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Official Journal of the American College of Sports Medicine PhysICaL EXaMINaTION: Initial examination of the hip demonstrated tenderness to palpation over the right adductor muscle at its insertion point on the pubic rami. No tenderness to palpation of the lumbar paraspinals, anterior-superior iliac spine, iliac crest, sacroiliac joint or trochanteric bursas were noted. Provocative maneuvers with FADIR (Flexion Adduction Internal Rotation) test in her right hip. PhysICaL EXaMINaTION: 1. Osteoarthritis. 2. Hip labral tear. 3. Femoroacetabular impingement. TESTS AND rEsuLTs: Ultrasound of the right hip revealed an anterior-superior acetabular labral tear Magnetic Resonance Arthrogram (MRA) of the right hip confirmed anterior-superior labral tear FINaL/WOrKING dIaGNOsIs: Anterior-Superior Labral Tear of the Right Hip TrEaTMENT aNd OuTCOMEs: 1. Failed repeat conservative management with oral diclofenac, transdermal lidocaine and physical therapy 2. Advanced imaging obtained revealing pathology 3. Surgery evaluation, patient opted for non-surgical management 4. Ultrasound-guided platelet-rich plasma (PRP) of the hip was then performed for the anterior-superior labral tear of the right hip 5. Four weeks post-injection she reported no pain, resumed waterskiing daily for the next three months with no recurrence of the hip pain at 6 months post procedure. 1044 May 30, 9:00 AM - 9:20 AM Knee Injury-basketball Danielle G. Hirsch, Dilip Patel, FACSM, Vani Sabesan. Western Michigan University School of Medicine Clinics, Kalamazoo, MI. (Sponsor: Robert J Baker, FACSM) (No relationships reported) hIsTOry: A 15-year-old male presented to the clinic for evaluation of right knee pain that has been ongoing for the past year. The patient can recall two injuries to the knee directly both occurring while playing basketball. The first injury one month prior to presentation occurred during a basketball game when he “bumped knees” with another player requiring him to sit out of the game for about 5 minutes then returning to play where he had to stop because he reported his leg gave out upon return to play. He was evaluated by his team trainer and was given crutches which he used for a short time. The second injury occurred one week prior to presentation to the clinic where he reports that upon attempting a lay-up he felt his knee give out and had to stop playing. He reports a limp now and for the pain and swelling he has been using ice and ibuprofen inconsistently without much relief. PhysICaL EXaM: Right knee: 2+ effusion. Lachman test was positive with a soft end point. McMurray Negative, Varus-Valgus stress negative. Patellar apprehension negative. ROM: Pain and limited flexion of the right knee. Straight leg raise reproduced pain in the right knee and hip. Upon squatting on the right knee there was a noted loss of balance. There was no pain or tenderness to touch along the joint lines or patella. His gait is remarkable for a limp. PhysICaL EXaMINaTION: 1.ACL tear 2.Tibial spine avulsion 3.Osteochonral fracture 4.Osteochondritis dissecans 5.Medial meniscus tear TEsT aNd rEsuLTs: MRI of Right knee: 1.ACL tear 2.Vertical peripheral posterior horn tears of the medial/lateral meniscus 3.Osseous contusions of the lateral condyles 4.Large effusion FINaL/WOrKING dIaGNOsIs: ACL, medial, and lateral meniscal tears TrEaTMENT aNd OuTCOMEs: 1.ACL reconstruction with medial and lateral meniscal repair 2.Physical therapy for range of motion and quad strengthening 3.Post-op placed in a gravity flow cryotherapy on the right knee for ROM 4.Weight bearing by 6 weeks post-op 1045 May 30, 9:20 AM - 9:40 AM Exercise Induced arterial Compression Rick Morgan. Steadman Hawkins Clinic of the Carolinas, Greenville, SC. (Sponsor: Kyle Cassas, FACSM) (No relationships reported) hIsTOry: 22 year old elite level professional cyclist presents with left leg cramping and loss of power for several months. He denies injury, numbness or pain. The onset has been gradual but progressively worsening. He has never had this problem before. The feeling is similar to a cramp, but not as intensely painful, and it involves the entire Vol. 45 No. 5 Supplement S189 leg. He denies back pain. He did change bike position over the winter and had some fit/ equipement issues with that including some mild low back pain that resolved. He had been the age group national champion the year prior, and despite more rigorous training and team support, had been unable to replicate that type of performance in the current season. At times he struggled with seasonal allergies and exercise induced asthma, both more significant in Europe than his native Utah. He was concerned about the fact that he had a series of mild viral illnesses throughout the early racing season and at one point was tested for EBV/mono and left Europe for