More than 30 million children and adolescents participate in organized sports in the United States.1,2 This incredibly high level of participation in community sport activities has increased the incidence of overuse syndromes and acute injuries.1,3,4 Among pediatric and adolescent athletes, chronic overuse injuries associated with the elbow joint occur more frequently than acute fractures or dislocations.3 Baseball, javelin, water polo, tennis, and bowling show a high prevalence of medial overuse injury1,5 Over the last decade, there has been an increase in the frequency of serious, overuse medial elbow injuries in young, overhead throwing athletes.1,5–7 The majority of studies involving medial elbow pain in young athletes specifically relate to baseball players.1,2 The incidence of elbow pain in young baseball players between 8 and 12 years of age is 20% to 30%; for baseball participants between 13 and 14 years of age, the incidence increases to 45%; and for high school players, the chance of medial elbow pain occurring progresses to more than 50%.1
Clinical symptoms of medial elbow pathology typically include pain of varying levels, which usually worsens with persistent use, and can progress to be accompanied by local swelling, warmth, and weakness in the wrist and/or hand, with difficulty carrying items.1,5,7 Range of motion (ROM) initially presents to be within or close to normal limits; however, with time, a decrease in elbow extension and occasional forearm supination can manifest.5 Ulnar neuritis and/or ulnar collateral instability may also result.1,5–6
Elbow pain may signify the presence of pathology not restricted to the soft tissues.7,8 Primary bone tumors represent the third leading tumor type in children and adolescents.9,10 In the upper extremity, these tumors most commonly not only occur in the humerus but also appear in the ulna and radius.11 The majority of pediatric bone tumors are initially benign, but aggressive in nature, and may metastasize into osteosarcoma.12,13 Osteosarcoma, the most common malignant bone tumor in children and adults, has an incidence of 4.4 per 1 million of the population, with the peak age of incidence between 10 and 20 years of age.8
Tumors often present with clinical symptoms similar to those associated with overuse injuries.7–9 Many of the subjective complaints include increase in pain with an increase in activity, nocturnal pain, tenderness, and swelling in the area of a bone or joint, initial normal ROM that can suddenly become compromised, tingling sensations, or loss of motor coordination.8,10,12 Differential diagnosis, including diagnostic imaging, is crucial for the subsequent medical management and promotion of optimal function.
A 17-year-old male elite high school baseball middle infielder and pitcher was referred by an orthopedic surgeon with a diagnosis of right medial epicondylitis. The patient and his parent provided informed consent for participation. The study was approved by the Institutional Review Board at Stockton University. On initial physical therapy (PT) visit, the patient reported moderate to severe right forearm pain and gradually decreasing muscle control over the past 4 months, with throwing accuracy decreased. Pain level increased significantly over the past 2 weeks and became “stabbing and unbearable,” causing him to pull himself out of a championship game.
At the time of the assessment, pain was reported to be 7-8/10 with activities of ball throwing and batting and at a 4-5/10 at rest. Pain was temporarily reduced to 0-1/10 by oral, nonsteroidal anti-inflammatory drugs, which included aspirin or ibuprofen. Over the course of the past 2 weeks, the medication had little effect despite his increased medication dosage to four 200-mg tablets of ibuprofen every 4 hours. During the previous 2 weeks, his pain had notably increased at night, waking him at least every hour. At the time of the evaluation, night pain was reported at 4-5/10. He had had a difficult time getting comfortable when lying in bed, experiencing increased pain with rolling or pressure on his right forearm.
His medical history included a growth plate fracture in the right forearm (same area as current symptoms), at 14 years old, which fully healed with no history of other disease processes, nor a significant family history. He returned to his sport 12 weeks after being diagnosed and played baseball 9 of 12 months each year, without any symptoms until “twinges” of pain started 4 months ago.
Communication ability, cognition, and vital signs were intact with integumentary and cardiopulmonary systems within normal limits. In addition, sensation and reflex testing for bilateral upper and lower extremities were equal and reactive.
