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Official Journal of the American College of Sports Medicine PhysICaL EXaMINaTION: Height 6’ 1.5”, Weight 175 lbs, BP 114/64, HR 58 General: WD, WN, NAD, A&O x 3 HEENT: WNL Neck: no JVD, bruit, thyromegaly, or lymphadenopathy CV: RRR without murmur, rub or gallop - auscultated in supine and upright positions; equal peripheral pulses; normal chest wall Lungs: CTAB ABD: ND, BS(+), NT, no HSM EXT: no edema or cyanosis Skin, MSK, and Neuro: WNL 2D screening echocardiogram: Moderately dilated LV, with EF 40%. No wall motion abnormalities. No LVH. Normal LVOT. Mild mitral regurgitation. Mild tricuspid regurgitation. Normal pulmonary pressure. Patent foramen ovale with left to right shunt. PhysICaL EXaMINaTION: 1. Myocarditis 2. Idiopathic cardiomyopathy 3. Prior stimulant or anabolic steroid abuse TEsT aNd rEsuLTs: Stress echocardiogram: Physiologic hemodynamic response to exercise. HRR at 1 minute 52. EF at rest 45%. Improved global LV function with exercise but does not get as hyperdynamic as expected for age, HR, and MET level achieved. No ischemic changes. Rare PAC’s. No arrhythmias. Cardiac MRI: LV dilated with diffuse hypokinesis. LVEF = 46%. RV dilated with mild diffuse hypokinesis. RVEF 51%. Trivial pericardial effusion. No myocardial edema. Diffuse myocardial fibrosis. Consistent with nonischemic cardiomyopathy. FINaL WOrKING dIaGNOsIs: Resolved myocarditis with resultant myocardial scarring TrEaTMENT aNd OuTCOMEs: Athlete is withheld from sports participation and exercise. He was placed on a low dose ACE-I. A repeat echocardiogram is scheduled for 3 months and follow up cardiac MRI is scheduled in 6 months. 1774 May 30, 4:15 PM - 4:35 PM heart Murmur- Basketball Michael R. Tiso, Luis Salazar. Ohio State, Columbus, OH. (Sponsor: Thomas M. Best, FACSM) (No relationships reported) hIsTOry: A 19-year-old African American college sophomore basketball player presented for a routine pre-participation physical. He reported no previous medical conditions or injuries, syncope with exercise, or previous loss of consciousness. He stated he had never had chest pain, shortness of breath, or palpitations while playing basketball. The athlete had no family history of sudden death but reports his mother had a “heart valve problem with prior surgeries.” PhysICaL EXaMINaTION: Vitals: Blood pressure 120/80, pulse 55, respiratory rate 14, and BMI 25. The patient was a physically fit athlete in no distress. A musculoskeletal exam showed normal strength, tone, and sensation. Respirations were clear to auscultation bilaterally. Cardiac exam revealed a regular rate and rhythm with normal S1/S2 and no gallop, rub, S3, or S4. JVD was not present, he had brisk carotid upstrokes bilaterally, and peripheral pulses were 2+ throughout. A 3/6 systolic murmur was heard loudest along the left sternal border which decreased in intensity with squatting and increased for 3-5 beats upon standing. PhysICaL EXaMINaTION: 1. Physiologic murmur 2. Hypertrophic obstructive cardiomyopathy 3. Mitral regurgitation 4. Ventricular septal defect 5. Aortic stenosis TEsTs aNd rEsuLTs: ECG: -Sinus bradycardia with LVH and T wave inversions in V3 - V5 Echocardiogram: -Normal LV function with EF of 65%. -Intraventricular septal wall 1.1cm in diameter, left ventricular posterior wall 1.4cm. Cardiac MRI: -Concentrically hypertrophied LV with normal cavity size and EF of 65%. -RV minimally hypertrophied with prominent trabeculations. -Septal thickness 1.4cm, LV free wall thickness 1.3cm -Anatomically normal valves. FINaL / WOrKING dIaGNOsIs: Hypertrophic obstructive cardiomyopathy TrEaTMENT aNd OuTCOMEs: 1. Case was