several weeks to recover.He seemed to recover well at that point, but upon returning to Europe to race he noted more consistent and problematic left leg cramping sensation and loss of power. PhysICaL EXaMINaTION: Gen--well, NAD. Slender but athletic build. MSK-normal gait. ROM in the ankles, knees, hips and lumbar spine is normal. No swelling or bruising noted in B LE. Toe walk, heel walk and single leg stand are normal bilaterally. EHL intact. DTR 2+ bilateral patella and achilles. Sensation grossly intact to LT in all LE dermatomes. Negative SLR and x SLR. He has mild discomfort with FABER on the L, but not c/w his presenting complaint PhysICaL EXaMINaTION: EIAC, lumbar disk with radiculopathy, SI dysfunction, Mono syndrome TEsT aNd rEsuLTs: Baseline CBC, ferritin (1/2012) wnl, EBV titers revealing exposure to Mono (4/2012) but normal CBC, CMP, presumed subacute. Then in June, ABI (abnormal), CT angiogram (negative), MRA (abnormal), power study cycling FINaL WOrKING dIaGNOsIs: L internal iliac compression due to exercise TrEaTMENT aNd OuTCOMEs: L iliac artery graft, 8 cm bovine patch. Hospitalization for 5 days, 2 weeks of limited activity (walks) followed by a gradual increase in activity. Return to cycling at 8 weeks. Currently has returned to training, offseason, and will be racing professionally again in 2013. 1046 May 30, 9:40 AM - 10:00 AM Proximal Thigh swelling Precipitates Numbness, Tingling and swelling In a 38yo stunt rider Ryan S. Wagner. Avita health System, Bucyrus, OH. (No relationships reported) hIsTOry: 38yo male presents to the clinic in mid-August 2012 with a complaint of a large hematoma over his proximal right thigh and focal swelling over his right patella after wrecking his motorcycle during a stunt-riding event on four weeks prior. He was diagnosed with hematoma and pre-patellar bursitis. The pre-patellar bursa was aspirated under ultrasound guidance and fully drained with prescription for prophylactic antibiotics. The bursitis resolved. Two months later he returned with persistent swelling to the proximal, anterolateral right thigh. He had developed constant numbness and tingling over the anterolateral aspect of his thigh progressing to just superior to the knee accompanied by severe burning pain. PhysICaL EXaMINaTION: Inspection: Discrete, fluctuant mass overlying the proximal anterolateral thigh, 10cm distal to inguinal crease, 10x7cm in dimension. No associated erythema, ecchymosis or wound. Otherwise unremarkable. Palpation: Burning pain is provoked with palpation of the medial third of the mass. Otherwise no specific tenderness. Neurologic: Normal strength and reflexes, diminished sensation in the distribution of the anterior branch of the Lateral Femoral Cutaneous Nerve (LCFN). Special maneuvers: +Tinel’s over the medial third of the fluctuant mass. PhysICaL EXaMINaTION: 1) Seroma, organized hematoma, soft tissue mass; 2) HNP/Radiculitis, meralgia paresthetica. TEsT aNd rEsuLTs: Diagnostic US of the lesion demonstrated a fluid filled mass with delineation between the muscular fascia and the sub-cutaneous tissue. A structure is visualized traversing the lumen located in the medial third of the lesion in the anatomic location of the LCFN, tented. The lesion was aspirated and 90mL of serosanguinous fluid was removed. Abstracts were prepared by the authors and printed as submitted. Thursday, May 30, 2013
Thursday, May 30, 2013 S190 Vol. 45 No. 5 Supplement FINaL WOrKING dIaGNOsIs: Morel-Lavallee lesion causing Meralgia Paresthetica TrEaTMENT aNd OuTCOMEs: The patient continued a compression wrap for 3 days after which the lesion recurred. Pain returned 4-5 days later. He requested a second aspiration. This was performed with 60mL of serosanguinous fluid removed and 100mg of Doxycycline reconstituted in 10mL of sterile water was injected back into the lesion for sclerodesis. He was instructed on continuing the compression wrap for 3-4 weeks. At 2 weeks the lesion has not yet recurred. C-23 Clinical Case Slide - Running Issues I May 30, 2013, 8:00 AM - 10:00 AM Room: 123 1047 Chair: Karl Bert Fields. Moses Cone Health System, Greensboro, NC. (No relationships reported) 1048 discussant: Irene Davis, FACSM. Harvard Medical School, Boston, MA. (No relationships reported) 1049 discussant: George Chiampas. Northwestern University, Chicago, IL. (No relationships reported) 1050 May 30, 8:00 AM - 8:20 AM Leg swelling - runner Melody Hrubes. Schwab Rehabilitation Hospital, Chicago, IL. (Sponsor: Terry Nicola, FACSM) (No relationships reported) hIsTOry: A 23-year-old collegiate runner first noticed a bump on the anterior aspect of his left tibia 13 months prior. There was no known trauma or previous injury to the area. He competed his entire senior season and even set personal bests, although the bump grew in size over the year. It was painful only if he pressed on it after