His neuromuscular system executed coordinated, refined movement patterns, except from the fingers of the right hand. He ambulated independently on all indoor and outdoor terrains and maintained single leg stance with eyes closed for a minimum of 30 seconds, with little to no body sway on both the left and the right. He alternately hopped on the right and left legs for 20 counts and easily accomplished imitation of rapid, complex finger opposition sequences from the left hand. However, those from the right were slower, completed with facial grimaces, and reported discomfort.
Musculoskeletal system examination revealed an overall good standing posture, with symmetrical alignment and height of the shoulders, elbows, wrists, pelvis, knees, and ankles. A lower quarter screening examination revealed normal trunk, bilateral lower extremity ROM, strength, and balance.
Active ROM and passive ROM were within normal limits from the neck, upper trunk, shoulder, elbow, wrist, and hands of both the right and left upper extremities. Girth measurements 1-inch increments above and below the olecranon process were equal except for 2 inches below the olecranon where the right arm measured 1/2 inch larger than the left. Manual Muscle Testing revealed normal (5/5) strength from all musculature of the neck, trunk, and both upper extremities. Moderate pain (6/10) was reported upon resisted right wrist flexion and forearm pronation. Repetitive movements of right wrist flexion and forearm pronation produced pain to a 7-8/10 at 10 and 12 repetitions, respectively. After a 5-minute rest and reported reduction of symptoms, pain was not reproduced with other repetitive wrist or forearm motions. Palpation of the right proximal, medial forearm musculature from the medial epicondyle of the humerus to approximately 2 inch distal to the olecranon process produced moderate (5/10) pain.
While the patient was categorized into Musculoskeletal Pattern 4-C, Impaired Muscle Performance, specific aspects of his overall presentation caused extreme concern and warranted a referral to his orthopedic physician. First, his medical history of a growth plate fracture at the current site of the pain coupled with the patient's reports of achiness in the arm and a difficult time finding a comfortable position for his elbow were congruent with facts that bone cysts or tumors often form at areas of previous trauma and can cause high levels of discomfort.10,12,14 Also, the notable (½-inch) increase in girth measurement and pain on palpation of the exact same region signaled the possibility of a growth causing pain/pressure in the localized area.8,10 Third, aspirin and ibuprofen have been associated with initially relieving symptoms of bone growths but effectiveness decreases with cyst/tumor enhancement.14,15 Finally, reports of increased night pain and inability to “get comfortable” for sleep signaled the final red flag.9,11 Increased night pain is indicative of the possible presence of a tumor and the combination of his other symptoms correlates with signs and subjective complaints of (benign) bone tumors. The patient was referred to his orthopedic surgeon with a recommendation for diagnostic imaging, specifically radiography and magnetic resonance imaging (MRI), and for further physical examination. At that time, the PT prognosis was guarded and future intervention was halted until receipt of additional medical examination and diagnostic imaging.
The patient was instructed to refrain from participation in sports; all physical education and the physician were notified of PT findings. To assist with muscular relaxation and decreased inflammation, he received physical and written instruction in gentle, passive forearm and wrist ROM exercise and icing protocols. He was able to demonstrate the exercises with good technique.
SUMMARY OF MEDICAL FOLLOW-UP APPOINTMENT
Radiographs of the right elbow joint were obtained; the doctor reported that the radiographs were negative for any pathology and referred the athlete for an MRI scan at a nearby facility where the patient underwent an MRI scan of the right elbow without contrast. Results of MRI were negative for any pathology, and the diagnosis of medial epicondylitis remained. This parent shared that the physician believed that the pain was of a psychological origin. When his mother further inquired about her son's increasing pain and decreasing capabilities, the doctor vocalized his concern for her mental well-being as well. The orthopedic surgeon supplied a new order for PT and asked the family not to return to his office. A PT appointment was scheduled for the next day.
