highly variable presentation ranging from asymptomatic to quadriparesis. 90% of C1 posterior arch anomalies involve failure of hemi-arch midline fusion. x-rays, CT and MRI images can diagnose the lesion and complications. Anomalies of the posterior arch are considered benign, however can lead to severe neurological compromise especially in high-risk subtypes. The most serious complications are spinal cord compression, due to inward buckling of the ligaments, and atlantoaxial instability. The literature lacks clear guidelines on management; however, many recommend restriction from contact sports.
Outcome: The patient was seen by neurosurgery who noted symptoms aligned with a stinger, however spinal cord apraxia could not be ruled out. It was discussed that his risk of serious injury with an incomplete C1 ring is above the average player, but to an unknown degree. The patient was given time to talk with his family regarding returning to football and scheduled for 2-week follow-up.
Follow-Up: After discussion with his family, the patient was leaning towards ending his football career given the increased risk of a catastrophic quadriplegic event in the setting of his incomplete C1 ring. His paresthesias and weakness had resolved. The rare incidence of C1 vertebral deficiencies leaves the shared discussion of continued participation, as in this case, between the provider and athlete.
A Collegiate Soccer Player's Sinister Stitch in the Side
Primary Author/Presenter: Peyton Kremer, DO
Sarah Robinson, DO and Matthew Sedgely, MD
Affiliation: MedStar Franklin Square, Baltimore, MD
History: A 19-year-old male soccer player presented to clinic with concern for recurrent, episodic pain in his right flank region (in the region of the posterolateral 8th-10th ribs). When present, he describes the pain as stabbing and sharp. Pt denies a traumatic event that may have caused an injury, though notes he dives frequently as he is a goalie. He denied any particular triggers for this pain. Also denies finding anything that alleviates pain when it is present. He has continued to play soccer and lift weights. At the time of his visit to clinic, he was seeing a physical therapist without much improvement in pain. The patient denied fever, chest pain, difficulty breathing, nausea, vomiting, abdominal pain, painful or bloody urine, or unusual rashes. His past medical history is significant for a grade 2 splenic laceration 4 or 5 years ago. He had no significant family history.
Physical Exam: The physical exam revealed a well-appearing male in no acute distress. There was no bruising or obvious deformity at the site of pain on the right flank. The patient was found to have tenderness in his lateral right chest wall along ribs 8 to 10. No palpable masses and no regional lymphadenopathy were identified. He was also found to have abnormal respiratory motion, primarily in his right ninth rib. Lungs were clear to auscultation. The heart exam revealed regular rate and rhythm, no murmurs.
Differential Diagnosis:
301. Rib fracture
302. Rib Contusion
303. Costochondritis
304. Nephrolithiasis
305. Expiratory/Inspiratory somatic dysfunction rib 9
Test Results: A chest x-ray was obtained that revealed multiple abnormalities of ribs 4 to 7 on the right side, consistent with old fractures versus lesions. An MRI was obtained for further clarification that showed expansile, sclerotic, dumbbell-shaped lesions that were concerning for a diagnosis of fibrous dysplasia. A nuclear medicine bone scan was obtained that confirmed lesions consistent with fibrous dysplasia, along with superimposed aneurysmal bone cyst in the eighth rib that was the likely etiology of patient.
Final Diagnosis: A bone biopsy revealed polyostotic fibrous dysplasia and a giant cell reparative granuloma with secondary aneurysmal bone cyst complicating fibrous dysplasia of the right eighth rib.
Discussion: This case illustrates the potential for more severe underlying pathology to musculoskeletal pain in collegiate athletes. While rare, fibrous dysplasia typically presents in the late teens to early twenties and it is an important diagnosis to include a differential as there are effective treatment modalities for pain available.
Outcome: Following this diagnosis, the patient underwent curettage resection of the active bone lesion on the eighth rib to facilitate pain relief, local control, and improved rehabilitation potential. The patient tolerated this procedure well with improvement in pain.
Follow-Up: The patient recovered well from his surgeries. He received regular clinic visits for follow-up to track his progress. At the time of his last visit, he had no restrictions and was advised to continue to escalate his activities as his pain permits. He was advised to follow-up in one year for repeat imaging.
Hoops and Hemoptysis: A Case of Chest Trauma in a Pediatric Basketball Player
Primary Author/Presenter: Cody Ward, MD
Linda Mansfield, MD
Affiliation: South Bend - Notre Dame Sports Medicine Fellowship
History: Fifteen-year-old previously healthy male basketball player presenting with hemoptysis. Four days prior, while playing basketball, he went up for a layup, was undercut by an opposing player, and fell on his thoracic spine and posterior ribs (video of fall available for review). Legs were compressed up to the chest, epistaxis post-fall despite lack of head trauma. He had persistent thoracic back/rib pain in the days following the fall, worse with inspiration. He developed a cough with 4 to 5 episodes of hemoptysis daily despite the resolution of his epistaxis and without difficulty breathing.