running, so he did not seek medical attention. He came into the Sports Medicine Clinic at the conclusion of his running season for further evaluation PhysICaL EXaMINaTION: Swelling was noted on the anterior-lateral aspect of the left tibia, approximately 2cm in diameter. It was non-tender, non-edematous, and non-blanching. Distal strength, pulses and reflexes were within normal limits and symmetric when compared to the right side. PhysICaL EXaMINaTION: 1. Enchondroma 2. Tibial fracture with ossification center 3. benign tumor TEsT aNd rEsuLTs: MEDICINE & SCIENCE IN SPORTS & EXERCISE ® Left Tibia/Fibula anterior-posterior and lateral radiographs: -Dense periosteal reaction is seen along the anterior medial aspect of the tibia that is focally greatest in the proximal third of the diaphysis. A horizontal lucency suggestive of a fracture is present through approximately 50% of the outer cortex. FINaL/WOrKING dIaGNOsIs: Dreaded black line (anterior tibial stress fracture) TrEaTMENT aNd OuTCOMEs: 1. Immobilization with air cast 2. Bone stimulation 3. Non weight-bearing with crutches for six weeks 4. Follow-up imaging at six weeks demonstrated interval healing and callous formation but continued visualization of fracture line, so continued crutches for five more weeks (11 weeks total). 5. Progressed to walking without air cast or crutches after 11 weeks. Fracture successfully healed without need for surgical intervention. He is currently advancing his exercise demands while wearing the air cast and continues to be asymptomatic. 6. Successful recovery from unstable fracture despite prior unrestricted competition for one year. 1051 May 30, 8:20 AM - 8:40 AM Exertional Leg Pain - runner Neil Sparks, Mark Rogers, Delmas Bolin, FACSM. Edward Via College of Osteopathic Medicine, Blacksburg, VA. (No relationships reported) hIsTOry: A 19-year-old female ROTC cadet presented with one year of progressive right lower extremity pain, tightness, and parasthesias with running. Pain localized to the medial and anterior third of the tibia and the proximal third of her calf. Calf tightness noted diffusely. Parasthesias described circumferentially around the distal 2/3 of the tibia and fibula to the toes. Symptoms possibly related to an increase in running intensity. Symptom onset within 8 to10 minutes of running, progresses to a 10/10 severity, and improves within 30 minutes to two hours of rest. Past history positive for ACL reconstruction with revision 2010 on symptomatic leg. PhysICaL EXaMINaTION: Right lower extremity examination revealed no edema or ecchymosis. Sensation to light touch and vibration decreased over the middle third of the tibia. Fibular head motion restricted and the right tibia internally rotated relative to the femur. Tenderness at the medial head of the gastrocnemius, anterior middle and medial third of the tibia, medial aspect of the tibialis anterior, and cuneiforms. Fascial compartments soft without palpable masses. Subtalar motion restricted. 20 toe raises reproduced symptoms. Tinel’s was positive at the common peroneal and sural nerves. Tibialis anterior strength 4/5. PhysICaL EXaMINaTION: 1.Tibial Stress Fracture 2.Medial Tibial Stress Syndrome 3.Popliteal Artery Entrapment Syndrome 4.Exertional Compartment Syndrome TEsTs aNd rEsuLTs: Tibia and fibula anterior-posterior and lateral radiographs: - Negative for stress fracture Lower extremity MRI: - Negative for stress fracture or mass Popliteal artery sonography: - No evidence of artery entrapment Compartment Pressure Testing of Two Compartments: - Elevated anterior compartment pressures at rest and increased with exertion. - Normal posterior compartment pressures Gait analysis: - Weak core with bilateral trendelenberg, limited external rotation of right tibia, lateral weight distribution throughout gait cycle FINaL/WOrKING dIaGNOsIs: Exertional (Anterior) Compartment Syndrome TREATMENT PLAN: 1.Surgical consultation to discuss fasciotomy; considered early given patient’s need to maintain military status. 2.Osteopathic manual treatment. 3.Physical therapy to include gait training 1052 May 30, 8:40 AM - 9:00 AM Finger Injury - running Fariba Shah, Monica Rho, Joel Press, FACSM. Rehabilitation Institute of Chicago, Chicago, IL. (No relationships reported) hIsTOry: A 37-year-old female runner sustained a finger injury when grasping her smart phone while running. At the end of her 3.5-mile run, she looked down at her phone to track her mileage, when she tripped and fell face forward to the ground. Her right hand was firmly grasping the phone, with her thumb on one side and her third and fourth digit wrapped around the back of the phone. The screen of the smart phone shattered on impact. She felt immediate pain with movement of her right fourth digit ACSM May 28 - June 1, 2013 Indianapolis, Indiana
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