The physical therapist, with the parent's permission, called to request a copy of the radiologist report completed following his MRI.
The patient explained that since his last PT visit, 5 days prior, his right forearm pain level had significantly increased despite rest, use of ice, and a basic stretching regimen. He specifically stated that “he has been constantly uncomfortable when trying to sleep” and night time pain has increased to 8/10 despite increasing dosages of ibuprofen to four to five 200-mg tablets every 3 hours around the clock. In addition, since examination of 5 days earlier, he reported significant worsening of physical symptoms including decreased ROM, decreased muscle strength, and pain upon palpation (Table 1). Noting the marked decrease in ROM and muscle strength due to pain, and increased reports of pain and tenderness on palpation, the PT reevaluation ceased. The therapist explained to the young man and his mother that these symptoms were not typical of the medical diagnosis of medial epicondylitis following a 5-day period of near complete rest and that it was time to either return to the referring doctor or seek a second medical opinion. (See Table 2 for the summary of clinical findings that led to the second medical referral.)
The requested MRI report arrived via a faxed transmission to the clinic, and the physical therapist noticed that the last line of the narrative stated, “A shadow was visible at the right proximal ulna.” After reading this statement, the parent was immediately advised to obtain the radiographs and magnetic resonance images/CD and submit to the physician providing the second opinion.
Formulation of a Diagnosis
The patient and his family sought a second medical consultation with another physician. Two weeks later during his visit with the second specialist, this physician visually examined the radiograph (Figure 1) and the magnetic resonance images (Figure 2) ordered by the patient's first orthopedist 2 weeks prior. Within minutes, the specialist observed a proximal ulnar lesion with a central nidus, well marginated and surrounded by a sclerotic rim. The magnetic resonance image (T1-weighted image) from the scan completed approximately 14 days earlier confirmed the diagnosis of a specific tumor and ruled out any soft-tissue encroachment (see Figure 2). The physician made a preliminary diagnosis of a benign tumor, with confirmation awaiting an official pathology report. The size of the tumor was 3 cm, thus making the diagnosis of an osteoblastoma versus an osteoid osteoma.15,16,17 A skeletal scintigraphy (bone scan) followed to rule out additional sites of metastasis. The scan found no other lesions, and a surgical date was set within 10 days.
Medical Management and PT Plan of Care
The patient underwent surgical curettage (scraping of the tumor) and biopsy, followed by 1 week of immobilization. Biopsy cell samples were sent to laboratories at 4 different cancer centers throughout the United States. Each of the centers confirmed the diagnosis of benign, aggressive osteoblastoma. Physical therapy was ordered for progressive ROM and strengthening with gradual return to full function.
Unfortunately, 4 months after surgery, pain exacerbated. An MRI scan was scheduled with the findings of tumor reoccurrence and involvement of the soft tissue. The young man was referred to an upper-limb tumor specialist at a renowned cancer center where a second, more extensive surgery was performed and the biopsy confirmed a benign, but aggressive osteoblastoma. One year later, a third surgery occurred, with biopsy revealing the same tumor type. This last surgery was most aggressive with curettage, soft-tissue removal, and follow-up rehabilitation. Despite the use of evidence-based PT treatment while working closely with the medical team, he has not been able to achieve normal ROM, with right elbow flexion limited to 10° to 120°. This young man continues to receive follow-up MRI scans every 6 months. He was unable to return to competitive baseball; however, he is enjoying a successful college experience and is independent with all activities of daily living.