Physical Exam: T: 99.1, HR: 61, RR: 16, BP: 110/70, O2: 99 percent on room air, HT: 70.5 inches, WT: 134 lbs Well appearing male in no acute distress. Mild TTP at midline of T5-T9. Symmetric motion of the ribs with inspiration and expiration. RRR, S1 and S2, no S3 or 4. No murmurs. Lungs are CTA bilaterally with non-labored respirations. Abdomen soft, NT/ND, with bowel sounds present.
Differential Diagnosis:
306. Hemoptysis from Upper Airway Bleed
307. Hemothorax
308. Pneumatocele
309. Pulmonary Embolism
310. Pulmonary Contusion
Test Results: CXR: Air fluid level at the level of the heart, just to the left of the midline. Follow-up CT advised. CT Chest w/Contrast: Oval-shaped cranial caudally oriented air high-density fluid collection involving the posterior medial left lower lobe immediately adjacent to the associated thoracic vertebral bodies. The lesion measures 8.5 centimeters × 2.8 centimeters × 2.0 centimeters. associated pleural and/or extrapleural thickening adjacent to the lesion. Consistent with traumatic pneumatocele.
Final Diagnosis: Pneumatocele.
Discussion: Symptoms such as chest pain, cough, hemoptysis, and dyspnea developing in the days following chest trauma are concerning, and these should raise suspicion for pleural and/or parenchymal pulmonary injury. Pneumatoceles are believed to result from explosive compression which tears the parenchyma followed by decompressive force on the chest wall which generates a negative pressure that lacerates the lung. After trapping air and/or blood, the lung retracts. Pneumatoceles must be followed closely as complications include infection and pneumothorax. Post-traumatic pneumatoceles will, typically, resolve spontaneously at an average of 3 months, but those >2 cm average 5 months for resolution.
Outcome: Our patient was referred to CT surgery given the size of the pneumatocele. He had gradual improvement and resolution of hemoptysis in the 2 weeks following the injury. CT chest was repeated at 5 weeks, which demonstrated a significant decrease in lesion size to 5.8 × 1.0 × 0.7 cm. CT chest at 7 months showed complete resolution of the pneumatocele. There were no issues after return to activity.
Follow-Up: For the first 5 weeks, he was only allowed to shoot baskets. He was instructed to avoid any activities that would rapidly change intrathoracic pressure. Given the decreased size of the pneumatocele on repeat CT, his activity progressed over the next week with running, weight training, and drills. As he was symptom-free, he was allowed to return to basketball at 6 weeks, which was tolerated well.
Be Careful What You Breathe
Primary Author/Presenter: Eric Bowman, DO
Affiliation: Phoenix Children's Hospital Phoenix, AZ
History: A 15-year-old male recreational soccer athlete with a 1-year history of intermittent ankle and back pain presents with pain and swelling in his right knee. Knee pain started about 4 to 5 months ago with no known injury. He reports significant swelling, warmth, and redness with his knee when it hurts. Pain is now so significant that he is unable to bear weight and has been in a wheelchair for the past 2 months. He has not been able to play recreational soccer for past 3 to 4 months because of pain. He was evaluated by his PCP 2 weeks prior with labs completed and was evaluated by ortho 1 year prior for ankle pain where labs were ordered, but he was lost to follow-up. He denies any fevers, cough, or other joint pain and denies sexual activity. No personal history of rheumatologic conditions, but rheumatoid arthritis in maternal grandmother.
Physical Exam: Healthy appearing male with no apparent distress. Vital signs: Temperature 98.4°F, HR 77, RR 18, O2 sat 96%, BP 133/73. Right Knee: Grade 2+ effusion with warmth to touch and redness; TTP over entire knee; strength in flexion and extension 4/5 secondary to pain; ROM limited to 70 degrees of flexion and 20 degrees of extension secondary to pain; unable to stand from wheelchair or bear weight; mild TTP of low back; no additional swelling, warmth, tenderness to palpation of any additional joints.
Differential Diagnosis:
311. Juvenile Idiopathic Arthritis (JIA)
312. Chronic meniscal tear
313. Septic arthritis of knee due to staph aureus
314. Septic arthritis of knee due to coccidiodomycosis
315. Gout
Test Results: Labs: R knee Synovial Fluid: yellow, turbid; WBC 35 275; RBC 5,000; 69% seg neutrophils, 11% lymphocytes, 20% macrophages; no crystals; no growth. CBC: WBC 9.8, HGB 9.5, Platelets 620. ESR 130. CRP 14.8. Coccidiodes: IgG positive, IgM negative. Right knee x-ray: no bone abnormality, moderate effusion. Right knee MRI: large effusion, synovial thickening & enhancement, patchy T2 signal with mild enhancement of distal femur. Fungal culture growth of coccidiodomycosis.