discussed between cardiology and sports medicine as the posterior wall thickness was in a diagnostic indeterminate zone. 2. Imaging did not meet criteria for hypertrophic cardiomyopathy; therefore athlete could not be disqualified from play. 3. Recommended deconditioning for six months with follow up echocardiogram / cardiac MRI. 4. Athlete decided to continue to play the season without incident. Vol. 45 No. 5 Supplement S343 1775 May 30, 4:35 PM - 4:55 PM Thigh Pain--cyclist Brian C. Liem, Mark A. Harrast. University of Washington, Seattle, WA. (Sponsor: Stanley Herring, FACSM) (No relationships reported) hIsTOry: A 49 year old competitive cyclist presented with progressively worsening 10 year history of right anterior thigh pain with exercise. She experienced a severe cramping sensation that would start in the anterior thigh and travel into the posterior thigh and calf with cycling and after several minutes. During more aggressive time trials or faster sprints her symptoms could present just after 30 seconds. She noted that when her heart rate reached 155 bpm symptoms would worsen and her leg would “shut down.” By slowing down and resting her pain improved. She had not been able to race at the level she wanted to for the prior 2 years specifically due to this right leg pain. She denied pain or weakness with regular ambulation. PhysICaL EXaMINaTION: Normal gait. Normal lumbar and hip range of motion without reproduction of symptoms. No tenderness to palpation over the groin or anterior thigh. Strength is 5/5 lower extremities bilaterally, sensation is normal and reflexes are symmetric. Negative dural tension signs. FABER and FADIR maneuvers negative. Normal pedal and popliteal pulses. Femoral pulses intact in supine but with hip flexion right femoral pulse diminishes. PhysICaL EXaMINaTION: 1. Hip Pathology 2. Lumbar radiculopathy 3. Vascular claudication 4. Femoral neuropathy TEsT aNd rEsuLTs: 1. Pelvis and Right femur X-rays: Normal. No fracture or osteoarthritis 2. Right Ankle Brachial Indexes: 1.29 pre-exercise, 0.38 post exercise 3. Duplex Doppler: Post exercise external iliac artery velocity 231 cm/sec, 50-99% stenosis. 4. CT angiogram: No stenosis. Minimal narrowing right external iliac artery FINaL WOrKING dIaGNOsIs: Right External Iliac Artery Endofibrosis TrEaTMENT aNd OuTCOMEs: 1. Given her desire to return to high level competition, referred patient for consultation with vascular surgery. 2. Underwent saphenous vein patch angioplasty. 3. Returned to cycling competition. 1776 May 30, 4:55 PM - 5:15 PM Concerns Of The heart In a Professional Football hopeful Leonie Prao 1 , Andrew Tucker 2 . 1 Union Memorial Hospital and University of Maryland Medical Center, Baltimore, MD. 2 Union Memorial Hospital, Baltimore, MD. (No relationships reported) hIsTOry: 22 year old AA male presents for a professional football free agent PPE . He denies any current complaints, but admits to history of a heart murmur. Awareness of his heart murmur resulted from a syncopal episode at the age of 16. While standing during a wedding, he felt dizzy, and fainted. This syncopal episode was thought to be vasovagal or neurocardiogenic in origin. Pediatric cardiology evaluation and echocardiogram in May of 2008 revealed mild MV prolapse and trivial, hemodynamically insignificant MV regurgitation. He was cleared to participate in college football and has had no cardiac symptoms throughout college. He currently denies any chest pain, palpitations, easy fatigability, or peripheral edema. PhysICaL EXaMINaTION: The player was noted to have normal blood pressure and heart rate. Cardiac examination revealed a 3/6 holosystolic murmur with