Musculoskeletal tumors are rare in the general population, contributing only 0.2% to 0.5% of reported malignancies.10,18 Although information on the incidence of general musculoskeletal tumors (benign and malignant) in the United States is currently unavailable, European incidence from 2015 supports that they are more commonly seen in children, comprising 3% to 5% of all tumors diagnosed in children younger than 15 years and 7% to 8% of all tumors in adolescents and young adults between 15 and 19 years of age.10,16,18,19 Geographic distribution and incidence of these tumors vary greatly around the world, with the lowest incidence in India and China and the highest incidence in Western Europe and the United States.10,16,18,19 Their cause is unclear, and the majority of these neoplasms exhibit relatively slow growth patterns.10,16 Two factors known to increase the risk for bone tumor occurrence include a history of trauma and previous radiotherapy.10,12,14 Upon physical examination, most bone tumors present with similar symptoms.8,10,14,16,19,20 A thorough patient history will typically reveal reports of nocturnal pain, as well as pain elicited by specific activities with progressive intensity as the tumor enhances.8,10,12,14,16 Clinical examination commonly presents with swelling at a specific site with palpable tenderness, sudden limitation in ROM with tumor enhancement, and neurogenic deficits including loss of coordination.8,10,11,15
Osteoblastoma, by definition, is a benign bone tumor with osteoblastic characteristics similar to that of an osteoid osteoma but with an enhanced potential for growth.15 Osteoblastomas and osteoid osteomas are differentiated by their size in length,16 with osteoblastic bone lesions larger than 1.5 cm classified as an osteoblastoma and lesions at 1.4 cm or less an osteoid osteoma.15–17 Osteoblastomas most frequently appear in white males,12,13,22 and the average age of onset is between 15 and 20 years, with 90% of all patients receiving a diagnosis before the age of 30 years.13,15,16,21
Aggressive osteoblastomas are a distinct type of osteoblastoma that present with more than a 50% chance of recurrence.12,15 Histologically, they are a borderline lesion between a typical osteoblastoma and an osteosarcoma.12,13,15–17,21 However, it is important to know that upon recurrence, aggressive osteoblastomas have, on rare occasions, transform into osteosarcomas or malignant neoplasms.13–15,16,21
Aggressive osteoblastomas have a similar radiographic appearance to conventional osteoblastoma, with well-defined margins, variable mineralization, and peritumoral sclerosis.11,15,17 These tumors can frequently invade the surrounding soft tissue, and for this reason, MRI is the preferred diagnostic imaging tool used to ascertain the extent of this lesion.23,24 The recommended treatment of aggressive blastoma is surgery with intralesion curettage.16,21,22 Excisional biopsy and cellular pathology are the definitive tests that confirm whether the suspected tumor is benign or malignant. In accord with their rate of reoccurrence, any patient with a diagnosis of osteoblastoma and who receives surgical excision is recommended for medical follow-up consisting of physical examination and diagnostic imaging (typically MRI) for 2 to 5 years following his or her last surgical procedure.11,13,15–17,21,22 It is crucial to note that radiotherapy, which is an indicated treatment of recurrent tumors, would not be an appropriate choice for aggressive osteoblastoma, as radiotherapy carries the devastating potential risk of transformation into malignant post–radiation sarcoma.16,17
This case report illustrates the differential diagnosis process used by a physical therapist suspecting underlying pathology to generate the appropriate referral to an orthopedic surgeon. The PT practitioner was able to integrate the patient management protocol and general knowledge of tumor incidence with the presentation of a decrease in effectiveness of salicylates, corresponding significant loss in function, and change in pain pattern with notable increase in nocturnal pain to arrive at a rational plan of care.7,8,10,11,13–15,25
Physical therapists consistently demonstrate the ability to be extremely competent, efficient, and cost-effective in managing neuromusculoskeletal dysfunction.26,27 It is imperative for physical therapists to be confident in the recognition of signs, symptoms, and “red flags,” which indicate pathological conditions outside the scope of PT practice, request comprehensive diagnostic workup, and make a referral to the appropriate medical source.4,26,27 Working as an interprofessional team will optimize outcomes in a timely manner.
The authors thank Peter McHugh, PT, and Dr Elaine Bukowski for their professional insights and encouragement.
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Keywords:Copyright 2019 © Academy of Oncology Physical Therapy, APTA
aggressive osteoblastoma; differential diagnosis osteoblastoma