Final Diagnosis: Septic arthritis secondary to disseminated coccidiodes with reactive anemia.
Discussion: Valley fever is the initial form of the coccidioidomycosis infection. Cocciodiodes is a fungus that is found in the Southwestern United States. The initial form of infection is often mild with few or no symptoms. Symptoms can occur 1 to 3 weeks after exposure and may be flu-like symptoms. Disseminated cocciodiodes is the most serious form of the disease and is uncommon, affecting less than 1% of those infected. It can lead to septic arthritis, meningitis, as well as infections of the skin (most common in 15%-20% of cases), liver, and heart. Prognosis of a single extra pulmonary lesion is typically better than multifocal disease, except in the case of meningitis.
Outcome: The patient had a surgical wash out by Orthopedics. He was ultimately in the hospital for 6 days for initiation of IV antifungal treatment with Amphotericin B and conversion to long-term fluconazole. He will have long-term follow-up with Rheumatology and the Cocci clinic for adjustment and maintenance of chronic medication.
Follow-Up: The patient has been unable to return to full athletic play with recreational soccer currently. He has been able to walk and bear weight with only minor pain. He is working with physical therapy on strengthening due to his prolonged period of immobilization in the wheelchair. Sports Medicine follow-up recommended if any new injuries occur as he returns to activity.
Traumatic Chest Pain in a High School Football Player
Primary Author/Presenter: Raahil Kajani, MD
Joshua Scott, MD
Affiliation: Kerlan-Jobe Institute, Los Angeles, CA
History: An 18-year-old male football player is evaluated on the field after sustaining a direct blow to the chest while being tackled during a high school football game. The patient was able to walk off the field without assistance, initially reporting that he “got the wind knocked out” of him. While resting on the sideline, patient started complaining of generalized chest tightness and multiple episodes of hemoptysis. The patient was sent to the emergency room for further evaluation and imaging. While in the ER, the patient’s symptoms resolved and a chest x-ray was obtained, which was interpreted as normal. He was discharged home the same evening and cleared for full activity. Three days after the injury, the patient called medical staff complaining of right-sided chest pain with deep respirations. Patient was removed from all activity and a stat chest computed tomography scan was obtained.
Physical Exam: On the sideline, patient was found to be alert and oriented with no acute distress. Vitals showed patient to be hemodynamically stable with a blood pressure of 124/70, pulse rate of 88 bpm, respiratory rate of 20 breaths/min, and oxygen saturation of 96% on room air. Exam of head and neck showed no blood in the oropharynx or in the nares, no signs of oral or dental trauma, no subcutaneous crepitus, and a patent airway. Lungs were clear to auscultation. Chest wall showed no gross deformity or flail segments of the ribs, however patient had mild tenderness to palpation diffusely over the lower posterior ribs on the right side. Sputum sample showed small amount of bright red blood.
Differential Diagnosis:
316. Pulmonary Contusion/Laceration
317. Pneumothorax/Hemothorax
318. Esophageal Trauma
319. Rib Fracture
320. Cardiac Contusion
Test Results: Chest x-ray in the emergency room showed no evidence of pleural effusion, consolidation, edema, or pneumothorax. Cardio mediastinal silhouette, pulmonary vasculature, osseous structures, and soft tissues were normal. Chest CT scan 3 days after injury showed a right lower lobe paravertebral type 2 pulmonary laceration measuring approximately 2.0 × 1.4 × 3.3 cm with surrounding pulmonary contusion and a small adjacent hemothorax. No rib fracture or vertebral body fracture noted.
Final Diagnosis: Type 2 pulmonary laceration with associated pulmonary contusion and hemothorax.
Discussion: Pulmonary lacerations are an uncommon injury that occurs due to severe blunt chest trauma resulting in the disruption of alveolar walls and tearing of pulmonary parenchyma. Patients with pulmonary injury usually will present with hemoptysis and may have a normal lung exam. In the acute setting, chest CT is often required for diagnosis as pulmonary lacerations are typically not seen on chest x-ray until 48 to 72 hours after injury. Most pulmonary lacerations are managed with supportive therapy, however close monitoring is required for the first 24 to 48 hours. Fitness to fly should be assessed carefully in these patients as there is risk of worsening existing pulmonary injury.
Outcome: Following the diagnosis of pulmonary laceration, the patient was removed from all strenuous activities to allow for appropriate healing. Patient’s chest pain with respirations resolved one day after obtaining advanced imaging. Repeat chest CT obtained 6 weeks later showed resolution of hemothorax and pulmonary contusion with significant decrease in size of the right lower lobe pulmonary laceration.
Follow-Up: After repeat imaging showed improvement, patient was cleared for gradual return to non-contact aerobic activities as tolerated. Given that cystic changes associated with prior pulmonary lacerations may persist for months to years, further imaging was not obtained. One patient was able to tolerate increased activity load and was cleared for full contact activity, which he tolerated without issue.