a mid-systolic click, best heard at the base, but able to be heard at the apex and bilateral sternal borders. Murmur increased with squatting. Normal S1, S2. No diastolic murmurs. No JVD. No peripheral edema, 2+ distal pulses bilaterally. Pulmonary exam normal. PhysICaL EXaMINaTION: 1) Persistent/Worsening Mitral Valve Prolapse/Regurgitation 2) Mitral/Aortic Stenosis 3) Atrial Myxoma 4) HOCM TEsT aNd rEsuLTs: EKG: Sinus bradycardia, HR 56, LVH, normal QRS aP/Lateral CXr-- mild cardiomegaly, rounded cardiac appearance TTE-Normal LV function w/ estimated LV EF 60%. No obvious segmental wall motion abnormalities. Mild tricuspid regurgitation. Pulmonary artery pressure 48mmHg consistent with pulmonary hypertension. 3+(Moderate) mitral regurgitation. Prominent prolapse of the posterior mitral valve. Normal intra-atrial and intraventricular septum. FINaL WOrKING dIaGNOsIs: Persistent/Progressive Mitral Valve Prolapse/Regurgitation Abstracts were prepared by the authors and printed as submitted. Thursday, May 30, 2013
Thursday, May 30, 2013 S344 Vol. 45 No. 5 Supplement TrEaTMENT aNd OuTCOMEs: 1) Referred to cardiology for further evaluation 2) TEE completed- progressive MV prolapse/regurgitation with the development of pulmonary HTN, the player underwent MV annuloplasty. 3) Repeat TTE 5 weeks status-post annuloplasty revealed normalization of PA pressures, resolved MV prolapse, but persistent mild-to-moderate MR. 4) Player was not cleared for participation. He was asked to return for re-evaluation 12 weeks after surgery to allow for ring stabilization. D-60 Clinical Case Slide - Pediatric Issues May 30, 2013, 3:15 PM - 5:15 PM Room: 117 1777 Chair: Nailah Coleman, FACSM. Phoebe Putney Memorial Hospital, Albany, GA. (No relationships reported) 1778 discussant: Andrew Gregory, FACSM. Vanderbilt University, Nashville, TN. (No relationships reported) 1779 discussant: Angela Smith, FACSM. Bryn Mawr, PA. (No relationships reported) 1780 May 30, 3:15 PM - 3:35 PM head Injury In youth Football (FB) - a Case report Verle D. Valentine1 , Jason C. Dorman2 , Shanna L. Kindt2 , Thayne A. Munce2 , Morgan M. Avery2 , Caitlin J. Pearl2 , Hannah K. Nelson2 , Tryg O. Odney2 , Michael F. Bergeron, FACSM2 . 1 2 Sanford Health, Sioux Falls, SD. National Institute for Athletic Health & Performance, Sioux Falls, SD. (No relationships reported) hIsTOry: A 12-year-old FB running back presented about one hour after he was hit at nearly the same instant by two defenders while attempting to run the ball. Both hits involved helmet-to-helmet contact to the frontal area of his helmet and were the first head impacts he sustained during the game. The athlete was wearing a helmet instrumented with Riddell® HITSystem accelerometers at the time of the injury. There was no LOC, but he appeared dazed with poor balance and was removed from the game immediately. Symptoms included headache, fogginess, feeling slowed down, and dizziness. No history of previous head injury. PhysICaL EXaMINaTION:Patient was alert & oriented, answered questions slowly and appeared dazed. Cranial nerves were intact, and neck was non-tender with normal ROM. No focal neurological deficits were noted. No amnesia. Immediate memory and 5-minute recall were normal, however concentration was poor. King- Devick (K-D) testing and reaction time were slower than baseline. Postural stability was poor compared to baseline. PhysICaL EXaMINaTION: - Concussion - Intracranial bleed - Second-impact syndrome TEsT aNd rEsuLTs: - Helmet accelerometers: two simultaneous impacts (peak linear accelerations) of 52.4 & 52.2 g’s. - ImPACT testing: abnormal at day 0, 2, 6 & 12; normal at day 20 - Reaction time: abnormal at day 0, 2, 6 & 12; normal at day 20 - K-D testing: abnormal at day 0, 2, 6 & 12; normal at day 20 - Postural stability testing: abnormal at day 0, 2, 6 & 12; normal at day 20 - NeuroCom® SOT scores: abnormal at day 2, 6 & 12; normal at day 20 - Post Concussion Symptom Score: abnormal at day 0, 2, 6, 12 & 20. FINaL WOrKING dIaGNOsIs: Concussion from two simultaneous head impacts of moderate magnitude. TrEaTMENT aNd OuTCOMEs: Physical rest and cognitive rest were advised. He was gradually returned to school after one week with accommodations as symptoms improved. His testing scores and physical examination returned to normal after 20 days; however, symptoms persisted past four weeks. dIsCussION: These data are particularly unique in that the breadth of baseline, immediate post-concussion and recovery evaluations is extensive. Moreover, this is the first report of quantifiable head impact data leading to a concussion in youth football. MEDICINE & SCIENCE IN SPORTS & EXERCISE ® 1781 May 30, 3:35 PM - 3:55 PM subtle Wrist pain - dance Chae Ko, Kyle Cassas, FACSM. Steadman Hawkins Clinic of the Carolinas, Greenville, SC. (Sponsor: Delmas Bolin, FACSM) (No relationships reported) hIsTOry: 10 year old female dancer. She complains of pain and swelling to left wrist. This has been intermittent since 6 months ago with no known injury. She actively participates in dance and has been in competition. Five months ago, she experienced swelling. She does not have any history of rheumatologic disease but this does run in the family. Denies any fevers or redness. No other joint involvement. She reports pain primarily along the distal radius. PhysICaL EXaM: Hand/wrist exam: On examination there is soft tissue swelling involving the left wrist. Her range of motion is limited because of pain. Pain with full pronation and supination. There is warmth but no erythema. She does have diffuse tenderness along the left wrist but no focal area that seems to be the most painful. She is neurovascularly intact. No other joint involvement. General exam is negative DIFFERENTIAL DIAGNOSES: 1. Distal radius physeal injury 2. Rheumatologic disease 3. Leukemia (Acute lymphocytic leukemia) 4. Post-infectious arthritis 5. Septic arthritis 6. Lyme disease 7. Behcet Syndrome 8. SLE TEsTs aNd rEsuLTs: 1. CBC with diff (Heme Profile with diff, HP with diff) neg 2. Sed Rate (ESR) 12 3. CRP Non Cardiac (C Reactive Protein) 2.8 4. Antinuclear Antibodies (ANA), reflex to titer positive (1:160) 5. Rheumatoid Factor (RA Factor, RF Factor) neg 6. ASO Quantitative (ASO Screen, Anti-streptolysin O Ab), serum neg 7. Comprehensive Metabolic Panel (CMP, CMET) neg 8. Lyme Disease AB Total w/reflex Western Blot neg 9. Hep B Core IgM ab neg 10. Hep B surf Ag neg 11. Hep A IgM ab neg 12. Hep C IgG ab neg 13. HLA B27 neg 14. Native DNA ab neg IMAGING: Xrays of AP, oblique, and lateral of left wrist is negative MRI left wrist: Swelling to radiocarpal joint space. Inflammation along dorsum of wrist and proximaly along distal radius. Subarticular bone marrow edema of scaphoid, lunate, and radial epiphysis. Tenosynovitis of 2 nd -5 th extensor compartments. Mild tenosynovitis of flexor tendons. Preserved articular cartilage. Sever/active inflammatory arthropathy, likely juvenile idiopathic arthropathy. FINaL/WOrKING dIaGNOsIs: Juvenile Idiopathic Arthritis TrEaTMENT aNd OuTCOME: 1. Immobilization and bracing for protection 2. Physical Therapy 3. Naprosyn BID 4. Pediatric rheumatology referral 5. Methotrexate 15mg PO q week 6. Follow up with pediatric rheumatology ACSM May 28 - June 1, 2013 Indianapolis, Indiana
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